OB case

[dilaudid]

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* 34 yo 32 weeks EGA admitted with severe pre-eclampsia (BPs 155- 172/ 88-104).* PMH signif for morbid obesity (BMI 48) and gestational DM (diet controlled).* OB team planning on indx of labor for severe pre-eclampsia.* Her cervix currently is not favorable, but the team is planning misoprostol ripening.* Would you place the epidural for labor analgesia?*

Labs:*
H/H:* 12/36
Plt: 72,000
AST/ALT:* 56/ 62 U/L
PT/ INR: 13.8/ 1.1
PTT: 25.3
*

 

[cincincyreds]

* 34 yo 32 weeks EGA admitted with severe pre-eclampsia (BPs 155- 172/ 88-104).* PMH signif for morbid obesity (BMI 48) and gestational DM (diet controlled).* OB team planning on indx of labor for severe pre-eclampsia.* Her cervix currently is not favorable, but the team is planning misoprostol ripening.* Would you place the epidural for labor analgesia?*

Labs:*
H/H:* 12/36
Plt: 72,000
AST/ALT:* 56/ 62 U/L
PT/ INR: 13.8/ 1.1
PTT: 25.3
*

Tough situation. The answer is it depends. First, get a full history first asking about recent easy bruising and bleeding like from the gums. Look over the trend of the platelet count. If there is a history of easy bruising and the platelet count has acutely decreased, I would avoid neuraxial blockade. If the patient has a baseline platelet count of 80-90 and there is no recent history of bleeding or easy bruising, I may consider an epidural as the benefit of pain and BP control in order to avoid a malignant hypertension episode with epidural may outweight the risk of an epidural hematoma.

 

[dhb]

Tough call : i would rather have the patient get some steroids and then a c/s than a crappy induction that will end up in a c/s anyway.
3 options:
no epidural which is going to be pita for everybody but you
epidural after platelet transfusion (for litigation protection)
strait epidural

which would i do? i don't know:1 or 3...

 

[sevoflurane]

I'm interested in the AW, platelet trend and what her back looks like.

In all likelihood, I would place an epidural and make sure my epidural is working perfectly as this whale is likely going to go to C/S.

You should ask yourself what the risk of epidural hematoma is in the general population?
It's low... extremely low, like 1:150-200k.

Go for the best space (not necessarily L3-4).

The other option is to give her GA when the time comes... or spinal which carries an even lesser chance of epidural hematoma. AW assesment is important at this point.

Remember that pediatricians tap patients with platelet counts of 5k. Food for thought.

... and the Epidural will help her pre-eclamptic BP.

 

[cb3221]

Ditto that it's about the trend of the platelets. When I was resident it always seemed to go the worst way. Redraw labs> pt seizes> ob decides to deliver vaginally > you place an epidural in a post ictal combative pt> she seizes again> platelets drop> emergent bleeding pt for c/s > epidural doesn't work> can't intubate an obese parturient > clusterf$&k.
In private practice you do a c/s for CPD > place spinal >baby out> back to bed

 

[BLADEMDA]

* 34 yo 32 weeks EGA admitted with severe pre-eclampsia (BPs 155- 172/ 88-104).* PMH signif for morbid obesity (BMI 48) and gestational DM (diet controlled).* OB team planning on indx of labor for severe pre-eclampsia.* Her cervix currently is not favorable, but the team is planning misoprostol ripening.* Would you place the epidural for labor analgesia?*

Labs:*
H/H:* 12/36
Plt: 72,000
AST/ALT:* 56/ 62 U/L
PT/ INR: 13.8/ 1.1
PTT: 25.3
*

Near my cutoff. I use 70-75,000. Spinal I use 50K. Recheck platelets in an hour. If still over 70K and normal PFA100 (I'd do that test with the blood draw) then proceed. If under 70K no epidural

 

[BLADEMDA]

My license, my malpractice risk, etc means my decision. Same for you. Literature is unclear below 75-80K regarding epiduaral for labor. Proceed with caution

 

[ssmallz]

Sounds like a classic oral boards scenerio

First figure out what the airway looks like and if GA for a crash c/s would even be feasible. Then figure out the platelet trend. Was it 130 yesterday or 75? This makes all the difference in the world. There is no absolute platelet cut off for when to place an epidural and when not to, it's all about risks and benefits.

