C-section nightmares

[Dinkyconductor]

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Sorry if this has been brought up before, but I wanted to get opinions...

You're brought back for a stat c-section for fetal bradycardia, no time for spinal, airway looks so-so, you give pentothal/sux...try to intubate, but no luck. You're able to mask ventilate with cricoid, you also could place an lma and ventilate with cricoid.

Do you let them cut without a secured airway, running a high risk of aspiration as they work in the abdomen, or do you tell them not to cut, let mom wake up again and attempt an awake fiberoptic, almost certainly meaning disaster for the baby?

Hasn't happened to me yet, but I want to have a plan in mind when/if it ever happens.

 

[urge]

Let them cut. You run the risk of aspiration. Morbidity/mortality from that is not that high anymore. It's better yet if you have a proseal lma in the ob suite, so you can throw a gastric tube in.

 

[DREZ Leptin]

Let them cut. This has happened to me. Remember, you've already given the pen and sux. They can get the baby out and the cord clamped in minutes. After that you have many more options. You can always bolus high dose narcotic and amnestic to keep a patient with an open abdomen comfortable while you explore your airway options.

Gosh, I don't miss OB!

 

[deleted126335]

.

 

[UTSouthwestern]

HELL NO. You said the airway looked "so-so". You don't induce GA if you doubt the airway. Our primary duty is to the mother. You can't risk a healthy mom for a baby that may no longer be viable. If you doubt the airway stand your ground and take the time for a spinal.

According to the original poster, induction has already occurred. You are already at that higher level of M&M from aspiration by having already induced. Place the proseal or throw down the combitube and get moving.

The combitube from the get go might be a wiser choice in any obstetric patient with a questionable airway.

Alternatively, strap the patient down, titrate in some ketamine and let them spontaneously breath and keep their airway reflexes intact, always mindful to have the suction ready to go if the patient hurls.

 

[swpm]

You're brought back for a stat c-section for fetal bradycardia, no time for spinal, airway looks so-so, you give pentothal/sux...

Not what I would do.

If the OBs are hysterically screeching that the BAAAaaabbbeeee's gonna DIIIIIiiiieeee and it's gonna be MY fault if I don't push the drugs RIGHT NOW, then I'd tell them to start under local, and I'd tell mom that things may suck for a few minutes, but it's what's best for her and the baby. I'm not going to risk mom's life because the baby (who's not my patient) might be at risk. It's just a baby, and she can have another one. She can't grow new neurons to replace the ones lost to the anoxic brain injury I inflicted by recklessly inducing her.

If someone else has already induced the patient, and I couldn't intubate her, a combitube might be the best way to start ventilating her while offering some protection vs aspiration. Maybe some trendelenburg too, so if she does regurgitate, it's maybe less likely to dribble down into her lungs.

 

[jwk]

If the OBs are hysterically screeching that the BAAAaaabbbeeee's gonna DIIIIIiiiieeee and it's gonna be MY fault if I don't push the drugs RIGHT NOW, then I'd tell them to start under local, and I'd tell mom that things may suck for a few minutes, but it's what's best for her and the baby.

AH - the local C-Section - about time someone brought that up. It ain't fun, it ain't pretty, but it's definitely do-able, especially with a ketamine chaser.

It's just a baby, and she can have another one.

Ouch - don't say that at the deposition.

If someone else has already induced the patient, and I couldn't intubate her, a combitube might be the best way to start ventilating her while offering some protection vs aspiration. Maybe some trendelenburg too, so if she does regurgitate, it's maybe less likely to dribble down into her lungs.

And although far from ideal, a mask a/w IS an airway. You're not all the way up **** creek yet.

 

[VentdependenT]

Cut buddy cut. You can cut before any airway device is placed as long as induction has already taken place.


LMA, ventilate. Put in a Proseal or FiberOptic 6.0 ETT through the LMA. Or attatch one of those Arndt blocker stylettes to the FO scope and and leave it in the trachea. Slide your tube over that.

Lesson learned. Always have an LMA and a Proseal on standby and ready to roll in your ob room. No time to be fumbling with the packaging, finding lube, finding a 20cc syringe, all while some non-anesthesiologist is letting go of cricoid because the patient is "asleep."

 

[Noyac]

Not what I would do.

If the OBs are hysterically screeching that the BAAAaaabbbeeee's gonna DIIIIIiiiieeee and it's gonna be MY fault if I don't push the drugs RIGHT NOW, then I'd tell them to start under local, and I'd tell mom that things may suck for a few minutes, but it's what's best for her and the baby. I'm not going to risk mom's life because the baby (who's not my patient) might be at risk. It's just a baby, and she can have another one. She can't grow new neurons to replace the ones lost to the anoxic brain injury I inflicted by recklessly inducing her.

