KungPOWChicken

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30 y/o 200lb Mallanpati #3 patient with high anxiety, fibromyalgia with multiple psych issues who has had a localized allergic reaction to lidocaine (says she had a raised red rash on arm from iv start with lidocaine). wants a general anesthetic for repeat c-section. (1st c-section was under general due to failed epidural- no anesthetic record available). Pt convinced to have spinal. No immediate reaction to lidocaine sq. 2 passes of spinal needle patient starts crying saying to stop she wants to be put to sleep. Pt converted to general anesthetic. Glidescope intubation showed edematous, friable airway. Glottis seen initially but difficulty passing ETT. Attempt x2 airway is now bloody and view is more difficult. She is easily maskable with an oral airway. Would you A) keep trying to intubate, B) wake patient up and tell her she's getting a spinal. C) wake patient up for an awake fiberoptic D) wake patient up and schedule for a different day when you are on vacation. E) place an LMA and proceed. F) Other
 

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30 y/o 200lb Mallanpati #3 patient with high anxiety, fibromyalgia with multiple psych issues who has had a localized allergic reaction to lidocaine (says she had a raised red rash on arm from iv start with lidocaine). wants a general anesthetic for repeat c-section. (1st c-section was under general due to failed epidural- no anesthetic record available). Pt convinced to have spinal. No immediate reaction to lidocaine sq. 2 passes of spinal needle patient starts crying saying to stop she wants to be put to sleep. Pt converted to general anesthetic. Glidescope intubation showed edematous, friable airway. Glottis seen initially but difficulty passing ETT. Attempt x2 airway is now bloody and view is more difficult. She is easily maskable with an oral airway. Would you A) keep trying to intubate, B) wake patient up and tell her she's getting a spinal. C) wake patient up for an awake fiberoptic D) wake patient up and schedule for a different day when you are on vacation. E) place an LMA and proceed. F) Other
Answers A and D are ******ed. B is an option but not a very good one. C is what I would do. E is a good choice if the baby is in jeopardy. F - trach.
 

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From a distance (obviously I wasn't there) it appears to me that the error was in giving up on the spinal so easily.

I wouldn't wake her up and go for an AFOI in this crazy flakes anxious patient who now has a bloody edematous airway. That will not work.

You've kind of backed yourself into a corner here. I might try an asleep FOI now and if it wasn't a chip shot, wake her up, eat some humble pie, and send her home. If I wake her up, we're done with this elective case for the day. She can come back later and get a spinal.

Don't wake her up and try another spinal. If it fails or she gets crazy mid case, or needs GA for another reason, you're in a bad spot.
 

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I am assuming, of course, that the spinal and airway were genuinely difficult and the failures at both were not at the hands of an August CA1.
 

sigrhoillusion

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This patient probably should have gone with Plan B. Granted it's probably 9 months too late for that...

But seriously, this patient needs a stern lecture on what is best for her baby. That being said, not sure why the spinal was so difficult. And again you backed yourself into the corner by succumbing to her whining and putting her to sleep and now facing a "difficult" bloody airway. At this point, with an easy ventilated patient, I would probably attempt an asleep FOI before the sux wore off (please pray God tell me you didn't use Roc...) If I couldn't get the asleep FOI I would probably wake the patient up and tell her I was going to to attempt the spinal one mroe time if she was willing. If she wasn't willing I'd postpone her for another day for her airway to heal and dry out. Cause once I wake her, there's no way I'm putting her back to sleep with a bloody airway after 3 intubation attempts. Sure she might be easy to ventilate now, but who knows what it will be in 10 minutes with the bleeding and edema. It's just not worth the risk in an elective case going forward with an unsecured airway that's been manipulated that much in my opinion.

And like someone else said, I doubt this drama queen is sitting for an awake FOI next time. So if she didn't agree to a spinal. I'd plan to have all my difficult equipment for sleepy time. Assuming she's easy to ventilate the second time, I'd go straight to FOI after a touch of glyco to dry her out.

Also, as a side note, any reason why this is a section and this woman can't do the real hard work and push the baby out naturally? Probably be the best for her, the baby and the delivery team...
 

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I would wake her up and do a spinal. If she refuses, come back another day.

