How would you answer this OB question:

[sevoflurane]

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So in light of our morbid obesity thread, here is another from a different point of view:

38 y/o 450lb. morbidly obese patient has managed to somehow get herself pregnant 🙂eek🙂. She is at 37weeks and your OB colleague says that FHR is 60 and has been there for 10 minutes. Scalp PH is 7.12. He says "we need to get this baby out stat... like yesterday".

1 Year ago she had a TKA and was found to be a unanticipated difficult airway, but the records are not available and you know nothing else.


What do you do?

1. RSI
2. LMA
3. Spinal
4. Epidural
5. CRIC
6. GA under face mask and hope she doesn't puke
7. Awake FOI
8. Anything else you can think of.

The FHR is now 45..... The baby is dying.

 

[proman]

1) Call for help.

 

[sevoflurane]

Nice.

 

[sevoflurane]

and very true....

 

[NotAMD]

So in light of our morbid obesity thread, here is another from a different point of view:

38 y/o 450lb. morbidly obese patient has managed to somehow get herself pregnant 🙂eek🙂. She is at 37weeks and your OB colleague says that FHR is 60 and has been there for 10 minutes. Scalp PH is 7.12. He says "we need to get this baby out stat... like yesterday".

1 Year ago she had a TKA and was found to be a unanticipated difficult airway, but the records are not available and you know nothing else.


What do you do?

1. RSI
2. LMA
3. Spinal
4. Epidural
5. CRIC
6. GA under face mask and hope she doesn't puke
7. Awake FOI
8. Anything else you can think of.

The FHR is now 45..... The baby is dying.

Surgeons can always do local.

Local alone is still used in some countries.

? "unanticipated" difficult airway?

id go with general straight away
if not npo, rsi - glidescope, if no luck intubating wake up, lma prn ventilation
if npo lma (supreme) straight away, inhalational+IV induciton

 

[sevoflurane]

Surgeons can always do local.

Local alone is still used in some countries.

? "unanticipated" difficult airway?

id go with general straight away
if not npo, rsi - glidescope, if no luck intubating wake up, lma prn ventilation
if npo lma (supreme) straight away, inhalational+IV induciton

Great answer.... and you are correct.. Local is an option.

 

[IlDestriero]

I find it sad that the old Circus Fat Lady is now routinely outclassed by the average disgusting fat body.
I like the "unanticipated difficult airway" part.
Unfortunately for her, the diagnosis of a known difficult airway would probably buy her an awake fiber or a spinal. I'm not sure that I would be willing to assume that I could intubate her with a glidescope or ventilate her with an LMA. If she knew going in that I might have to give her a cricothyroidotomy or retrograde wire if the other options failed, I might give it a go. Unfortunately, you really don't have time to get informed consent. Tough choices and no right answer. It's a classic oral board question. At the exam, make a decision, justify your answer and don't be wishy washy.

 

[Mman]

If I'm really, really worried about the airway I'm only thinking of 2 real options. And since she is big and fat and previous unanticipated difficult intubation (and now pregnant on top) I'm thinking it's going to be bad.

1) Gimme a shot at a spinal. I don't care how big she is. ACOG guidelines say stat c-section should be done within 30 minutes. Give me 5 minutes with a 22 g needle and I can probably get a spinal regardless of how fat she is.

2) Awake FOI. I can topicalize in about 2-4 minutes and get her to cooperate with some ketamine and it shouldn't take long to get a tube in.


I'm kinda gun shy about inducing pregnant known difficult airways unless I'm mighty sure I'll be able to ventilate afterwards.

 

[sevoflurane]

If I'm really, really worried about the airway I'm only thinking of 2 real options. And since she is big and fat and previous unanticipated difficult intubation (and now pregnant on top) I'm thinking it's going to be bad.

1) Gimme a shot at a spinal. I don't care how big she is. ACOG guidelines say stat c-section should be done within 30 minutes. Give me 5 minutes with a 22 g needle and I can probably get a spinal regardless of how fat she is.

2) Awake FOI. I can topicalize in about 2-4 minutes and get her to cooperate with some ketamine and it shouldn't take long to get a tube in.


I'm kinda gun shy about inducing pregnant known difficult airways unless I'm mighty sure I'll be able to ventilate afterwards.

