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This one should go pretty quickly, but some of you new attendings may not have come across this in the past.

35 y/o female presents with pre-eclampsia and contracting. 2cm. X2 previous C/S. Baby is breach. Stopped by Mccdonalds on the way to the hospital. Short and Obese. MP IV, HM 1 FB, thick neck. Previous history of T12-S1 posterior lumbar fusion.

B.P. 235/120
FHR 180's

OB calls and is pushing for a C/S.

What do you do?
 

G0S2

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Non reassuring airway and McD.

Check plts and trend. Coags.

Slow dosed epidural. Have US available to look at spaces.

If wet tap place cath and slowly dose.

I'd place an art line beforehand.

Once epidural in and FHR reassuring I would wait as long as possible prior to CS.

Emergency airway cart in OR in case **** hits fan.
 

RxBoy

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Non reassuring airway and McD.

Check plts and trend. Coags.

Slow dosed epidural. Have US available to look at spaces.

If wet tap place cath and slowly dose.

I'd place an art line beforehand.

Once epidural in and FHR reassuring I would wait as long as possible prior to CS.

Emergency airway cart in OR in case **** hits fan.
This.... except intentional wet tap with cath placement. Not taking chances with epidural anesthesia. Titrate slowly. Also get backup help. Make sure tighter bp control and on mag.

All else fail:

Afobi with a-line and esmolol/nitroglycerin on hand. Gonna be tricky doing an afobi on a pt with sky high bp and high risk of stroke.
 
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G0S2

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That's why neuraxial is first choice.


AFOI will be hard. Hypertension, stroke. I'd use some Precedex but I'm really worried about McAspiration.
 

caligas

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If they are pushing for c/s as the pt hits the door, unlikely you will get to wait for coags/platelets.

This case is a question of airway management, and the answer is awake intubation, by whatever means is most effective for you.
 

Noyac

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Can someone please tell me why this is so urgent? I don't see it.

Treat BP. Wait 6-8 hrs if pt doesn't progress to complete and as long as baby is stable. This is not emergent.
 

Colba55o

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wouldn't attempt neuraxial on this patient if she's going for section. T12-S1 fusion will make neuraxial difficult and the poking around would probably drive her bp up as much as an AFOI would.

preop A line
if she's tachy titrate in esmolol if brady NTG.
topicalize and reassure that this is the best choice. Hx of 2 previous CS could be at risk for accreta, intraop hemorrhage, HELLP and other badness. Her fusion probably increases her risk for failed neuraxial anyway. I don't want to deal with having to convert to GA intraoperatively. FHR is stable so we have time to do a controlled AFOI
 

Noyac

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wouldn't attempt neuraxial on this patient if she's going for section. T12-S1 fusion will make neuraxial difficult and the poking around would probably drive her bp up as much as an AFOI would.

preop A line
if she's tachy titrate in esmolol if brady NTG.
topicalize and reassure that this is the best choice. Hx of 2 previous CS could be at risk for accreta, intraop hemorrhage, HELLP and other badness. Her fusion probably increases her risk for failed neuraxial anyway. I don't want to deal with having to convert to GA intraoperatively. FHR is stable so we have time to do a controlled AFOI
This is a good board response.
I personally would probably try a spinal but that's me. In 8 hrs though.
 

drcrispmd

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The baby is tachy. It would depend on the variability of the fetal strip. Tachy alone is not a sign of distress but with minimal variability or decels then baby would need to be delivered sooner than later.

PT is at risk for HELLP regardless of how many c/s they have had when they have bp that high. I have seen several G1 with HELLP.
 
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This is a good board response.
I personally would probably try a spinal but that's me. In 8 hrs though.
Same here. The OB may be pushing for a section, but unless the baby is in distress, the OB can kiss my a_ss.
 

Ignatius J

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Same here. The OB may be pushing for a section, but unless the baby is in distress, the OB can kiss my a_ss.
No neuraxial with the fusion.

Talk to OB. I bet I can talk her into waiting for basic labs and T/S (20 minutes at our hospital.) place a-line while I wait.

If she says it is an "emergency", then I document and move on. Previous contracting with severe pre-ecclampsia is good enough for me.