Since there is a high rate of anxious behavior, crying, and screaming( very rare), with patients ("adults") that are rather close to decompensation over in OB.

What tips or strategies do you use to get through a C-section ,etc? Every now and then, I'll have a pt during a c-section start to "lose it" when there's a bit tugging or externalization of uterus,etc. Sometimes, I've thought that if we'd been on the OR bed for ten or fifteen more minutes, the patient would have come close to being emotionally upset. I'm talking about crying, emotional outbursts, complaining,etc. The above is with a good/decent spinal. I try to allay their anxiety with talking,etc, then move to drugs... Any tips on smoothing things out? It's frustrating having to deal with some of these people, especially at 0200!
 

sigrhoillusion

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I would wake her up and do a spinal. If she refuses, come back another day.

Since there is a high rate of anxious behavior, crying, and screaming( very rare), with patients ("adults") that are rather close to decompensation over in OB.

What tips or strategies do you use to get through a C-section ,etc? Every now and then, I'll have a pt during a c-section start to "lose it" when there's a bit tugging or externalization of uterus,etc. Sometimes, I've thought that if we'd been on the OR bed for ten or fifteen more minutes, the patient would have come close to being emotionally upset. I'm talking about crying, emotional outbursts, complaining,etc. The above is with a good/decent spinal. I try to allay their anxiety with talking,etc, then move to drugs... Any tips on smoothing things out? It's frustrating having to deal with some of these people, especially at 0200!
Special K my friend...
 

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First, always add some fentanyl and morphine to the spinal. Opiate helps immensely with the visceral pain and will help. The fentanyl is needed to cover the gap before the morphine kicks in.

If they freak out anyway, the answer is handholding and talking, and judiciously titrated midazolam and/or ketamine. And sometimes, getting rid of dad helps, because not infrequently the antics are a performance for his benefit.
 
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Wake the patient up and re-attempt CSE or AFOI in a day or two after some decadron is the oral boards answer 100 times out of 100. In real life, assuming mask ventilation was still easy, I'd consider making sure she was still paralyzed/deep and drop in a proseal, evacuate stomach contents through OG port, load a 7.0 on the scope and take a look at the glottis. If I couldn't see cords or scope doesn't pass like butter, she gets woken up.

I would wake her up and do a spinal. If she refuses, come back another day.

Since there is a high rate of anxious behavior, crying, and screaming( very rare), with patients ("adults") that are rather close to decompensation over in OB.

What tips or strategies do you use to get through a C-section ,etc? Every now and then, I'll have a pt during a c-section start to "lose it" when there's a bit tugging or externalization of uterus,etc. Sometimes, I've thought that if we'd been on the OR bed for ten or fifteen more minutes, the patient would have come close to being emotionally upset. I'm talking about crying, emotional outbursts, complaining,etc. The above is with a good/decent spinal. I try to allay their anxiety with talking,etc, then move to drugs... Any tips on smoothing things out? It's frustrating having to deal with some of these people, especially at 0200!
Don't even need narcotics for this situation. Benadryl 25-50mg IV plus phenergan 12.5-25mg IV titrated to effect- they're out cold, not nauseated, and ventilating perfectly.
 
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sigrhoillusion

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Wake the patient up and re-attempt CSE or AFOI in a day or two after some decadron is the oral boards answer 100 times out of 100. In real life, assuming mask ventilation was still easy, I'd consider making sure she was still paralyzed/deep and drop in a proseal, evacuate stomach contents through OG port, load a 7.0 on the scope and take a look at the glottis. If I couldn't see cords or scope doesn't pass like butter, she gets woken up.



Don't even need narcotics for this situation. Benadryl 25-50mg IV plus phenergan 12.5-25mg IV titrated to effect- they're out cold, not nauseated, and ventilating perfectly.
"I'd consider making sure she was still paralyzed/deep and drop in a proseal, evacuate stomach contents through OG port, load a 7.0 on the scope and take a look at the glottis. If I couldn't see cords or scope doesn't pass like butter, she gets woken up."

Pretty much what my plan would be. Again, this is assuming you were smart and went with sux. If you went with roc you might as well bite the bullet and do the section while "securing" her airway as best as you can, cause you just bought yourself 30-45 minutes regardless of paralysis if you burnt your bridge with roc. But I'm really hoping it was sux. As vector and I mentioned, asleep FOI +/- LMA while very deep and still paralyzed. If that fails, then PULL OUT like the father of the baby should have done and GET OUT OF DODGE!!!
 