Totally agree. I would never induce GA with a (M)RSI in this patient (and what I mean by that is giving sux or roc). That is going over the red line. So I would cross that off the list.

 

[sevoflurane]

This question becomes difficult to answer because AFOI or Spinal can take some time and we have a dying fetus so time is of great importance. Geesh I hope I never get this in real life, but I do have a plan.....

 

[rsgillmd]

In the ideal world I would have prevented this situation by doing a preop evaluation on the patient before she event got to this point, and having a discussion with surgeons and patient that there will be no STAT C/S.

However, being that I'm already in the situation, if I thought she would not be ventilatable via LMA I would go for a deliberate continuous spinal with a Tuohy. It'll be faster than the "C/S under local" route.

Asking me to induce GA in a patient with a known difficult intubation history is like asking me to fire a loaded gun. If I thought she would be ventilatable via LMA, I'd consider going with LMA Fastrach so I could intubate through it -- usually blind, but via fiberoptic if I had to.

Problem for me is that if I want to use a fiberoptic scope, I have to wait for respiratory to bring it. In my hospital they control the fiberoptic scopes.

 

[pgg]

I've never seen a section done under local and I bet most obstetricians haven't either. If they were willing to try, great, they can charge ahead while I work on securing her airway awake.


Otherwise ...

Bicitra, Reglan.

Plan A is "Ma'am, this is going to suck, open your mouth and try to hold still" followed by a quick blast of benzocaine spray and an awake look with a Glidescope (better view, less force/pain). Good view -> bougie through the cords -> induce -> ETT. Although not the sweet birth experience she was hoping for, this is fast, safe, and if she can keep her mouth open for 5 seconds, it's very likely to be successful. Failure there ...

... plan B is to attempt a spinal while a colleague does more airway topicalization. (Even a nurse could set up a 4% lidocaine nebulizer.) I bet I could get a spinal into even a morbidly obese patient faster than I could prep and do an AFOI.

Plan C awake FOI.


I wouldn't RSI a person with a known difficult airway. She wasn't pregnant when she got her TKA, she's surely gained at least 50 pounds of "baby" weight since then, her airway won't be any better.


A gradual ketamine induction while maintaining SV -> DL -> LMA is a defensible option. Lots of "right" answers, none without risk of course.


APGARs are gonna be 9/9 anyway. 🙂

 

[Gern Blansten]

In the ideal world I would have prevented this situation by doing a preop evaluation on the patient before she event got to this point, and having a discussion with surgeons and patient that there will be no STAT C/S.

My thoughts exactly. This is a preventable problem with proper planning. You would have ample time to have all equipment available. The OBs would know not to wait 10 minutes before letting you know of concern. No stat c-sections. Only a quick awake FOI which was prepared for because you knew about the patient. As a colleague used to say, "do you want one dead patient or two?" A hypoxic mom is not any good for baby either.

 

[pgg]

In the ideal world I would have prevented this situation by doing a preop evaluation on the patient before she event got to this point, and having a discussion with surgeons and patient that there will be no STAT C/S.

Agreed -

We see all patients as soon after admission as possible (even the ones with doolas who don't want epidurals). Huge patients and those with bad airways get a 3-way OB-anesthesia-patient discussion about an early epidural or even intrathecal catheter.

The only way I'll ever end up in one of these nightmares is if
- the patient refuses early catheter placement
- the patient crashes in through triage

 

[deleted9493]

Yeah, I'd topicalize w/ benzocaine (she'll tolerate a touch more, perhaps?), let her know that life is going to be miserable for a minute and put the glidescope to work. If that fails, I'm opting for a spinal while the tech grabs the fiberoptic equipment.

 

[doctor712]

I've never seen a section done under local and I bet most obstetricians haven't either. If they were willing to try, great, they can charge ahead while I work on securing her airway awake.


Otherwise ...

Bicitra, Reglan.

Plan A is "Ma'am, this is going to suck, open your mouth and try to hold still" followed by a quick blast of benzocaine spray and an awake look with a Glidescope (better view, less force/pain). Good view -> bougie through the cords -> induce -> ETT. Although not the sweet birth experience she was hoping for, this is fast, safe, and if she can keep her mouth open for 5 seconds, it's very likely to be successful. Failure there ...