A-line. Rapid sequence induction w/ CMAC/fiber optic/fast track LMA immediately available.

RSI w/ CMAC (my back up preference). Hope for the best. LMA Supreme down the hatch if unsuccessful and quick suctioning.
 

G0S2

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There is time.

Airway bad and just ate.

Neuraxial in the setting of a fusion is possible and has been done many times. I've done it. You are OBLIGATED to attempt an epidural or neuraxial cath given the time currently allowed provided plts and coags ok.

If neuraxial no go due to plts or coags then there is time to prepare for securing airway.
 

caligas

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The macho stuff plays great on an anethesia message board. But If you delay when the OB is pushing for c/s, they will hang your ass out to dry if baby does poorly. They form the obestric plan, not us. We form the anesthetic plan based on their obstetric plan.
 

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I also agree with waiting to get labs. Hook baby up to monitor and put in a-line while waiting for labs. Labetalol IV and nitro gtt to get that pressure down. If baby shows signs of distress then I would go to OR with GA and awake fiberoptic. Good topicalization and some precedex +/- alfentanil in very, very small doses.

Either way, I wouldn't delay the case for more then a hour. I want plts, coags and T&C for four units - would like to have this all before going to the OR even if I am planning on GA. I agree this pt is at risk for accreta thus I would want to know where the placenta is located on ultrasound. Even though ultrasound isn't fantastic, if the placenta is posterior, the risk is much lower.

If plts and coags fine - then it would be a spinal catheter. I also wouldn't want to rely on an epidural in this pt since her vertebral anatomy is all messed up and the block wouldn't' work. I would explain she has a 50% chance of PDPR (and possibly not have treatment options since a blood patch also may not work) but this risk is small compared to her risk of aspiration +/- difficult intubation which all is much worse. Of course if pt refuses then it would be GA with fiberoptic.

I would test the hell out of that spinal catheter before actually letting the OBs start too … I don't want to be doing an emergency intubation mid surgery b/c the block suddenly doesn't work.
 
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pjl

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The macho stuff plays great on an anethesia message board. But If you delay when the OB is pushing for c/s, they will hang your ass out to dry if baby does poorly. They form the obestric plan, not us. We form the anesthetic plan based on their obstetric plan.
To be more accurate, almost all risk is to mother in this case, so it will be when she strokes out, they will blame you for not allowing definitive treatment of delivery of child.
That said, BP management first is prudent.
 
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What do you do?
Ask her why the hell she got pregnant and if she understands the concept of birth control. Then talk to the OB/GYN and suggest what they used to call in residency a "merciful" tubal ligation during the procedure.
 
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Seriously, good suggestions here. GA after adequate control of the pre-eclampsia (mag, BP control, etc.). It's usually never as bad as you think it's going to be, especially with the Glidescope these days. RSI. Talk to the baby-daddy and family. And pray. And make sure she understands just how stupid the McD's trip was on the way to the hospital. And...

DOCUMENT, DOCUMENT, DOCUMENT.
 
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Great answers.

Not sure about the "stroking out" commnet as i've seen exactly zero strokes with pre-eclampsia when BP is treated appropriately. I've seen plenty of seizures, but not strokes. So why not just treat the HTN?

Do we really need to go right now with this C/S? Why or why not? Cuz the OB want's to isn't good enough for me or the patient.

An NPO difficult AW carries some risk. A difficult AW with a big mac and french fries + a 40 week prego uterus carries a lot more risk. To me this is more dicey than anything else.

Labetalol works pretty fast... add some mag and maybe some other tocolytics or even a pre-emptive spinal catheter and I bet you can control that BP pretty fast.

This is not an emregent C/S based on the data given.

Epidural is out of the question with a Difficult AW (unpredictable with spinal fusion). Spinal or spinal catheter is the way to go IMO.

Treat BP. In the mean time give some reglan, get some labs and do a controlled spinal catheter or spinal. No need to rush things here. Wait 6-8 hours.
 
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Noyac

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No neuraxial with the fusion.

Talk to OB. I bet I can talk her into waiting for basic labs and T/S (20 minutes at our hospital.) place a-line while I wait.