Then you need to have a serious talk w/the OB about the risks and benefits of a trial of labor. I find that most OBs don't understand that it's not going to be a 5 minute spinal in this pt if things go bad. Explain to them the risks of laboring and how it may be difficult to place an epidural or spinal in this pt for a crash section. Also explain that GA is likely out because a BMI of 48 is going to lead to difficult intubation. I would think that a planned c/s would be better because you take your time and place a spinal and if that doesn't work you can always do an AFOI and induce GA.

If they insist on proceeding with a trial of labor, I would almost insist on an epidural because if a crash section is necessary it will take way too long to induce and GA is likely out. If the platlets were holding steady I would proceed w/an epidrual and follow neuro checks q2h for 24hrs after the epdiural is removed. If the platelets were dropping I would likely transfuse to place the epidrual.

An epidural hematoma is a rare but devastating event. The more likely risk of failed airway and/or failed regional in a crash section leading to a bad baby takes precedence IMO and I'd be more lenient with my platelet cut offs in this pt as opposed to one w/a BMI of 25 or 30.

 

[Robert Loblaw]

My license, my malpractice risk, etc means my decision. Same for you. Literature is unclear below 75-80K regarding epiduaral for labor. Proceed with caution

So...which, in your opinion, carries the higher likelihood of occurrence and magnitude of liability: an epidural hematoma in a patient with no clinical signs of coagulopathy but a platelet count of 65K, or failed or delayed airway management in the setting of urgent c-section.

The present literature suggests the incidence of failed airway management in a parturient (not a morbidly obese pre-ecclamptic) is somewhere on the order of 1 in 300, compared to 1 in 3000 in the general population. These numbers, of course, do not reflect changes in incidence since the addition of the glidescope to our arsenal.

Personally, I'm far more concerned about failed airway management in this patient than an epidural hematoma.

 

[RxBoy]

The present literature suggests the incidence of failed airway management in a parturient (not a morbidly obese pre-ecclamptic) is somewhere on the order of 1 in 300, compared to 1 in 3000 in the general population. These numbers, of course, do not reflect changes in incidence since the addition of the glidescope to our arsenal.

Personally, I'm far more concerned about failed airway management in this patient than an epidural hematoma.

Failed airway management will not necessarily result in hypoxic brain injury. Epidural hematomas are devastating. In my limited experience I have seen it twice, once s/p AAA repair and once during a standard epidural placement for a parturient. Both resulted in LE paralysis. I agree I would take paralysis over anoxic brain injury/severe ARDS but if it was a fairly standard airway, I would go the GETA route.

But as for this case, like others discussed need to know a lot more about her history/lab trends.

 

[narcusprince]

I would follow the trend of the platelet count. If their is a major drop then I would not place the epidural. I would also check the airway and evaluate her for a general anesthetic. In my practice I would offer her an early epidural placement for labor analgesia I would also perform a dural puncture maybe some intrathecal narcotics bet definitely no local. I am not a fan of the CSE with local anesthetics unless its for a patient who is late in the game 10cm contracting primi or a multip at 6cm in 10/10 pain. I would send a sonoclot too to evaluate platelet. Blade I would appreciate some literature for use of the sonoclot in obstetrics. Reminds me of another patient I had on OB. 30 something year old patient with factor 11,12 deficiency and protein C deficiency presenting for labor on ASA. PTT is elevated at 47 someone sent a TEG(not a smart decision because what will you do with the results of a TEG) TEG showed prolonged R time. Presenting for induction of labor and wants an epidural.

