OB Case

[Dexter77]

Let's add another variable to the case: Pt also has a platelet count of 67. OB is calling it HELLP. Last result was >200 (2 days ago).
Who would change their plan to GETA? Who thinks the risk of aspiration outweighs that of hematoma and would proceed with spinal?

OB says it's urgent, needs to go in <30 min.

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[TIVA23]

have not started residency yet so this may not be the smartest answer but, why not awake fiberoptic intubation? I can't see it taking significantly longer than a spinal. If time is a significant factor then I would think RSI is best.

 

[deleted171991]

have not started residency yet so this may not be the smartest answer but, why not awake fiberoptic intubation? I can't see it taking significantly longer than a spinal. If time is a significant factor then I would think RSI is best.

Because just the effect of glycopyrrolate on the salivary secretion can take up to 20 mins to kick in, let's not mention all the topicalization etc.

This is RSI until proven otherwise. You can also do a quick gastric ultrasound on the patient, if the machine is easily available, to get an idea how full that stomach is, and maybe drop an NG first (or reconsider the plan).

Also, HELLP per se should not be a 30-minute emergency.

 

[Arch Guillotti]

Because just the effect of glycopyrrolate on the salivary secretion can take up to 20 mins to kick in, let's not mention all the topicalization etc

So do an awake intubation in a manner that does not require topicalization.

 

[deleted171991]

So do an awake intubation in a manner that does not require topicalization.

You mean ketamine (or similar)? I have no experience with it in full stomachs. Or do you mean nerve blocks with injected LA?

The saliva can still get in the way of the FO, so I would still need time for glyco.

 

[fakin' the funk]

You mean ketamine (or similar)? I have no experience with it in full stomachs. Or do you mean nerve blocks with injected LA?

The saliva can still get in the way of the FO, so I would still need time for glyco.

Hey uh, wtf are we talking about here?

AFOI'ing the not-fully-fasted urgentish Csection, or AFOI'ing the urgentish HELLP'er? Either way, why are we AFOI'ing?

 

[Arch Guillotti]

Hey uh, wtf are we talking about here?

AFOI'ing the not-fully-fasted urgentish Csection, or AFOI'ing the urgentish HELLP'er? Either way, why are we AFOI'ing?

Unanticipated tangent as the original scenario described did not indicate a difficult airway.

I think glyco is helpful but not at all necessary for an awe fiber done with nerve blocks. For topicalization it is very helpful.

 

[nimbus]

have not started residency yet so this may not be the smartest answer but, why not awake fiberoptic intubation? I can't see it taking significantly longer than a spinal. If time is a significant factor then I would think RSI is best.

It takes longer than a spinal.

 

[deleted171991]

It takes longer than a spinal.

The question is: would you do a spinal in HELLP with platelets of 67 (and probably still dropping), just a couple of days after they were 200?

 

[nimbus]

The question is: would you do a spinal in HELLP with platelets of 67 (and probably still dropping), just a couple of days after they were 200?

No

 

[deleted162650]

The question is: would you do a spinal in HELLP with platelets of 67 (and probably still dropping), just a couple of days after they were 200?

9 times outta 10 I'm just gonna put her to sleep, but under the right set of circumstances I could be talked into spinalizing her (no clinical coagulopathy, normal coags and TEG, seemingly easy spinal, very good reason to avoid GA, and a pt who is intelligent/reliable enough to understand the increased risk).

The trajectory of the platelet drop isn't really an issue for a SS spinal (assuming it's a fresh lab hot off the presses). It's not like there's a gonna be a catheter that needs to come out hours to days later.

 

[periopdoc]

And: maternal changes associated with pregnancy making far more difficult airway's

No.

Reduced FRC and higher VO2, but not more difficult airways.

SAB on the Original patient. RSI on the HELLPer with full stomach and platelets of 67.

If it's an elective case, then using regional to get around the NPO guidelines is indefensible.

This isn't an elective case, and SAB has the lowest risk of aspiration.

 

[Timeoutofmind]

No.

Reduced FRC and higher VO2, but not more difficult airways.

Ummm maybe read a text book or something?