This is the worst attitude and response I have seen in a long time. How many of you have seen a c/s done under local? I haven't and I've seen more than my share of crash c/s's with bad airways. I have even masked a pt throughtout the whole c/s. That baby is as much your respnsibilty as the mother is as long as it is in the uterus. Once it is out there are people to resusitate it. IMHO you are risking a life no matter what. Now how many moms have you seen die on the OR table from airway issues. Sure they happen but I've never seen one. Its your job to help get that baby out as fast as possible. If you can't intubate or ventilate you have options. Aspiration is now far back in my mind. She can survive aspiration and suction is your friend. Worst case scenario, cric her.

I don't understand how anesthesiologists can claim that the baby is not our responsibility. It may not be our primary responsibilty but it is still our responsibility to some degree.

Don't be an obstructionist. This is my opinion and many of you may disagree. Fine.

Now I will go back to the sidelines were I have been directed by the authorities.

 

[Noyac]

Sorry if I appeared to be attacking you, swpm. I was not. I have heard this very same attitude by many and that is the direction my response was aimed.

 

[Pilot Doc]

It's just a baby, and she can have another one.

You clearly don't have kids.

But moving on, I wonder if anyone has asked patients about this. Moms who get pregnant on purpose have set themselves up for a dangerous, difficult task. I don't think many of them would support a value system that assigns no more importantace to a fetus than a gall bladder.

 

[brmc]

I gotta agree, I do not think I could face myself if I did not make every effort to save both mother and baby. Possible mortality if it goes wrong versus certain mortality if you do nothing. Me, I gotta try. Hope it never happens.

 

[Gasworks]

Besides comfort issues what is the risk of dropping an NG into the patient and sucking out their stomach pre-induction. May not get every last ml of gastric juice but would probably help when the patient had a happy meal a few hours ago. Last I checked the recommendation for bowel obstructions is to suck out the belly, pull the NG and do rapid sequence so the same logic should apply to any full stomach correct?

 

[johankriek]

This is the worst attitude and response I have seen in a long time. How many of you have seen a c/s done under local? I haven't and I've seen more than my share of crash c/s's with bad airways. I have even masked a pt throughtout the whole c/s. That baby is as much your respnsibilty as the mother is as long as it is in the uterus. Once it is out there are people to resusitate it. IMHO you are risking a life no matter what. Now how many moms have you seen die on the OR table from airway issues. Sure they happen but I've never seen one. Its your job to help get that baby out as fast as possible. If you can't intubate or ventilate you have options. Aspiration is now far back in my mind. She can survive aspiration and suction is your friend. Worst case scenario, cric her.

I don't understand how anesthesiologists can claim that the baby is not our responsibility. It may not be our primary responsibilty but it is still our responsibility to some degree.

Don't be an obstructionist. This is my opinion and many of you may disagree. Fine.

Now I will go back to the sidelines were I have been directed by the authorities.

I am not gonna put an obese parturient with a bad airway and full stomach to sleep just because the baby is gonna die. there is plenty of maternal morbidity and mortality out there. Thats why we do regional as standard of care because the maternal morbidity and mortality was up there. So I dont think he has a bad attitude. He has a realistic attitude. If the patient has a bad airway. DOnt put the patient to sleep. simple as that. do a fiberoptic, take a look awake. Last thing you wanna be doing is masking a patient during a hemmorhaging c section late at night.. I mean you are screwed either way. I dont wanna see either die baby or mom. But i can tell you if the mom dies your ass will be toast.. If the baby dies they can try to blame it on you.. but you can splain away. You have standards.. The mother is your first priority. Do a fiberoptic.

 

[Noyac]

I am not gonna put an obese parturient with a bad airway and full stomach to sleep just because the baby is gonna die. there is plenty of maternal morbidity and mortality out there. Thats why we do regional as standard of care because the maternal morbidity and mortality was up there. So I dont think he has a bad attitude. He has a realistic attitude. If the patient has a bad airway. DOnt put the patient to sleep. simple as that. do a fiberoptic, take a look awake. Last thing you wanna be doing is masking a patient during a hemmorhaging c section late at night.. I mean you are screwed either way. I dont wanna see either die baby or mom. But i can tell you if the mom dies your ass will be toast.. If the baby dies they can try to blame it on you.. but you can splain away. You have standards.. The mother is your first priority. Do a fiberoptic.

