Quasi-Interesting OB Case

[Twiggidy]

---

Members don't see this ad.

I joke about a lot of academic BS, but not about monitoring requirements for what might be a > 1 hour case. I'm willing to forgo temp monitoring for a 60 second case, not for major abdominal surgery. That's my real world private practice answer.

And that's fine and the strictly speaking you 1000% correct, but show of hands whose attendings during residency stuck that temperature monitor to the patient having a C-section's forehead.......I'll wait.

 

[pgg]

I suppose it's worth mentioning that SCIP-Inf-10 demands (for procedures >1 hour) a documented temp >36 in the window of 30 minutes before or 15 minutes after anesthesia end time, OR use of active warming.

A really easy way to comply with this is to monitor and document temperature (even a useless skin sticker counts). But the point here isn't patient care, but paperwork care.

 

[Mman]

ASA standard 5.2:
Every patient receiving anesthesia shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated or suspected.


I do many cases for which I don't intend, anticipate, or suspect clinically significant changes in temperature.

Sure, how many of those cases have several hundred mls of blood loss?

 

[Mman]

Are you using skin probes to do this on awake patients or foleys with temp probes?

skin probes

 

[deleted50478]

And that's fine and the strictly speaking you 1000% correct, but show of hands whose attendings during residency stuck that temperature monitor to the patient having a C-section's forehead.......I'll wait.

I don’t do that. I do get irritated if the CRNA puts a skin temp on an awake patient. I think asking “Are you cold?” is a more than adequate monitor.

 

[vector2]

And that's fine and the strictly speaking you 1000% correct, but show of hands whose attendings during residency stuck that temperature monitor to the patient having a C-section's forehead.......I'll wait.

I never put the temp probe on the forehead.



Cause that's where the EKG ground lead goes.

 

[coffeebythelake]

Hypothermia after cesarean delivery and its reversal with lorazepam. - PubMed - NCBI

 

[coffeebythelake]

Neuraxial anesthesia can alter temperature sensation and regulation. In some cases patients may not be aware even of profound hypothermia

 

[deleted50478]

Hypothermia after cesarean delivery and its reversal with lorazepam. - PubMed - NCBI

Inadvertent perioperative hypothermia induced by spinal anesthesia for cesarean delivery might be more significant than we think: are we doing enough to warm our parturients?

 

[deleted162650]

So now that things are sufficiently sidetracked, I'll relay how it went down. OB was nice enough to give us a heads up about this pt a week in advance. One of my partners met with her. She already had a postpartum MS prophylaxis treatment plan in place with her neurologist. My partner explained her options (SAB v. GA w/ TAPs), and asked her to follow-up with neurology to see if he had any recs.

Turns out the neurologist recommended SAB and quoted her a < 0.0-something chance of SAB causing an MS flare, and even said that a GA may be ever so slightly more likely to trigger a flare (not sure what that opinion was based on). I told her I'd give it a try in light of her fusion and plan B would be GA + TAPs. I tried to cheat by looking up her IR spinal tap from 2 years prior. Turns out our IR guy didn't save any images and his note said procedure was performed "in the lumbar region." 😕 (Our main IR guy is really good, but he's pretty much the human version of the turtle from Finding Nemo).

Get her in the OR and her back is fused in a nice lordotic posture. Felt nice spinous processes around L3 so took a stab - bone. A handful of redirects = bone, bone, bone. Paramedian might have worked batter given her inability to curl up, but I was worried that would put the hardware right in my trajectory. Move down to L5-ish where I couldn't really palpate anything but took a stab and bingo CSF on the first pass. 1.4 heavy marcaine + fent + duramorph and things proceeded as usual.

Exciting isn't it. I know you were all on the edge of your stools for that one.

 

[Twiggidy]

I never put the temp probe on the forehead.



Cause that's where the EKG ground lead goes.

 

[fakin' the funk]

33yo F G1 s/f C-Section at 36wks due to twins (di/di) with worsening IUGR and double breech presentation. Last meal at 1300 so OB puts her on for 2100. Not laboring and babies are fine on the strip.

Story/timing don't make sense. 36 weeks, worsening IUGR twins, not healthy mom, ok. But you don't do this at 2100.

Firstly, IUGR didn't just happen overnight so CS at 36wks always on the table. Why you eating momma?

Secondly, presumably just had 36wks US and now sent straight to L and D unit. She ate. Still an elective CS. Not your problem. Do this with assistance available since obvious GETA.

Thirdly, no prepartum anesthesia consult? What kinda flim flam operation u running?

 

[fakin' the funk]

ASA standard 5.2:
Every patient receiving anesthesia shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated or suspected.