 

[deleted162650]

Ummm maybe read a text book or something?

Ummmm maybe take care of a lot of OB pts or something before blindly following what the textbook says?

I'm with pod on this one.

 

[Ronin786]

Ummm maybe read a text book or something?

Many factors have been reported to contribute to airway difficulties in obstetrics including the influence of pregnancy-related physiological, anatomical, and pathological changes (Table 1). In contrast to commonly held beliefs, a systematic review found no evidence that tracheal intubation is more difficult in the obstetric population than in the non-obstetric population.4 Whether or not this is true, the consequences of failure to intubate may be more serious in the obstetric patient.5

https://academic.oup.com/bjaed/article/12/2/86/251341/Difficult-and-failed-intubation-in-obstetrics

 

[deleted171991]

No.

Reduced FRC and higher VO2, but not more difficult airways.

Most textbooks indicate increased engorgement and edema of the airway mucosa, which decreases its cross-section (hence the occasional use of smaller tubes) and predisposes to bleeding.

Not that I care, especially if I have a glidescope, it's just what the theory says.

 

[nimbus]

I wouldn't say never, but ob patients are young women and as a group young women have some of the easiest airways around. It's also seen in the bariatric population. They're just not hard. I think it has to do with the pliability and suppleness of their tissue. Kids too.

 

[pgg]

Ummm maybe read a text book or something?

 

[sevoflurane]

Most textbooks indicate increased engorgement and edema of the airway mucosa, which decreases its cross-section (hence the occasional use of smaller tubes) and predisposes to bleeding.

This is true. And it's true in practice as well, but not to the extent that the textbooks make it out to be. Every now and again (hardly ever) I'll see some real beefy arytenoids that are swollen and hyperemic. These patients are usually pre-eclamptic and have swollen faces and extremities. The glottic opening is therefore not as easily passed in a known patient with a difficult airway that is now pregnant. Certainly, the tube may get hung up more easily- maybe some would have passed the VC on the first try if not pregnant. I think that minute ventilation, decreased FRC, oxygen consumption and anemia are important issues during pregnancy as someone here described. Had a presumed large PE in a patient recently who ended up having peripartum cardiomyopathy. In respiratory failure when I got her. Just no reserve largely due to her 37 week pregnant status.

In most cases however, OB patients tend to be far easier airways compared to some of the general OR patients I take care of: big ENT cases, morbidly obese, s/p radiation, etc. I tend to think that the airways of the 20 year old pregos are generally easier than that of a 60 year old that has had most of his/her life to gain weight the American way and work on that neck circumference.

Now that is not to say that it doesn't in the OB population. Every now and again I bust out the harpoon tuhuoy and leave the catheter 5cm into the space and 18-2o cm at the skin.

But, going to do a stat c/s doesn't really set off the spider sense as much as doing an in the middle of the night ENT case for Ludwig's Angina/I&D of a submandibular abscess with thick woody edema on a patient that has well developed, life style driven Jabba the Hutt-like folds under his/her chin.

Woody edema associated with submandibular abscess.

IMO, OB is not even remotely close to the complexity of AW cases we tend to see in the ENT/trauma/general ORs. Therefore, spider sense generally stays on standby.

Just my 2cents.

 

[Hoya11]

I wouldn't say never, but ob patients are young women and as a group young women have some of the easiest airways around. It's also seen in the bariatric population. They're just not hard. I think it has to do with the pliability and suppleness of their tissue. Kids too.

I always thought they were usually easy airways because they were young. Young and fat usually no problem, Old and fat a different story

 

[IlDestriero]

The onco folks will do a spinal on the cancer kiddies if the platelets are >=28. We're probably overly conservative.


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Il Destriero

 

[pgg]

The onco folks will do a spinal on the cancer kiddies if the platelets are >=28. We're probably overly conservative.

We're probably overly conservative with NPO guidelines too - look at what the ER does and gets away with regularly. That's also not a line I toe, not an envelope I push.


