clinical case: consultation for elective c-section

[Robert Loblaw]

30 y/o university researcher currently at 26 weeks for consultation for elective c-section. she is g1p1, previous c-section for failure to progress. pmhx notable for glanzmann's thrombasthenia. reports an allergy to succinylcholine, but she is unclear as to the exact nature of the allergy--it was reported to her after her previous c-section. there is no plan for tolac.

what further history is important? what are the management issues/?

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[sevoflurane]

Ummmm.....

Glanzmann's......Nice.

 

[sevoflurane]

Could end up being an expensive c/s.

 

[Noyac]

Get a copy of the last c/s and figure out what the allergy to succ is. If this is an elective C/s then no need for succ. I assume she received plts for the last c/s. Reserve plts for her surgery and have them HLA matched to prevent a reaction. It is possible that this is the real source of her allergic reaction to succ. If you have rFVII at our facility, this can be a useful tool if things go bad.

Btw, shouldn't she be G2P1?

 

[Ignatius J]

30 y/o university researcher currently at 26 weeks for consultation for elective c-section. she is g1p1, previous c-section for failure to progress. pmhx notable for glanzmann's thrombasthenia. reports an allergy to succinylcholine, but she is unclear as to the exact nature of the allergy--it was reported to her after her previous c-section. there is no plan for tolac.

what further history is important? what are the management issues/?

I would like to take a stab at this (no pun intended).

First issue is the Glanzmann's, which I admittedly had to look up. So you expect PT/PTT to be okay, but with a prolonged bleeding time. I would probably transfuse platelets preoperatively as the patient essentially has a functional platelet shortage and try to do my best to normalize bleeding time. I would also consider consulting hematology way before she comes in for her C-section and appreciate their input.

Regardless, I would take the allergy to sux seriously. Always be ready for general (especially in this case since she has an increased risk of bleeding). RSI with rocuronium of course.

Have two good-working IVs readily available. Also would get an arterial line.

Hope for the best.

Whaddaya think?

 

[Noyac]

I would like to take a stab at this (no pun intended).

First issue is the Glanzmann's, which I admittedly had to look up. So you expect PT/PTT to be okay, but with a prolonged bleeding time. I would probably transfuse platelets preoperatively as the patient essentially has a functional platelet shortage and try to do my best to normalize bleeding time. I would also consider consulting hematology way before she comes in for her C-section and appreciate their input.

Regardless, I would take the allergy to sux seriously. Always be ready for general (especially in this case since she has an increased risk of bleeding). RSI with rocuronium of course.

Have two good-working IVs readily available. Also would get an arterial line.

Hope for the best.

Whaddaya think?

Why wouldn't you do a spinal?

What if the allergy to succ is a rash?

 

[BobBarker]

How can you identify the allergy as succ? Could be any of the medications given prior to the succ..

 

[pd4emergence]

Why wouldn't you do a spinal?

What if the allergy to succ is a rash?

I would definitely get some guidance from hematology. This could be a bloody mess and their help would be essential. If this lady's airway is ok, I would not risk a regional. Do we know if she is homozygous or heterozygous? Either way I would be hard pressed to do a neuroaxial anesthetic in this lady. Would you do a spinal on someone who came in and had a big dose of integrelin? That's essentially what this sounds like. The succ "allergy" is concerning, we need more data on that, but regardless, I would sleep her.

 

[BobBarker]

Why are we doing the section at 26 weeks?

 

[Ignatius J]

Why wouldn't you do a spinal?

What if the allergy to succ is a rash?

Absolutely, I would do a spinal, especially since this is an elective case and should be taken back when the patient's coagulopathy is optimized.

For the sux allergy, I could take time to find it or ask more questions. In the event that it's just not able to be determined, I know several studies have shown that there is no significant difference in intubating conditions after .6mg/kg roc versus 1mg/kg of sux. Even though roc may be expected to have a slightly longer onset, the data says that overall success rate is the same. Of course, decreased FRC lends it's hand to want a quick acting paralytic, but given the equivocal success rate, I have no problem just using roc instead.

