Interesting case

[Conflicted]

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Ok just a clinical question to see what everyone thinks.

You have a 30 y/o pregnant female who is afraid of needles. She is in for csection and tells you she doesn't want an epidural but wants that "gas stuff".

This is an elective csection not emergent.

What do you do?

What do you feel are the risks to you legally, if any?

Would you refuse the GA?

 

[Monty Python]

Ok just a clinical question to see what everyone thinks.

You have a 30 y/o pregnant female who is afraid of needles. She is in for csection and tells you she doesn't want an epidural but wants that "gas stuff".

This is an elective csection not emergent.

What do you do?

What do you feel are the risks to you legally, if any?

Would you refuse the GA?

Discuss (and document) the risks and benefits of the various modalities available, and honor her wishes after she signs a fully informed consent. Stick a tube in her throat assuming no profound Mal 8+ airway issues.

 

[jwk]

Ok just a clinical question to see what everyone thinks.

You have a 30 y/o pregnant female who is afraid of needles. She is in for csection and tells you she doesn't want an epidural but wants that "gas stuff".

This is an elective csection not emergent.

What do you do?

What do you feel are the risks to you legally, if any?

Would you refuse the GA?

Invite her to go elsewhere. The key word is ELECTIVE.

 

[timtye78]

Remember that one of the absolute contraindications to regional anesthesia is patient refusal. I agree with the other responses as well.

 

[Conflicted]

Hello Dr tye

So would you refuse as jwk mentioned or inform and perform?

Remember that one of the absolute contraindications to regional anesthesia is patient refusal. I agree with the other responses as well.

 

[VentdependenT]

If she doesn't want an epidural needle then fine. Just tell her its not the SAFEST way to go. FULL CONSENT + a big phat page long note in your handwriting in the chart revealing the disclosure and the pt's understanding.

I hope she is at least OK with the IV.

 

[InGasWeTrust]

Informed consent documented on chart

Pre02

Cricoid pressure

Stick of white stuff, followed by half a stick of sux

Tube

wake up


Onto next case.......

 

[Noyac]

She goes to sleep.

What more do you have to explain to her that is not already written on the typical GA consent?

 

[militarymd]

She goes to sleep.

What more do you have to explain to her that is not already written on the typical GA consent?

bingo

 

[jwk]

I'm somewhat playing devils advocate here, because I've done many hundreds of GA C-Sections without incident.

However - as I noted previously - the key word is ELECTIVE. We would not offer a general anesthetic to someone simply because that's what they want because they don't like needles. We're not forcibly going to stick a needle in someone's back. But we will also not be forced into doing something that is not consistent with a well-recognized standard of care. For an ELECTIVE C-Section, we would simply tell the patient that we would not be able to offer her a general anesthetic on these terms.

 

[militarymd]

I'm somewhat playing devils advocate here, because I've done many hundreds of GA C-Sections without incident.

However - as I noted previously - the key word is ELECTIVE. We would not offer a general anesthetic to someone simply because that's what they want because they don't like needles. We're not forcibly going to stick a needle in someone's back. But we will also not be forced into doing something that is not consistent with a well-recognized standard of care. For an ELECTIVE C-Section, we would simply tell the patient that we would not be able to offer her a general anesthetic on these terms.

The phrase "Standard of Care" is a VERY strong phrase.

Can you show me where is it published or written where the "standard of care" for elective C-Section is regional anesthesia.

Which society has such published "standards"?

 

[Conflicted]

This is an excellent discussion

One of the questions I would ask is about liability.

Now i realize that the incidence of risk during GA in extremely low. However, it is also true that the majority of anesthesia lawsuits result from airway issues with pregnant patients under GA.

Does this cocnern you or is it an acceptable risk to meet patient request?

While a GA consent is standard, it is by no means protective against a lawsuit. So if something went wrong and the baby was harmed or died, you could bet the mom/family will testify in court that had they known this could happen they would have never consented.

Has anyone had any experience in this regard?

 

[timtye78]

You can be sued for anything at any time. Believe it or not, you can be sued even if you did everything right. So others have made the important question:

Is epidural/spinal standard of care?


'Elective' unfortunately is a tricky situation. Many 'indicated' C/S are called elective if they are done between 9-5. Most obgyn still tell the patients that
C/S in not THEIR choice. It is published that objection is a contraindication to RA. Declining a case based on this will cause you to justify to the obgyn why you are not going to do the case. If you feel this strong about it, its your choice. Are you willing to tell the head of your anesthesia group why you declined the GA C/S?

So, if it were me..How is their airway exam? What are their platelets? Comorbidities? Discussing the IV might be a good idea actually, because a 20g angiocath is bigger than the 25g you are going to use for numbing up her back for the epidural. Is she afraid of seeing the needle-b/c she wont ever see the needle.

Interesting discussion..I think I will ask my attendings what they think.

 

[fval28]

I have found that the OB's assistance in these types of situations go a long way. They have a relationship with the patient and can help with stating your case to her in a way that may be the most persuasive.

Not to say GA is a bad choice but in this case it seems as if her reticence is born more of ignorance than knowledge of her risks involved with the procedures.