Anyway, the r:b for intrathecal chemo for cancer is of course very different than for a c-section when GA is a very reasonable alternative. Also, thrombocytopenic parturients are thrombocytopenic for (several) different reasons than cancer kiddies. Platelet quality/function matters too.

It's an interesting line of thought, but the fact that kids get stuck down to 28K shouldn't have much bearing on how we think of platelet thresholds for c-section spinal.

 

[psychbender]

The onco folks will do a spinal on the cancer kiddies if the platelets are >=28. We're probably overly conservative.


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Il Destriero

Great, they can be called by L&D at 0300 for the stat section.

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[nimbus]

We're probably overly conservative with NPO guidelines too - look at what the ER does and gets away with regularly. That's also not a line I toe, not an envelope I push.


Anyway, the r:b for intrathecal chemo for cancer is of course very different than for a c-section when GA is a very reasonable alternative. Also, thrombocytopenic parturients are thrombocytopenic for (several) different reasons than cancer kiddies. Platelet quality/function matters too.

It's an interesting line of thought, but the fact that kids get stuck down to 28K shouldn't have much bearing on how we think of platelet thresholds for c-section spinal.

That said, our arbitrary cutoffs of 70k or 100k plts are not exactly scientific. Neither is 8hrs of npo. Why not 6hrs or 9 hrs or 10hrs? We've already changed the clear npo guidelines with ERAS protocols.

 

[deleted171991]

That said, our arbitrary cutoffs of 70k or 100k plts are not exactly scientific. Neither is 8hrs of npo. Why not 6hrs or 9 hrs or 10hrs? We've already changed the clear npo guidelines with ERAS protocols.

What probably happens is that, as enough case reports accumulate, we lower the thresholds accordingly.

In the end, everything in medicine is risks vs benefits, including the risk of getting PTSD and one's career destroyed from getting sued even when obviously innocent. I bet the guidelines are much less followed in places with world-class malpractice systems, where the term "defensive medicine" means only military healthcare. I had never encountered the concept before practicing in the US; one just did whatever one thought was right for the patient.

 

[pjl]

Do you have institutional limits to plt count for epidurals or spinals? What are they?


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[Noyac]

This thread is awesome. I'm not talking about he content or subject but the flow. We have here many opinions with some disagreements. But no name calling. Well done everyone.

Carry on.


Btw, I agree with most statements. Even if they are conflicting.

 

[deleted162650]

We have here many opinions with some disagreements. But no name calling. Well done everyone.

Carry on.


Btw, I agree with most statements. Even if they are conflicting.

What kind of long-hair, hippie, mountain man bullsh*t comment is that you ******?

There, now that's better.

 

[GigiBuffon]

No.

Reduced FRC and higher VO2, but not more difficult airways.

SAB on the Original patient. RSI on the HELLPer with full stomach and platelets of 67.

If it's an elective case, then using regional to get around the NPO guidelines is indefensible.

This isn't an elective case, and SAB has the lowest risk of aspiration.

NO? OB airways can give you one hell of a surprise. Swollen, edematous, friable... no VC, you're just looking for bubbling in between the pink folds. It would be funny if it hadn't frightened the $#*- out of me before. "He who approaches an OB airway without concern is a fool." And yes, on top of that, less reserve and higher O2 consumption.

 

[Arch Guillotti]

No.

Reduced FRC and higher VO2, but not more difficult airways.

Disagree 100%.

 

[sevoflurane]

BTW... what is it with the 70 year old skinny VCs that looks like Moses parted them open. Funny how age and habitus does play a real role in airway anatomy.
You guys know what i'm talking about right? Like you get out a 7.5 and really could have used an 8.5 easily in this sub-popuation- Visualizing a large set of tracheal rings on the way in.
I would venture to guess that in the same patient, 50 years earlier, the glottic opening was more narrow and not as accommodating.

Just an observation. Not sure of the studies out there that support this observation.

 

[periopdoc]

Read a textbook? How about read the studies that the textbooks are based on and then talk to the authors of those studies.

Can there be difficult airways in OB? Of course, just like there can be difficult airways in every OR. Are they more frequent in OB? No. Are the difficult ones predictable? Yes, just like they are in every OR.