Well thats why I said "many may disagree" as you do. Sure I'd probably pop a spinal in b/4 going down the difficult airway algorythm. But he said a so so airway and to be honest that doesn't scare me at this stage in my career. If you don't feel comfortable putting her to sleep then don't. I was mostly talking about the attitude that the baby is not our responsibility and that she can just have another one. That attitude.

Now to address the original question. The pt is asleep and you are masking, do you let them cut or do you wake her up. I say tell them to cut. You can mask her so you have some time to get a definitive airway.

The Oral Board answer would be not to put her to sleep or do a fiberoptic intubation but how many of you actually do exactly as you would answer the orals? And if you do a spinal on the boards it will surely be a high spinal which I have never seen. At least not high enough to intubate.

This case can be damned if you do and damned if you don't. I had a similiar case 2 weeks ago witht he babies HR in the 50's for over 5 minutes. THe mom was a large woman with a so so airway. I tubed her. Maybe I got lucky and then again maybe I didn't. Both the mom and baby did just fine.

 

[Arch Guillotti]

I believe there are case reports of safely masking patients with difficult airways through c-sections so long as cricoid pressure is maintained. I have voiced this opinion in a mock orals scenario and it seemed to go over OK.

I have been involved in a few c-sections requiring general anesthesia thus far in residency. One involved a woman coming back for severe fetal distress, she was the normal OB large size with a so-so airway. THE OB's were chomping at the bit. They brought her in the room LIKE GANGBUSTERS. She was moved over and they were starting to prep before we could hardly get a pulse ox on. It kind of backs us up in a corner, but what are you gonna do? Take a time out and sit her up to do a spinal while the baby dies? No way, it was RSI general ALL THE WAY. Fortunately for me, the DL was a slam dunk although her entire oropharnyx was extremely edematous. It really was a rush to slap that ET tube in.

The other case similarly came back LIKE GANGBUSTERS. It was a hispanic lady (didn't speak a lick of English) with a prolapsed cord and severe fetal distress. There was no way to sit for a spinal nor would a lateral spinal have been in the cards. Fortunately she was a thin little thing and her airway is a slam dunk.

Though we all know about the difficulties that you may have in these airways I think that a Mac 4 with fiberoptic light source, a bougie and some arm strength will get you through almost any airway.

Now if either of these patients had been morbidley obese with TERRIBLE airways maybe things mighyt be a little different.

 

[jetproppilot]

I am not gonna put an obese parturient with a bad airway and full stomach to sleep just because the baby is gonna die.

I am.

And have.

 

[powermd]

I believe there are case reports of safely masking patients with difficult airways through c-sections so long as cricoid pressure is maintained. I have voiced this opinion in a mock orals scenario and it seemed to go over OK.

We have an attending who trained in South Africa that used to mask gigantic African patients through c-sections ALL THE TIME. Aspiration risk doesn't seem to be as high as we're led to believe.

 

[jetproppilot]

Aspiration risk doesn't seem to be as high as we're led to believe.

I've said that in many, many posts.

 

[fval28]

Well thats why I said "many may disagree" as you do. Sure I'd probably pop a spinal in b/4 going down the difficult airway algorythm. But he said a so so airway and to be honest that doesn't scare me at this stage in my career. If you don't feel comfortable putting her to sleep then don't. I was mostly talking about the attitude that the baby is not our responsibility and that she can just have another one. That attitude.

Now to address the original question. The pt is asleep and you are masking, do you let them cut or do you wake her up. I say tell them to cut. You can mask her so you have some time to get a definitive airway.

The Oral Board answer would be not to put her to sleep or do a fiberoptic intubation but how many of you actually do exactly as you would answer the orals? And if you do a spinal on the boards it will surely be a high spinal which I have never seen. At least not high enough to intubate.

This case can be damned if you do and damned if you don't. I had a similiar case 2 weeks ago witht he babies HR in the 50's for over 5 minutes. THe mom was a large woman with a so so airway. I tubed her. Maybe I got lucky and then again maybe I didn't. Both the mom and baby did just fine.

I agree with you 100% Noy.

The baby IS our responsibility as well as mom- and there are a bunch of options besides spinal vs ETT.

I would have no qualms about masking or LMA'ing a parturient if I had failed at tubing her- As long as I can get oxygen to her and the baby, they have a fighting chance. Aspiration can and does occur (rarely) but the chances of her surviving an aspiration are much higher than her chances of surviving prolonged anoxia.

