Hi Everyone, Join Siv and I as we sit down to discuss a couple of interesting obstetric related topics. The first is the pharmacology around the choice and strength of local anaesthetics used in epidural analgesia – thanks Siv. The second part we discuss a very large pragmatic study in the New England Journal of Medicine of 11000 women studying the use of tranexamic acid as a prophylaxis during caesarean surgery (elective and emergency). Spoiler alert it didn’t show any difference (death or transfusion). Thanks Siv! References Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery Pacheo et al N Engl J Med 2023; 388:1365-1375 Minimum local analgesic concentration of local anaesthetics. Malachy Columb, Iain Gall Continuing Education in Anaesthesia Critical Care &amp; Pain, Volume 10, Issue 4, August 2010, Pages 114–116 Determination of the Minimum Local Analgesic Concentrations of Epidural Bupivacaine and Lidocaine in Labor. Columb, Malachy O. FRCA; Lyons, Gordon FRCA. Anesthesia &amp; Analgesia 81(4):p 833-837, October 1995.

Hi Everyone, Join Siv and I as we sit down to discuss a couple of interesting obstetric related topics. The first is the pharmacology around the choice and strength of local anaesthetics used in epidural analgesia – thanks Siv. The second part we discuss a very large pragmatic study in the New England Journal of Medicine of 11000 women studying the use of tranexamic acid as a prophylaxis during caesarean surgery (elective and emergency). Spoiler alert it didn’t show any difference (death or transfusion). Thanks Siv! <h2>References</h2> <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207419" rel="nofollow" target="_blank">Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery Pacheo et al N Engl J Med 2023; 388:1365-1375</a> <a href="https://academic.oup.com/bjaed/article/10/4/114/380733" rel="nofollow" target="_blank">Minimum local analgesic concentration of local anaesthetics. Malachy Columb, Iain Gall Continuing Education in Anaesthesia Critical Care &amp; Pain, Volume 10, Issue 4, August 2010, Pages 114–116</a> <a href="https://journals.lww.com/anesthesia-analgesia/fulltext/1995/10000/determination_of_the_minimum_local_analgesic.30.aspx" rel="nofollow" target="_blank">Determination of the Minimum Local Analgesic Concentrations of Epidural Bupivacaine and Lidocaine in Labor. Columb, Malachy O. FRCA; Lyons, Gordon FRCA. Anesthesia &amp; Analgesia 81(4):p 833-837, October 1995.</a>

116 Epidural local anaesthetics and another TXA article with Siv

Hi Everyone, This week we are joined by Dr Anastazia Keegan an obstetric haematologist and the head of Haematology at our Women’s hospital here in Western Australia. Join us as Anastazia educates us about congenital bleeding disorders in pregnancy – the common ones, Von Willebrands disease and haemophilia – and how to approach a woman with one of the many uncommon ones (which working in a tertiary referral centre are more common than you would expect). Thanks for all the great advice and insights – we look forward to having Anastazia back in the near future for the lowdown on some more really important haematological conditions we encounter in women’s health. References Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210 (7): Online Bleeding Assessment Tool ISTH-BAT

Hi Everyone, This week we are joined by Dr Anastazia Keegan an obstetric haematologist and the head of Haematology at our Women’s hospital here in Western Australia. Join us as Anastazia educates us about congenital bleeding disorders in pregnancy – the common ones, Von Willebrands disease and haemophilia – and how to approach a woman with one of the many uncommon ones (which working in a tertiary referral centre are more common than you would expect). Thanks for all the great advice and insights – we look forward to having Anastazia back in the near future for the lowdown on some more really important haematological conditions we encounter in women’s health. <h3>References</h3> <a href="https://www.mja.com.au/journal/2019/210/7/updated-australian-consensus-statement-management-inherited-bleeding-disorders" rel="nofollow" target="_blank">Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210 (7):</a> <a href="https://bleedingscore.certe.nl" rel="nofollow" target="_blank">Online Bleeding Assessment Tool ISTH-BAT</a>

115 Congenital bleeding disorders in pregnancy with Dr Anastazia Keegan

Hi Everyone, This is part 2 of a discussion (see the previous episode for part 1). We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music…… Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below: References Challenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023 Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings Handbook of Communication in Anaesthesia &amp; Critical Care: A Practical Guide to Exploring the Art Illustrated Edition. Dr Allan Cyna

Hi Everyone, This is part 2 of a discussion (see the previous episode for part 1). We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music…… Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below: <h3>References</h3> <a href="https://www.anzca.edu.au/getattachment/72f4b3cb-f4aa-4c46-a4c6-8be1790d0673/2023-Obstetric-Anaesthesia-SIG-meeting-program" rel="nofollow" target="_blank">Challenges and Choices in Obstetric Anaesthesia </a>– Sydney Convention centre May 3-4 2023 <a href="https://www.oaa-anaes.ac.uk/" rel="nofollow" target="_blank">Obstetric Anaesthetist’s Association OAA-UK</a> – see links to their annual meetings <a href="https://www.amazon.com/Handbook-Communication-Anaesthesia-Critical-Care/dp/0199577285" rel="nofollow" target="_blank">Handbook of Communication in Anaesthesia &amp; Critical Care: A Practical Guide to Exploring the Art Illustrated Edition.</a> Dr Allan Cyna

114 Highlights from the OA SIG Meeting Sydney part 2

Hi Everyone, We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music…… Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below: References Challenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023 Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings Moran, NF, Bishop, DG, Fawcus, S, Morris, E, Shakur-Still, H, Devall, AJ, et al. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023; 130(1): 114– 117. https://doi.org/10.1111/1471-0528.17292

Hi Everyone, We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music…… Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below: <h3>References</h3> <a href="https://www.anzca.edu.au/getattachment/72f4b3cb-f4aa-4c46-a4c6-8be1790d0673/2023-Obstetric-Anaesthesia-SIG-meeting-program" rel="nofollow" target="_blank">Challenges and Choices in Obstetric Anaesthesia </a>– Sydney Convention centre May 3-4 2023 <a href="https://www.oaa-anaes.ac.uk/" rel="nofollow" target="_blank">Obstetric Anaesthetist’s Association OAA-UK</a> – see links to their annual meetings Moran, NF, Bishop, DG, Fawcus, S, Morris, E, Shakur-Still, H, Devall, AJ, et al. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023; 130(1): 114– 117. <a href="https://doi.org/10.1111/1471-0528.17292" rel="nofollow" target="_blank">https://doi.org/10.1111/1471-0528.17292</a>