Why were there so many airway complications in the studies that the textbooks are based on? Because the studies examined a time when OB was the bastard stepchild of anesthesia, and the attendings would send the CA-1s to manage the C-sections solo. Of course there were more airway complications when the least experienced individuals were managing them without any supervision.

This perception is reinforced by the fact pre-eclamptic, edematous patients, who have a contraindication to SAB, are heavily over-represented in the population of OB patients that get intubated now.

Empiric smaller tube for the uncomplicated parturient airway? Reminds me of the anesthesiologists who won't put a 8 ETT for EBUS in a female because "it's too big," but have no qualms about placing a DLT in the same patient when they return for their wedge/lobectomy/whatever. Have you compared the outside diameter of the two tubes? I might drop down a 1/2 size for a profoundly edematous pre-eclampsia patient.

Also, I might add... lube. Lube is your friend. KY Jelly isn't lube. It's shocking to me how many people don't use a good lube on their tube. They seem to be the same people who get this "stuck tube" phenomenon.

 

[dhb]

I've never felt like i needed to lube my ETT.

 

[pgg]

NO? OB airways can give you one hell of a surprise. Swollen, edematous, friable... no VC, you're just looking for bubbling in between the pink folds. It would be funny if it hadn't frightened the $#*- out of me before. "He who approaches an OB airway without concern is a fool." And yes, on top of that, less reserve and higher O2 consumption.

Did this OB patient just roll up from the ER after getting a GSW to the face?

Every airway deserves respect but OB fears are exaggerated.

 

[deleted171991]

And we're back to our regular programming on this forum: you don't know **** and you'll have to take my word for that.

 

[nimbus]

I've never felt like i needed to lube my ETT.

I only lube DLTs.

 

[Noyac]

What kind of long-hair, hippie, mountain man bullsh*t comment is that you ******?

There, now that's better.

Can you tell that I'm getting older and that I'm sitting in more and more meetings? If that isn't enough, I'm also getting more leadership and team building training. That should give you plenty of fodder to last the next few months.

 

[chrisv]

What do you guys think of Stat c-section + DA, spinal vs. GETA?

Stat c-section, OB says you have about 20-30 mins, hx of DA (chart biopsy shows fiberoptic used previously, no mass/radiation/weird stuff), she's NPO > 12 hrs...spinal or GETA? I would personally avoid spinal and attempt GETA (awake with topicalization otherwise some ketamine or precedex to maintain spontaneous ventilation) due to risk of high spinal or prolonged c-section.

Usually, I would choose an option to prevent (or circumvent) a problem (for example: you don't go around putting chest tube in a COPD patient before doing a central line just incase they develop a pneumothorax, rather you take preventative measures: ultrasound, low peak airway pressures etc). But in this scenario I'm choosing a moderately risk technique (intubation) to avoid a very rare although catastrophic and potentially un-salvageable event of high spinal leading to airway compromise.

Any thoughts? Do you see this as an either or situation? Or are you definitely on one side of this issue?

 

[deleted162650]

SAB all day. If you're worried then I'd probably go epidural before GA. If you're really scared sh*tless then spinal cath and dose her up slow and apologize in advance for the HA.

 

[risnwb]

What do you guys think of Stat c-section + DA, spinal vs. GETA?

Stat c-section, OB says you have about 20-30 mins, hx of DA (chart biopsy shows fiberoptic used previously, no mass/radiation/weird stuff), she's NPO > 12 hrs...spinal or GETA? I would personally avoid spinal and attempt GETA (awake with topicalization otherwise some ketamine or precedex to maintain spontaneous ventilation) due to risk of high spinal or prolonged c-section.

Usually, I would choose an option to prevent (or circumvent) a problem (for example: you don't go around putting chest tube in a COPD patient before doing a central line just incase they develop a pneumothorax, rather you take preventative measures: ultrasound, low peak airway pressures etc). But in this scenario I'm choosing a moderately risk technique (intubation) to avoid a very rare although catastrophic and potentially un-salvageable event of high spinal leading to airway compromise.

Any thoughts? Do you see this as an either or situation? Or are you definitely on one side of this issue?

