OB case

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sevoflurane said:
The one and only AW I have not been able to get in my career was an OB patient much like this one.
She ended up with an LMA. Not ideal...but I skidded by with a little luck.
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There are always exceptions. That's why I love ketamine and maintaining spontaneous ventilation for inducing most morbidly obese patients with nonreassuring airways. I can ventilate with a Supreme in 90+% of patients, I just don't like to pray for proper ventilation while she's burning O2 like a race car.

Was it with a glide/C-Mac, by the way? (Not that those can help much when the anatomy itself is unrecognizable.)
 
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There is absolutely nothing about this case that makes me think spinal. I can think of so many reasons not to do one...most of which have been mentioned. There is a high likelihood that this patient will need to be intubated anyway depending upon how she looks clinically. This is an urgent c-section, but not a crash section. Her airway needs to be addressed early. You don't want to have to worry about her airway if she decompensates during the procedure.
 
GravelRider said:
. This is an urgent c-section, but not a crash section. Her airway needs to be addressed early. You don't want to have to worry about her airway if she decompensates during the procedure.
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Now we are getting to some of the unusual points of this case that as anesthesiologists we don't necessarily think about.
This pt is awake and maintaining her airway. She is following commands and is in labor. BP stable at 100/70 HR- 100, FHR-130.
Ideas?
 
My guess is that she'll need the C-section before she qualifies for a neuraxial. Hence she needs to be optimized NOW for a semi-elective C-section. Hence she needs to be intubated while things are still under control (i.e. now), and go from there. What she doesn't need is having to be induced emergently for a crash C-section while in septic shock and while her airway is nonreassuring.

Btw, her platelets are 87 most likely because of her sepsis. 😉

Her stable status can be misleading. She's like many "healthy" urosepsis patients, easily controlled even just with high doses of phenylephrine, unless hugely bacteremic. But that can get worse.
 
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Noyac said:
Now we are getting to some of the unusual points of this case that as anesthesiologists we don't necessarily think about.
This pt is awake and maintaining her airway. She is following commands and is in labor. BP stable at 100/70 HR- 100, FHR-130.
Ideas?
Click to expand...

Any respiratory distress?
Can she lie flat?
Is the OB calling for a Stat or emergent C/S?
Proceed with case.
Secure the AW.
 
Noyac said:
Now we are getting to some of the unusual points of this case that as anesthesiologists we don't necessarily think about.
This pt is awake and maintaining her airway. She is following commands and is in labor. BP stable at 100/70 HR- 100, FHR-130.
Ideas?
Click to expand...

What does she look like, clinically? Is she breathing 40 times a minute? If so, is it from contractions or from being sick? How did her pressure stabilize? She was hypotensive at the start of the thread. Does she have increasing/decreasing/stable pressor requirements?

Based on what I know, I still think general anesthesia for an urgent section. Address airway concerns now before they have to be addressed in a more dire situation. I'm an anesthesiologist...I like to have control 😉.
 
GravelRider said:
What does she look like, clinically? Is she breathing 40 times a minute? If so, is it from contractions or from being sick? How did her pressure stabilize? She was hypotensive at the start of the thread. Does she have increasing/decreasing/stable pressor requirements?

Based on what I know, I still think general anesthesia for an urgent section. Address airway concerns now before they have to be addressed in a more dire situation. I'm an anesthesiologist...I like to have control 😉.
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Good questions.
RR 15-20 depending on ctx's
Leave'em'dead decreasing
Afebrile
Pressure stabilizing due to Zosyn presumably.
Plan?
 
Noyac said:
Good questions.
RR 15-20 depending on ctx's
Leave'em'dead decreasing
Afebrile
Pressure stabilizing due to Zosyn presumably.
Plan?
Click to expand...

If she's responding well to therapy and as you mention above, her tracing looks good, it's probably time to talk w/ the OBs about stopping the contractions. She's still early and ideally would deliver at a later date. Given that platelet count, she's still a general case for me, but maybe in a day or two her platelets will rebound as well.
 
d9sccr said:
If she's responding well to therapy and as you mention above, her tracing looks good, it's probably time to talk w/ the OBs about stopping the contractions. She's still early and ideally would deliver at a later date. Given that platelet count, she's still a general case for me, but maybe in a day or two her platelets will rebound as well.
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Ok, how would you stop ctx's.
Two ways for everyone's information,
Nifedipine
Terbutaline
And maybe fluid boluses, maybe.
 
Noyac said:
Ok, how would you stop ctx's.
Two ways for everyone's information,
Nifedipine
Terbutaline
And maybe fluid boluses, maybe.
Click to expand...