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The mistake was giving up on the spinal so easily and allowing the patient to run the show. You need to be in control of the situation. The customer is not always right. The patient has had an epidural before so obviously a spinal/epidural is possible. 2 passes of a spinal needle is nothing. Talk to the patient, give her some fentanyl if needed, etc. This is a completely non-urgent situation. If you aren't successful, call a colleague.
 

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30 y/o 200lb Mallanpati #3 patient with high anxiety, fibromyalgia with multiple psych issues who has had a localized allergic reaction to lidocaine (says she had a raised red rash on arm from iv start with lidocaine). wants a general anesthetic for repeat c-section. (1st c-section was under general due to failed epidural- no anesthetic record available). Pt convinced to have spinal. No immediate reaction to lidocaine sq. 2 passes of spinal needle patient starts crying saying to stop she wants to be put to sleep. Pt converted to general anesthetic. Glidescope intubation showed edematous, friable airway. Glottis seen initially but difficulty passing ETT. Attempt x2 airway is now bloody and view is more difficult. She is easily maskable with an oral airway. Would you A) keep trying to intubate, B) wake patient up and tell her she's getting a spinal. C) wake patient up for an awake fiberoptic D) wake patient up and schedule for a different day when you are on vacation. E) place an LMA and proceed. F) Other
Place an LMA and move on with your life!
You already induced GA and you already did everything you can to make her vomit and she did not! What are you afraid of?
 
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I would hope people aren't routinely using rocuronium for c-sections, but every hospital ought to have sugammadex available now. There's no excuse not to.
 
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Place an LMA and move on with your life!
You already induced GA and you already did everything you can to make her vomit and she did not! What are you afraid of?
The risk that error #1 will be followed by error #2, with #3 hiding in the wings somewhere. :)
 
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KungPOWChicken

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The mistake was giving up on the spinal so easily and allowing the patient to run the show. You need to be in control of the situation. The customer is not always right. The patient has had an epidural before so obviously a spinal/epidural is possible. 2 passes of a spinal needle is nothing. Talk to the patient, give her some fentanyl if needed, etc. This is a completely non-urgent situation. If you aren't successful, call a colleague.
Honestly the only time I'm in absolute control is when the patient is under general anesthesia. Her previous epidural failed so she was induced. She refused a spinal initially. Now she's crying for me stop. I was done hand holding and convincing at that point.
 

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The risk that error #1 will be followed by error #2, with #3 hiding in the wings somewhere. :)
The patient is already under GA, which means the most likely time for her to vomit and aspirate (induction and airway manipulation) is well behind you!
You already exposed the fetus to GA and all you need to do now is complete your anesthetic and get the case done.
Or, you can continue your masturbatory approach: wake her up ( emergence is still going to be a good time for her to vomit), or do a semi asleep crappy fiberoptic intubation which has the potential of turning into a disaster in the wrong hands, or do another spinal anesthetic attempt after you wake her up and she is really pissed at you!
Sometimes what's needed is just some common sense!
 
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Honestly the only time I'm in absolute control is when the patient is under general anesthesia. Her previous epidural failed so she was induced. She refused a spinal initially. Now she's crying for me stop. I was done hand holding and convincing at that point.
This sentence doesn't make sense to me. If you don't feel in control of a technique or situation then you shouldn't be doing it. You should feel like you are always in control...even when doing neuraxial, regional, or sedation.
 
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Wake the patient up and re-attempt CSE or AFOI in a day or two after some decadron is the oral boards answer 100 times out of 100.
I'm fairly certain the oral board answer would be to wake patient up and rediscuss her acting like an adult and getting a spinal. 2 needle passes before her meltdown is nothing. For someone with a known difficult airway, I'd give it a serious attempt at multiple levels before abandoning ship.

I'd probably wake her up and have her put on schedule for tomorrow and we start over acting rationally and she gets a spinal. The odds of her being a truly difficult/impossible spinal at her size are well under 1%.
 