Sometimes we are handed a big bag of $h_t and just have to do the best we can with it.

If the OB says its an emergency and there's no time for a regional, I am not going to second guess him and put mom, baby and myself at risk.

 

[johankriek]

. Aspiration risk doesn't seem to be as high as we're led to believe.

If i remember correctly it still carries a hefty mortality, not to mention morbidity. all depends on what she aspirated. if a hotdog i can pretty much guarantee a heavy duty inflammatory reaction. at any rate i would not minimize aspiration on the oral boards or anywhere if I were you. This is what you do for a living.

 

[Planktonmd]

Wow,
There is still some life in this forum 🙂

Ok,

Here is the bottom line:
Before induction: you must strongly believe that the airway is IMPOSSIBLE to justify not proceeding with GA when the baby is dying, this type of certainty is very, very, very rare in real life!
After induction: If you can't intubate but you can mask ventilate you are golden, stop messing with the airway and let them start, a mask anesthetic is better than LMA in this case because if she vomits you will see it.
If ventilation is not good enough place LMA, watch her closely and don't allow her to be light because light anesthesia is the main reason why they vomit.
The reason why I did not say combitube is because it is very rough to place and might cause the patient to vomit in the process while an LMA in our hands is usually a smooth process as long as you keep the patient well anesthetized at all times.

 

[brmc]

I tooI could not brea have had acouple of crash sections and they just wheeled patient in and preppied as I places a pulse-ox induced and PTL got a tube in. I agree you can survive aspiration, and mom will appreciate that more then a dead baby.

 

[johankriek]

Wow,
There is still some life in this forum 🙂

Ok,

Here is the bottom line:
Before induction: you must strongly believe that the airway is IMPOSSIBLE to justify not proceeding with GA when the baby is dying, this type of certainty is very, very, very rare in real life!
After induction: If you can't intubate but you can mask ventilate you are golden, stop messing with the airway and let them start, a mask anesthetic is better than LMA in this case because if she vomits you will see it.
If ventilation is not good enough place LMA, watch her closely and don't allow her to be light because light anesthesia is the main reason why they vomit.
The reason why I did not say combitube is because it is very rough to place and might cause the patient to vomit in the process while an LMA in our hands is usually a smooth process as long as you keep the patient well anesthetized at all times.

it just has to be difficult.. i dont know what impossible means. youd ont put an anticipated difficult airway to sleep.. I dont care where you are and who else is dying because you will have 2 dead people instead of one.

 

[Noyac]

it just has to be difficult.. i dont know what impossible means. youd ont put an anticipated difficult airway to sleep.. I dont care where you are and who else is dying because you will have 2 dead people instead of one.

I'm curious, how many difficult airways have died on you? How many people have you had that you couldn't intubate that ended up dying on you? My guess is none. Maybe you have been unfortunate enough to have had one but that is most like it. Bottom line is we don't have these people die on us. We always manage to pull them through. I understand your stance and I can't fault it. but I am not about to take that stance.

But you are making this an anticipated difficult airway when the OP called it so so. These are different to me. I'm putting the so so airway to sleep and she will do fine as will her baby.

 

[Planktonmd]

it just has to be difficult.. i dont know what impossible means. youd ont put an anticipated difficult airway to sleep.. I dont care where you are and who else is dying because you will have 2 dead people instead of one.

An impossible airway is the one you take one look at the patient and you say to yourself: There is no way on earth I could tube this one, I should have called in sick today!

 

[Dinkyconductor]

Yup, I thought this might stir up some pretty strong opinions. Thanks for all the input.

To the guy who suggested placing an NG tube before induction...I don't really think that would be practical in a crash c-section...since the mother is already freaking out, I think shoving a tube down her nose would be pretty much impossible to do quickly enough (the two minutes it would take to do that would seem like an eternity as they're pouring betadine on the abdomen).

My program director from residency told us his all-time worst anesthesia experience was exactly this situation. Impossible airway, severe fetal distress. He opted for a spinal, apparently the OB was screaming "you're killing the baby" the whole time. Spinal went in quickly, but obviously still took longer than crash general would have. The baby did very very badly. Mom was fine. My program director says he's still unsure to this day whether he made the right decision.

 

[swpm]

You clearly don't have kids.

I have three. Cherished snowflakes all. What's more, my wife endured three very difficult and complicated pregnancies to produce them, and there was never, ever any question as to which life came first if a difficult decision ever had to be made. We're both glad she had doctors who shared our priorities, whose judgment wasn't going to be swayed by someone panicking about the BAAAAAAAbbbbbbeeeeee.