113 Highlights from the OA SIG Meeting Sydney part 1

You are called to a code blue medical on labour ward – a previously well nulliparous woman has just had a seizure, and now seems confused. Her observations are normal, she is not hypertensive and the CTG appears fine. She is presumed to have had an eclamptic seizure and is given oxygen, magnesium and has some urgent pre-eclampsia bloods and urine sent. The midwife states she has been trying to stay well hydrated with lots of coconut water and has been on oxytocin to augment her labour for a number of hours. Her results are all normal except for a sodium of 111. She suddenly starts to begin seizing again……. Hi everyone, This week I am joined by two guests – Siv our current education fellow and Jess who is a senior ICU trainee working in our department  to discuss a very important but perhaps somewhat often overlooked condition – peripartum hyponatraemia. As we acknowledge in the podcast hyponatraemia is a huge topic and in order to make this podcast more manageable and practical we have chosen to focus specifically on peripartum hyponatraemia, it’s common causes, recognition &amp; diagnosis, practical management and how to avoid the harms associated with excessively rapid correction. Thanks Jess! References Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017

You are called to a code blue medical on labour ward – a previously well nulliparous woman has just had a seizure, and now seems confused. Her observations are normal, she is not hypertensive and the CTG appears fine. She is presumed to have had an eclamptic seizure and is given oxygen, magnesium and has some urgent pre-eclampsia bloods and urine sent. The midwife states she has been trying to stay well hydrated with lots of coconut water and has been on oxytocin to augment her labour for a number of hours. Her results are all normal except for a sodium of 111. She suddenly starts to begin seizing again……. Hi everyone, This week I am joined by two guests – Siv our current education fellow and Jess who is a senior ICU trainee working in our department to discuss a very important but perhaps somewhat often overlooked condition – peripartum hyponatraemia. As we acknowledge in the podcast hyponatraemia is a huge topic and in order to make this podcast more manageable and practical we have chosen to focus specifically on peripartum hyponatraemia, it’s common causes, recognition &amp; diagnosis, practical management and how to avoid the harms associated with excessively rapid correction. Thanks Jess! <h2>References</h2> <a href="https://www.rqia.org.uk/RQIA/files/df/dfd57ddd-ceb3-4c0d-9719-8e33e179d0ff.pdf" rel="nofollow" target="_blank">Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017</a>

112 Peripartum hyponatraemia with Jess & Siv

Mike Jamison

Hi Everyone, In our tertiary women’s hospital here in Perth we use remifentanil PCA in labour approximately 15 times a year – and we are told that in Australian terms this is considered a “heavy user” of this labour analgesic technqiue. This week I sit down with Mike Jamison an anaesthetic fellow from Belfast spending a year with us here in Perth. When he arrived in WA we quickly learned from him that remifentanil PCA is commonly used for labour analgesia in Northern Ireland with one unit he worked in having prescribed this technique for more than 11,000 women. We sit down to have a deep dive into the use of remifentanil PCA in labour in Northern Ireland. What aspects of their approach have led it to become such a commonly utilised technique? What is their recipe? How do they prescribe it, how do they monitor the women and how is this technique now viewed amongst the obstetric, midwifery and wider Northern Irish community! If you are attending the upcoming Obstetric Anaesthesia satellite meeting in Sydney in a few weeks – come along to hear Mike talk on this in person! References Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet volume 392, p662-672, AUGUST 25, 2018 Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years’ experience. H Murray, P Hodgkinson, D Hughes. Int J Obstet Anesth 2019 Aug;39:29-39

Hi Everyone, In our tertiary women’s hospital here in Perth we use remifentanil PCA in labour approximately 15 times a year – and we are told that in Australian terms this is considered a “heavy user” of this labour analgesic technqiue. This week I sit down with Mike Jamison an anaesthetic fellow from Belfast spending a year with us here in Perth. When he arrived in WA we quickly learned from him that remifentanil PCA is commonly used for labour analgesia in Northern Ireland with one unit he worked in having prescribed this technique for more than 11,000 women. We sit down to have a deep dive into the use of remifentanil PCA in labour in Northern Ireland. What aspects of their approach have led it to become such a commonly utilised technique? What is their recipe? How do they prescribe it, how do they monitor the women and how is this technique now viewed amongst the obstetric, midwifery and wider Northern Irish community! If you are attending the upcoming Obstetric Anaesthesia satellite meeting in Sydney in a few weeks – come along to hear Mike talk on this in person! <h2>References</h2> <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31613-1/fulltext" rel="nofollow" target="_blank">Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet volume 392, p662-672, AUGUST 25, 2018</a> <a href="https://pubmed.ncbi.nlm.nih.gov/31230993/" rel="nofollow" target="_blank">Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years’ experience. H Murray, P Hodgkinson, D Hughes. Int J Obstet Anesth 2019 Aug;39:29-39</a><a href="https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Int+J+Obstet+Anesth%22%5BTitle+Abbreviation%5D" rel="nofollow" target="_blank"></a>

111 – Remifentanil PCA in labour – the Belfast experience with Mike Jamison

You are referred a patient who needs urgent surgery and the obstetrician tells you she has some obscure medical condition which you have never heard of before. Does her condition have any implications for the safe conduct of anaesthesia? How can you find out in a timely manner what the specific anaesthetic issues are and what anaesthetics have been used safely by others in these patients before? Hi everyone, This week I am joined by Siv and Sarah to discuss this tricky situation and to give a free plug for the website orphananesthesia.eu a site started by the German society of anaesthesiology and now contributed to by anaesthesia providers from all over the world to help with these difficult patients. Correction: In the podcast we referred to Stoelting’s textbook – this text is actually titled “Anesthesia and co-existing disease” – but not dedicated specifically to rare or uncommon disorders. A more relevant text would have been Fleischer et al “Anaesthesia and uncommon diseases”. References https://www.orphananesthesia.eu/en/