If she says it is an "emergency", then I document and move on. Previous contracting with severe pre-ecclampsia is good enough for me.

A-line. Rapid sequence induction w/ CMAC/fiber optic/fast track LMA immediately available.

RSI w/ CMAC (my back up preference). Hope for the best. LMA Supreme down the hatch if unsuccessful and quick suctioning.
Wtf?
 

Noyac

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There is time.

Airway bad and just ate.

Neuraxial in the setting of a fusion is possible and has been done many times. I've done it. You are OBLIGATED to attempt an epidural or neuraxial cath given the time currently allowed provided plts and coags ok.

If neuraxial no go due to plts or coags then there is time to prepare for securing airway.
What makes you "obligated" to attempt regional?
 
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drcrispmd

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Great answers.

Not sure about the "stroking out" commnet as i've seen exactly zero strokes with pre-eclampsia when BP is treated appropriately. I've seen plenty of seizures, but not strokes. So why not just treat the HTN?

Do we really need to go right now with this C/S? Why or why not? Cuz the OB want's to isn't good enough for me or the patient.

An NPO difficult AW carries some risk. A difficult AW with a big mac and french fries + a 40 week prego uterus carries a lot more risk. To me this is more dicey than anything else.

Labetalol works pretty fast... add some mag and maybe some other tocolytics or even a pre-emptive spinal catheter and I bet you can control that BP pretty fast.

This is not an emregent C/S based on the data given.

Epidural is out of the question with a Difficult AW (unpredictable with spinal fusion). Spinal or spinal catheter is the way to go IMO.

Treat BP. In the mean time give some reglan, get some labs and do a controlled spinal catheter or spinal. No need to rush things here. Wait 6-8 hours.
What tocolytics are suggesting?
 

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In my experience trying to delay any OB from doing a c-section is impossible, but in this case I would insist on an 8 hour delay. Antihypertensives and mag are a must. Would hit her with reglan and bicitra. I would plan on waiting for the full 8 hours but I would have her teed up in case things went south. I would worry her epidural space was disrupted by her prior fusion making for a patchy block, so epidural is out. Spinal is a possibility if the labs are ok; but this may be a long case and there are complications and GA may be needed mid-case. I would opt for a GA with RSI with glide scope and emergency airway stuff ready.

Had a case similar to this two weeks ago. 35 yo G2p1 with twins and HELLP. Plts were 70 and trending down quickly so went with GA. She only had a bowl of fruit prior to coming in, no McD's.
 

Colba55o

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OBLIGATED to attempt regional? Please elaborate.

With a full stomach AND a difficult appearing airway AND high risk of intraop complications why put yourself in that predicament of having to secure an airway emergently? (high spinal anyone?) Of course preeclamptics are sectioned under spinal all the time, but the OP made a point of how crappy her airway looks.

I would send labs but dont think in real life would wait for the results as they wouldn't change my management. I'm more worried about a lost airway than about spinal hematoma.
 

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How does delaying for 8 hours change her npo status? Shes still a laboring pregnant woman, I'm not sure any amount of time would remove the mcdonalds from her stomach.

What about passing a big ol' NGT and sucking out as much as possible? :barf:





..........what does the birth plan say to do in this situation????? :rolleyes:
 

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i'd look at the last platelet count available - and if reassured i'd treat BP then go to spinal.
epidural I think would be likely to fail due to poor spread of LA.

otherwise - remi bolus -- propofol -- sux -- mac3 ... plan B VLS ... plan C LMA
 

Planktonmd

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No neuraxial with the fusion.

Talk to OB. I bet I can talk her into waiting for basic labs and T/S (20 minutes at our hospital.) place a-line while I wait.

If she says it is an "emergency", then I document and move on. Previous contracting with severe pre-ecclampsia is good enough for me.

A-line. Rapid sequence induction w/ CMAC/fiber optic/fast track LMA immediately available.

RSI w/ CMAC (my back up preference). Hope for the best. LMA Supreme down the hatch if unsuccessful and quick suctioning.
I think "hope for the best" should not be part of any anesthetic plan!
 