Just a resident's perspective, so I've never actually had to do a RSI with anything other than sux.

 

[Noyac]

I would definitely get some guidance from hematology. This could be a bloody mess and their help would be essential. If this lady's airway is ok, I would not risk a regional. Do we know if she is homozygous or heterozygous? Either way I would be hard pressed to do a neuroaxial anesthetic in this lady. Would you do a spinal on someone who came in and had a big dose of integrelin? That's essentially what this sounds like. The succ "allergy" is concerning, we need more data on that, but regardless, I would sleep her.

I'm more in line with your thoughts here. I'd probably avoid regional unless I saw the last C/S record and it showed that a spinal was done without complication. Hematology would be a big part of my planning here.

I wouldn't do a spinal on someone who just had a big dose of integrelin but this is a bit different. This pt can theoretically be treated with plts which will function normally.

I believe the the succ allergy maybe a hoax. I wouldn't get cavalier with it tho. Anyone have a good idea what it could be?

 

[Robert Loblaw]

Absolutely, I would do a spinal, especially since this is an elective case and should be taken back when the patient's coagulopathy is optimized.

For the sux allergy, I could take time to find it or ask more questions. In the event that it's just not able to be determined, I know several studies have shown that there is no significant difference in intubating conditions after .6mg/kg roc versus 1mg/kg of sux. Even though roc may be expected to have a slightly longer onset, the data says that overall success rate is the same. Of course, decreased FRC lends it's hand to want a quick acting paralytic, but given the equivocal success rate, I have no problem just using roc instead.

Just a resident's perspective, so I've never actually had to do a RSI with anything other than sux.

big difference between sux and roc in a parturient. with the glidescope, the incidence of failed intubation is probably less, but in the parturient it has been estimated to be about ten times more common---roughly 1 in 280 versus 1 in 3000.

noyac, yes i did mean g2p1 thanks.

we are doing a consultation at 26 weeks. the patient is apprehensive and wants to talk--not a bad idea, we were appreciative of the opportunity to think about this ahead of time.

 

[PinchandBurn]

First I would illicit a focused history.

Does she bleed easy? Bruise easy? Any spontaneous bleeding? Brushing teeth, is it ok. What did she have with the last anesthetic. Get the record. She's only 26 WGA. So send her to hematology and get it worked up. Also send to an allergist. See if the allergy is reallyto sux.

Then, give us more info on her a/w. If acceptable a/w then RSI with roc advanced a/w equipment available.

If a/w is unfavorable and the case was emergent (assuming), then we have to weigh the r/b of doing a spinal anesthetic versus an awake FOI. If the case was emergent, then I would tell the patient that there is a risk of Hematoma,etc from doing a spinal. But I am going to give her a transfusion of plts, have rVII available, and give her DDAVP prophylactically. I would do the spinal because, the r/o loosing the a/w >>>r/o spina hematoma in the parturient population. We would then do q 1 hour neuro checks AFTER the spinal.

The question will then arise, what about getting a 'high spinal" in a pt with unfavorable a/w. In that case, you have to have all the emergency equipment available. Do the laryngeal blocks, and an awake FOI. If that fails and the spinal is 'really high', you probably wont need ANY muscle relaxants at that point and would just have to intubate with cric pressure and videolaryngoscopy/DL.

Would consider an Aline, but not sure what benefit that would give us, except if we were in 'massive transfusion' mode for increased bleeding.

 

[Robert Loblaw]

so...

1) the hematologist sent a letter along, recommending that she receive plts prior to her c-section, regardless of the anesthetic technique employed. does this change the anesthetic plan?

2) the patient reports that her sux allergy is not a true allergy. from what she understands, during her previous c-section, she had some sort of response to the drug such that the anesthesiologist told her afterwards that she should list it as an allergy. fortunately, the previous c/s was performed at our hospital in 2004. unfortunately, the record confusingly states something to the following effect "rsi (prop/sux) with difficulty opening mouth; dl x ii with mac3/miller2 no view; #4 lma placed with satisfactory gas exchange; patient intubated via fiberscope thru lma."

what is the importance of this?