I do many cases for which I don't intend, anticipate, or suspect clinically significant changes in temperature.

ASA defines such cases as GA or neuraxial longer than 60 minutes IIRC. Not monitoring is breach of standard of care.

CS is the one difficult case to do it in.

 

[deleted162650]

Story/timing don't make sense. 36 weeks, worsening IUGR twins, not healthy mom, ok. But you don't do this at 2100.

Firstly, IUGR didn't just happen overnight so CS at 36wks always on the table. Why you eating momma?

Secondly, presumably just had 36wks US and now sent straight to L and D unit. She ate. Still an elective CS. Not your problem. Do this with assistance available since obvious GETA.

Thirdly, no prepartum anesthesia consult? What kinda flim flam operation u running?

Prepartum anesthesia consult - we saw her a week in advance. How much more time do you need??

She ate, got her U/S, and was sent L&D (are you saying she shouldn’t be allowed to eat at all once she hits 36 wks??). Not laboring so OB booked it for when she met NPO guidelines. Inconvenient - ya, but that’s OB anesthesia for ya. Punt it till tomorrow and all you did was make it inconvenient for more people.

How much assistance do you need for a GA on a skinny parturient?? Plus I’m at a Level 2 trauma and have help 24/7 if I need it.

Obvious GA?? You really gotta read the whole thread.

 

[fakin' the funk]

Prepartum anesthesia consult - we saw her a week in advance. How much more time do you need??

She ate, got her U/S, and was sent L&D. Not laboring so OB booked it for when she met NPO guidelines. Inconvenient - ya, but that’s OB anesthesia for ya. Punt it till tomorrow and all you did was make it inconvenient for more people.

How much assistance do you need for a GA on a skinny parturient?? Plus I’m at a Level 2 trauma and have help 24/7 if I need it.

Obvious GA?? You really gotta read the whole thread.

I didn't read the whole thread before responding - my response is to your first post. That seemed in the spirit of your first post. Cool tho.

Anesthesia consult at 35 wks twins pt with IUGR, MS and spinal fusion would be considered late at my place, yep.

Doing a case at 2100 even if NPO status is met still necessitates a component of clinical urgency. This is 100% elective. Unclear why they admitted her. Nonetheless, how and when you staff this case depends on your local staffing model (also applies to 2100 comment above).

For me, this is an obvious GA. Not going to needle that back. I didn't make the bed.

 

[deleted162650]

I didn't read the whole thread before responding - my response is to your first post. That seemed in the spirit of your first post. Cool tho.

Anesthesia consult at 35 wks twins pt with IUGR, MS and spinal fusion would be considered late at my place, yep.

Doing a case at 2100 even if NPO status is met still necessitates a component of clinical urgency. This is 100% elective. Unclear why they admitted her. Nonetheless, how and when you staff this case depends on your local staffing model (also applies to 2100 comment above).

For me, this is an obvious GA. Not going to needle that back. I didn't make the bed.

Why are you afraid to needle her back?

 

[Psai]

I didn't read the whole thread before responding - my response is to your first post. That seemed in the spirit of your first post. Cool tho.

Anesthesia consult at 35 wks twins pt with IUGR, MS and spinal fusion would be considered late at my place, yep.

Doing a case at 2100 even if NPO status is met still necessitates a component of clinical urgency. This is 100% elective. Unclear why they admitted her. Nonetheless, how and when you staff this case depends on your local staffing model (also applies to 2100 comment above).

For me, this is an obvious GA. Not going to needle that back. I didn't make the bed.

What are you going to do different if you saw her earlier? Fix the ms and iugr?

 

[pgg]

ASA defines such cases as GA or neuraxial longer than 60 minutes IIRC. Not monitoring is breach of standard of care.

Where are you getting that? The length of the case is not referenced in the ASA monitoring standards document.

Case length is part of the SCIP criteria but even then, monitoring isn't required, just documented active warming OR normothermia in the PACU.


Note that I'm not arguing against temperature monitoring - but the ASA standard I quoted is explicit and unambiguous: "shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated or suspected."

If you want to go another direction and cite local community standards I would wager (I know) that temperature monitoring is often skipped for low risk cases.

 

[kmurp]

I suppose it's worth mentioning that SCIP-Inf-10 demands (for procedures >1 hour) a documented temp >36 in the window of 30 minutes before or 15 minutes after anesthesia end time, OR use of active warming.

A really easy way to comply with this is to monitor and document temperature (even a useless skin sticker counts). But the point here isn't patient care, but paperwork care.

We collect this exact data as one of our “quality” measures for CMS.

 

[Psai]

We collect this exact data as one of our “quality” measures for CMS.