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Actually working on a preeclampsia talk right now (CA-2) while on my OB rotation. I read through the most recent ACOG guidelines for HTN disorders in pregnancy yesterday, which includes preeclampsia. (Interesting tangential fact: proteinuria is no longer required to make diagnosis if patient has other severe features in absence of proteinuria).

To my knowledge, after reading the ACOG guidelines and the chapter in Chestnut... I need to know a few things before proceeding:
1. What is the gestational age of the baby? Is it <34 weeks or >34 weeks. If <34 weeks the fetus needs steroids. Can we use tocolytics (mag, procardia, etc)? Patient is getting mag regardless with her numbers, but we can likely slow down labor with other adjuncts, too.
2. We haven't even started treating the HTN yet. Severe HTN is not an indication for surgery. Severe HTN that is recurrent and/or REFRACTORY to treatment is an indication. Yes, the patient's blood pressure is very high and this is frightening given the concern for potential cerebrovascular hemorrhage, MI, pulmonary edema, etc.... but "I want a c-section" from the OB isn't an indication.

So, in my mind this sets up two scenarios:
1. The fetus is <34 weeks. I would give steroids and attempt to control hypertension with your drug of choice (labetalol, nitroglycerin, hydralazine, etc). If refractory to treatment then would proceed to OR regardless of gestational age with an AFOI given the fact that I don't know what the patient's platelets are. If I have platelet information and its acceptable, would probably place a spinal catheter given concern for patchy epidural and probable lengthy procedure given two prior c/s and possibility of accretta/percretta, hemorrhage, etc. Art line. If spinal cath attempt was unsuccessful, would proceed with AFOI with field blocks (glossopharyngeal, SLN, and trans-trach). Takes <3-5 minutes from start of blocks to tube. Esmolol right before tube goes into mouth for help with BP/HR control. Induce once tube is in place. Airway trumps everything here.
2. If fetus is >34 weeks. would do all of the above with exception of fetal steroids IF my treatment for HTN was unsuccessful, but I would treat the HTN first. Get platelets, coags, type and screen/cross.

Unless the patient is having other "severe features" such as signs of cerebral vasoconstriction (severe HA, changes in vision), elevated liver enzymes, severe thrombocytopenia, newly developed acute renal failure (>1.1 or doubled in absence of other disease), pulmonary edema, or poor fetal metrics (Biophasic profile, neonatal stress test).....I would TREAT the hypertension and only proceed if it was refractory to treatment.

This all comes from a lowly CA-2, but the literature is pretty fresh right now.
 

Noyac

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This is not a difficult case if you discuss with the OB and have a solid plan. There should not be a precreta/accreta by surprise. These pt get US exams usually throughout the prenatal course. And even if she had no prenatal care an US should be done prior to c/s. But we all know that surprises can occur so it should be on your mind.


If this were any other type of OR case the McD's wouldn't be a reason to delay if the case were urgent at all in my book. But a c/s with BP like this I feel there is time to treat and not jump into something willynilly. HELLP synd is possible but I have taken care of my fair share if these and still some delay will not drastically impact the case. If HELLP were bad enough she wouldn't have eaten since her RUQ pain would have probably been too bad.

This airway is probably going to be ok BUT it has potential to be real bad, especially with the Big Mac. Delay is warranted in my opinion. If OB feels it isn't wise to delay then have them document why.

Tocolytics are an option. Be aware of terbutaline and tachycardia in this setting however.

So with all this work done on her spine there are a couple things I want to know. Did she have a spinal for either of her other c/s cases? And did they work well? What dosing was used? I think in a boards scenario there is a eal potential for a high spinal here if you go that way. In real life the potential is less but still present. So what dose would you guys give if you choose to go with a spinal?

As far as airway goes, if I'm not doing a spinal then I want the BP better controlled. If labetalol doesn't do it then I'll start a NTG drip if they are pushing to go now but remember, she will bleed more and the uterus won't contract well so you need to have a plan here. This is one big reason I would push for some delay in order to get BP controlled better. I do not want to be needing NTG if I can avoid it. If we are going now and this airway truly looks as bad as described then I'm doing an awake intubation of some sort. How we choose to do this is left up to the anesthesiologists discretion.
 