(i'm not making this case up, by the way)

 

[PinchandBurn]

so...

1) the hematologist sent a letter along, recommending that she receive plts prior to her c-section, regardless of the anesthetic technique employed. does this change the anesthetic plan?

2) the patient reports that her sux allergy is not a true allergy. from what she understands, during her previous c-section, she had some sort of response to the drug such that the anesthesiologist told her afterwards that she should list it as an allergy. fortunately, the previous c/s was performed at our hospital in 2004. unfortunately, the record confusingly states something to the following effect "rsi (prop/sux) with difficulty opening mouth; dl x ii with mac3/miller2 no view; #4 lma placed with satisfactory gas exchange; patient intubated via fiberscope thru lma."

what is the importance of this?

(i'm not making this case up, by the way)

this is actually a good thing.

Assuming her body habitus and anatomy has not changed that drastically (try to illicit from her history)....the worse case scenario, you now know that you can atleast ventilate her through a LMA. So if you ran into trouble (emergently), you could do the case with cric pressure and LMA. The anesthesiologist did this via a Fiberoptic. Nowadays, most have videolaryngoscopes, so it should even be more of a controllable situation.

 

[Robert Loblaw]

what about the "difficulty opening mouth" and subsequent instructions to list sux as an allergy?

 

[pd4emergence]

Absolutely, I would do a spinal, especially since this is an elective case and should be taken back when the patient's coagulopathy is optimized.

For the sux allergy, I could take time to find it or ask more questions. In the event that it's just not able to be determined, I know several studies have shown that there is no significant difference in intubating conditions after .6mg/kg roc versus 1mg/kg of sux. Even though roc may be expected to have a slightly longer onset, the data says that overall success rate is the same. Of course, decreased FRC lends it's hand to want a quick acting paralytic, but given the equivocal success rate, I have no problem just using roc instead.

Just a resident's perspective, so I've never actually had to do a RSI with anything other than sux.

There was a pretty good study not too long ago that showed the airway risk in preggos has probably been historically overblown. That being said I am by no means going to sleep a csection unless there is in my opinion a favorable risk benefit profile. If her airway looks good here, why risk a spinal? Even correcting her coagulopathy, I just don't think it's worth the risk. There is also the possibility of severe volume loss here that can be made worse with a neuroaxial technique. Planned section, pt npo, reglan, Zantac, bicitra, rsi, I think in the right patient, the incidence of an airway disaster or aspiration would be very low.

 

[pd4emergence]

so...

1) the hematologist sent a letter along, recommending that she receive plts prior to her c-section, regardless of the anesthetic technique employed. does this change the anesthetic plan?

2) the patient reports that her sux allergy is not a true allergy. from what she understands, during her previous c-section, she had some sort of response to the drug such that the anesthesiologist told her afterwards that she should list it as an allergy. fortunately, the previous c/s was performed at our hospital in 2004. unfortunately, the record confusingly states something to the following effect "rsi (prop/sux) with difficulty opening mouth; dl x ii with mac3/miller2 no view; #4 lma placed with satisfactory gas exchange; patient intubated via fiberscope thru lma."

what is the importance of this?

(i'm not making this case up, by the way)

How does her airway look now? Does she open?

 

[doctor712]

what about the "difficulty opening mouth" and subsequent instructions to list sux as an allergy?

Shot in the dark of course, coming from me, but can't trismus be caused by MH? And having said that, was this woman given an inhalational/general anesthestic for prior c/s (for whatever reason)? I know that the first thing you do when MH is suspected is turn off the triggering agent, so I'm guessing if she was given general, could this "allergy" have been incorrectly and brutally documented as sux reaction, and not MH?

Shot. In the dark. I'll await my clobbering.

D712

 

[Idiopathic]

yeah this is MH-susceptibility until proven otherwise, no sux, she gets a TIVA for general, which you try to avoid at all costs.

 

[DreamLover]

yeah this is MH-susceptibility until proven otherwise, no sux, she gets a TIVA for general, which you try to avoid at all costs.

