OB Case

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ethilo

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Starting the night shift and this case came in 2 hours prior to my arrival:

25 yo G1P0 @ 39 week gestation, BMI 77, 210 kg, admitted for attempted IOL for fetal macrosomia and super morbid obesity.

PMH:
- Likely OSA, PSG scheduled in 3 weeks. Can lie flat and breathe comfortably if awake but sleeps on side at night due to waking up from obstruction. Worse since pregnancy.
- Mild intermittent asthma, uses inhaler 1-2x every 2 weeks. Worse since being pregnant.
- Chiari 1 malformation dx'd 2 years ago after workup for migraines, neurosurgery said no intervention unless symptoms become severe. Migraines have been infrequent (~q2 weeks) without neurologic symptoms.
- Category 1 tracing at a NST in clinic earlier this week.

airway exam is favorable - MP1, has some neck with good ROM. Previous Mac 3 Gr 2a 2 years ago for cholecystectomy.

Difficult to monitor baby continuously here due to body habitus, currently getting intermittent monitoring. Vaginal exam is closed. Cytotec was placed and it's causing some tolerable cramping currently.

OB wants to try IOL for 24 hours and see if there's progress but if any issues, their plan is to C-section.
 
So, what's the question?
If you want to do an epidural it's going to be a little bit challenging but you never know you might get lucky and look like a rock star.
If they decide to section her and you were not successful placing an epidural (likely scenario) then put her to sleep and intubate her.
I would just use video laryngoscopy if I were you.
Make sure you have an LMA and an extra pair of hands in the room just in case.
If you are not feeling adventurous then you can explain to her what an awake intubation is, do good topical anesthesia and/or airway blocks and do either FOB or good old glidescope.
 
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I'm just putting the scenario out there to hear what people's plans or thoughts would be. Thanks for the ideas!
 
Place the epidural, then use it if she needs a section. If it is patchy and you have the time, place a SAB. If the section is emergent and it is inadequate, do a GA. Not sure what you’re thinking about this scenario would require a different plan.
 
I'm guessing the big concern is for epidural with ACM1. Higher risks associated with a wet tap. The good thing is it's an easy pathway. Decide if you're doing an epidural or GA. If an epidural, get it in early and make sure it works so you can convert in an emergency. If GA, have your difficult airway equipment around. Wouldn't mess around with half measures or troubleshooting a patchy epidural.

A spinal is always an option, but would be tough to get in a jiffy and I'd rather have the reassurance of a functioning epidural up front.
 
one concern I had with the case is if you go the epidural route, patient goes to c section and after taping up the pannus with draping the patient has a tough time breathing. Also considering difficulty with getting NIBPs with big arms.

I was thinking PSV with a facemask and straps to help with breathing while intraop... And as far as blood pressure, A line?
 
Start by attempting to harpoon that whale before labor starts. Use US if you can to visualize the spinous processes and then bust out the big big needle. If she can’t get an epidural then you could try a spinal, may be easier just stabbing away. If she can’t lay flat then I would be frank with the OBs that this chick is getting an RSI with tube.
 
SaltyDog said:
One of the most ridiculous things I've read on this forum in quite some time.
Click to expand...

Maybe he likes to challenge himself in OB by ensuring he has to aspirate cheeseburger supernatant from the deepest recesses of the right lower lobe.
 
Break out the long tuohy. Place the epidural early on, before pt has significant pain. If not successful, you already know the pt is not a difficult airway. Regarding your other concerns, put her in a little reverse trend and back up if you're worried about her breathing with the epidural. Place a normal sized cuff on her lower arms to allow the BP's to cycle faster.
 
Epidural. 100% chance this will go to CS, so place it early, tape it well, make sure it works. Hopefully her breathing is ok with a level, if not RSI with a glide scope.
 
Early epidural. Thread at least 5 cm and lay them down before securing at the skin, since all that fat shifting will suck some more catheter under the skin.

