Csection case

[Hoya11]

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An LMA for a c/s in a lady with a BMI of 52? No thanks.

you dont think that would be preferable for 20 minutes vs an ETT that she dies with ?

Its easy to dump her in the ICU and who cares right?

 

[Twiggidy]

you dont think that would be preferable for 20 minutes vs an ETT that she dies with ?

Its easy to dump her in the ICU and who cares right?

That is why I mentioned that it depends on the skill of the OB (I think I did). If it’s a no nonsense OB you may be able to squeak by with an LMA but if it’s one of these 2 hr slow pokes we may have to just do the tube

 

[Urzuz]

you dont think that would be preferable for 20 minutes vs an ETT that she dies with ?

Its easy to dump her in the ICU and who cares right?

you’re insane if you would put an LMA in this pregnant whale

 

[FiO2@21]

you dont think that would be preferable for 20 minutes vs an ETT that she dies with ?

Its easy to dump her in the ICU and who cares right?

I get that “Covid intubation = death” has been one of the anesthesia/critical care memes lately, but in this situation I struggle to see how she’s doomed just because her trachea is intubated.

Now that I think about it, I’d probably have RT come in the OR and extubate the patient to HFNC. I know some attendings would absolutely never do that. Maybe I wouldn’t once I grow up either.

I wouldn’t necessarily leave them intubated unless something else came up.

A question here is if this is COVID PNA or pulm edema from AS, or both. Would still probably give some Lasix intraop.

 

[chocomorsel]

I get that “Covid intubation = death” has been one of the anesthesia/critical care memes lately, but in this situation I struggle to see how she’s doomed just because her trachea is intubated.

Now that I think about it, I’d probably have RT come in the OR and extubate the patient to HFNC. I know some attendings would absolutely never do that. Maybe I wouldn’t once I grow up either.

I wouldn’t necessarily leave them intubated unless something else came up.

A question here is if this is COVID PNA or pulm edema from AS, or both. Would still probably give some Lasix intraop.

I doubt she'd be extubatable that quickly and if she is, I see her getting the tube again pretty quickly with fluid shifts and AS post delivery.
But in this situation, it wouldn't hurt to try to see if she flies considering the Covid has a high probability of killing her given her weight.

 

[deleted87051]

I get that “Covid intubation = death” has been one of the anesthesia/critical care memes lately, but in this situation I struggle to see how she’s doomed just because her trachea is intubated.

Now that I think about it, I’d probably have RT come in the OR and extubate the patient to HFNC. I know some attendings would absolutely never do that. Maybe I wouldn’t once I grow up either.

I wouldn’t necessarily leave them intubated unless something else came up.

A question here is if this is COVID PNA or pulm edema from AS, or both. Would still probably give some Lasix intraop.

I doubt she'd be extubatable that quickly and if she is, I see her getting the tube again pretty quickly with fluid shifts and AS post delivery.
But in this situation, it wouldn't hurt to try to see if she flies considering the Covid has a high probability of killing her given her weight.

Postop reintubation triggers an M+M. I don’t like doing M+M’s. I’m not extubating anybody who’s preop O2 sat is low 90s on NRB, COVID or no COVID. Call me a monkey.

 

[FiO2@21]

Something something if you're not reintubating 50% you're not extubating enough.

But seriously I think it'd be fair to at least put her on pressure support and see how she does. If she was requiring a certain FiO2 or PEEP above an arbitrary limit I wouldn't extubate. But if I was getting away with 60% FiO2 with minimal PEEP, I would still consider extubating to HFNC. But I get that there's more support in the unit for more tenuous extubations. I'm sure we've all transported marginal patients to the unit and had them extubated soon after dropping them off.

 

[chocomorsel]

Postop reintubation triggers an M+M. I don’t like doing M+M’s. I’m not extubating anybody who’s preop O2 sat is low 90s on NRB, COVID or no COVID. Call me a monkey.

What’s an M&M? Haha. I have actually never worked in a hospital in PP that had that to my knowledge. I get ya though.

 

[BobLoblaw78]

Csection under local. BOOM! You guys are welcome

 

[IMGASMD]

Csection under local. BOOM! You guys are welcome

This and this all day long.


I’ve never seen it done tho, doesn’t mean it’s impossible.
Also make sure she knows she ain’t going to sleep. And will probably feel everything..... and be awake the whole time.
Maybe your lawyers contact information.

 

[pgg]

Something something if you're not reintubating 50% you're not extubating enough.

Sure but you've got to pick your battles. I totally agree that for many patients their best chance for early extubation is in the OR, vs dropping them off in the unit and hoping someone's motivated to try today. But a morbidly obese, immediately postpartum, can't lay flat at baseline, severe AS, COVID+, well I'd pick another hill to climb, another day. Spike the football after the c-section is done and GTFO.

 

[FiO2@21]

Sure but you've got to pick your battles. I totally agree that for many patients their best chance for early extubation is in the OR, vs dropping them off in the unit and hoping someone's motivated to try today. But a morbidly obese, immediately postpartum, can't lay flat at baseline, severe AS, COVID+, well I'd pick another hill to climb, another day. Spike the football after the c-section is done and GTFO.

To be clear I don’t think that adage really applies in the OR like it might in the ICU. And I’m not sure it applies in the icu either lol.

Either way my broader point is that intubation isn’t a death sentence for her. Definitely wouldn’t say LMA during an oral board exam. And as for dosing up an epidural to avoid an intubation... not super sold.

 

[MirrorTodd]

Would y'alls management change if you put a probe on her yourself and found that her AS was moderate vs severe? I suppose this is more a question for the CT peeps since I wouldn't know **** all about properly evaluating a valve with tte.

 

[abolt18]

Would y'alls management change if you put a probe on her yourself and found that her AS was moderate vs severe? I suppose this is more a question for the CT peeps since I wouldn't know **** all about properly evaluating a valve with tte.

Assuming you can get good enough images (not easy on patients of this magnitude), and that previous echo report was not performed extremely recently, then yes.

But really if the echo was recent, and I was getting smaller gradients than they did, I would assume it was an error on my part or that I was just not getting in perfect parallel with the flow of blood through the LVOT/vlalve (which would underestimate the velocities and gradients and therefore underestimate the severity of the stenosis).

 

[DocVapor]

Csection under local. BOOM! You guys are welcome

Local? Why not QL blocks?

(Lol)

 

[coffeebythelake]

is

Would y'alls management change if you put a probe on her yourself and found that her AS was moderate vs severe? I suppose this is more a question for the CT peeps since I wouldn't know **** all about properly evaluating a valve with tte.

She can't lay flat

 

[GassYous]

Local? Why not QL blocks?

(Lol)

Cause they don't make needles that are long enough haha

Extubating a covid fatty is not easy. Their respiratory status is horrible from the obesity and from the covid. Just let them wake up slowly in icu, that's the safest imo.

If I had any question about the severity of the AS and couldn't see it well myself I would just treat them as severe as. Tank em up and keep the bp up because I've seen them spiral down to death after someone wasn't careful with the pressure.

 

[jwk]

Spray and pray.

That's referred to as the "splash technique" in South Georgia.