By the way, if its for an elective section, why not just a spinal? I have convinced more than a few patient to have a spinal once I showed them the thin little 25-27 ga whitacre and compared it to the 18 ga IV that they already have in their hand.

 

[militarymd]

For you ...Have to do Spinal crowd.

Something to thnk about....In Germany...over 70% of elective C-Sections are done under GA.

Do you really think that the Germans are dumber than us?

 

[jwk]

For you ...Have to do Spinal crowd.

Something to thnk about....In Germany...over 70% of elective C-Sections are done under GA.

Do you really think that the Germans are dumber than us?

I would be willing to bet that the medicolegal climate in Germany is substantially different than our litigious society here.

 

[militarymd]

I would be willing to bet that the medicolegal climate in Germany is substantially different than our litigious society here.

I am pretty sure that their neonatal mortality rates are about half of the United States.

So regardless of what their lawyers are doing....their doctors are doing something right.

 

[Conflicted]

mil and jwk

You both make excellent points.

While Germany may be doing something right medically, unfortunately we have to live with the legal system in the USA.

Do you feel there is real concern there or not?

 

[ZA_Gasman]

To my mind, this is a no brainer. However, I'm not practising in your litiginous environment, and the following should be taken in that context, and discarded as worthless if you should so feel.

Good informed consent - no more, no less than a regular informed consent procedure, mention the increased risk of aspiration.

Good airway assessment - we all do this properly, don't we? 😕

If she is really scared of needles - EMLA cream, small IV line for induction and change it afterwards.

Pump the agents, and shove in a tube.

What is the problem? I'm with MilitaryMD here. As far as I'm concerned, anyone who calls themselves an anesthesiologist, should have no qualms about doing a GA for a CS. If you take reasonable steps to avoid complications, then you are doing your job as a professional. I'm continually amazed at how the legal profession has the american medical system at their mercy. Since when is a jury of non-experts qualified to say whether or not you as a specialist anaesthetist made the right decision. Bl@@dy H##L!

Would the medico-legal situation be any different if you had a patchy/failed spinal and had to convert? Surely informed consent for spinal would encompass this possibility (I know mine does)?

Personally, I have a problem with advocating Spinal anaesthesia as standard of care. AFAIK, there is some controversy about this. We have to remember that we are service providers, and our patients are our consumers. If she doesn't want a spinal, we have no right to force it on her.

/Ducks behind desk....

 

[jwk]

I am pretty sure that their neonatal mortality rates are about half of the United States.

So regardless of what their lawyers are doing....their doctors are doing something right.

Isn't the concern more with maternal mortality as far as general vs regional?

 

[militarymd]

Isn't the concern more with maternal mortality as far as general vs regional?

It was just a statement about the quality of healthcare that is delivered in places other than the US

 

[Noyac]

Why all the talk of the litigious nature in the US? How many of you guys have actually been sued? You perform a good safe anesthetic whether regional or general and you are safe, in almost all circumstances. Of course there are exceptions, but you can't worry about the exception.

 

[nimbus]

One of the few useful things I learned during my psych rotation in medical school was the concept of a "therapeutic alliance". Patients generally do better when they believe their doctors care about them and want to do their best for them.

Sometimes patients put us in difficult positions by asking us to do things which we believe are wrong or suboptimal. This case is a good example. Another are Jehovah's witnesses about to undergo major procedures. As previously stated, it is important to inform them of the additional risks of having nonstandard or unconventional care. Beyond that I generally abide by their wishes.

Assuming no other complicating factors, this case is pretty much a no brainer to me. I explain to her why a spinal is the preferrred anesthetic technique for this procedure but that neither technique is perfect or risk free. I tell her that in my experience, most women would choose this technique again if they have a choice. I would tell her there is a SLIGHT increased risk of death and some other complications with GA. At the same time, I would REASSURE her that she and her baby will most likely do fine even if she has a GA. Then I would put her to sleep. I would NOT WASTE half an hour trying to make her feel like an idiot or try to scare her more than she already is in order to change her mind.

 

[militarymd]

Where's the data on the "SLIGHT" increase in risk with GA?????

Show me the data.

 

[Doc13]

Actually, according to the following reference, The case-fatality risk ratio for general anesthesia was 2.3 (95% confidence interval [CI], 1.9-2.9) times that for regional anesthesia before 1985, increasing to 16.7 (95% CI, 12.9-21.8) times that after 1985.

This data was compiled on all births in the US from 1979-1990. The data may not be too helpful because most likely, the sickest patients were done with GA, so its hard to say if GA is "higher risk", but we can say that far more patients undergoing GA die during delivery than those undergoing regional.

Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990.
Hawkins JL - Anesthesiology - 01-FEB-1997; 86(2): 277-84

 

[militarymd]

Actually, according to the following reference, The case-fatality risk ratio for general anesthesia was 2.3 (95% confidence interval [CI], 1.9-2.9) times that for regional anesthesia before 1985, increasing to 16.7 (95% CI, 12.9-21.8) times that after 1985.