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This sentence doesn't make sense to me. If you don't feel in control of a technique or situation then you shouldn't be doing it. You should feel like you are always in control...even when doing neuraxial, regional, or sedation.
Have you ever had a spinal or epidural that appears to work great. Only to have the patient jump off the bed? Have you ever had a patient start screaming in pain or freaking out mid way through a c-section. This doesn't happen under general anesthesia.
 

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Oral boards already failed when you gave up on the spinal after just 2 attempts. I never even discuss GA with my section patients routinely, only if it looks like I'm gonna need to induce. Agree with LMA in this scenario just tell the surgeon to move fast
 

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The patient is already under GA [...]
Hey, I don't entirely disagree with you, I'm just saying, "we" are in this spot because an error was made going to GA in the first place. What I would do in the real world is just handwaving SDN-speak because I wouldn't be down this path in the first place. :)

Yes, an LMA is a totally reasonable option in the asleep urgent/emergent c-section with a difficult airway. No controversy there.

For this specific elective c-section, while I agree that her risk of aspiration is very low, it's not zero, and it'd be hard to defend this specific series of decisions if there was an injury. I have seen an NPO OB patient aspirate and I am risk averse in elective cases. I've got better things to do with my time and money than spend either with lawyers.
 
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Oral boards already failed when you gave up on the spinal after just 2 attempts. I never even discuss GA with my section patients routinely, only if it looks like I'm gonna need to induce. Agree with LMA in this scenario just tell the surgeon to move fast
Don't care too much about oral boards anymore. So if a patient tells you to stop do you say sorry but this is what you're getting. She's had a general anesthetic for her last c- section. And she was initially demanding a general anesthetic. Do you think you can convince her to continue on? Let me just say that by the time you convince her I'd have her in the recovery room and would have started my next case.
 

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Don't care too much about oral boards anymore. So if a patient tells you to stop do you say sorry but this is what you're getting. She's had a general anesthetic for her last c- section. And she was initially demanding a general anesthetic. Do you think you can convince her to continue on? Let me just say that by the time you convince her I'd have her in the recovery room and would have started my next case.
If ever asked about GA my reply is spinal is safest for you and the baby. General anesthesia carries a higher risk of DEATH. As to when to stop if she turns around and says "doc, I am excercising my right as a patient to refuse a procedure and demand that you stop",then I stop. If it is the usual whining then me and the nurses just talk her through it. These OB patients need a firm hand.
 

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Doing elective c-sections under general anesthesia is not uncommon in other parts of the world, but I'm in the USA and I assume you are too.

Patient refusal is an absolute contraindication to regional. She gives you a hard no, of course you stop. If it's typical garden variety OB angst, you talk her through it because it's the right thing to do.

Say what you will about GA being A-OK in parturients, I'll agree with 98% of it. I think most of us here would agree that the historic aversion to GA in pregnant women is mostly dogma, and that a good anesthesiologist shouldn't have any anxiety or fear of GA, when indicated.

It's maybe too easy to 2nd guess and MMQB how you got to this point :) ... but dogma aside, in this actual real patient, eagerness to just GETA-it-and-be-done-with-it got you halfway to disaster.


So, what actually happened next?
 

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Don't care too much about oral boards anymore. So if a patient tells you to stop do you say sorry but this is what you're getting. She's had a general anesthetic for her last c- section. And she was initially demanding a general anesthetic. Do you think you can convince her to continue on? Let me just say that by the time you convince her I'd have her in the recovery room and would have started my next case.
If I were you I would have explained both anesthetic techniques to her in a simple and NEUTRAL way, without much drama or attempting to scare her of GA. After that little talk if she still wanted GA I would be glad to do what she wanted under controlled and relaxed conditions.
General anesthesia for an elective C section is not the devil and it can be done very safely.
 

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If ever asked about GA my reply is spinal is safest for you and the baby. General anesthesia carries a higher risk of DEATH. As to when to stop if she turns around and says "doc, I am excercising my right as a patient to refuse a procedure and demand that you stop",then I stop. If it is the usual whining then me and the nurses just talk her through it. These OB patients need a firm hand.
:whistle:
 

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If I were you I would have explained both anesthetic techniques to her in a simple and NEUTRAL way, without much drama or attempting to scare her of GA. After that little talk if she still wanted GA I would be glad to do what she wanted under controlled and relaxed conditions.
General anesthesia for an elective C section is not the devil and it can be done very safely.
? Neuraxial is the standard of care for c sections so as the anesthesiologist (physician) you don't make a neutral reccomendation, you make a strong one. If she still refuses neuraxial you need to explain all the risks of GA (last I checked this is called informed consent) and preferably have a witness for the patients refusal. While I agree that GA can be safely done in pregnant patients, so long as neuraxial remains standard of care I will continue to use this approach. Any complications of GA in a section when general could have been avoided and you are screwed.
 