You are referred a patient who needs urgent surgery and the obstetrician tells you she has some obscure medical condition which you have never heard of before. Does her condition have any implications for the safe conduct of anaesthesia? How can you find out in a timely manner what the specific anaesthetic issues are and what anaesthetics have been used safely by others in these patients before? Hi everyone, This week I am joined by Siv and Sarah to discuss this tricky situation and to give a free plug for the website <a href="http://orphananesthesia.eu" rel="nofollow" target="_blank">orphananesthesia.eu</a> a site started by the German society of anaesthesiology and now contributed to by anaesthesia providers from all over the world to help with these difficult patients. Correction: In the podcast we referred to Stoelting’s textbook – this text is actually titled “Anesthesia and co-existing disease” – but not dedicated specifically to rare or uncommon disorders. A more relevant text would have been Fleischer et al “Anaesthesia and uncommon diseases”. <h3>References</h3> <a href="https://www.orphananesthesia.eu/en/" rel="nofollow" target="_blank">https://www.orphananesthesia.eu/en/</a>

110 Rare diseases and OrphanAnesthesia with Siv and Sarah.

Arterial lines – let’s face it who doesn’t love them? When you have a truly sick patient these humble and often underrated devices bring so much to the table, precise control of the haemodynamics, assessment of gas exchange, blood sampling to assess coagulation, anaemia and many other parameters. There is nothing more frustrating however when these lines don’t go in easily, malfunction or stop working altogether….. Hi everyone, This week I sit down with Graeme and Siv to dissect &amp; discuss a great review article. The authors do a great job performing a deep dive into almost every imaginable aspect of their use, including insertion techniques, ultrasound, angle of insertion, length, size, site, construction, securement, and more. Join us and no matter what your level of experience I am sure you will learn something new – I know I certainly did! References Preventing radial arterial catheter failure in critical care – Factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med 2022 Aug;41(4):101096. *Unfortunately this is an article in a journal owned by Elsevier (in my humble opinion a company not very supportive of open access) and is behind a pay-wall. You can access this through the ANZCA library or your own institutions library in some cases.

Arterial lines – let’s face it who doesn’t love them? When you have a truly sick patient these humble and often underrated devices bring so much to the table, precise control of the haemodynamics, assessment of gas exchange, blood sampling to assess coagulation, anaemia and many other parameters. There is nothing more frustrating however when these lines don’t go in easily, malfunction or stop working altogether….. Hi everyone, This week I sit down with Graeme and Siv to dissect &amp; discuss a great review article. The authors do a great job performing a deep dive into almost every imaginable aspect of their use, including insertion techniques, ultrasound, angle of insertion, length, size, site, construction, securement, and more. Join us and no matter what your level of experience I am sure you will learn something new – I know I certainly did! <h4>References</h4> <a href="https://pubmed.ncbi.nlm.nih.gov/35490863/" rel="nofollow" target="_blank">Preventing radial arterial catheter failure in critical care – Factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med 2022 Aug;41(4):101096.</a> *Unfortunately this is an article in a journal owned by Elsevier (in my humble opinion a company not very supportive of open access) and is behind a pay-wall. You can access this through the ANZCA library or your own institutions library in some cases.<a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Anaesth+Crit+Care+Pain+Med%22%5Bjour%5D&amp;sort=date&amp;sort_order=desc" rel="nofollow" target="_blank"></a>

109 Radial arterial line strategies to prevent failure with Graeme & Siv

Lloyd Green

(Hypothetical case)  You are called to the PACU to review a patient, who despite face mask oxygen has saturations of only 88%. She is a woman in her 50s who has just undergone a 3 hour laparoscopic hysterectomy for endometrial cancer. She has a BMI of 48, has been a smoker for 30 years, and had a chest infection 3 weeks ago. When she walked into the hospital earlier this morning she was breathing relatively normally. She had a long period of time when we she was steeply head down, there was a pneumoperitoneum of gas pushing on her lung bases and we were positively ventilating her with the anaesthetist choosing what gas mixture, pressures and ventilation modes they used. What has happened during this operation and anaesthetic that now she has serious respiratory dysfunction here only a few hours later in PACU? Are there any strategies that we could have employed intraoperatively to try and minimise or avoid postoperative respiratory problems like this? Join Lloyd and I as we discuss this thorny issue which is not uncommon in gynaecological patients having laparoscopic and open abdominal surgery.  Part 1: We discuss post pulmonary dysfunction and consensus statements on the topic. Part 2: We talk about practical intraoperative &amp; postoperative strategies you might consider to try and protect the lungs and prevent any problems. “Lloyd’s Recipe”  Check the patient’s oxygen sats whilst supine – pre induction (use to plan target sats intra &amp; post) Individualise FiO2 for pre-oxygenation and not necessarily 100% for most (usually 80%) Have the APL valve at around 5cm H20 when preoxygenating Head-up / ramped (to maintain FRC) Recruitment manoeuvre after intubation and before pneumoperitoneum – use a machine technique not hand recruitment. Start with a PEEP 5-8cm H20, individualise during the case – may need higher whilst head down and pneumoperitoneum. Small Tidal Volumes (TV) 5-8ml/kg of ideal body weight – (obese patients don’t get bigger TV’s) Keep FiO2 &lt; 0.4 I:E ratio 1:1 If disconnection – repeat recruitment maneouvre At emergence / extubation – sitting upright, don’t disconnect to suction ETT, recruit again if laparoscopic procedure or obese. Routinely use NM monitoring – ensure TOFR &gt;0.95 Don’t use 100% O2, Aim FiO2 &lt; 0.8 If breathing on manual ventilation setting have APL valve at 5-10 to maintain PEEP Squeeze bag as extubating Immediately post extubation place face mask with APL still at 5-10 Be cautious / avoid excessive opioids that will suppress respiratory drive in PACU  References A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications BJA 2018 May 120(5) Postoperative pulmonary complications BJA: British Journal of Anaesthesia, Volume 118, Issue 3, March 2017, Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis BMJ 2020; 368 Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations BJA 2019 Dec;123(6)