This data was compiled on all births in the US from 1979-1990. The data may not be too helpful because most likely, the sickest patients were done with GA, so its hard to say if GA is "higher risk", but we can say that far more patients undergoing GA die during delivery than those undergoing regional.

Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990.
Hawkins JL - Anesthesiology - 01-FEB-1997; 86(2): 277-84

Bias.

GA only when there is an emergency....Is it the "emergency" that causes the increased mortality or the GA...

You can't sort it out...UNLESS you do a prct

 

[Conflicted]

true

I wonder how a lawyer would read it and use it? All they will see is a stat that says almost 17X higher mortality with GA.

I think noyac makes a good point, its rare. On the otherhand, once it happens i think your position is indefensible.

 

[nimbus]

Honestly, I do not think about lawyers during my daily clinical decision making. I document important aspects of care but this is more for my colleagues who may run across a patient in the future.

 

[fakin' the funk]

No RCT data on this topic?...

The data may not be too helpful because most likely, the sickest patients were done with GA, so its hard to say if GA is "higher risk", but we can say that far more patients undergoing GA die during delivery than those undergoing regional.

Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990.
Hawkins JL - Anesthesiology - 01-FEB-1997; 86(2): 277-84

 

[ZA_Gasman]

No RCT data on this topic?...

Unlikely. Which ethics committee is going to give approval for such a study in this day and age? It is going to be one of those issues we'll probably never get to the bottom of, because of all the confounding variables.

Intuitively, it would seem that GA is more dangerous, because we do so many spinals, and airway mx in the parturient becomes rusty, and that is certainly what we are noticing in our setting.

Couldn't find any recent papers which are helpful. The UK report on confidential enquiries into maternal deaths 1976-1978 confirmed spinal safer than GA, but the concerns of bias towards emergency/sick patients in the general group remain.

 

[amar_ml]

Why all these deliberations. Regional anesthesia is contraindicated if patient refuses. Go ahead with GA. Moreover its an elective case. Prepare yourself for it and prepare the patient too. There is nothing much frightening in GA as such, you just need an RSI and with hold opiods till baby is delivered.🙂

 

[achieman]

dont' talk patients into things they don't want. What if you talked the patient into a spinal and a complication occurred, like hematoma and she end's up paralyzed. You then will have a MEGA lawsuit, with the patient stating "I didn't want it done in the first place ,but the doctor FORCED me into getting the spinal, telling me its his/her way or no C section".

 

[pgg]

I am pretty sure that their neonatal mortality rates are about half of the United States.

How's Germany's neonatal mortality rate calculated?

I ask only because I just roll my eyes whenever unwashed hippies people cite the lower "infant death rate" in (for example) Cuba as evidence that their medical system is better than ours ... when the truth is that the numbers aren't comparable. Eg, we count every 25 week crack baby who made it out of mom alive as a dead baby and they count the 33 week preemie who dies in their ghetto fly-infested "hospital" as a stillbirth or apply some other non-dead-baby term.

In any case, neonatal mortality rate in a 1st world country, however it's calculated, probably as much to do with the demographics of the nation as its medical system.

... or if the medical system is a factor, I'd bet that free access to prenatal care in Germany is a bigger factor than whether the anesthesiologist chooses a big needle or a little needle.

I know you're not an unwashed hippie and Germany is not Cuba. 🙂 Just asking.

 

[militarymd]

How's Germany's neonatal mortality rate calculated?

I ask only because I just roll my eyes whenever unwashed hippies people cite the lower "infant death rate" in (for example) Cuba as evidence that their medical system is better than ours ... when the truth is that the numbers aren't comparable. Eg, we count every 25 week crack baby who made it out of mom alive as a dead baby and they count the 33 week preemie who dies in their ghetto fly-infested "hospital" as a stillbirth or apply some other non-dead-baby term.

In any case, neonatal mortality rate in a 1st world country, however it's calculated, probably as much to do with the demographics of the nation as its medical system.

... or if the medical system is a factor, I'd bet that free access to prenatal care in Germany is a bigger factor than whether the anesthesiologist chooses a big needle or a little needle.

I know you're not an unwashed hippie and Germany is not Cuba. 🙂 Just asking.

deaths per 1000 live births......

My statement is related to just overall state of medical care...and not just about anesthesia.

 

[pgg]

deaths per 1000 live births......

Yes, but the point is that different countries define a "live birth" differently.

In the US, the 22 weeker who dies after 18 hours in the NICU is a live birth. In many countries the same unfortunate kid would be viewed as a fetal death and would not be counted in a statistic pertaining to infant mortality.

This is how Cuba claims "lower infant mortality" than the United States. I was just curious if Germany or other 1st world countries with socialized medicine (and its implications for expensive care on high mortality patients) cooked their statistics the same way.

 

[Noyac]

with hold opiods till baby is delivered.🙂

I'm not so sure about this. I have seen many providers do many different things and some of them will give fentanyl on induction. I have never seen it become an issue with the infant.

 

[2ndyear]

Ever see what the OB's do to people who decline epidurals? "Morphine sleep" is one term for it. I've seen PCA's used as well in the L&D area before birth.