It's often much easier to place epidurals in these super morbid obese patients if you go high ... somewhere T10-T12. Usually the majority of the fat will be legs and buttocks and many of these patients will have a marked ingress of the butt-shelf right around T12. A low thoracic epidural is likely to be technically easier, maybe even easy. The spinous processes are still horizontal at that level so it's a big space to aim at, and you can still enter perpendicular to the skin. Google "linea de blass":

Figura-1-Linea-de-Blass-La-linea-atraviesa-el-interespacio-entre-las-vertebras-T11-y.png


They will get good labor analgesia and it'll be fine for the inevitable c-section.

On the off chance they actually deliver vaginally, they may have some sacral sparing from a T11-ish epidural, but tell the OB to supplement with some pudendal blocks.
 
I've had this case twice now except it was induction for hypertension in the super morbid patient. Epidural straight away before they start the induction and she gets uncomfortable. I used ultrasound to chart the path, both went in on first pass. I did place an arterial line because of the hypertension, need for mag, and frequent labs. Frequent forearm NIBPs are uncomfortable and unreliable in my experience. I also placed the IVs because I wanted lines I could trust. Both went about as smooth as you could expect with a supermorbid patient. Overkill? Maybe but I never wanted to be in the weeds if I could prevent it.
 
DrThom said:
I've had this case twice now except it was induction for hypertension in the super morbid patient. Epidural straight away before they start the induction and she gets uncomfortable. I used ultrasound to chart the path, both went in on first pass. I did place an arterial line because of the hypertension, need for mag, and frequent labs. Frequent forearm NIBPs are uncomfortable and unreliable in my experience. I also placed the IVs because I wanted lines I could trust. Both went about as smooth as you could expect with a supermorbid patient. Overkill? Maybe but I never wanted to be in the weeds if I could prevent it.
Click to expand...
How in the world do you get OB nurses to deal with an art line?
 
SaltyDog said:
One of the most ridiculous things I've read on this forum in quite some time.
Click to expand...

I just wonder what you're supposed to do otherwise if she can't breathe well while lying flat. OBs will tape her pannus up, you could tape her breasts down. A slight revT is probably not going to do much. If she's awake, alert, and conscious I don't think PSV with facemask would be a problem with the caveat that if she appears nauseated or loses consciousness you would obvious stop the PPV and secure her airway.
 
ethilo said:
Starting the night shift and this case came in 2 hours prior to my arrival:

25 yo G1P0 @ 39 week gestation, BMI 77, 210 kg, admitted for attempted IOL for fetal macrosomia and super morbid obesity.

PMH:
- Likely OSA, PSG scheduled in 3 weeks. Can lie flat and breathe comfortably if awake but sleeps on side at night due to waking up from obstruction. Worse since pregnancy.
- Mild intermittent asthma, uses inhaler 1-2x every 2 weeks. Worse since being pregnant.
- Chiari 1 malformation dx'd 2 years ago after workup for migraines, neurosurgery said no intervention unless symptoms become severe. Migraines have been infrequent (~q2 weeks) without neurologic symptoms.
- Category 1 tracing at a NST in clinic earlier this week.

airway exam is favorable - MP1, has some neck with good ROM. Previous Mac 3 Gr 2a 2 years ago for cholecystectomy.

Difficult to monitor baby continuously here due to body habitus, currently getting intermittent monitoring. Vaginal exam is closed. Cytotec was placed and it's causing some tolerable cramping currently.

OB wants to try IOL for 24 hours and see if there's progress but if any issues, their plan is to C-section.
Click to expand...

Low dose Remi PCA for delivery, forget neuraxial. Im surprised they are letting her push and increase ICP with the chiari malformation.

Maybe I would have a few attempts at epidural if it looked humanly possible.

IMO you wont get an epidural you can rely on, and you dont want to do a spinal catheter (that would otherwise be great in this situation) due to chiari.

If she needs a CS (which is likely) I would do GA with glidescope and slow extubation.

BMI 77 is another level. I deal with a morbidly obese patient population but BMI 77 is rare, not too many around. KISS
 
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epidural probably won't be that tough, usually don't even need the harpoon (we see plenty of 400+ lbers on L&D, though 500+ lbs is pretty damn rare). They usually have a nice shelf of butt fat that you can go just above. Occasionally need the big needle but I definitely would not start with it.