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Doing elective c-sections under general anesthesia is not uncommon in other parts of the world, but I'm in the USA and I assume you are too.

Patient refusal is an absolute contraindication to regional. She gives you a hard no, of course you stop. If it's typical garden variety OB angst, you talk her through it because it's the right thing to do.

Say what you will about GA being A-OK in parturients, I'll agree with 98% of it. I think most of us here would agree that the historic aversion to GA in pregnant women is mostly dogma, and that a good anesthesiologist shouldn't have any anxiety or fear of GA, when indicated.

It's maybe too easy to 2nd guess and MMQB how you got to this point :) ... but dogma aside, in this actual real patient, eagerness to just GETA-it-and-be-done-with-it got you halfway to disaster.


So, what actually happened next?
I wasn't about to wake her up(oral board answer). Awake fiber optic was out of the question due to her inability to cooperate and inability to topicalize (lidocaine allergy). Any spinal placement would likely fail miserably like her epidural. Mainly related to psych issues.

She was intubatable as I had views of her glottis but her oxygen reserve was terrible and she desaturated quickly. Ultimately, I placed an LMA gave rocuronium ( we have sugammadex which I use for reversal 95% of the time), and I used the aintree intubation catheter over a fiberoptic allowing me to ventilate her through the LMA. They have a specific adapter for this. Airway secured out of the room within an hour. Otherwise, LMA only.

Aspiration risk is extremely low. My guess is that people get so focused on intubating patients get light, relaxant wears off and they either laryngospasm or cough/vomit. I've never noticeably had a patient vomit/regurg ett or LMA mid case. The one LMA case where I had a patient vomit. It was immediately after induction when she was light. No complications were noted.
 
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? Neuraxial is the standard of care for c sections so as the anesthesiologist (physician) you don't make a neutral reccomendation, you make a strong one. If she still refuses neuraxial you need to explain all the risks of GA (last I checked this is called informed consent) and preferably have a witness for the patients refusal. While I agree that GA can be safely done in pregnant patients, so long as neuraxial remains standard of care I will continue to use this approach. Any complications of GA in a section when general could have been avoided and you are screwed.
A standard of care as long as the patient agrees to it!
If the patient is telling you that she does not want a spinal but you insist on it and use drama and scare tactics to enforce your dogmatic opinion, you need to pray that the spinal is going to be perfect because if anything goes wrong she is coming after you!
And your standard of care is not going to help you!
 

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I wasn't about to wake her up(oral board answer). Awake fiber optic was out of the question due to her inability to cooperate and inability to topicalize (lidocaine allergy). Any spinal placement would likely fail miserably like her epidural. Mainly related to psych issues.

She was intubatable as I had views of her glottis but her oxygen reserve was terrible and she desaturated quickly. Ultimately, I placed an LMA gave rocuronium ( we have sugammadex which I use for reversal 95% of the time), and I used the aintree intubation catheter over a fiberoptic allowing me to ventilate her through the LMA. They have a specific adapter for this. Airway secured out of the room within an hour. Otherwise, LMA only.

Aspiration risk is extremely low. My guess is that people get so focused on intubating patients get light, relaxant wears off and they either laryngospasm or cough/vomit. I've never noticeably had a patient vomit/regurg ett or LMA mid case. The one LMA case where I had a patient vomit. It was immediately after induction when she was light. No complications were noted.
Excellent management!
 

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Nice job

I agree, most aspiration is probably related to airway instrumentation with light anesthesia. I think that's why the ER gets away with "sedating" full stomach patients with 20 of etomidate for reductions. They don't touch the airway.
 
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Thanks. The main point I wanted to bring up is I think the aintree is great method to fiberoptically intubate. It easily passes through an I gel or air q which I typically use and most importantly allows for ventilation during placement.
 