Wait.... your rationale for intubating is that you MIGHT have to intubate after you do a spinal?


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[deleted171991]

Spinal, if you have and are good at using Supreme LMAs if needed.

Anyway, you are supposed to have a risks vs benefits discussion with the patient, and she should decide not you.

 

[Arch Guillotti]

What do you guys think of Stat c-section + DA, spinal vs. GETA?

Stat c-section, OB says you have about 20-30 mins, hx of DA (chart biopsy shows fiberoptic used previously, no mass/radiation/weird stuff), she's NPO > 12 hrs...spinal or GETA? I would personally avoid spinal and attempt GETA (awake with topicalization otherwise some ketamine or precedex to maintain spontaneous ventilation) due to risk of high spinal or prolonged c-section.

Usually, I would choose an option to prevent (or circumvent) a problem (for example: you don't go around putting chest tube in a COPD patient before doing a central line just incase they develop a pneumothorax, rather you take preventative measures: ultrasound, low peak airway pressures etc). But in this scenario I'm choosing a moderately risk technique (intubation) to avoid a very rare although catastrophic and potentially un-salvageable event of high spinal leading to airway compromise.

Any thoughts? Do you see this as an either or situation? Or are you definitely on one side of this issue?

SAB 100% of the time.

 

[chrisv]

Wait.... your rationale for intubating is that you MIGHT have to intubate after you do a spinal?


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Yes, that's what my oral boards (UBP) books tells me to do. I've been surveying A LOT of people on this issue. For elective cases, about 49.71% are leaning towards intubation. For urgent scenarios, most are likely towards SAB due to timing issues.

 

[chrisv]

Spinal, if you have and are good at using Supreme LMAs if needed.

Anyway, you are supposed to have a risks vs benefits discussion with the patient, and she should decide not you.

FFP for the save! Those examiners could've failed me for not including the patient in this decision. Every OB attending who shared difficult airway story saved the day with an LMA (maybe they weren't sharing botched trach stories since they can't speak of a unsettled lawsuits???).

 

[codeb1ue]

Not to prolong this exhaustive thread on the benefits of spinal over GA but if I may ask one more question...

What if this was an elective c-section and the patient ate a hearty breakfast on the way to the hospital? Would you delay the case? Or assume her stomach is full regardless and proceed with the spinal.


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[fakin' the funk]

Yes, that's what my oral boards (UBP) books tells me to do. I've been surveying A LOT of people on this issue. For elective cases, about 49.71% are leaning towards intubation. For urgent scenarios, most are likely towards SAB due to timing issues.

Sorry dude, but this is garbage.

 

[fakin' the funk]

What if this was an elective c-section and the patient ate a hearty breakfast on the way to the hospital? Would you delay the case? Or assume her stomach is full regardless and proceed with the spinal.

Delay for full NPO status. Stomach might be fairly full even after a fast, but it's definitely less full than right after a hearty breakfast.

 

[fakin' the funk]

Stat c-section, OB says you have about 20-30 mins, hx of DA (chart biopsy shows fiberoptic used previously, no mass/radiation/weird stuff), she's NPO > 12 hrs...spinal or GETA? I would personally avoid spinal and attempt GETA (awake with topicalization otherwise some ketamine or precedex to maintain spontaneous ventilation) due to risk of high spinal or prolonged c-section.

Think about what you're saying. Urgent C-section, otherwise uncomplicated, and you've put yourself down a garden path of AFOI, KETAMINE and PRECEDEX. Wtf?! How much more complicated can you make it?

 

[fakin' the funk]

I wouldn't say never, but ob patients are young women and as a group young women have some of the easiest airways around. It's also seen in the bariatric population. They're just not hard. I think it has to do with the pliability and suppleness of their tissue. Kids too.

This.

 

[chrisv]

This.

Good to know, but I had to ask since my oral boards book had me convinced to do an AFOI or at least a sedated FOI, and at first I thought it was strange answer, but it did have an appeal in terms of...can't go wrong with securing an airway. It might be ( a little) complicated but also very safe. I think the jury is still out.