Noyac

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You would not use terb in a patient hypertensive or a baby with tachy. This will drive up the BP and the FHR even more. Not an option at all in this case. Also you don't use tocolytics on a full term pregnancy.
I've seen it used often on full term pts.
Like Sevo said, it's the OB's call.
 

G0S2

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Why are you obligated?

Because of a horrible airway, obesity and McD on way to hospital. Intrathecal catheters have been successfully placed after a fusion. I've done it and there are case reports. This is not a rush to the OR. You will have time to try. With the high BP you could very slowly dose.

If you don't try and just go for an awake FOI and she aspirated it just looks bad. If you couldn't get a neuraxial block and document that in chart then you are better "protected" from a bad GA event.

This is my humble opinion and I'm only 1 yr 4m in PP. I would try.
 

pgg

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I would have little faith that an epidural would provide reliable, uniform anesthesia after that back surgery.

I would, however, be confident in a spinal, assuming I'm able to actually put the needle into the CSF. Which I would expect to be able to do. It's not like fusions put a layer of armor plating over the spine ... at worst the hardware limits optimal patient positioning, but there's room to get past the hardware. I would also have every expectation that a single shot spinal would produce reliable, even anesthesia to a similar level as in a similarly sized patient without hardware. There's no reason to think the hardware would influence the spread of a drug injected on the other side of the dura. But, if for some reason you did think a high spinal was a significant non-oral-board, in-real-life risk, then an intrathecal catheter dosed incrementally is a good answer ... and might even be technically easier than a spinal in a short obese woman whose back won't bend well to get her in good position.

A spinal, after some BP optimization while waiting for basic labs, would be my plan. Unless the OB declared it to be an emergency, which I just don't see from the presentation, there is time.

If she refused regional, AFOI. If we're really in an emergent crash for some reason, I might even consider an awake Glidescope look after some hurried topicalization.
 
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Noyac

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Because of a horrible airway, obesity and McD on way to hospital. Intrathecal catheters have been successfully placed after a fusion. I've done it and there are case reports. This is not a rush to the OR. You will have time to try. With the high BP you could very slowly dose.

If you don't try and just go for an awake FOI and she aspirated it just looks bad. If you couldn't get a neuraxial block and document that in chart then you are better "protected" from a bad GA event.

This is my humble opinion and I'm only 1 yr 4m in PP. I would try.
Your post came into question because you stated that you or we were "obligated" to try regional. I and others here disagree with the inference that we are obligated. Our only " obligation" is to take care of our pt in the best manner we see fit. If regional is the best manner then so be it but I don't see an obligation to attempt regional here. I may attempt it if it were my pt but no obligation. And I'm sure a intrathecal catheter is a reasonable option. Nobody's is saying it isn't.
You bring up a good point in the defense of a disaster where you attempted a spinal but couldn't get it so went to plan B. But I doubt that really will matter in court. I may be wrong but I doubt it.
 
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G0S2

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Spinal fusion is not a contraindication to neuraxial and has been performed many times.

Neuraxial is preferred in all parturients unless clear CI or emergency situation.

This pt has a bad airway and just are a likely large greasy meal. This case is not an emergency as presented. It's urgent.

It is my opinion that you are obligated to attempt neuraxial in this pt after reviewing labs. A GA plan, in this pt, is plan B or plan A if it becomes an emergency.

You try neuraxial (spinal cath) and if no go, document and prepare for GA. I do believe that aspirating under non emergency conditions under GA after being on the ob floor for a few hours without attempting a neuraxial block would pose a challenge in court. Emergency is different. I realize she could aspirate even with neuraxial.
 

Noyac

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Spinal fusion is not a contraindication to neuraxial and has been performed many times.

Neuraxial is preferred in all parturients unless clear CI or emergency situation.

This pt has a bad airway and just are a likely large greasy meal. This case is not an emergency as presented. It's urgent.

It is my opinion that you are obligated to attempt neuraxial in this pt after reviewing labs. A GA plan, in this pt, is plan B or plan A if it becomes an emergency.