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She was intubatable as I had views of her glottis but her oxygen reserve was terrible and she desaturated quickly. Ultimately, I placed an LMA gave rocuronium ( we have sugammadex which I use for reversal 95% of the time), and I used the aintree intubation catheter over a fiberoptic allowing me to ventilate her through the LMA. They have a specific adapter for this. Airway secured out of the room within an hour. Otherwise, LMA only.

.
Does that mean you did not give rocuronium for the original laryngoscopy? Why?
 
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Does that mean you did not give rocuronium for the original laryngoscopy? Why?
I induced with propofol and sux. after masking her easily I felt comfortable giving more propofol 100mg and 30mg of Roc which should be easily reversed with one vial of sugammadex. I still use sux in potential difficult airways (morbidly obese men) or with RSI. That may change the more I use sugammadex though.
 

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Don't care too much about oral boards anymore. So if a patient tells you to stop do you say sorry but this is what you're getting. She's had a general anesthetic for her last c- section. And she was initially demanding a general anesthetic. Do you think you can convince her to continue on? Let me just say that by the time you convince her I'd have her in the recovery room and would have started my next case.
No, you don't. The #1 reason for not doing a regional anesthetic is patient refusal.
 

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A standard of care as long as the patient agrees to it!
If the patient is telling you that she does not want a spinal but you insist on it and use drama and scare tactics to enforce your dogmatic opinion, you need to pray that the spinal is going to be perfect because if anything goes wrong she is coming after you!
And your standard of care is not going to help you!
In this scenario, the patient was already agreeable to the spinal. But most likely the patient was not happy with something after being poked in the back so began panicking as these types of patients tend to do. This is the point where you don't just give up and convert to general just because it's most convenient for you and her. We all know that these patients need a little extra tlc and require more attention to detail and skill from the anesthesiologist. I have dealt with many crazy and demanding patients in OB and have never once gone GA unless it was emergent.
 
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Gaseous Clay

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Thank you for posting the case. It brings to light how we often say, "for oral boards, I would do this, but in reality, I would do that instead."

I feel KungPOW handled the situation very well. If you do enough OB, you get that one patient every year or two who is absolutely crazy and unreasonable. There is nothing you can do. Talking them into at least trying a spinal is a feat in itself. But once the patient starts flipping out it's game over and GETA it is. It is like trying to reason with a 4 year old. Yes my argument about safer for you and baby makes sense, but when the patient doesn't understand that, you won't win in the end. People also bring up lawsuits and aspiration. The patient can sue you for pain, suffering, emotional, and traumatic stress from the spinal attempts. She can claim that during the surgery she felt pain and that you did nothing for her. At the end of the day, this patient puts you in a lose lose situation but it's your job to get her through the surgery safely.

What I would've done depends on the surgeon and how much help I have. Fast surgeon in the middle of the night means keep masking/LMA placement and make him/her do this in 15 minutes. Slow surgeon with no help available means I tell OR nurse to call in my anesthetist and possibly anesthesia tech. Place LMA and have help bring fiberoptic up. From there basically same route as KungPOW.

If it's in the middle of the day with lots of help, then I may have ONE colleague who I feel is very good take a look. If that doesn't work I would've tried an asleep fiberoptic. If that fails then try same LMA possible aintree technique.

Fortunately an easy mask and stable FHR and patient case. Good thing there wasn't a big drop in heart tones or 1000 ml of thick, hamburger chunks coming out of the patient's pharynx.
 

Gaseous Clay

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In this scenario, the patient was already agreeable to the spinal. But most likely the patient was not happy with something after being poked in the back so began panicking as these types of patients tend to do. This is the point where you don't just give up and convert to general just because it's most convenient for you and her. We all know that these patients need a little extra tlc and require more attention to detail and skill from the anesthesiologist. I have dealt with many crazy and demanding patients in OB and have never once gone GA unless it was emergent.
Fair point. Often stepping back, reassuring, having her take a few deep breaths, maybe a dose of stadol or fentanyl gets you through. But I've also seen a patient go bat **** crazy and trying to reason with her doesn't get you anywhere. Off to sleep she does ...
 