Personally, never made that call, but I'd probably lean towards terbutaline in this patient bc of the sepsis and prior septic shock picture. Plus, there's no antagonizing action with my pressors if things take a turn for the worse
 
This was my thinking during all of this as well. Nifedipine is out for obvious reasons but I wasn't sure about terbutaline. I didn't want her HR any higher so I was thinking it wasn't a good idea at the time. But now with things stabilizing somewhat it might be reasonable.
This was my discussion with the OB who obviously was making these decisions, not me.
OB tells me that terbutaline never works but it's probably worth a try.

How many times have you seen a pt come into your OR with a HR 140 after terbutaline. I saw it a lot when FP managed laboring pts and midwives of course. Not so much with OB.
 
d9sccr said:
If she's responding well to therapy and as you mention above, her tracing looks good, it's probably time to talk w/ the OBs about stopping the contractions. She's still early and ideally would deliver at a later date. Given that platelet count, she's still a general case for me, but maybe in a day or two her platelets will rebound as well.
Click to expand...

I agree with this. If she's improving clinically, we've identified and treated the source of her sepsis, and the fetus looks good, I would at least discuss the possibility of trying to stop her labor. I think she'll ultimately need the section, sooner rather than later. However, cautious observation is a reasonable way to go here.

In terms of stopping her labor, I would guess terbutaline, but I honestly would need to discuss that with the OB. I'm not putting a needle in her back at this point in time.

I would make sure the patient (and father) is very aware of the circumstances. I would ask if she can bear with us while we continue to stabilize her and try to stop her contractions. I still think we are heading towards c-section soon with general. I know I've done "urgent" sections for a lot weaker indications.
 
Noyac said:
Ok, how would you stop ctx's.
Two ways for everyone's information,
Nifedipine
Terbutaline
And maybe fluid boluses, maybe.
Click to expand...
Everything that will decrease her contractions will also drop her BP. Terbutaline is a Beta2-agonist, i.e. vasodilator.

AFAIK, contractions can rarely be stopped long-term, especially if the patient is contracting q2 min.
 
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Noyac said:
Good questions.
RR 15-20 depending on ctx's
Leave'em'dead decreasing
Afebrile
Pressure stabilizing due to Zosyn presumably.
Plan?
Click to expand...
Temporize, temporize, temporize. At least she may get out of septic shock by the time she needs the section. Still, at what point will you be comfortable doing a spinal in this lady? I personally would like to see her self-diuresing first, and those platelets rising, well above 100.
 
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Noyac said:
Maybe a dumb question, but why not let her deliver vaginally?
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While on pressors? That will be good (i.e. risky, I can see it turn into a crapfest).

If she's not in shock anymore, you are perfectly right about my tunnel vision. My problem is what happens when we she crashes/becomes hypotensive mid-vaginal delivery, because of the low reserve, big vessel compression etc.

At this point, it looks like she's turning around fast (like many urosepsis patients do, once the infection is under control). She'll probably be in a much better place in 24-48 hours, if only the baby can wait till then.
 
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Noyac said:
Maybe a dumb question, but why not let her deliver vaginally?
Click to expand...

I don't think this is a dumb question, but the patient would have to be willing to labor without an epidural...for now. I would like to demonstrate that her platelet count is also improving along with her hemodynamics and clinical status before I consider neuraxial again.

What is the vertical transmission of bacteremia? Is this a consideration? Do you monitor this by fetal heart rate alone?
 
Is the OB going to do the section or what?

Noyac said:
30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?
Click to expand...

Noyac said:
Ok, how would you stop ctx's.
Two ways for everyone's information,
Nifedipine
Terbutaline
And maybe fluid boluses, maybe.
Click to expand...

Noyac said:
This was my thinking during all of this as well. Nifedipine is out for obvious reasons but I wasn't sure about terbutaline. I didn't want her HR any higher so I was thinking it wasn't a good idea at the time. But now with things stabilizing somewhat it might be reasonable.
This was my discussion with the OB who obviously was making these decisions, not me.
OB tells me that terbutaline never works but it's probably worth a try.
Click to expand...
 
FFP said:
There are always exceptions. That's why I love ketamine and maintaining spontaneous ventilation for inducing most morbidly obese patients with nonreassuring airways.
Click to expand...

So you are going to take a look in a morbidly obese pregnant patient who may have a full stomach when she is not paralyzed?

What could possibly go wrong?😉
 
Arch Guillotti said:
So you are going to take a look in a morbidly obese pregnant patient who may have a full stomach when she is not paralyzed?

What could possibly go wrong?😉
Click to expand...
Obviously not with a full stomach. A full stomach is awake intubation vs RSI.