 

[jwk]

Ditto that it's about the trend of the platelets. When I was resident it always seemed to go the worst way. Redraw labs> pt seizes> ob decides to deliver vaginally > you place an epidural in a post ictal combative pt> she seizes again> platelets drop> emergent bleeding pt for c/s > epidural doesn't work> can't intubate an obese parturient > clusterf$&k.
In private practice you do a c/s for CPD > place spinal >baby out> back to bed

In private practice (we laugh in the face of BMI=48) Seizure > RSI > cut > baby out > back to bed. 😉

 

[Mman]

Sounds like a classic oral boards scenerio

Also explain that GA is likely out because a BMI of 48 is going to lead to difficult intubation. I would think that a planned c/s would be better because you take your time and place a spinal and if that doesn't work you can always do an AFOI and induce GA.

Is 48 supposed to be big these days? No reason that it "is going to lead to difficult intubation". I mean I'd examine the airway. I've intubated plenty of parturients bigger than that without much difficulty.

I'd have a discussion with the patient about the risks and benefits of epidurals, spinals, and GA. What I would do would depend somewhat on patient preference after they understood all the risks.

 

[ssmallz]

Is 48 supposed to be big these days? No reason that it "is going to lead to difficult intubation". I mean I'd examine the airway. I've intubated plenty of parturients bigger than that without much difficulty.

I'd have a discussion with the patient about the risks and benefits of epidurals, spinals, and GA. What I would do would depend somewhat on patient preference after they understood all the risks.

A BMI of 48 means that if she's 5'5 she's 290bs. You're right that it might not be too big for a standard RSI but it's def concerning. As always doing a solid airway exam and figuring out if you think you can intubate and ventilate the pt is the key to any decision made on the risks and benefits of an neuraxial technique

 

[Mman]

A BMI of 48 means that if she's 5'5 she's 290bs. You're right that it might not be too big for a standard RSI but it's def concerning. As always doing a solid airway exam and figuring out if you think you can intubate and ventilate the pt is the key to any decision made on the risks and benefits of an neuraxial technique

I guess your world in Southern California is different than taking care of patients in the stroke belt. 290 lbs wouldn't even be noticeable in our population. I start to notice when the BMI hits 60 on the OB floor. Anything less than that is fairly run of the mill these days (unfortunately). And the Glidescope is key to surviving.

 

[rsgillmd]

Forget the BMI. It's one factor in a list of them.

As others have said, look at the airway -- weight distribution can play a big role.

The main concern about airway for me is that a true severe preeclamptic can have significant facial/airway edema even if they are a normal BMI.

 

[Arch Guillotti]

In my practice I would offer her an early epidural placement for labor analgesia I would also perform a dural puncture maybe some intrathecal narcotics bet definitely no local.

Why not?

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=663595&highlight=platelets

 

[pmichaelmd]

I guess your world in Southern California is different than taking care of patients in the stroke belt. 290 lbs wouldn't even be noticeable in our population. I start to notice when the BMI hits 60 on the OB floor. Anything less than that is fairly run of the mill these days (unfortunately). And the Glidescope is key to surviving.

Sadly, I agree. We typically have patients in this size range. My personal record was a GI case with a BMI of 84. Awesome times in the big, biscuit-poisoned South!

Ditto the above, airway exam is key and I also have a threshold of 70-75k for platelets. PFAs give me a little more solid ground if I decided to proceed in a non-emergent fashion with an epidural.

Not to be a thread-jacker, but I had an interesting OB case as well. 22-year old G2P1 drop in, Native American, only in our state for a graduation, diagnosed with CML @ 23 weeks EGA this pregnancy, refused Hem-Onc consultation and treatment, in denial regarding diagnosis, claimed her WBC count of 305k was due to ingesting glutens. We were able to get records from the Southwest on a Sunday and her platelets had dropped from >600k to 418k, blasts were increased from 2% to 8%. She was about 36 wks EGA, had escalating BPs, and had a BMI of about 40. Decisions, decisions...

 

[Robert Loblaw]

Failed airway management will not necessarily result in hypoxic brain injury. Epidural hematomas are devastating. In my limited experience I have seen it twice, once s/p AAA repair and once during a standard epidural placement for a parturient. Both resulted in LE paralysis. I agree I would take paralysis over anoxic brain injury/severe ARDS but if it was a fairly standard airway, I would go the GETA route.

But as for this case, like others discussed need to know a lot more about her history/lab trends.