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KungPOWChicken

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I love regional and any chance that I get I will do regional over general, but at the same time I think patient selection is important and it can't be every patient gets regional or else. Within the last year I had a patient who was 20 y/o mentally delayed with a history of combative behavior and outbursts. Scheduled for a primary c-section. No labor for this chick She weighed 350lbs, BMI 60 thick neck, big tongue. Do you think she got a spinal. Absolutely not. She was actually a chip shot glidescope. So someone like this I have a hard time killing myself over. I gave her the options, risks, benefits, etc. She made the choice and can live with those consequences. She seemed pretty happy post op too which means my patient satisfaction score goes up too ;).
 

NightNight

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I love regional and any chance that I get I will do regional over general, but at the same time I think patient selection is important and it can't be every patient gets regional or else. Within the last year I had a patient who was 20 y/o mentally delayed with a history of combative behavior and outbursts. Scheduled for a primary c-section. No labor for this chick She weighed 350lbs, BMI 60 thick neck, big tongue. Do you think she got a spinal. Absolutely not. She was actually a chip shot glidescope. So someone like this I have a hard time killing myself over. I gave her the options, risks, benefits, etc. She made the choice and can live with those consequences. She seemed pretty happy post op too which means my patient satisfaction score goes up too ;).
Lol who went to jail/the nuthouse for getting this chick pregnant?


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Wait, aintree thru an LMA was the "secured airway"? While I agree aspiration risk is low and most likely related to induction and airway manipulation I do think a couple of OBs mashing on the stomach to push the baby out may also push stomach contents the wrong way. So that doesn't make any sense to me if you already knew she was easy to ventilate and had an LMA in place. You may as well just use the LMA in that case as the aintree isn't giving you any aspiration protection and in fact may stimulate her.

If im reading your management incorrectly and you used the aintree for ventilation just to temporize until using it as a tube exchanger then I recant the above.
 
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KungPOWChicken

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Wait, aintree thru an LMA was the "secured airway"? While I agree aspiration risk is low and most likely related to induction and airway manipulation I do think a couple of OBs mashing on the stomach to push the baby out may also push stomach contents the wrong way. So that doesn't make any sense to me if you already knew she was easy to ventilate and had an LMA in place. You may as well just use the LMA in that case as the aintree isn't giving you any aspiration protection and in fact may stimulate her.

If im reading your management incorrectly and you used the aintree for ventilation just to temporize until using it as a tube exchanger then I recant the above.
Place catheter while ventilating LMA. Pull LMA while leaving catheter. Thread 7.0 ett over catheter. Works great! (The catheter fits over the fiberoptic scope)
 

sethco

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I would hope people aren't routinely using rocuronium for c-sections, but every hospital ought to have sugammadex available now. There's no excuse not to.
Apparently, I am still living in the dark ages. I regularly go to 10 hospitals and none of them are stocking it.
 

sethco

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Has anybody ever used the FOB and Glidescope at the same time? Only had to do this once, but worked beautifully when the airway was so edematous/anterior that an ETT couldn't be directed towards the cords with the Glidescope by itself
 
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KungPOWChicken

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Has anybody ever used the FOB and Glidescope at the same time? Only had to do this once, but worked beautifully when the airway was so edematous/anterior that an ETT couldn't be directed towards the cords with the Glidescope by itself
Love it! I don't even really look through the fiberoptic as much as using it as a stylet I can guide easily through the cords
 

polar403

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Has anybody ever used the FOB and Glidescope at the same time? Only had to do this once, but worked beautifully when the airway was so edematous/anterior that an ETT couldn't be directed towards the cords with the Glidescope by itself
Yes, works great for an anterior airway.

Also have done an ETT over a fiberoptic scope through an LMA. Slide the ETT over the scope through the LMA and leave the LMA and ETT in place until the end of the case.
 

SaltyDog

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Yes, works great for an anterior airway.

Also have done an ETT over a fiberoptic scope through an LMA. Slide the ETT over the scope through the LMA and leave the LMA and ETT in place until the end of the case.
This is the way to do it. And if you wanna be even slicker you can put a bronch elbow on the ETT and ventilate continuously while you drive the tube through the LMA. Then, if you're inclined to remove the LMA (i.e. Pt is ICU bound) either use one of those purpose built tube pushers or just 1 size smaller ETT to push/hold the tube in place while you slide out the LMA.
 
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