Airway mishaps are the #1 cause of anesthesia-related M&M in pregnant women. I wouldn't charge ahead with an induction in a nonpregnant patient with a bad airway, and I'm not going to lower my standard of care just because a patient is pregnant. Especially since there are other ways for the OBs to get the kid out quickly in an awake spontaneously breathing mom-to-be. Perhaps it won't be the comfortable delivery that gets videotaped and shown to the neighbors, but no one ever said childbirth had to be a pleasant experience.

I'll say it again: she can grow another kid, but not another brain. Everyone else in the OR can get hysterical, emotional, illogical, panicky, angry, and reckless just because there's a fetus involved. Not me.

Bottom line is we don't have these people die on us. We always manage to pull them through.

So, if we always manage to pull them through, how do you account for the well-documented increase in maternal airway-related M&M? That 10-fold increase in unexpected difficult airways is real.

But you are making this an anticipated difficult airway when the OP called it so so. These are different to me. I'm putting the so so airway to sleep and she will do fine as will her baby.

Fair enough; "so-so" is a vague term. I can accept that a so-so airway is more intimidating to me as a resident than it probably is to an experienced anesthesiologist, and that someone senior to me might reasonably approach the patient differently.

Despite your disdain for my attitude I'm interested in your opinion and experience. But I want my positions criticized because they're weak or wrong, not because of ... whatever it was that made you go off.

 

[gas87]

great discussion.
so what IS the answer on the boards?

 

[Noyac]

Despite your disdain for my attitude I'm interested in your opinion and experience. But I want my positions criticized because they're weak or wrong, not because of ... whatever it was that made you go off.

If you look at my #10 you will see that I was not attacking you. YOu are welcome to your opinion here as am I.

The attitude that I disagree with is that we are not responsible for the baby.

 

[swpm]

If you look at my #10 you will see that I was not attacking you.

Sorry, I missed that post. 😳

 

[Planktonmd]

great discussion.
so what IS the answer on the boards?

The answer on the boards is awake fiberoptic intubation.

 

[johankriek]

I'm curious, how many difficult airways have died on you? How many people have you had that you couldn't intubate that ended up dying on you? My guess is none. Maybe you have been unfortunate enough to have had one but that is most like it. Bottom line is we don't have these people die on us. We always manage to pull them through. I understand your stance and I can't fault it. but I am not about to take that stance.
.

your guess of none is right? and i wanna keep it that way. and if i go ahead and be cavalier about so-so airways in pregnant women it wont be none for long.. actually she doesnt need to be pregnant. If Im not near 100 percent sure that i can intubate someone after induction and i have good reason to think that awake fiberoptic or awake something is the way to go. what is the downside?

 

[Noyac]

what is the downside?

The baby may die or suffer an irreversible injury like CP. Just as the mother may as well. So I am not telling you to put her to sleep but I am saying that I would put a "so so" airway to sleep.

 

[johankriek]

The baby may die or suffer an irreversible injury like CP. Just as the mother may as well. So I am not telling you to put her to sleep but I am saying that I would put a "so so" airway to sleep.

and im not saying youre wrong at all. that is where judgement comes into play. BUt i will tell you that in court and amongst your peers, in my opinion, you will be faulted far greater and criticized by the experts if you guess wrong with the moms life then you will with the babies life. If the baby dies there are multitude of people to blame, and rightfully.. you arent the only one to take part in the killing,,, but if the mom dies or worse is a vegetable for life... who else can they blame but you.. What are you gonna say? The obstetrician made me do it your honor..

I cant believe many people dont see that scenario playing out in their head everytime they are taking care of obstetrical patients.. because i certainly do every time i am up there.

 

[Noyac]

and im not saying youre wrong at all. that is where judgement comes into play. BUt i will tell you that in court and amongst your peers, in my opinion, you will be faulted far greater and criticized by the experts if you guess wrong with the moms life then you will with the babies life.

You are absolutely right about what will happen in court. Thats the chance you take. My peers on the otherhand are going to be on all sides of the fence. Just look at the opinions here. Unfortunately the prosecuter will only use those that say I was wrong, such is life. Please remember, this was a so so airway. If it was an impossible airway, she gets a spinal or awake FOB.

My board response: awake FOB. I'd preface it with, I see all the the OB pts in labor early when on OB call. If I see a bad airway I tell the OB's to not let the situation get out of hand b/c I will need time to secure her airway. This obviously will not help on the boards but it will get you some points. if the baby is dying they can give local and proceed (on the boards, don't count on this in real life).