Now we can debate forever what qualifies as full stomach in a laboring patient. What if she hadn't had anything to eat for 12 hours before she went into labor, and then she had only ice chips or nothing for 2 days? What if she threw up at some point and hasn't had anything else PO for 24 hours? What if this, what if that? It's all a matter of risks/benefits, equipment/drugs and skills/experience.
 
FFP said:
Obviously not with a full stomach. A full stomach is awake intubation vs RSI.

Now we can debate forever what qualifies as full stomach in a laboring patient. What if she hadn't had anything to eat for 12 hours before she went into labor, and then she had only ice chips or nothing for 2 days? What if she threw up at some point and hasn't had anything else PO for 24 hours? What if this, what if that? It's all a matter of risks/benefits, equipment/drugs and skills/experience.
Click to expand...

So would you do it with this patient?

Assume she is 8 hours NPO.
 
Arch Guillotti said:
If this is an urgent c/s are you going to wait on ENT? What are they going to do for you?
Click to expand...

Well it COMPLETELY depends on the AW exam and the patients symptoms. Noyac said sausage lips on a morbidly obese patient. If the AW exams looks disasterous and the mother is currenlty doing ok YOU bet I would call an ENT surgeon. Mother first. No sense in knocking off mom with a full stomach if it can be avoided. How often would this scenario happen where I didn't feel comfortable with an OB AW? Hardly ever. But I do reserve the right to try and do the right thing if the situation demanded it.

If this C/S is emergent because of non-reassuring FHT AND mom looks like Jabba the hut with swollen eyes and lips then she gets priority and I do what I can to keep her safe. It's all a game of odds, but if the odds are highly unfavorable with prop, sux, tube, then I'm not rolling the dice. This is a classic board question.

I've have not had an ENT surgeon for an OB case, but I def. have had them while I tubed the patient on a hand full of occasions. (GSW to the face, Hereditary Angioedema, Throat/Oropharynx ca., ACDF/carotid bring back with impending AW loss, etc.).

As I mentioned in my previous post, the only AW I have not been able to secure was an emergent OB patient. Ended up with an LMA and got lucky.
If she had begun vomiting/aspirating copious amounts of gastric contents, she would not have done well. The whole case I was like... :xf::xf::xf: until it was over.
 
Arch Guillotti said:
If this is an urgent c/s are you going to wait on ENT? What are they going to do for you?
Click to expand...

What if this same patient showed up to your OB ward presenting emergently for C/S due to non-reassuring FHR and in the chart the notes say:
Falied intubation x 2 :wideyed:🙂
 
sevoflurane said:
What if this same patient showed up to your OB ward presenting emergently for C/S due to non-reassuring FHR and in the chart the notes say:
Falied intubation x 2 :wideyed:🙂
Click to expand...
What if you have a patient with known history of failed spinal and known difficult airway previously unable to be intubated for "urgent" C-section. This happened to a friend. Put in a spinal, failed (not high enough level). No time for anything else, put the patient to sleep, and indeed was almost impossible intubation and very difficult ventilation. LMA won't seat. Finally intubated via fiber-optic with the O2 sat in the crapper.

Scary. Personally, I would have augmented the spinal with some IV ketamine and seen how far we could go.
 
facted said:
What if you have a patient with known history of failed spinal and known difficult airway previously unable to be intubated for "urgent" C-section. This happened to a friend. Put in a spinal, failed (not high enough level). No time for anything else, put the patient to sleep, and indeed was almost impossible intubation and very difficult ventilation. LMA won't seat. Finally intubated via fiber-optic with the O2 sat in the crapper.

Scary. Personally, I would have augmented the spinal with some IV ketamine and seen how far we could go.
Click to expand...

AFOI v. AVL w/ Bilat TAPS for post-op pain
 
What is the ENT surgeon gonna do? The most id do is give the surgeon a heads up about a difficult airway. But the patient got 5L, i doubt she will be un awakeable.
 
FFP said:
While on pressors? That will be good (i.e. risky, I can see it turn into a crapfest).

If she's not in shock anymore, you are perfectly right about my tunnel vision. My problem is what happens when we she crashes/becomes hypotensive mid-vaginal delivery, because of the low reserve, big vessel compression etc..
Click to expand...
Then you turn her on her side some and crank the pressors. No biggie
 
GravelRider said:
I don't think this is a dumb question, but the patient would have to be willing to labor without an epidural...for now. I would like to demonstrate that her platelet count is also improving along with her hemodynamics and clinical status before I consider neuraxial again.