So your value as an anesthesiologist is measured by whether you type in 37c on the electronic chart somewhere

 

[Twiggidy]

So your value as an anesthesiologist is measured by whether you type in 37c on the electronic chart somewhere

Many hospitals have quality measures that have absolutely nothing with the actual practice of anesthesia.

 

[Twiggidy]

I didn't read the whole thread before responding - my response is to your first post. That seemed in the spirit of your first post. Cool tho.

Anesthesia consult at 35 wks twins pt with IUGR, MS and spinal fusion would be considered late at my place, yep.

Doing a case at 2100 even if NPO status is met still necessitates a component of clinical urgency. This is 100% elective. Unclear why they admitted her. Nonetheless, how and when you staff this case depends on your local staffing model (also applies to 2100 comment above).

For me, this is an obvious GA. Not going to needle that back. I didn't make the bed.

You really trying to be the one to tell and OB when they can and can't do a C/S in a high risk patient who per their clinical assessment the babies (plural) aren't doing that great?

 

[deleted162650]

You really trying to be the one to tell and OB when they can and can't do a C/S in a high risk patient who per their clinical assessment the babies (plural) aren't doing that great?

And we bitch when a surgeon tries to tell us we don’t need an A-line 🙄🙄

 

[facted]

I have no issue with people wanting to document temp on a MAC case, or even a C-section. But I have a HUGE issue with putting a skin temp probe on and writing that number down as if it's more correlated with body temp than a random number generator. It's not. Skin temp is not a core body temperature, and even less so when your probe is in the armpit next to the bair hugger...

 

[fakin' the funk]

You really trying to be the one to tell and OB when they can and can't do a C/S in a high risk patient who per their clinical assessment the babies (plural) aren't doing that great?

I might. In this case, I think I would. The timing is part of the consultation. Like I said, it also depends on how safely you can do this *100% elective* case at 2100 versus the next day; if it's truly a wash then clearly there's no benefit to waiting. And, like I said, not clear why they admitted mom. I didn't do OB residency, but I pay attention, and this is just common sense.

 

[fakin' the funk]

And we bitch when a surgeon tries to tell us we don’t need an A-line 🙄🙄

To generalize a bit, the point you're now defending is "My opinion in the timing of surgical cases is immaterial." Do you actually feel that way? I don't.

 

[Arch Guillotti]

I might. In this case, I think I would.

You are nuts to delay a case that is a dime a dozen. The patient is NPO, how exactly will the case be safer the next day?

 

[fakin' the funk]

Why are you afraid to needle her back?

a) risk of infecting hardware
b) risk of block difficulty/pain for pt
c) risk of block failure
d) risk of MS exacerbation

 

[fakin' the funk]

You are nuts to delay a case that is a dime a dozen. The patient is NPO, how exactly will the case be safer the next day?

Ortho says "I want to do a total knee at 9pm. Pt NPO." Your response is "hell yeah!" ?

 

[fakin' the funk]

You are nuts to delay a case that is a dime a dozen. The patient is NPO, how exactly will the case be safer the next day?

Maybe I didn't delineate my concerns about doing elective Csections at 9pm well enough. Where I'm at, we are on a skeleton crew nights and weekends. That's anesthesia, nursing, OB, peds, techs, blood bank, runners, etc etc. There is a nontrivial increase in risk doing cases after hours. Elective case.

 

[Twiggidy]

Maybe I didn't delineate my concerns about doing elective Csections at 9pm well enough. Where I'm at, we are on a skeleton crew nights and weekends. That's anesthesia, nursing, OB, peds, techs, blood bank, runners, etc etc. There is a nontrivial increase in risk doing cases after hours. Elective case.

All of those are the same concerns if you're doing an urgent or emergent c-section on a night or weekend so why wouldn't you do a "stable" patient on a night/weekend? By your logic an emergent/urgent section is less likely to cause trouble than an elective section.

 

[Twiggidy]

Ortho says "I want to do a total knee at 9pm. Pt NPO." Your response is "hell yeah!" ?

Yes, because I like my job and there's a line of people waiting down the street that want it.

Edit: I like 50% of my job and I tolerate the other 50%

 

[fakin' the funk]

By your logic an emergent/urgent section is less likely to cause trouble than an elective section.

I didn't say that, and that's not my logic. Wtf?

 

[Twiggidy]

I didn't say that, and that's not my logic. Wtf?