I'm curious, if it was the anesthesiologist from the first CSXN that informed the pt of this mysterious Sux allergy, and the original record is describing masseter muscle spasm....was the first CSXN completed by TIVA? I would think that could help you decipher what the first anesthesiologist was thinking.

Personally, if I had a pt for whom I was worried about MH susceptibility, my patient would know the letters MH or know about Malignant Hyperthermia or be sent for/or informed about testing....and at the least...MH would make it's way to the chart, not just Sux allergy...

 

[Noyac]

First I would illicit a focused history.

Does she bleed easy? Bruise easy? Any spontaneous bleeding? Brushing teeth, is it ok. What did she have with the last anesthetic. Get the record. She's only 26 WGA. So send her to hematology and get it worked up. Also send to an allergist. See if the allergy is reallyto sux.

Then, give us more info on her a/w. If acceptable a/w then RSI with roc advanced a/w equipment available.

Good questions but I have one for you. When was the last time you sent someone to an allergist? Have only done it once and it was was after an anaphylactic run to suspected latex which was confirmed by the allergist. Succ allergy is very different and I'm not so sure an allergist is going to be a big help. When someone says they have a succ allergy a few things should go thru your mind.
MH
Anaphylaxis
Mild rash
Pseudocholinesterase def

Can't you determine which one it may be from the past record? If not and you are really concerned about MH then use something else. You don't need an allergist for this.

 

[Noyac]

this is actually a good thing.

Assuming her body habitus and anatomy has not changed that drastically (try to illicit from her history)....the worse case scenario, you now know that you can atleast ventilate her through a LMA. So if you ran into trouble (emergently), you could do the case with cric pressure and LMA. The anesthesiologist did this via a Fiberoptic. Nowadays, most have videolaryngoscopes, so it should even be more of a controllable situation.

I wouldn't be so bold. Pregnancy is very different. Just because someone could ventilate her with an LMA during her last pregnancy doesn't mean it will be successful this go around.

 

[Noyac]

Shot in the dark of course, coming from me, but can't trismus be caused by MH? And having said that, was this woman given an inhalational/general anesthestic for prior c/s (for whatever reason)? I know that the first thing you do when MH is suspected is turn off the triggering agent, so I'm guessing if she was given general, could this "allergy" have been incorrectly and brutally documented as sux reaction, and not MH?

Shot. In the dark. I'll await my clobbering.

D712

That's a good shot in the dark. Do you have any idea how common the two are? I'll put it this way. I have had about 5 cases of trismus and only one case of MH in my career. The point is, you avoid succ in these pts but not all trismus is MH.

 

[Noyac]

There was a pretty good study not too long ago that showed the airway risk in preggos has probably been historically overblown. That being said I am by no means going to sleep a csection unless there is in my opinion a favorable risk benefit profile. If her airway looks good here, why risk a spinal? Even correcting her coagulopathy, I just don't think it's worth the risk. There is also the possibility of severe volume loss here that can be made worse with a neuroaxial technique. Planned section, pt npo, reglan, Zantac, bicitra, rsi, I think in the right patient, the incidence of an airway disaster or aspiration would be very low.

I totally agree that airway issues are overblown in pregos. I also try to avoid GA in these pts but not because I fear the airway. More because a c/s GA is just not a pleasant case to me. But neither is a spinal fora c/s pleasant to me. I just would prefer to do just about any other case.
You may be right that a spinal may not be worth the risk here but it's not because of blood loss. C/S's under spinal don't have greater EBL. It is the GA that has greater EBL. The problem witha spinal and large blood loss is that the pt begins to decompensate. They get hypotensive, nauseated, restless etc and then you are forced to do something about it like convert to GA in someone that may be actively vomiting.

 

[Noyac]

Someone mentioned doing airway blocks in this pt in case you needed to,convert to a GA. Is this really a good idea?

 

[doctor712]

That's a good shot in the dark. Do you have any idea how common the two are? I'll put it this way. I have had about 5 cases of trismus and only one case of MH in my career. The point is, you avoid succ in these pts but not all trismus is MH.