Don't agree with this at all. Failed airway in this patient who is obese AND severely preeclamptic is a serious concern, and the morbidity that will be incurred in these situation is not only far more probable (1/300 to 1/500), but far more morbid as well, with likely poor outcome for the baby as well as the mother. I think the greater liability exposure is in failing to secure the airway.

 

[Idiopathic]

Failed airway management will not necessarily result in hypoxic brain injury. Epidural hematomas are devastating. In my limited experience I have seen it twice, once s/p AAA repair and once during a standard epidural placement for a parturient. Both resulted in LE paralysis. I agree I would take paralysis over anoxic brain injury/severe ARDS but if it was a fairly standard airway, I would go the GETA route.

But as for this case, like others discussed need to know a lot more about her history/lab trends.

in a patient like this, you would have extremely heightened suspicion, and i think the appropriate thing to do would be to have this patient monitored with q1h neuro checks for the next 24-48 hours. you get into trouble with these when you never suspect them or are just blind to the symptoms. i agree with you that we need more info, but you may not get it. you can decline to place an epidural, but whats your plan for the inevitable section?

 

[btbam]

Sadly, I agree. We typically have patients in this size range. My personal record was a GI case with a BMI of 84. Awesome times in the big, biscuit-poisoned South!

Ditto the above, airway exam is key and I also have a threshold of 70-75k for platelets. PFAs give me a little more solid ground if I decided to proceed in a non-emergent fashion with an epidural.

Not to be a thread-jacker, but I had an interesting OB case as well. 22-year old G2P1 drop in, Native American, only in our state for a graduation, diagnosed with CML @ 23 weeks EGA this pregnancy, refused Hem-Onc consultation and treatment, in denial regarding diagnosis, claimed her WBC count of 305k was due to ingesting glutens. We were able to get records from the Southwest on a Sunday and her platelets had dropped from >600k to 418k, blasts were increased from 2% to 8%. She was about 36 wks EGA, had escalating BPs, and had a BMI of about 40. Decisions, decisions...

We had one on OB last week with a BMI of 100...oh and she was only 21 weeks 😱

 

[Robert Loblaw]

in a patient like this, you would have extremely heightened suspicion, and i think the appropriate thing to do would be to have this patient monitored with q1h neuro checks for the next 24-48 hours. you get into trouble with these when you never suspect them or are just blind to the symptoms. i agree with you that we need more info, but you may not get it. you can decline to place an epidural, but whats your plan for the inevitable section?

Agree with this. It is imperative that this patient understand the relative risks involved to a level that she can understand. She needs to understand that the risk are what they are for reasons out of her anesthesiologists control. And she needs to understand that your job as her doctor is to pick the plan that best manages these risks. More important than all of this, she needs to feel that you are not some aloof, Rolex-wearing, Porsche-driving 'rich-ass doctor'...even if you are. This will go very far if something goes wrong...

Another thing to remember is that you can dose the epidural very conservatively if you are really worried about hematoma so earlier signs of a hematoma are not masked.

 

[BLADEMDA]

Agree with this. It is imperative that this patient understand the relative risks involved to a level that she can understand. She needs to understand that the risk are what they are for reasons out of her anesthesiologists control. And she needs to understand that your job as her doctor is to pick the plan that best manages these risks. More important than all of this, she needs to feel that you are not some aloof, Rolex-wearing, Porsche-driving 'rich-ass doctor'...even if you are. This will go very far if something goes wrong...

Another thing to remember is that you can dose the epidural very conservatively if you are really worried about hematoma so earlier signs of a hematoma are not masked.

Sure. She will understand real well if an epidural hematoma develops🙄

In my practice I'll get the glidescope and plan an intubation if the SAB is refused or the case is emergent. How do you justify placing an epidural with a platelet count of less than 70,000 if there is a complication?

 

[deleted126335]

Sure. She will understand real well if an epidural hematoma develops🙄

In my practice I'll get the glidescope and plan an intubation if the SAB is refused or the case is emergent. How do you justify placing an epidural with a platelet count of less than 70,000 if there is a complication?

You can't. All you can do is hope that you didn't roll snake eyes.