(Hypothetical case) You are called to the PACU to review a patient, who despite face mask oxygen has saturations of only 88%. She is a woman in her 50s who has just undergone a 3 hour laparoscopic hysterectomy for endometrial cancer. She has a BMI of 48, has been a smoker for 30 years, and had a chest infection 3 weeks ago. When she walked into the hospital earlier this morning she was breathing relatively normally. She had a long period of time when we she was steeply head down, there was a pneumoperitoneum of gas pushing on her lung bases and we were positively ventilating her with the anaesthetist choosing what gas mixture, pressures and ventilation modes they used. What has happened during this operation and anaesthetic that now she has serious respiratory dysfunction here only a few hours later in PACU? Are there any strategies that we could have employed intraoperatively to try and minimise or avoid postoperative respiratory problems like this? Join Lloyd and I as we discuss this thorny issue which is not uncommon in gynaecological patients having laparoscopic and open abdominal surgery. Part 1: We discuss post pulmonary dysfunction and consensus statements on the topic. Part 2: We talk about practical intraoperative &amp; postoperative strategies you might consider to try and protect the lungs and prevent any problems. <h4>“Lloyd’s Recipe”</h4> <ol> <li>Check the patient’s oxygen sats whilst supine – pre induction (use to plan target sats intra &amp; post)</li> <li>Individualise FiO2 for pre-oxygenation and not necessarily 100% for most (usually 80%)</li> <li>Have the APL valve at around 5cm H20 when preoxygenating</li> <li>Head-up / ramped (to maintain FRC)</li> <li>Recruitment manoeuvre after intubation and before pneumoperitoneum – use a machine technique not hand recruitment.</li> <li>Start with a PEEP 5-8cm H20, individualise during the case – may need higher whilst head down and pneumoperitoneum.</li> <li>Small Tidal Volumes (TV) 5-8ml/kg of ideal body weight – (obese patients don’t get bigger TV’s)</li> <li>Keep FiO2 &lt; 0.4</li> <li>I:E ratio 1:1</li> <li>If disconnection – repeat recruitment maneouvre</li> <li>At emergence / extubation – sitting upright, don’t disconnect to suction ETT, recruit again if laparoscopic procedure or obese.</li> <li>Routinely use NM monitoring – ensure TOFR &gt;0.95</li> <li>Don’t use 100% O2, Aim FiO2 &lt; 0.8</li> <li>If breathing on manual ventilation setting have APL valve at 5-10 to maintain PEEP</li> <li>Squeeze bag as extubating</li> <li>Immediately post extubation place face mask with APL still at 5-10</li> <li>Be cautious / avoid excessive opioids that will suppress respiratory drive in PACU</li> </ol> <h4>References</h4> <a href="https://www.sciencedirect.com/science/article/pii/S0007091218301156?via%3Dihub" rel="nofollow" target="_blank">A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications BJA 2018 May 120(5)</a> <a href="https://academic.oup.com/bja/article/118/3/317/2982040" rel="nofollow" target="_blank">Postoperative pulmonary complications BJA: British Journal of Anaesthesia, Volume 118, Issue 3, March 2017,</a> <a href="https://www.bmj.com/content/368/bmj.m540" rel="nofollow" target="_blank">Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis BMJ 2020; 368</a> <a href="https://www.sciencedirect.com/science/article/pii/S0007091219306476?via%3Dihub" rel="nofollow" target="_blank">Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations BJA 2019 Dec;123(6)</a>

108 Postoperative pulmonary complications and protective lung ventilation strategies with Lloyd Green

Hi everyone, This week three of us sit down to discuss a great review article (and topic) – the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery.  For many the classic technique for a GA caesarean has been thio / sux tube then volatile &amp; nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it’s role for women having caesarean surgery and GA for management of postpartum haemorrhage. Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation).  It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know. Informal Twitter Poll result from Parita!: References The role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022 Comments on above article – M.Paech IJOA June 28, 2022

Hi everyone, This week three of us sit down to discuss a great review article (and topic) – the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery. For many the classic technique for a GA caesarean has been thio / sux tube then volatile &amp; nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it’s role for women having caesarean surgery and GA for management of postpartum haemorrhage. Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation). It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know. Informal Twitter Poll result from Parita!: <h3>References</h3> <a href="https://www.obstetanesthesia.com/article/S0959-289X(22)00050-4/fulltext" rel="nofollow" target="_blank">The role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022</a> <a href="https://www.obstetanesthesia.com/article/S0959-289X(22)00289-8/fulltext" rel="nofollow" target="_blank">Comments on above article – M.Paech IJOA June 28, 2022</a>

107 TIVA for GA caesarean with Parita & Sneha

A podcast discussing critical care, anaesthesia and pain medicine in obstetrics and gynaecology

Obsgynaecritcare

Nolan McDonnell

Hi Everyone,This week we have the audio from another great talk given at our departmental meeting by our colleague Assoc Prof Nolan McDonnell on labour epidural analgesia. This talk was originally given at the Obstetric Anaesthesia special interest group meeting held in Sydney in early May. Nolan discusses many important aspects of the physiology and pharmacology of labour pain, and the history of how the regimen we use in our institution has evolved over the last decade. The second part of the talk centres around the evidence for what is the best epidural analgesia regimen to use in labour and what might the future hold?Thanks again Nolan!For those who would like to view this as a video with the powerpoint slides you can do so here:Video recording - Labour epidural analgesia regimens Nolan Mcdonnell.

Hi Everyone, This week we have the audio from another great talk given at our departmental meeting by our colleague Assoc Prof Nolan McDonnell on labour epidural analgesia. This talk was originally given at the Obstetric Anaesthesia special interest group meeting held in Sydney in early May. Nolan discusses many important aspects of the physiology and pharmacology of labour pain, and the history of how the regimen we use in our institution has evolved over the last decade. The second part of the talk centres around the evidence for what is the best epidural analgesia regimen to use in labour and what might the future hold? Thanks again Nolan! For those who would like to view this as a video with the powerpoint slides you can do so here: Video recording - Labour epidural analgesia regimens Nolan Mcdonnell.

035 – Labour epidural analgesia regimens discussed – Nolan McDonnell

Hi Everyone,This week I am joined again by Nolan who was involved in writing the recently published international consensus guidelines on the use of uterotonic drugs at caesarean section. We discuss the pharmacology and mechanisms of all the different drugs used in clinical practice.  From a practical point of view these guidelines differentiate between oxytocin naive women, those who have been exposed to oxytocin (in labour) and those practitioners working in less well resourced settings.A big thank you to Trilby for helping to setup the new audio equipment! Hopefully the quality of these podcasts will start to improve over the next few episodes as we get to grips with how to use all this new stuff!LinkInternational consensus statement on the use of uterotonic agents during caesarean section. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14757

Hi Everyone, This week I am joined again by Nolan who was involved in writing the recently published international consensus guidelines on the use of uterotonic drugs at caesarean section. We discuss the pharmacology and mechanisms of all the different drugs used in clinical practice.  From a practical point of view these guidelines differentiate between oxytocin naive women, those who have been exposed to oxytocin (in labour) and those practitioners working in less well resourced settings. A big thank you to Trilby for helping to setup the new audio equipment! Hopefully the quality of these podcasts will start to improve over the next few episodes as we get to grips with how to use all this new stuff! Link International consensus statement on the use of uterotonic agents during caesarean section. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14757" rel="nofollow" target="_blank">https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14757</a>