If they go to section, either use an epidural or put a spinal in. I've had a small number of these super morbidly obese patients that could not tolerate breathing while supine with a neuraxial anesthetic and had to go with GA, but that is really pretty rare.
 
1) surprised they're inducing her if they can't monitor the baby well
2) as said before, the epidural (DPE or CSE) may not be that tough, esp with US to identify midline. I just placed one on BMI 96 and LOR was at 10cm last month.
3) in event of CSx would not give duramorph
4) in event of CSx elevate the HOB to where the patient feels comfortable, I've done several cardiomyopathy patients who couldn't lay flat so the HOB was significantly elevated, no question its challenging on the OBs but good surgeons should be able to handle it
 
ethilo said:
one concern I had with the case is if you go the epidural route, patient goes to c section and after taping up the pannus with draping the patient has a tough time breathing. Also considering difficulty with getting NIBPs with big arms.

I was thinking PSV with a facemask and straps to help with breathing while intraop... And as far as blood pressure, A line?
Click to expand...

Would you thus insufflate the stomach, right when they have to sit on top of the patient for fundal pressure? No A-line.
 
CubsDynasty said:
4) in event of CSx elevate the HOB to where the patient feels comfortable, I've done several cardiomyopathy patients who couldn't lay flat so the HOB was significantly elevated, no question its challenging on the OBs but good surgeons should be able to handle it
Click to expand...

usually can just put them in reverse t-berg to make it easier to breathe and only have to flatten the bed out when it's time to deliver
 
Hoya11 said:
BMI 77 is another level. I deal with a morbidly obese patient population but BMI 77 is rare, not too many around. KISS
Click to expand...

Off topic, but in some parts of the country (mine) it’s pretty common to have patients with BMI > 65. Had one today for a cysto.

And I’ve done 3 trachs on BMI > 75 in the last 6 months alone.
 
Arch Guillotti said:
How in the world do you get OB nurses to deal with an art line?
Click to expand...

Had to place an a-line in the pt's room a few times on congenital patients/severe pre-E when I was a resident....the nurses treated the transducer and tubing as if it was an exhaust vent to Chernobyl's reactor core.
 
Hoya11 said:
Low dose Remi PCA for delivery, forget neuraxial. Im surprised they are letting her push and increase ICP with the chiari malformation.

Maybe I would have a few attempts at epidural if it looked humanly possible.

IMO you wont get an epidural you can rely on, and you dont want to do a spinal catheter (that would otherwise be great in this situation) due to chiari.

If she needs a CS (which is likely) I would do GA with glidescope and slow extubation.

BMI 77 is another level. I deal with a morbidly obese patient population but BMI 77 is rare, not too many around. KISS
Click to expand...
That is a very interesting take. You think remi pca is keeping it simple? And you'd elect to do a GA?
I dont think you'd be with the majority on that one!
 
She's admitted for an IOL. Personally I'd sit down with an obstetrician and the patient and have a proper chat about what that means and likely outcomes. Discuss exchanging the IOL for an elective list that commences in 12 hours time. If she doesn't want to, then so be it.
 
Yeah our biggest concern was emergent procedure at night. We in anesthesia agreed elective CS in our main ORs with a proper PACU recovery nurse post op. OB still wants to try for IOL :-/
 
ethilo said:
Yeah our biggest concern was emergent procedure at night. We in anesthesia agreed elective CS in our main ORs with a proper PACU recovery nurse post op. OB still wants to try for IOL :-/
Click to expand...
Saw this post on trending forums. OBs are essentially fearless. I dont know why. I'm guessing it's because of all the lawsuits and they are less sensitive to risk. I dont know what the rate of failed IOL on a super heavyweight might be, but I'm sure it's quite low. Then you are doing emergent surgery on a high risk patient. Elective c section under controlled conditions is the prudent choice. In this case airway management might be less challenging than regional anesthesia since she has been intubated in the past. Hopefully she wasnt 100kg slimmer at that time. . Let us know how this turned out.
 