 

[IN2B8R]

Sure. She will understand real well if an epidural hematoma develops🙄

In my practice I'll get the glidescope and plan an intubation if the SAB is refused or the case is emergent. How do you justify placing an epidural with a platelet count of less than 70,000 if there is a complication?

You cannot justify it. Castration will be coming and you will just need to make the decision as to which testicle you will be giving up for making a stupid decision....

 

[Robert Loblaw]

How do you justify placing an epidural with a platelet count of less than 70,000 if there is a complication?

Since we all agree that there is no evidence to guide decision making regarding platelet counts, i fail to see how your personal threshold of 75K protects you anymore than anothers personal threshold of 65K or 50K. if you put an epidural in a similar patient with a platelet count of 80K and a complication occurs, you will still be asked to justify your choice of neuraxial technique.

Just to be clear, I'm not saying we should go around throwing epidurals into all pre-ecclamptics regardless of platelet count, only that it is not so cut and dry as to say "no epidural if your platelets are less than 75K" because the risk of hematoma is TOO high. it may be increased, but i doubt the incidence is still more common than failed airway management, which carries, i am arguing, a similar if not increased litigation risk in a morbidly obese patient with severe pre-ecclampsia. i would also add that the mallampati score at admission does not correlate with MP score at delivery, so airways get worse over time.

my practice is to assess the patient for signs of coagulopathy and determine a trend in the platelet count. i then weigh risks of hematoma against risk of failed airway management. if a patient has a class iv airway, no signs of coagulopathy, and a stable platelet count of 50K over 6 hours, i would place an epidural with appropriate discussion with the patient and obstetrician, documenting of, course, these conversations in great detail...

 

[Idiopathic]

this is why we need to outlaw OB threads

 

[Robert Loblaw]

"Spinal epidural haematoma


Although spinal epidural haematoma is more common than previously thought it is rare in the obstetric population. Moen et al. [24] reported spinal epidural haematomas over a 10-year period in Sweden, covering 1 260 000 spinal and 450 000 epidural blockades. The incidence was 1: 5400 in orthopaedic patients as opposed to 1: 200 000 in obstetrics. Both obstetric epidural haematomas occurred in parturients with HELLP syndrome, a condition known for increased bleeding. A national audit from the United Kingdom covering more than 700 000 neuraxial blocks showed only five epidural haematomas in the overall population including obstetrics [25••]. Of these, none occurred during spinal anaesthesia. The data again demonstrated that neuraxial blockade is much safer in pregnant patients than in other populations. In thrombocytopenic patients, the trend in platelet count may be more important than actual platelet numbers, with a lowest count to perform neuraxial blockade safely currently not identified. As spinal anaesthesia is associated with a significantly reduced risk of epidural haematoma compared with epidural anaesthesia, spinal anaesthesia should be preferred in this patient population. A survey among anaesthesiologists showed that a platelet count below 65 × 109/l was considered an absolute contraindication for epidural anaesthesia by 64.5% of the respondents, and an absolute contraindication for spinal anaesthesia by 51.3% of the respondents, indicating that spinal anaesthesia was preferred in the presence of thrombocytopenia [26]. If additional antiplatelet drugs or heparins are administered, adherence to national guidelines is recommended [27]."



Gogarten W. Preeclampsia and anaesthesia. Curr Opin Anaesthesiol. 2009 Jun;22(3):347-51.

 

[BLADEMDA]

Anesth Analg. 1997 Aug;85(2):385-8. Links

Safe epidural analgesia in thirty parturients with platelet counts between 69,000 and 98,000 mm(-3).

Beilin Y, Zahn J, Comerford M.
Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York, USA.
Regional anesthesia is a popular form of pain relief for the management of labor and delivery. Thrombocytopenia is considered a relative contraindication to the administration of regional anesthesia. Some authorities have recommended that an epidural anesthetic be withheld if the platelet count is <100,000 mm(-3). For the period of March 1993 through February 1996, we reviewed the charts of all parturients who had a platelet count <100,000 mm(-3) during the peripartum period. Eighty women met this criterion. Of these 80, 30 had an epidural anesthetic placed when the platelet count was <100,000 mm(-3) (range 69,000-98,000 mm(-3)), 22 had an epidural anesthetic placed with a platelet count >100,000 mm(-3) that subsequently decreased below 100,000 mm(-3), and 28 did not receive a regional anesthetic. We found no documentation of any neurologic complications in the medical records. We conclude that regional anesthesia should not necessarily be withheld when the platelet count is <100,000 mm(-3).
PMID: 9249118 [PubMed - indexed for MEDLINE

 

[BLADEMDA]

Click on image to view larger version.