058 – Uterotonics with Prof Nolan McDonnell

Hi everyone,This week on the podcast I have a fascinating interview with Dr Wynand Breytenbach a GP anaesthetist and obstetrician working in Narrogin WA. Join us on the podcast - we have a great conversation where Wynand recounts for us a case he had as a junior doctor working for the South African govt when he was stationed in Namibia on the border with Angola many years ago........Thanks for listening!RegardsRoger

Hi everyone, This week on the podcast I have a fascinating interview with Dr Wynand Breytenbach a GP anaesthetist and obstetrician working in Narrogin WA. Join us on the podcast - we have a great conversation where Wynand recounts for us a case he had as a junior doctor working for the South African govt when he was stationed in Namibia on the border with Angola many years ago........ Thanks for listening! Regards Roger

021 – Uterine rupture in Namibia with Dr Wynand Breytenbach

Hi Everyone,After last weeks fascinating case discussion, Nolan and I continue with our discussion on amniotic fluid embolism. In this discussion we drill down into some of the current theories and understanding of the pathophysiology, prevalence, risk factors and AMOSS, the Australasian Maternities Outcomes Surveillance System, which has focussed on AFE in Australasia.The exact biological mechanism of AFE is still not fully understood as this is a rare unpredictable condition with no reproducible animal model which makes it exceedingly difficult to study. The knowledge we currently have has been gleaned from descriptions of case reports / case series and the pathophysiology that was observed. Current theories favour the condition to be an immune mediated reaction triggered by maternal exposure to fetal amniotic fluid and that the term "embolism" may be misleading.Listen to our podcast above for some more nuanced discussion on this topic. If anyone has any comments, questions or personal experiences they'd like to share please leave us a comment we'd love hear from you!RogerReferences 	AMOSS, the Australasian Maternities Outcomes Surveillance System: https://www.amoss.com.au/ 	Society for Maternal-Fetal Medicine (SMFM) with the assistance of Pacheco LD, Saade G, et al. Amniotic fluid embolism:diagnosis and management. Am J Obstet Gynecol 2016;Aug;215(2):B16-24. 	McDonnell NJ, Percival V, Paech MJ.Amniotic fluid embolism: a leading cause of maternal death yet still a medical conundrum. Int J Obstet Anesth. 2013 Nov;22(4):329-36Listen to last weeks fascinating case of AFE:019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell

Hi Everyone, After last weeks fascinating case discussion, Nolan and I continue with our discussion on amniotic fluid embolism. In this discussion we drill down into some of the current theories and understanding of the pathophysiology, prevalence, risk factors and AMOSS, the Australasian Maternities Outcomes Surveillance System, which has focussed on AFE in Australasia. The exact biological mechanism of AFE is still not fully understood as this is a rare unpredictable condition with no reproducible animal model which makes it exceedingly difficult to study. The knowledge we currently have has been gleaned from descriptions of case reports / case series and the pathophysiology that was observed. Current theories favour the condition to be an immune mediated reaction triggered by maternal exposure to fetal amniotic fluid and that the term "embolism" may be misleading. Listen to our podcast above for some more nuanced discussion on this topic. If anyone has any comments, questions or personal experiences they'd like to share please leave us a comment we'd love hear from you! Roger References 	AMOSS, the Australasian Maternities Outcomes Surveillance System: <a href="https://www.amoss.com.au/" rel="nofollow" target="_blank">https://www.amoss.com.au/</a> 	Society for Maternal-Fetal Medicine (SMFM) with the assistance of Pacheco LD, Saade G, et al. Amniotic fluid embolism:diagnosis and management. Am J Obstet Gynecol 2016;Aug;215(2):B16-24. 	McDonnell NJ, Percival V, Paech MJ.Amniotic fluid embolism: a leading cause of maternal death yet still a medical conundrum. Int J Obstet Anesth. 2013 Nov;22(4):329-36 Listen to last weeks fascinating case of AFE: 019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell

020 – Amniotic Fluid Embolism pathophysiology with Assoc Prof Nolan McDonnell

Hi Everyone,This week we have a friend and colleague on the podcast, Assoc Prof Nolan McDonnell where he discusses a challenging case of amniotic fluid embolism which he was personally involved with earlier in his career. Join us and listen to the case where Nolan describes what it was like on a personal level - the uncertainty at first as to what is happening when there is a maternal collapse - and then the clinical utility of transoesophageal echocardiography and inhaled nitric oxide and how they helped in the management of this critically unwell woman.This is a unpredictable and challenging clinical condition which anyone involved in the care of obstetric woman in the peripartum period may be unfortunate enough to encounter. Stay tuned for next weeks podcast where Nolan and I do more of a "deep dive" into the epidemiology, pathophysiology and history of this fascinating condition.ReferenceMcDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxde in a parturient with amniotic fluid embolism. Int J Obstet Anesth. 2007 Jul;16(3):269-73https://www.ncbi.nlm.nih.gov/pubmed/17337177

Hi Everyone, This week we have a friend and colleague on the podcast, Assoc Prof Nolan McDonnell where he discusses a challenging case of amniotic fluid embolism which he was personally involved with earlier in his career. Join us and listen to the case where Nolan describes what it was like on a personal level - the uncertainty at first as to what is happening when there is a maternal collapse - and then the clinical utility of transoesophageal echocardiography and inhaled nitric oxide and how they helped in the management of this critically unwell woman. This is a unpredictable and challenging clinical condition which anyone involved in the care of obstetric woman in the peripartum period may be unfortunate enough to encounter. Stay tuned for next weeks podcast where Nolan and I do more of a "deep dive" into the epidemiology, pathophysiology and history of this fascinating condition. Reference McDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxde in a parturient with amniotic fluid embolism. Int J Obstet Anesth. 2007 Jul;16(3):269-73 <a href="https://www.ncbi.nlm.nih.gov/pubmed/17337177" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/17337177</a>