You try neuraxial (spinal cath) and if no go, document and prepare for GA. I do believe that aspirating under non emergency conditions under GA after being on the ob floor for a few hours without attempting a neuraxial block would pose a challenge in court. Emergency is different. I realize she could aspirate even with neuraxial.
I don't want to be an ass but you are missing the point, greatly.

It makes me wonder how you did on your oral exam. Or have you even taken it yet?
If I were your examiner, you would fail. And not because of your choice of anesthetic.
 
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chmd

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I would have little faith that an epidural would provide reliable, uniform anesthesia after that back surgery.

I would, however, be confident in a spinal, assuming I'm able to actually put the needle into the CSF. Which I would expect to be able to do. It's not like fusions put a layer of armor plating over the spine ... at worst the hardware limits optimal patient positioning, but there's room to get past the hardware. I would also have every expectation that a single shot spinal would produce reliable, even anesthesia to a similar level as in a similarly sized patient without hardware. There's no reason to think the hardware would influence the spread of a drug injected on the other side of the dura. But, if for some reason you did think a high spinal was a significant non-oral-board, in-real-life risk, then an intrathecal catheter dosed incrementally is a good answer ... and might even be technically easier than a spinal in a short obese woman whose back won't bend well to get her in good position.

A spinal, after some BP optimization while waiting for basic labs, would be my plan. Unless the OB declared it to be an emergency, which I just don't see from the presentation, there is time.

If she refused regional, AFOI. If we're really in an emergent crash for some reason, I might even consider an awake Glidescope look after some hurried topicalization.

I tried a few sedated glidescopes in residency but could never make it work, too much gagging. Suggestions?
 

Noyac

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I tried a few sedated glidescopes in residency but could never make it work, too much gagging. Suggestions?
Oh boy, I love the awake Glidescope. It's almost too easy. My first attempt was on a 650lbs guy in ICU who could not complete a 3 word sentence without his sat's dropping in the 60's, no ****. It did this one with the pt sitting upright and basically holding the scope backwards while standing in front of the pt. The last one I did was in ER with a pharyngeal abscess. Every time I do the awake Glidescope I'm surprised at how easy it is.
My approach is simple ( much like my AFOI).
-glyco if appropriate
-viscous lido gargle
-trans tracheal injection
-Glidescope
-tube.
 

pgg

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Topicalization and a motivated patient.

Edit - anything awake goes 1000x easier if you have good upper airway anesthesia. It can be done fairly quickly, as Noyac described. The awake flails I've been a part of, either as an observer or learner, have all had lousy topical anesthesia at their root.
 
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Jay K

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Agree with BP control.

Agree it's not an emergency.

Slight aside:
Boards answer IMHO would be AFOI with adequate topicalization and aspiration premeds for GETA with A-line and BP pre-treatment and in-line options, b/c if you choose SAB they're gonna make it a high spinal (and you'd tell them that was your concern) and now your emergent intubation will be a disaster. Slow dosing of a spinal catheter might be an option which will allow you/make them ask you all the pertinent details about bleeding risk with pre-eclampsia and HELLP, however if her previous spine surgeries result in a patchy block mid-surgery, it'll put you in yet another bad spot for the examiners to stymie you and offer another avenue for a disastrous emergent intubation and/or aspiration.

HOWEVER, if you're aware of and ready to "talk" about all these things, you might intentionally choose certain avenues so it gives you an opportunity to "dig" yourself out of trouble and demonstrate your knowledge. Though I feel you better be pretty bad ass if you feel like "gaming" your board examiners in such a fashion; I'm not certain I'd want to lead my fictional patient into aspiration just so I could talk about it and how it would be managed in the ICU post-op. Also, a final thought that most board examiners are testing to "weed out" anesthesiologists who would practice dangerously.

In practice, truthfully, I'd go with AFOI or awake Glidescope for a GETA as above.
 

JobsFan

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excuse my ignorance ... why is this patient at increased risk of a high spinal?
I know she's short and fat and pregnant ... am I missing something here? it seems like most of our obstetric population fits that description.
 

Libertas

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I think they're saying if spinal is your board answer on this case the examiner will likely go down the high spinal route