I was afforded the chance to do a c-section for a similarly large patient within the past year. We used spinal anesthesia for the C-section.. I did everything in my most comfortable way, which meant she sat up on the side of the table with 2 nurses on her front side to help position her and keep her from falling off the table. These cases are not the time to try experimenting with new techniques. Do what you do best. As others have mentioned, fat doesn't accumulate as much directly midline, especially above the "shelf", so her vertebral interspaces were palpable, if only barely. Because I do far more of them, I am better at epidurals than spinals. So my go-to method for a difficult spinal is to use an epidural needle as my finder. It is thick and easy to maneuver. After I find the epidural space, I can nearly always insert a long 25 G pencil point spinal needle through and obtain CSF without any more aiming.

On that day I looked like a rock star, because it went in on the first try and the rest of the case went smoothly. I did hub the needle with a little big of tenting, but that still allowed me to use the long spinal needle.

We used the newer giant tape to hold her pannus up. This tape looks almost like a large tegaderm with edges and other portions peeling off at different times going from sterile to handing off to me. She had no trouble breathing, especially because I did not sedate her.

Had they wanted to try inducing her, I would have gone through much of the same process, but instead putting in an epidural catheter, even if we didn't turn it on early. Our hospitals also are using "Hovermats" to move larger patients, which is actually quite useful on some of the larger patients, or with a team of small nurses.
 
Impromptu said:
I was afforded the chance to do a c-section for a similarly large patient within the past year. We used spinal anesthesia for the C-section.. I did everything in my most comfortable way, which meant she sat up on the side of the table with 2 nurses on her front side to help position her and keep her from falling off the table. These cases are not the time to try experimenting with new techniques. Do what you do best. As others have mentioned, fat doesn't accumulate as much directly midline, especially above the "shelf", so her vertebral interspaces were palpable, if only barely. Because I do far more of them, I am better at epidurals than spinals. So my go-to method for a difficult spinal is to use an epidural needle as my finder. It is thick and easy to maneuver. After I find the epidural space, I can nearly always insert a long 25 G pencil point spinal needle through and obtain CSF without any more aiming.

On that day I looked like a rock star, because it went in on the first try and the rest of the case went smoothly. I did hub the needle with a little big of tenting, but that still allowed me to use the long spinal needle.

We used the newer giant tape to hold her pannus up. This tape looks almost like a large tegaderm with edges and other portions peeling off at different times going from sterile to handing off to me. She had no trouble breathing, especially because I did not sedate her.

Had they wanted to try inducing her, I would have gone through much of the same process, but instead putting in an epidural catheter, even if we didn't turn it on early. Our hospitals also are using "Hovermats" to move larger patients, which is actually quite useful on some of the larger patients, or with a team of small nurses.
Click to expand...

A good technique. 22g Whitacre would be my pick here personally. 3.5”/5” both open on the spinal tray.
 
Impromptu said:
I was afforded the chance to do a c-section for a similarly large patient within the past year. We used spinal anesthesia for the C-section.. I did everything in my most comfortable way, which meant she sat up on the side of the table with 2 nurses on her front side to help position her and keep her from falling off the table. These cases are not the time to try experimenting with new techniques. Do what you do best. As others have mentioned, fat doesn't accumulate as much directly midline, especially above the "shelf", so her vertebral interspaces were palpable, if only barely. Because I do far more of them, I am better at epidurals than spinals. So my go-to method for a difficult spinal is to use an epidural needle as my finder. It is thick and easy to maneuver. After I find the epidural space, I can nearly always insert a long 25 G pencil point spinal needle through and obtain CSF without any more aiming.

On that day I looked like a rock star, because it went in on the first try and the rest of the case went smoothly. I did hub the needle with a little big of tenting, but that still allowed me to use the long spinal needle.

We used the newer giant tape to hold her pannus up. This tape looks almost like a large tegaderm with edges and other portions peeling off at different times going from sterile to handing off to me. She had no trouble breathing, especially because I did not sedate her.