So, I understand nights and weekends have less people around, but that really isn't a valid reason to not do an elective section. An elective section probably has less risk that a section after labor, but you're not going to say "I'm not doing that because it's only arrest of labor and it's 3am. She can wait until 7am" Trust me, I applaud you for having the ability to do that, but that also isn't the norm. In most places you do this case and likewise, in most places the person on-call grumbles and does the knee, especially if the nursing staff has agreed to do it. You don't want to be the lonely guy on the island saying "cancel". That's a quick way to lose a contract.

 

[Southpaw]

CS at 2100 for IUGR twins in a patient who may very well require GA isn't straightforward. I'm not saying for sure delay to the next day, but that's completely reasonable depending on resources available. There's absolutely no question that in many hospitals such a case is safer at 9am than 9pm.

 

[Arch Guillotti]

CS at 2100 for IUGR twins in a patient who may very well require GA isn't straightforward. I'm not saying for sure delay to the next day, but that's completely reasonable depending on resources available. There's absolutely no question that in many hospitals such a case is safer at 9am than 9pm.

Why?

The world is not perfect.

Do the case. Keep everybody happy. Nobody is going to lose a contract over a single case but nobody likes an obstructionist.

 

[Southpaw]

Why?

The world is not perfect.

Do the case. Keep everybody happy. Nobody is going to lose a contract over a single case but nobody likes an obstructionist.

I'm not saying be an obstructionist. I'm saying do what your group would normally do in your setting. Is a 2100 completely elective CS for 36 wks twin IUGR the norm? Yes? Ok, go right ahead. If not, just ensure you have the resources available for you head back. Honestly I'd rather do the totally elective TKA at 2100 (which wasn't a bad analogy honestly), but that's just been my personal experience.

 

[DocVapor]

So, I understand nights and weekends have less people around, but that really isn't a valid reason to not do an elective section. An elective section probably has less risk that a section after labor, but you're not going to say "I'm not doing that because it's only arrest of labor and it's 3am. She can wait until 7am" Trust me, I applaud you for having the ability to do that, but that also isn't the norm. In most places you do this case and likewise, in most places the person on-call grumbles and does the knee, especially if the nursing staff has agreed to do it. You don't want to be the lonely guy on the island saying "cancel". That's a quick way to lose a contract.

This seems backwards. The urgent or emergent c-sections are done because the risk of poor outcome due to waiting outweigh the risks of doing a case that might go sideways on a skeleton crew. When it's an elective case with no to minimal risk of poor outcome due to waiting, but real risk if things go sideways at night on a skeleton crew, the ratio is in favor of waiting.

Contract concerns come after that.

 

[Arch Guillotti]

I'm not saying be an obstructionist. I'm saying do what your group would normally do in your setting. Is a 2100 completely elective CS for 36 wks twin IUGR the norm? Yes? Ok, go right ahead. If not, just ensure you have the resources available for you head back. Honestly I'd rather do the totally elective TKA at 2100 (which wasn't a bad analogy honestly), but that's just been my personal experience.

Are you insulated from OB anesthesia?

This case is a no brainer for me or any of my partners.

 

[Southpaw]

Are you insulated from OB anesthesia?

This case is a no brainer for me or any of my partners.

I’m in a different group now, but in my old group we covered OB and elective IUGR 36 wk twins wasn’t the norm. We didn’t have a NICU and peds wasn’t in-house 24/7.

The actual case is a no brainer. The anesthesia for the mom is straight forward. Ensuring resources for 2 IUGR 36 weekers may not be....

 

[Twiggidy]

This seems backwards. The urgent or emergent c-sections are done because the risk of poor outcome due to waiting outweigh the risks of doing a case that might go sideways on a skeleton crew. When it's an elective case with no to minimal risk of poor outcome due to waiting, but real risk if things go sideways at night on a skeleton crew, the ratio is in favor of waiting.

Contract concerns come after that.

I'll admit the contract comment was extreme but anyone who's been in those negotiating meeting knows that even the little things get thrown on the table.

That point aside, I still think using "skeleton crew" as a reason to delay an "elective" section is not valid. If an OB determines it's time for some babies to come out at the first chance possible, I don't think it's very appropriate for an anesthesiologist to say no.

 

[DocVapor]

I'll admit the contract comment was extreme but anyone who's been in those negotiating meeting knows that even the little things get thrown on the table.

That point aside, I still think using "skeleton crew" as a reason to delay an "elective" section is not valid. If an OB determines it's time for some babies to come out at the first chance possible, I don't think it's very appropriate for an anesthesiologist to say no.

Well I mean using skeleton crew as the direct reason is weak, but the implication is that now if a true emergency does happen, whatever crew you do have is already tied up in an elective case. Now that other woman in labor that starts having late decels down into the 60's once the drapes go up has to wait. Wouldn't be our fault but can't say I'd feel particularly good about the situation.