I did know that MH was rare, but I don't know the numbers. I will look it up though.
Thanks for the follow-up!

D712

 

[pgg]

Someone mentioned doing airway blocks in this pt in case you needed to,convert to a GA. Is this really a good idea?

I don't really see an upside, but I also don't see a huge risk with a transtracheal block with a tiny needle. Don't know if I'd let the CA1 dig around for sup laryngeal blocks ...

That said - if you're really so worried about a forced conversion to GA for a section that you're going to do airway blocks beforehand, quit playing games and start with a controlled, deliberate GA from the start.


At this point I'd favor a non-triggering GA from the get-go. Airway to be managed depending on current exam - not ignoring the notes from the previous section, but taking them with a grain of salt. Is she also 100 pounds heavier compared to her first section? If she can voluntarily open her mouth normally, I wouldn't anticipate trouble after roc.

 

[Noyac]

I don't really see an upside, but I also don't see a huge risk with a transtracheal block with a tiny needle. Don't know if I'd let the CA1 dig around for sup laryngeal blocks ...
.

What do you think would happen if a pt was lying flat under a spinal with her airway blocked and then she started to vomit?

The transtracheal wouldn't be as big of a deal as the supra glottic blocks. But this something I have always been cautious of when performing airway blocks.

Therefore, IMO if you are going to do the blocks then put a tube in.

 

[pgg]

What do you think would happen if a pt was lying flat under a spinal with her airway blocked and then she started to vomit?

I see what you're getting at, loss of airway reflexes. Thought you were alluding to bleeding risk and sticking needles in someone's neck.

I'm not sure I can conceive of a case that I'd feel compelled to do airway blocks though, and not immediately put a tube in. If you're that worried about the airway being plan B, it probably ought to be plan A.

 

[Idiopathic]

I'm curious, if it was the anesthesiologist from the first CSXN that informed the pt of this mysterious Sux allergy, and the original record is describing masseter muscle spasm....was the first CSXN completed by TIVA? I would think that could help you decipher what the first anesthesiologist was thinking.

Personally, if I had a pt for whom I was worried about MH susceptibility, my patient would know the letters MH or know about Malignant Hyperthermia or be sent for/or informed about testing....and at the least...MH would make it's way to the chart, not just Sux allergy...

ive gotten burned relying on other people to either know what to do or to tell patients the appropriate things (or even realize that MMR could predict MH susceptibility), but also, masseter spasm doesnt always turn into MH and it sometimes turns into MH down the road, so while not all MMR leads to MH, I think you have to prepare for it as though she is MH susceptible

question: do they still put methylparaben in sux? i read a case report from many years ago of "anaphylaxis" to sux and that was deemed to be the culprit

 

[PinchandBurn]

Good questions but I have one for you. When was the last time you sent someone to an allergist? Have only done it once and it was was after an anaphylactic run to suspected latex which was confirmed by the allergist. Succ allergy is very different and I'm not so sure an allergist is going to be a big help. When someone says they have a succ allergy a few things should go thru your mind.
MH
Anaphylaxis
Mild rash
Pseudocholinesterase def

Can't you determine which one it may be from the past record? If not and you are really concerned about MH then use something else. You don't need an allergist for this.

you're write, I've never sent someone to an allergist. However, in this case, with the lady being only 26WGA and PLENTY of time until she's going to labor, what's the downside to sending her to an allergist. Especially if this is an elective,we've got time. It would help determine one BIG issue...can we use sux or not.

Now, of course it would NOT tell us if she's MH susceptible of course.

Granted, I do not know if the allergist could test for sux Allergy. But again, no harm in finding out.

 

[Noyac]

, what's the downside to sending her to an allergist. Especially if this is an elective,we've got time. It would help determine one BIG issue...can we use sux or not

Well the downsides I can think of are, time, cost, anxiety for starters.

Plus I highly doubt that it will determine whether we could use succ or not.

I would just review the record from the last case and if I wasn't clear on the particulars, I'd just avoid using it and call it good.