What is the vertical transmission of bacteremia? Is this a consideration? Do you monitor this by fetal heart rate alone?
Click to expand...
Not every laboring pt needs or deserves an epidural. Contrary to what their OB says.
In my book, this one goes it alone.
 
Arch Guillotti said:
If this is an urgent c/s are you going to wait on ENT? What are they going to do for you?
Click to expand...
If anyone says, "local on the field for c/s, I'm gonna ****."
I'd bet in this country there have been less than 5 cases of local for c/s in the past 10yrs. I have no idea. But this is an option for boards only, not the real world. You better find a way to do this case.
 
ill tell you what happened soon.
But as far as airway goes. If I was sitting in front of some board examiners this would be my response. Btw, if they give you this case and keep grilling you and pushing you then I would assume you are doing pretty well because there is no great answer here.
I think ENT is a great option but in my facility, it ain't happening. This is your baby. Get familiar with your emergent cric kit. If not then be ready to ask for a scalpel and make a big enough hole to place a 7.0 ETT. Then call surgery to come stop the bleeding because it will bleed. Or you could bovie the **** out of the area yourself. One way or another the ETT is going into the trachea. That's your answer.
Maybe in this order:
FHR below 60
Induce RSI
Tell OB to GO!
Glidescope, no beuno
Mask, no beuno
LMA no bueno, but in all likelihood it will work
Sats 40's and heart rate dropping
CUT!!!!!
 
Noyac said:
FHR below 60
Induce RSI
Tell OB to GO!
Glidescope, no beuno
Mask, no beuno
LMA no bueno, but in all likelihood it will work
Sats 40's and heart rate dropping
CUT!!!!!
Click to expand...

I had this happen to me on my first month of ob
 
Assuming you can't wait for her sepsis and Vasopressor requirement to abate, her swelling to go down/diuresis to occur, and platelet count to remain normal so you can neuraxial her;

And assuming no increase in urgency due to FHR shenanigans. I'd plan for AFOI, 2 good PIVs in addition to the PICC, and an a-line.

If it goes down more urgent/emergently I think you have to RSI her and quickly progress to blade, finger, bougie, ETT if the VL or LMA are unsuccessful. Though I've got to say I feel like I'd use the FOB thru an LMA that is successfully ventilating or give it one attempt before the neck cutting if the LMA fails and she's about to drop off the cliff. But of course this is a judgement call based on how long she's been apneic and where the SpO2 is at as well as your comfort with the FOB or cutting the neck.
 
sevoflurane said:
FHR in the 60s for the last 45 minutes....
Click to expand...

72ec92243f30edd0ff0c4acb4eec107f.jpg
 
Robotic Wis-Hipple said:
Assuming you can't wait for her sepsis and Vasopressor requirement to abate, her swelling to go down/diuresis to occur, and platelet count to remain normal so you can neuraxial her;

And assuming no increase in urgency due to FHR shenanigans. I'd plan for AFOI, 2 good PIVs in addition to the PICC, and an a-line.

If it goes down more urgent/emergently I think you have to RSI her and quickly progress to blade, finger, bougie, ETT if the VL or LMA are unsuccessful. Though I've got to say I feel like I'd use the FOB thru an LMA that is successfully ventilating or give it one attempt before the neck cutting if the LMA fails and she's about to drop off the cliff. But of course this is a judgement call based on how long she's been apneic and where the SpO2 is at as well as your comfort with the FOB or cutting the neck.
Click to expand...

Nice post Broseph. 👍

I've had ENT on standby for many intubations. Literally there in the room. It's not something to be ashamed of... because IF and WHEN your intubation leaves you stranded on an island it's nice to see an ENT boat on shore ready to throw you a line. Waiting for that boat to arrive might bite you in the butt some day. I COULD do the cric myself, but my N=0. I do like the 18G squirt through the cric membrane prior to handling a real AW disaster.
Of course I leave the 18G there ready if I need it.

Was recently called to the ED by none other than an ENT surgeon. Epiglottitis about to loose the AW. Wanted the patient intubated in the ED.
Went down there, shook hands with my ENT collegue and proceeded to handle the AW situation. They are dependant on us too... you know. So it's a 2 way street. Post-tonsillar bleed or ludwig angina at 2 am? It's a 2 way street out there.
 
Arch Guillotti said:
Same here. If you are that worried about the airway do an awake fiberoptic intubation.
Click to expand...
Fetus is dying. How are you gonna topicalize a septic, edematous, hysterical pt to perform an AFOI? This sounds like the answer but in reality, you are not going to do this. The edema alone won't topicalize enough to do it in a calm pt.
AFOI is not going to work, so don't waste your time or the fetus' last moment trying.
 
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