 

[ZzzPlz]

In my experience, it is much less of a headache in the long run to just do the case. Sure, you can cancel it and stay in bed, but you’ll be getting several calls and likely have to explain yourself the following days.

This is different when you have a surgeon that repeatedly pushes non-emergent crap on nights and weekends. That’s when the whole group should step up and call for changes.

 

[fakin' the funk]

That point aside, I still think using "skeleton crew" as a reason to delay an "elective" section is not valid. If an OB determines it's time for some babies to come out at the first chance possible, I don't think it's very appropriate for an anesthesiologist to say no.

It doesn't seem you'll ever grasp this point, but just consider this: is there a reason we do elective cases between 7am and ~5pm (typically) and not at 2am?

A lot of the commentary on this thread is from eat-what-you-kill PP solo MDs. That's not the only practice model out there. Any resources you divert to doing an elective case at 2100 are resources not available for emergencies, which is what most hospitals are staffed for at 2100. So, rubber hits the road, you inject your intrathecal dose in this elective case and 30 seconds later there is a crash CS called. Is there still a full complement of resources available to do that case? If so, I have many more questions.

 

[fakin' the funk]

That point aside, I still think If an OB determines it's time for some babies to come out at the first chance possible, I don't think it's very appropriate for an anesthesiologist to say no.

There are some surgeons that I will near-blindly trust based on their reputation, skills, prior decision making etc,

...and then there are OBs.

 

[Twiggidy]

, rubber hits the road, you inject your intrathecal dose in this elective case and 30 seconds later there is a crash CS called. Is there still a full complement of resources available to do that case? If so, I have many more questions.

I’ll raise....You take a patient to the OR for failure to progress and load the epidural and a prolapsed cord comes off the elevator......

To answer your question we have nurses on the floor that can be scrub techs and there is a back up anesthesiologists on call. If it’s really a disaster, then I’m running two rooms with one of the nurses playing CRNA.

 

[jwk]

That point aside, I still think using "skeleton crew" as a reason to delay an "elective" section is not valid. If an OB determines it's time for some babies to come out at the first chance possible, I don't think it's very appropriate for an anesthesiologist to say no.

Agree. Hell, I'd be giving the OB dude props for saying up front "I'll wait 8 hours" for the NPO. Pretty much anywhere, OB makes the call on what the appropriate time is for a section. That's rarely, if ever, our call. If he's saying we can wait 8 hours, but YOU think it would be better to move ahead considering you might have better resources available earlier in the day, by all means have an adult discussion about that and come to an agreement. My guess is the OB would be happy to do it earlier as well.

 

[pgg]

IUGR, not in labor, with a reassuring strip is 1000% elective.

Some hospitals I work at have hard rules that elective stuff doesn't get done at night or on the weekend, because they're anxious about committing emergency personnel to something that could wait.

Anyway. A c-section is a super fast case everywhere but an academic hospital, so the "don't want to commit emergency staff to this elective case" argument just doesn't carry the same weight on OB as it does in the main OR, where elective after hours stuff may take hours. Worst case, the SHTF elsewhere 30 seconds after uterine incision, and the other case has to wait 20 or 30 minutes. That's not a longer delay than it would be if the call team was at home waiting for a phone call.

 

[Twiggidy]

It’s could be elective but again that’s not our call.

It would be like if you decide to use a glidescope and another doctor is telling you it’s an easy airway so you shouldn’t use it. Granted they don’t have control over your actually using it but where do they get off telling you what’s easy or not. They’re not the airway experts just as we’re not the OB experts.

 

[vector2]

It’s could be elective but again that’s not our call.

It would be like if you decide to use a glidescope and another doctor is telling you it’s an easy airway so you shouldn’t use it. Granted they don’t have control over your actually using it but where do they get off telling you what’s easy or not. They’re not the airway experts just as we’re not the OB experts.

Cmon, dude, it may not be our call but an anesthesiologist who has been around the block on OB is more than capable of understanding the reasoning. Is the mother at risk for an impending serious physiological derangement? Is the fetus? If the answer to both these is no then I don't think having the OB explain the rationale for a twin section at 9pm is me being an obstructionist. Likewise, if someone wants to question my glidescope use, I have no problem educating them and explaining to them that while the MP was ok, the TM and neck circumference are bad and the literature about OB airway says blah blah

At the end of the day it's always about doing what's best for the patient. I don't think the risk of a bad outcome is vastly higher when rolling at 9pm, but there is no question that there is some small incremental safety benefit during the day when the lab, bloodbank, nicu, pharmacy, OB, nursing staff, and anesthesia all have an extra pair of hands readily available.