 

[pd4emergence]

If you cant rule out masseter spasm for sure, I would go with idio's plan. Get the machine ready per guidelines, put some propofol on a pump, use roc and tell the surgeon to take his/her time. I kinda of like doing tiva cases, also no gas to relax the uterus, which always seems to be an issue with ga csections. Here again you can take the chance, say nah she will be fine, there is lots to lose and little to be gained by taking the chance.

 

[RussianJoo]

A few months ago I had a case of psuedocholine esterase deficiency. The lady gave me a vague history of having general anesthesia 25 years ago and she remembers that the anesthesiologist told her they had a tough time waking her up and that she was very sensitive to anesthesia. I didn't think too much of it since so much has changed in 25 years, but was a little cautious with the narcotic and volatile anesthetic doses. Like I mentioned before we use sux like water here and she was induced with sux, didn't get her strength back for 10 hrs. We drew her blood sent it out, dibucaine number came back as 27, about 10 days later. We called her explained to her what she had and documented it in the Medical records, she now has a Sux allergy, along with a few other drugs that are broken down by psuedocholine esterase. Anyway what I am trying to get at is maybe this ladies allergy to sux is pseudocholine esterase deficiency.

just a thought.

 

[MiracleforMD]

A few months ago I had a case of psuedocholine esterase deficiency. The lady gave me a vague history of having general anesthesia 25 years ago and she remembers that the anesthesiologist told her they had a tough time waking her up and that she was very sensitive to anesthesia. I didn't think too much of it since so much has changed in 25 years, but was a little cautious with the narcotic and volatile anesthetic doses. Like I mentioned before we use sux like water here and she was induced with sux, didn't get her strength back for 10 hrs. We drew her blood sent it out, dibucaine number came back as 27, about 10 days later. We called her explained to her what she had and documented it in the Medical records, she now has a Sux allergy, along with a few other drugs that are broken down by psuedocholine esterase. Anyway what I am trying to get at is maybe this ladies allergy to sux is pseudocholine esterase deficiency.

just a thought.

Very good post.

 

[Robert Loblaw]

How does her airway look now? Does she open?

looks fine--mp 2, normal mh distance....

 

[Robert Loblaw]

Shot in the dark of course, coming from me, but can't trismus be caused by MH? And having said that, was this woman given an inhalational/general anesthestic for prior c/s (for whatever reason)? I know that the first thing you do when MH is suspected is turn off the triggering agent, so I'm guessing if she was given general, could this "allergy" have been incorrectly and brutally documented as sux reaction, and not MH?

Shot. In the dark. I'll await my clobbering.

D712

good questions, all relevant. curiously, after securing the airway, they proceeded with an inhalational anesthetic, but then apparently felt the need to counsel the patient about a sux allergy. is the fact that she "successfully" received triggering agents reassuring?

 

[sevoflurane]

looks fine--mp 2, normal mh distance....

 

[Robert Loblaw]

is mentohyoid distance less ironic?

 

[doctor712]

good questions, all relevant. curiously, after securing the airway, they proceeded with an inhalational anesthetic, but then apparently felt the need to counsel the patient about a sux allergy. is the fact that she "successfully" received triggering agents reassuring?

Is that question for me? I would say it's reassuring until a problem arises, like symptoms of MH... or, according to the MHAUS website, up to one hour following surgery. So, maybe short lived relief? I really don't know, maybe a med stud or resident would like to chime in...

D712

 

[Noyac]

good questions, all relevant. curiously, after securing the airway, they proceeded with an inhalational anesthetic, but then apparently felt the need to counsel the patient about a sux allergy. is the fact that she "successfully" received triggering agents reassuring?

Yes it is reassurring. But it doesn't mean it won't raise it ugly head either.

My question would be, was she extubated at the end of the case or did they have to wait a bit?

 

[Noyac]

really don't know, maybe a med stud or resident would like to chime in...

D712

or even a smartass AA

 

[Noyac]

What is the normal mh distance in a case like this.

 

[PinchandBurn]

What is the normal mh distance in a case like this.

ask the CRNA...they'll know.