 

[BLADEMDA]

Please look at the data posted above. There is evidence for the safety of Epidural in labor patients with a stable platelet count above 70,000. Below 70,000 the evidence becomes more scant and less convincing about safety. Spinal anesthesia seems safe at platelet counts of 50,000 or more.

Hence, since my area is very litigious I use a cut-off of 70,000 (prefer 75,000) for a labor epidural. If you decide to use 60,000 that is your decision.

 

[Idiopathic]

Please look at the data posted above. There is evidence for the safety of Epidural in labor patients with a stable platelet count above 70,000. Below 70,000 the evidence becomes more scant and less convincing about safety. Spinal anesthesia seems safe at platelet counts of 50,000 or more.

Hence, since my area is very litigious I use a cut-off of 70,000 (prefer 75,000) for a labor epidural. If you decide to use 60,000 that is your decision.

you present data in the setting of ITP. we consider it fairly safe to place SAB in these patients and will often infuse platelets will doing it but have blocked patients with platelet counts in the 30s. i cannot say that the same results apply to the pre/eclamptic population, or the patient with unexplainable low platelet count on first glance.

 

[BLADEMDA]

you present data in the setting of ITP. we consider it fairly safe to place SAB in these patients and will often infuse platelets will doing it but have blocked patients with platelet counts in the 30s. i cannot say that the same results apply to the pre/eclamptic population, or the patient with unexplainable low platelet count on first glance.

Some of those studies include Gestational Thrombocytopenia and not just ITP.

 

[Robert Loblaw]

Please look at the data posted above. There is evidence for the safety of Epidural in labor patients with a stable platelet count above 70,000. Below 70,000 the evidence becomes more scant and less convincing about safety. Spinal anesthesia seems safe at platelet counts of 50,000 or more.

Hence, since my area is very litigious I use a cut-off of 70,000 (prefer 75,000) for a labor epidural. If you decide to use 60,000 that is your decision.

i searched a little bit last night for updated data on obstetric airway disaster, hoping to find studies post-glidescope but again, little data is available to guide decision making. do you disagree with older data suggesting difficult intubation in 1/300-500 parturients (non preecclamptic)?

part of the issue here is the difference in perceived liability in doing something electively (epidural) and causing a complication and being forced to do something emergently (intubate) and having a complication. do you disagree that the liability in these two scenarios is equivalent?

 

[Mman]

i searched a little bit last night for updated data on obstetric airway disaster, hoping to find studies post-glidescope but again, little data is available to guide decision making. do you disagree with older data suggesting difficult intubation in 1/300-500 parturients (non preecclamptic)?

part of the issue here is the difference in perceived liability in doing something electively (epidural) and causing a complication and being forced to do something emergently (intubate) and having a complication. do you disagree that the liability in these two scenarios is equivalent?

Anecdotally I severely disagree with the 1/300 to 1/500 number. I'm guessing an order of magnitude lower than that with the glidescope.

 

[Robert Loblaw]

Anecdotally I severely disagree with the 1/300 to 1/500 number. I'm guessing an order of magnitude lower than that with the glidescope.

incidentally, i agree...anectdotally. but i would just qualify this by saying then that the incidence of failed airway management in the general population is supposedly 1/3000, which i also find somewhat higher than experience would suggest.

 

[BLADEMDA]

Anecdotally I severely disagree with the 1/300 to 1/500 number. I'm guessing an order of magnitude lower than that with the glidescope.

The actual number is at least 10-15 times lower than 1 in 300. Our experience in a busy OB center shows zero failed airways ( we have had a few tough ones requiring glidescope, LMA, fiber optic, etc). I can assure you I have done sections on 400 pounders more than a few times in my career.