... plan B is to attempt a spinal while a colleague does more airway topicalization. (Even a nurse could set up a 4% lidocaine nebulizer.) I bet I could get a spinal into even a morbidly obese patient faster than I could prep and do an AFOI.

Plan C awake FOI.


I wouldn't RSI a person with a known difficult airway. She wasn't pregnant when she got her TKA, she's surely gained at least 50 pounds of "baby" weight since then, her airway won't be any better.


A gradual ketamine induction while maintaining SV -> DL -> LMA is a defensible option. Lots of "right" answers, none without risk of course.


APGARs are gonna be 9/9 anyway. 🙂

Pgg,

Re: Plan 1... can mom say, "This is gonna suck???? bite me. you're not doing that awake nonsense to me...?" (And this woman could indeed take a big chunk out of you I imagine.) Is she within her right to deny that plan with the baby dying? How would that go down? Mom is your patient, but, is kid your patient too? Before, after, or equal to mom?

D712

 

[sevoflurane]

I've never seen a section done under local and I bet most obstetricians haven't either. If they were willing to try, great, they can charge ahead while I work on securing her airway awake.

I have. I can tell you this: Not so good... but it is an alternative when your hands are bound. She got put to sleep right as the baby was being delivered. Horrible experience. As luck would have it, this had not been done at our hospital in 8+ years... I just happened to be the lucky guy on that evening.

 

[jwk]

Problem for me is that if I want to use a fiberoptic scope, I have to wait for respiratory to bring it. In my hospital they control the fiberoptic scopes.

Ouch - put that FOB on next year's capital budget. Every department should have one on their difficult airway cart exclusively for use by anesthesia.

 

[Arch Guillotti]

id go with general straight away
if not npo, rsi - glidescope, if no luck intubating wake up, lma prn ventilation
if npo lma (supreme) straight away, inhalational+IV induciton

Go straight to general with a supposed known difficult airway? Wow.

I don't really care about her NPO status since she is pregnant and morbidly obese I consider her a full stomach no matter what.

Putting her to sleep to see what happens, then failing then "waking her up" seems like a miserable plan at best.

 

[pgg]

Re: Plan 1... can mom say, "This is gonna suck???? bite me. you're not doing that awake nonsense to me...?" (And this woman could indeed take a big chunk out of you I imagine.) Is she within her right to deny that plan with the baby dying? How would that go down? Mom is your patient, but, is kid your patient too? Before, after, or equal to mom?

Mom can refuse the awake look. She could also refuse the spinal, the FOI, and the c-section itself if she wanted. All you can do is make sure she understands that she might die or her baby might die or have a severe brain injury if she refuses, and use your magnificent bedside manner and calm reassuring aura to help her make the right decision.

Legally, a pregnant woman refusing lifesaving treatment for her unborn child is not the same as a parent refusing lifesaving treatment for a child.

My plans A B & C all require a minimum "hold still" level of patient cooperation. In any case, if the patient is uncooperative, I don't think there's a safe way to proceed at all here. The baby will die and mom will survive.

 

[epidural man]

I would attempt a 3 needle placement technique.

1rst needle in her back. An 18 gauge tuohy makes an excellent spinal needle. I probably would thread a catheter. (<5min)

If that doesn't work, two 14 gauge needles through the cricothyroid membrane (spontaneous breathing is possible through two 14 gauges) - minimal discomfort and perhaps life saving.

I would glide scope her, using a fiber optic as the a guidable stylet under a spontaneously well topicalized (probably asleep) patient. An awake patient is going to make it more difficult and take longer. I can put her asleep and keep her breathing with the fully reversible drugs midazolam and opioids and maybe some gas. I like the idea of topicalizing while placing the spinal - I like nebulized lidocaine. (I just read an article yesterday that 2% works as well in both density of block and speed of onset as 4%)

 

[epidural man]

Of course all this discussion is mute because the first question they ask you is, "we have been trying for an iv in this lady, can you help us get an iv?"

Do they make an IO with a needle long enough?

 

[pgg]

Of course all this discussion is mute because the first question they ask you is, "we have been trying for an iv in this lady, can you help us get an iv?"

And she won't speak English, either. 🙂

Do they make an IO with a needle long enough?

Even the stupendously large don't carry much of their stupendousness pretibial. Never had an IO fail me. Granted the n is small.