On another note...let's make this case more interesting. Imagine she walks in to the labor ward w/o having coming to your pre op clinic. Say she's 300+ lbs and has a bad airway AND is going to be a 'emergent' C/S (you know the typical baby is deceling stuff)...

Who here would transfuse the patient with plts, tell her the r/b and do a spinal or a slowly titrated epidural, informing her that there is a high risk of epidural hematoma formation but that you will have to monitor her q 1 hour with neuro checks afterwards?

I know the Oral Boards may state to do an awake FOI....but do you really think doing all those blocks and an awake FOI coudl be done faster than a spinal/epidural? The option is of course, surgeon infiltration of local anesthetic and mild midaz/ketamine sedation, but seems a little barbaric...

 

[Robert Loblaw]

What is the normal mh distance in a case like this.

do we not like mh distance anymore? i was merely trying to convey in common parlance that her face head and neck was not worrisome for difficult intubation. my own personal feelings are that each practitioner develops a gestalt-type airway exam that is based on experience and subtle cues. for example, i tend to notice when the mandibular incisors are bunched together and overlapping, suggesting a narrow jaw.

she was extubated at the end of the case, if i recall correctly.

 

[Robert Loblaw]

Is that question for me? I would say it's reassuring until a problem arises, like symptoms of MH... or, according to the MHAUS website, up to one hour following surgery. So, maybe short lived relief? I really don't know, maybe a med stud or resident would like to chime in...

D712

no, not directed at you, just in general. you gave a very insightful answer, even more so considering your experience (i'm not being sarcastic, this is a compliment).

 

[Robert Loblaw]

ask the CRNA...they'll know.




On another note...let's make this case more interesting. Imagine she walks in to the labor ward w/o having coming to your pre op clinic. Say she's 300+ lbs and has a bad airway AND is going to be a 'emergent' C/S (you know the typical baby is deceling stuff)...

Who here would transfuse the patient with plts, tell her the r/b and do a spinal or a slowly titrated epidural, informing her that there is a high risk of epidural hematoma formation but that you will have to monitor her q 1 hour with neuro checks afterwards?

I know the Oral Boards may state to do an awake FOI....but do you really think doing all those blocks and an awake FOI coudl be done faster than a spinal/epidural? The option is of course, surgeon infiltration of local anesthetic and mild midaz/ketamine sedation, but seems a little barbaric...

so, just to add another twist to this scenario. the patient brought with her a note from her hematologist. you would think that every single one of us on this board would be certain that the hematologist would say something like "epidural is contraindicated given the risk of epidural hematoma," but she didn't. i can't recall the exact wording but she said something to the effect that she did not think that the risk of neuraxial anesthesia after platelet transfusion would be unacceptable...

 

[BLADEMDA]

The presence of antiplatelet antibodies meant that platelet transfusions might not be effective. Native blood Thrombelastograph® analysis was performed at this stage, which showed normal clot initiation but poor clot strength (Fig. 1). With this information in mind, we decided that regional anaesthesia was contraindicated and that peripartum haemorrhage was inevitable. An illustration of the Thrombelastograph® indices measured is given in Figure 2.


http://bja.oxfordjournals.org/content/88/5/734.full#ref-1

 

[BLADEMDA]

Glanzmann's thrombasthenia is a rare, autosomal recessive platelet disorder manifested by a lack of the glycoprotein IIb–IIIa complex in the platelet membrane.1 Platelet aggregation is severely impaired by the absence of this integral membrane complex, which holds the receptor for fibrinogen.2 Patients may have normal platelet counts but can exhibit very abnormal platelet function. The disorder is characterized by potentially major mucocutaneous bleeding, and is usually diagnosed in childhood following such an episode. Information regarding the long‐term outcome of these patients is limited and, as a consequence, their management is not evidence based. It is considered hazardous for such patients to conceive, with a high risk of severe peripartum haemorrhage.3
We describe the peripartum management of a 31‐yr‐old primipara with Glanzmann's thrombasthenia. We make special reference to the use of the Thrombelastograph® analyser, which enabled us to assess the efficacy of various therapies.