019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell

(*Hypothetical case)You are the anaesthetist on for obstetrics and a young woman is rushed from labour ward into your theatre for an emergency caesarean for fetal distress. Your registrar is talking with the patient and so you help with the team time out discussion. The obstetrician leading this asks "can you please give 2g of Cefazolin?". No worries - you grab the 20ml syringe and give the antibiotics over the next 30seconds whilst you help slide the patient onto the table and you instruct your registrar to start topping up her epidural. Your registrar says "no worries" but then looks confused and turns to ask you "where is my syringe?" With a sudden sickening feeling building in your stomach you look down at the now empty 20ml syringe in your hand. You slowly roll it over to reveal a previously hidden sticker....................... "bupivacaine 0.5%"Do you ever use local anaesthetics?This sort of local anaesthetic misadventure is one of those life threatening scenarios which make most anaesthetists break out in a cold sweat but the truth is this is a topic that everyone who uses local anaesthetics needs to be aware of. Indeed many of the reported cases of this life threatening complication have been local anaesthetics used by surgeons, dentists, and other health care practitioners.What is LAST? Local Anaesthetic Systemic ToxicityLocal anaesthetics are amazing analgesic medications which have  many advantages over analgesics like opioids (we here at obsgynaecritcare are big fans of regional analgesia techniques). However in the wrong dose or route these medications block sodium channels in the heart and brain &amp; can cause lethal CNS and cardiac toxicity.This week I interview Dr Chris McGrath one of our anaesthesia fellows. We discuss the updated ASRA guidelines for management of LAST. There are now some new considerations to traditional ALS and we detail the role of more specific therapies such as intralipid and ECMO.Links 	http://www.lipidrescue.org/      The definitive website on the use of intralipid to treat local anaesthetic toxicity (and other drug toxicities). There is a fascinating explanation of the discovery of intralipid therapy by Guy Weinberg (a US anesthesiology researcher), as well as many interesting cases and a great up to date review of the research on this therapy. 	https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity     The ASRA (American Society of Regional Anaesthesia and Pain Medicine), checklist for the management of LAST 	 https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf    AAGBI (Association of Anaesthetists of Great Britain and Ireland) 2010 LA Toxicity guideline 	Bupivacaine 0.75% causing maternal deaths.    Read this report to the British Journal of Anaesthesia in 1986 describing the withdrawal of bupivacaine 0.75% for use in obstetrics by the FDA following up to 31 maternal deaths from LA toxicity in epidural anaesthesia in North America.References 	CHEER Trial.  Stub, D et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 86. (2015) 88-94. 	ASRA Guidelines. Neal, J et al. The American Society of Regional Anaesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Regional Anesthesia and Pain Medicine. Vol 43(2) pg. 150-153 	ASRA Case Series. Gitman, M et al. Local Anesthetic Systemic Toxicity: A Review of recent Case Reports and Registries. Regional Anesthesia and Pain Medicine. Vol 43(2) 124-130. 	AAGBI Guidelines. The Association of Anaesthetists of Great Britain and Ireland 2010. Cave, G et al. AAGBI Safety Guideline: Management of Severe Local Anaesthetic Toxicity. Available [On-Line]:https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdfLasts Weeks Quiz!Congratulations to Sneha and Jeremy (a close second).

(*Hypothetical case) You are the anaesthetist on for obstetrics and a young woman is rushed from labour ward into your theatre for an emergency caesarean for fetal distress. Your registrar is talking with the patient and so you help with the team time out discussion. The obstetrician leading this asks "can you please give 2g of Cefazolin?". No worries - you grab the 20ml syringe and give the antibiotics over the next 30seconds whilst you help slide the patient onto the table and you instruct your registrar to start topping up her epidural. Your registrar says "no worries" but then looks confused and turns to ask you "where is my syringe?" With a sudden sickening feeling building in your stomach you look down at the now empty 20ml syringe in your hand. You slowly roll it over to reveal a previously hidden sticker....................... "bupivacaine 0.5%" Do you ever use local anaesthetics? This sort of local anaesthetic misadventure is one of those life threatening scenarios which make most anaesthetists break out in a cold sweat but the truth is this is a topic that everyone who uses local anaesthetics needs to be aware of. Indeed many of the reported cases of this life threatening complication have been local anaesthetics used by surgeons, dentists, and other health care practitioners. What is LAST? Local Anaesthetic Systemic Toxicity Local anaesthetics are amazing analgesic medications which have  many advantages over analgesics like opioids (we here at obsgynaecritcare are big fans of regional analgesia techniques). However in the wrong dose or route these medications block sodium channels in the heart and brain &amp; can cause lethal CNS and cardiac toxicity. This week I interview Dr Chris McGrath one of our anaesthesia fellows. We discuss the updated ASRA guidelines for management of LAST. There are now some new considerations to traditional ALS and we detail the role of more specific therapies such as intralipid and ECMO. Links 	<a href="http://www.lipidrescue.org/" rel="nofollow" target="_blank">http://www.lipidrescue.org/</a>      The definitive website on the use of intralipid to treat local anaesthetic toxicity (and other drug toxicities). There is a fascinating explanation of the discovery of intralipid therapy by Guy Weinberg (a US anesthesiology researcher), as well as many interesting cases and a great up to date review of the research on this therapy. 	<a href="https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity" rel="nofollow" target="_blank">https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity</a>     The ASRA (American Society of Regional Anaesthesia and Pain Medicine), checklist for the management of LAST 	 <a href="https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf" rel="nofollow" target="_blank">https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf</a>    AAGBI (Association of Anaesthetists of Great Britain and Ireland) 2010 LA Toxicity guideline 	Bupivacaine 0.75% causing maternal deaths.    Read this report to the British Journal of Anaesthesia in 1986 describing the withdrawal of bupivacaine 0.75% for use in obstetrics by the FDA following up to 31 maternal deaths from LA toxicity in epidural anaesthesia in North America. References 	CHEER Trial.  Stub, D et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 86. (2015) 88-94. 	ASRA Guidelines. Neal, J et al. The American Society of Regional Anaesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Regional Anesthesia and Pain Medicine. Vol 43(2) pg. 150-153 	ASRA Case Series. Gitman, M et al. Local Anesthetic Systemic Toxicity: A Review of recent Case Reports and Registries. Regional Anesthesia and Pain Medicine. Vol 43(2) 124-130. 	AAGBI Guidelines. The Association of Anaesthetists of Great Britain and Ireland 2010. Cave, G et al. AAGBI Safety Guideline: Management of Severe Local Anaesthetic Toxicity. Available [On-Line]:<a href="https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf" rel="nofollow" target="_blank">https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf</a> Lasts Weeks Quiz! Congratulations to Sneha and Jeremy (a close second).