 

[sevoflurane]

I would glide scope her, using a fiber optic as the a guidable stylet under a spontaneously well topicalized (probably asleep) patient.

2 person technique, but worth while.

 

[Jay K]

To keep in mind (as others have alluded to in their plans) although not pleasant to realize:

dead mom & baby >>> worse >>> dead baby

I wouldn't cowboy mom's care b/c baby is circling the drain. If they have to resuscitate baby, then so be it... I'm not going to be the one who killed mom and subsequently baby.

but, is kid your patient too?

No. I'll help intubate and resuscitate the kid after it's born... but until then, the kid's not my patient... and some may argue, still not the anesthesiolgist's patient.

 

[epidural man]

2 person technique, but worth while.

valid point but hopefully in this pt there would be another person around.

 

[RxBoy]

I've never seen a section done under local and I bet most obstetricians haven't either. If they were willing to try, great, they can charge ahead while I work on securing her airway awake.


Otherwise ...

Bicitra, Reglan.

Plan A is "Ma'am, this is going to suck, open your mouth and try to hold still" followed by a quick blast of benzocaine spray and an awake look with a Glidescope (better view, less force/pain). Good view -> bougie through the cords -> induce -> ETT. Although not the sweet birth experience she was hoping for, this is fast, safe, and if she can keep her mouth open for 5 seconds, it's very likely to be successful. Failure there ...

... plan B is to attempt a spinal while a colleague does more airway topicalization. (Even a nurse could set up a 4% lidocaine nebulizer.) I bet I could get a spinal into even a morbidly obese patient faster than I could prep and do an AFOI.

Plan C awake FOI.


I wouldn't RSI a person with a known difficult airway. She wasn't pregnant when she got her TKA, she's surely gained at least 50 pounds of "baby" weight since then, her airway won't be any better.


A gradual ketamine induction while maintaining SV -> DL -> LMA is a defensible option. Lots of "right" answers, none without risk of course.


APGARs are gonna be 9/9 anyway. 🙂

👍👍👍👍👍

 

[Idiopathic]

now give her platelets of 15K

 

[IlDestriero]

now give her platelets of 15K

I occasionally (generally against my wishes as I absolutely hate it) have to provide GA for kids in the Onco clinic. The oncologists are very happy to proceed with taps and intrathecal chemotherapy with a platelet count of 15k.
A little low for me to do it, but it's their party.

 

[sevoflurane]

In a nml size patient with no signs of active bleeding/firbrinolysis/falling platelets and nml coags, I'd do an epidural with 50K. Example: someone with myelodysplastic syndrome who is otherwise fine.

Now, if I was at an academic hospital, that number would prolly be higher.

 

[Idiopathic]

In a nml size patient with no signs of active bleeding/firbrinolysis/falling platelets and nml coags, I'd do an epidural with 50K. Example: someone with myelodysplastic syndrome who is otherwise fine.

Now, if I was at an academic hospital, that number would prolly be higher.

i wouldnt thread a catheter but id do a spinal at that number

 

[ProRealDoc]

WHen I did ny OB rotation, it was the OB anesthesia director's policy that every fattie was to be seen ASAP (as soon as she checked in) and have an epidural placed before she went into labor. This was done especically to avoid this scenario.

 

[Mman]

I occasionally (generally against my wishes as I absolutely hate it) have to provide GA for kids in the Onco clinic. The oncologists are very happy to proceed with taps and intrathecal chemotherapy with a platelet count of 15k.
A little low for me to do it, but it's their party.

To some extent, they are providing a potentially life saving therapy for the patient. I mean if their platelets are never going to be above 100K ever even with transfusion, the kid still needs the chemo.

My lifesaving therapy is a piece of plastic between the vocal cords for an emergency c-section. I mean every situation where you would want to place a spinal or an epidural is also a possible failed spinal/epidural. I mean there are some people you can't get one in. We've all been there.

 

[maceo]

Totally agree. I would never induce GA with a (M)RSI in this patient (and what I mean by that is giving sux or roc). That is going over the red line. So I would cross that off the list.

what the **** is a redline. what is that a niels speil? but i agree anyone who induces this lady voluntarily probably is like in his/her early 60s and the retirement party date in the departement is set. in other words, he does not give a **** about the repercussions. Thats a career ender.