Had they wanted to try inducing her, I would have gone through much of the same process, but instead putting in an epidural catheter, even if we didn't turn it on early. Our hospitals also are using "Hovermats" to move larger patients, which is actually quite useful on some of the larger patients, or with a team of small nurses.
Click to expand...
Is a hovermat as cool as it sounds?
 
Impromptu said:
I was afforded the chance to do a c-section for a similarly large patient within the past year. We used spinal anesthesia for the C-section.. I did everything in my most comfortable way, which meant she sat up on the side of the table with 2 nurses on her front side to help position her and keep her from falling off the table. These cases are not the time to try experimenting with new techniques. Do what you do best. As others have mentioned, fat doesn't accumulate as much directly midline, especially above the "shelf", so her vertebral interspaces were palpable, if only barely. Because I do far more of them, I am better at epidurals than spinals. So my go-to method for a difficult spinal is to use an epidural needle as my finder. It is thick and easy to maneuver. After I find the epidural space, I can nearly always insert a long 25 G pencil point spinal needle through and obtain CSF without any more aiming.

On that day I looked like a rock star, because it went in on the first try and the rest of the case went smoothly. I did hub the needle with a little big of tenting, but that still allowed me to use the long spinal needle.

We used the newer giant tape to hold her pannus up. This tape looks almost like a large tegaderm with edges and other portions peeling off at different times going from sterile to handing off to me. She had no trouble breathing, especially because I did not sedate her.

Had they wanted to try inducing her, I would have gone through much of the same process, but instead putting in an epidural catheter, even if we didn't turn it on early. Our hospitals also are using "Hovermats" to move larger patients, which is actually quite useful on some of the larger patients, or with a team of small nurses.
Click to expand...

What I hate is when you look and feel like an absolute rockstar after placing the spinal first shot on one of these ladies, then their assurance that they can breath fine laying flat ends up being inaccurate. I make them all actually lay flat and push their bellies up after a really bad experience.

This case seems like low chance an epidural/spinal will cut it. I would place an epidural if they intend vaginal delivery, and would try bolusing when they go to c/s, but I would absolutely expect a GA STAT C/S at some point, probably 3 am right after I get my teddy bear settled under my chin.

Plus every patient over 300 has a hovermat placed standard in my hospital, those things are great. Just make sure you have “blockers” to stop them from going too far, and take them out of reverse tburg before turning it on. I can move a 500 lbs woman almost by myself, and I am a 150lbs weakling (hidden in a fat 220 lbs body).
 
Arch Guillotti said:
Awful plan.
Click to expand...

an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor
 
Newtwo said:
That is a very interesting take. You think remi pca is keeping it simple? And you'd elect to do a GA?
I dont think you'd be with the majority on that one!
Click to expand...

remi is pretty simple yeah i dont even have to go there
and yeah GA on a probably easy airway vs spinal on a BMI 77 back with chiari malformation
 
Hoya11 said:
an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor
Click to expand...
Respectfully......I disagree and from a quick glance, so do some of the studies.
 
Hoya11 said:
an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor
Click to expand...

I disagree. If your labor analgesia plan is a Remi drip and you have to go to urgent section, you are forced down your only option - GA.

If you have placed an epidural, then at least you have two options when going to C/S and may have the opportunity to choose between the lesser of two evils.

I don’t think anyone is boasting about their epidural skills. For some practices and some regions of the country, a BMI of 77 is not unusual and even sometimes routine. It is entirely reasonable to have a perfectly working epidural in these patients.
 
Hoya11 said:
an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor
Click to expand...
I'm amazed you think this. Do you have any literature to support it?

Any ob obese literature I've seen supports early epidural.

I've had probably 5 BMI 65 to 75 parturients cs in the last 8 years and they all did fine with an epidural. Not exactly stellar numbers but Imo it's ok for me to keep doing it. The epidurals weren't all even that harder than say BMI 40s

I've never heard of 1st line Remi in a supermorbid obese lady
 
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