027 – LAST – local anaesthetic systemic toxicity

"Where the f**k is the anaesthetist! I asked for the epidural 45min ago, those obstetric doctors took five goes to put in my drip, the midwife has turned up the hormone drip and now I am going crazy! Aaarghhhh!"Seem familiar?Hi everyone,Welcome back this week I am joined by long time listener and first time interviewee - Dr Sneha Neppali who sits down with me to discuss a couple of projects she has recently completed - epidural analgesia response times and the use of abbreviations in healthcare - specifically obs / gynae ones used during her recent time here at our women's hospital.How many of these abbreviations do you know?Want to see how Sneha faired on her recent TV appearances follow the links below:The Chase https://www.youtube.com/watch?v=tEG7JZUTgyk&amp;feature=youtu.be&amp;fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63AMillionaire Hot Seathttps://www.youtube.com/watch?v=DcVJyd5j_9A&amp;feature=youtu.be&amp;fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0

"Where the f**k is the anaesthetist! I asked for the epidural 45min ago, those obstetric doctors took five goes to put in my drip, the midwife has turned up the hormone drip and now I am going crazy! Aaarghhhh!" Seem familiar? Hi everyone, Welcome back this week I am joined by long time listener and first time interviewee - Dr Sneha Neppali who sits down with me to discuss a couple of projects she has recently completed - epidural analgesia response times and the use of abbreviations in healthcare - specifically obs / gynae ones used during her recent time here at our women's hospital. How many of these abbreviations do you know? Want to see how Sneha faired on her recent TV appearances follow the links below: The Chase  <a href="https://www.youtube.com/watch?v=tEG7JZUTgyk&amp;feature=youtu.be&amp;fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63A" rel="nofollow" target="_blank">https://www.youtube.com/watch?v=tEG7JZUTgyk&amp;feature=youtu.be&amp;fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63A</a> Millionaire Hot Seat <a href="https://www.youtube.com/watch?v=DcVJyd5j_9A&amp;feature=youtu.be&amp;fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0" rel="nofollow" target="_blank">https://www.youtube.com/watch?v=DcVJyd5j_9A&amp;feature=youtu.be&amp;fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0</a>

060 Epidural response times and abbreviations in healthcare part 1

Matt Rucklidge

Hi everyone,Welcome to part 2 of our series on cell salvage in obstetrics and gynaecology!Last week we had a great discussion on the basics of cell salvage and focused on what the team in the surgical field need to know to do a great job. If you haven't listened to that yet check it out here:LinkThis week we welcome back Dr Matt Rucklidge and we have the recording of the talk he gave our department recently on the latest thoughts surrounding the use of cell salvage in obstetrics. If you haven't been watching this space closely over the last few years you may be unaware that there has been a definite change in approach to many aspects of how obstetric cell salvage is now done. Listen to Matt present a very balanced and thoughtful discussion on the following: 	it's ok to be collecting amniotic fluid during cell salvage 	the use of only one suction is now routine in many centres 	a softening in the stance on the need for use of leukodepletion filters when reinfusing salvaged obstetric blood.Some of his talk is based on the following recent articles:RECENT ARTICLES 	LATEST VERSION JULY 2018 UK GUIDANCE ON CELL SALVAGE -This is open access and free (hooray!) https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14331 	SALVO STUDY  - fulltext (also open access hooray!) :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736174/ VIDEO VERSION OF THIS TALKhttps://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0WHAT ABOUT VAGINAL CELL SALVAGE? 	Cell salvage for postpartum haemorrhage during vaginal delivery: a case series. Blood Transfus 2017 	Is cell salvaged vaginal blood loss suitable for re-infusion? IJOA 2015ONLINE EDUCATION RESOURCESNational Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/icsGreat resource from the UK pdfs and free slides on all the various aspects of cell salvage: https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-educationWHY SHOULD WE USE CELL SALVAGE?If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode:

Hi everyone, Welcome to part 2 of our series on cell salvage in obstetrics and gynaecology! Last week we had a great discussion on the basics of cell salvage and focused on what the team in the surgical field need to know to do a great job. If you haven't listened to that yet check it out here: Link This week we welcome back Dr Matt Rucklidge and we have the recording of the talk he gave our department recently on the latest thoughts surrounding the use of cell salvage in obstetrics. If you haven't been watching this space closely over the last few years you may be unaware that there has been a definite change in approach to many aspects of how obstetric cell salvage is now done. Listen to Matt present a very balanced and thoughtful discussion on the following: 	it's ok to be collecting amniotic fluid during cell salvage 	the use of only one suction is now routine in many centres 	a softening in the stance on the need for use of leukodepletion filters when reinfusing salvaged obstetric blood. Some of his talk is based on the following recent articles: RECENT ARTICLES 	LATEST VERSION JULY 2018 UK GUIDANCE ON CELL SALVAGE -This is open access and free (hooray!) <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14331" rel="nofollow" target="_blank">https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14331</a> 	SALVO STUDY  - fulltext (also open access hooray!) :<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736174/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736174/</a> VIDEO VERSION OF THIS TALK <a href="https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0" rel="nofollow" target="_blank">https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0</a> WHAT ABOUT VAGINAL CELL SALVAGE? 	Cell salvage for postpartum haemorrhage during vaginal delivery: a case series. Blood Transfus 2017 	Is cell salvaged vaginal blood loss suitable for re-infusion? IJOA 2015 ONLINE EDUCATION RESOURCES National Blood Authority guidelines for intraoperative cell salvage: <a href="https://www.blood.gov.au/ics" rel="nofollow" target="_blank">https://www.blood.gov.au/ics</a> Great resource from the UK pdfs and free slides on all the various aspects of cell salvage: <a href="https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education" rel="nofollow" target="_blank">https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education</a> WHY SHOULD WE USE CELL SALVAGE? If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode:

041 – Obstetric cell salvage an update, what only one suction, no filter and more with Dr Matt Rucklidge

Sonya Ting

Hi everyone,Join us on the podcast where this week we have part 2 of the discussion with Dr Sonya Ting on tips for management of acute perioperative pain. We explore some advice on how to manage a tricky obstetric patient with post caesarean pain issues.I also failed dismally to entice any responses to last weeks quiz entitled "Anaesthetist or serial killer". In one final last ditch attempt to rescue this quiz from abject failure I have now rebranded it. I have supplied you with a small crossword which can be used to get some hints as to the name of the individual who is pictured - and then I am guessing using the power of  the internet someone should be able to figure out who this is!QUIZ 4 - Anaesthetist or serial killer? Who is this person?