 

[fakin' the funk]

* 34 yo 32 weeks EGA admitted with severe pre-eclampsia (BPs 155- 172/ 88-104).* PMH signif for morbid obesity (BMI 48) and gestational DM (diet controlled).* OB team planning on indx of labor for severe pre-eclampsia.* Her cervix currently is not favorable, but the team is planning misoprostol ripening.* Would you place the epidural for labor analgesia?**

The number one thing an anesthesiologist can do to contribute to a positive outcome for this patient is avoiding general anesthesia and the risk of lost airway, aspiration, etc. A close 2nd would be avoiding severe HTN from the start of this induced labor until the time the fetus is delivered.

I would transfuse 1 unit of plateletpheresis, and do the epidural. I wouldn't do the epidural with the current PLT of 72K (with the caveats on trend and history of coagulopathic symptoms noted). The epidural is more likely than your "average" patient to be difficult, require multiple needle passes, result in bloody tap, etc. If and when I reached the epidural space, I would do a dural puncture with a CSE spinal needle (no IT dose) just to be sure.

Whether or not the data on failed intubation are 1:300 or 1:3000, it doesn't matter. The airway and aspiration risks of GA in this patient are WAYYY higher than the spinal/epidural hematoma risk. The risk of a single PLT transfusion is low. The risk of uncontrolled HTN in this pt during a painful, augmented labor, is not low, and a labor epidural is a great way to handle both problems.

 

[Mman]

The number one thing an anesthesiologist can do to contribute to a positive outcome for this patient is avoiding general anesthesia and the risk of lost airway, aspiration, etc. A close 2nd would be avoiding severe HTN from the start of this induced labor until the time the fetus is delivered.

I would transfuse 1 unit of plateletpheresis, and do the epidural. I wouldn't do the epidural with the current PLT of 72K (with the caveats on trend and history of coagulopathic symptoms noted). The epidural is more likely than your "average" patient to be difficult, require multiple needle passes, result in bloody tap, etc. If and when I reached the epidural space, I would do a dural puncture with a CSE spinal needle (no IT dose) just to be sure.

Whether or not the data on failed intubation are 1:300 or 1:3000, it doesn't matter. The airway and aspiration risks of GA in this patient are WAYYY higher than the spinal/epidural hematoma risk. The risk of a single PLT transfusion is low. The risk of uncontrolled HTN in this pt during a painful, augmented labor, is not low, and a labor epidural is a great way to handle both problems.

Since you are so sure of your answer...devil's advocate.

Why do a CSE to "confirm" placement? What if you get a good loss after 4 or 5 needle passes, but no CSF? Are you going to take another 5 or 10 swings at it until you get CSF from the spinal? And if you are puncturing dura, why not just go ahead and give some IT narcotics at least?

Why transfuse platelets? Are you going to transfuse even more platelets when it's time to D/C the catheter? Because her platelet count is probably going to be even lower after delivery. And FWIW platelet transfusions have a pretty high rate of adverse effects relative to other blood products. How many units of platelets is she going to get in total?


Why does the risk of airway difficulty in this lady make no difference to your management? It should.

Is an epidural the only or best way to control HTN in a pre-eclamptic patient?

 

[BLADEMDA]

* 34 yo 32 weeks EGA admitted with severe pre-eclampsia (BPs 155- 172/ 88-104).* PMH signif for morbid obesity (BMI 48) and gestational DM (diet controlled).* OB team planning on indx of labor for severe pre-eclampsia.* Her cervix currently is not favorable, but the team is planning misoprostol ripening.* Would you place the epidural for labor analgesia?*

Labs:*
H/H:* 12/36
Plt: 72,000
AST/ALT:* 56/ 62 U/L
PT/ INR: 13.8/ 1.1
PTT: 25.3
*

1. No Epidural
2. Re-check platelet count
3. Talk with OB Doc about C Section sooner rather than later; discuss with OB about need for platelets in OR (? have avail)
4. I'd do a PFA-100
5. Spinal anesthetic if Platelet count greater than 50,000 for the section.