Hi everyone, Join us on the podcast where this week we have part 2 of the discussion with Dr Sonya Ting on tips for management of acute perioperative pain. We explore some advice on how to manage a tricky obstetric patient with post caesarean pain issues. I also failed dismally to entice any responses to last weeks quiz entitled "Anaesthetist or serial killer". In one final last ditch attempt to rescue this quiz from abject failure I have now rebranded it. I have supplied you with a small crossword which can be used to get some hints as to the name of the individual who is pictured - and then I am guessing using the power of  the internet someone should be able to figure out who this is! QUIZ 4 - Anaesthetist or serial killer? Who is this person?

032 – Part 2 perioperative acute pain management tips with Sonya Ting and a second attempt at quiz 4

You are in a peripheral hospital without onsite laboratory support after hours and you are involved in the care of a young parturient with uterine atony who has now bled over 2litres. Although you have called in someone to do some laboratory testing - you know that these results will be at least 45-90minutes away. How likely is it that this woman has become  coagulopathic? What approach should you take in this setting? Should you use empiric coagulation supportive therapy? FFP? Fibrinogen? TXA?Hi everyone,This week we have the audio of a great talk Nolan wrote for the obstetric intensive care symposium held in Adelaide earlier this year, and which he then kindly presented to our department in April.Pregnancy is a procoagulant state and during haemorrhage obstetric coagulopathy is actually relatively rare. The underlying mechanisms are different to trauma and other patient groups and we should use this knowledge to help us in our use of blood product therapy especially when rapid coagulation testing (eg viscoelastic tests like ROTEM) are not rapidly available.However there are some exceptions to this rule - beware early onset of coagulopathy in women with abruption, HELLP, and AFE!LinksObstetric Intensive Care Symposium Adelaide 2018https://www.picet.org.au/programme.phpIf you want to watch the video of this talk with it's powerpoint slides:https://www.dropbox.com/s/y57pf26ge9mry8g/Obstetric%20coagulopathy%20Nolan%20KEMH%20dept%20talk%20version.mp4?dl=0

You are in a peripheral hospital without onsite laboratory support after hours and you are involved in the care of a young parturient with uterine atony who has now bled over 2litres. Although you have called in someone to do some laboratory testing - you know that these results will be at least 45-90minutes away. How likely is it that this woman has become  coagulopathic? What approach should you take in this setting? Should you use empiric coagulation supportive therapy? FFP? Fibrinogen? TXA? Hi everyone, This week we have the audio of a great talk Nolan wrote for the obstetric intensive care symposium held in Adelaide earlier this year, and which he then kindly presented to our department in April. Pregnancy is a procoagulant state and during haemorrhage obstetric coagulopathy is actually relatively rare. The underlying mechanisms are different to trauma and other patient groups and we should use this knowledge to help us in our use of blood product therapy especially when rapid coagulation testing (eg viscoelastic tests like ROTEM) are not rapidly available. However there are some exceptions to this rule - beware early onset of coagulopathy in women with abruption, HELLP, and AFE! Links Obstetric Intensive Care Symposium Adelaide 2018 <a href="https://www.picet.org.au/programme.php" rel="nofollow" target="_blank">https://www.picet.org.au/programme.php</a> If you want to watch the video of this talk with it's powerpoint slides: <a href="https://www.dropbox.com/s/y57pf26ge9mry8g/Obstetric%20coagulopathy%20Nolan%20KEMH%20dept%20talk%20version.mp4?dl=0" rel="nofollow" target="_blank">https://www.dropbox.com/s/y57pf26ge9mry8g/Obstetric%20coagulopathy%20Nolan%20KEMH%20dept%20talk%20version.mp4?dl=0</a>

025 – obstetric induced coagulopathy with Nolan McDonnell

Case scenario:Mrs A Nonymous is a 67 yr old woman with a diagnosis of probable ovarian cancer who is booked for a midline laparotomy and debulking cancer surgery. She is a smoker, has a BMI of 50 and weighs 115kg. She was diagnosed with OSA 5 years ago but doesn't use CPAP because she couldn't tolerate it. She has had longstanding back pain for many years which she blames on an epidural which she had during childbirth 30 years ago. She has had 2 previous back operations "which didn't help" and now takes 3 analgesics for this pain which include moderately high dose oxycodone, pregabalin, and tramadol. She tells you that she definitely will not consent to any spinal or epidural because of all of her previous back issues...She is opioid tolerant and at high risk of serious opioid related respiratory adverse effects - how are you going to manage her pain, get her mobilising and avoid any technique that involves a needle in the back!Hi everyone,This week we have an interview with Dr Matt Rucklidge, a colleague and good friend who is also a consultant anaesthetist practicing here in Western Australia. Matt trained in the UK and worked in southern England, one of the pioneering regions, where he first became acquainted with the use of rectus sheath catheters for postoperative analgesia after midline laparotomy. He has helped us successfully introduce this very effective technique into our institution where it has now become the default analgesic technique for the majority of our patients undergoing major intra-abdominal surgery with a midline incision.BJA EDUCATION Articlehttps://bjaed.org/article/S2058-5349(18)30033-7/abstractUnfortunately contrary to my comments on the podcast - this article does not appear to be open access and when I tried to access it today it requires an institutional subscription or an individual payment. If you are an employee of a health service / university or a member of a college you may be able to access the article through these channels.Want to know more about the open access debate? See our previous podcast on this here:https://www.obsgynaecritcare.org/036-sci-hub-earthquakes-listener-mail-pirate-jokes-and-another-quiz/Instructional Videoshttps://youtu.be/Xq-H3SLLwO0https://youtu.be/_r_pVQf4C5w

Case scenario: Mrs A Nonymous is a 67 yr old woman with a diagnosis of probable ovarian cancer who is booked for a midline laparotomy and debulking cancer surgery. She is a smoker, has a BMI of 50 and weighs 115kg. She was diagnosed with OSA 5 years ago but doesn't use CPAP because she couldn't tolerate it. She has had longstanding back pain for many years which she blames on an epidural which she had during childbirth 30 years ago. She has had 2 previous back operations "which didn't help" and now takes 3 analgesics for this pain which include moderately high dose oxycodone, pregabalin, and tramadol. She tells you that she definitely will not consent to any spinal or epidural because of all of her previous back issues... She is opioid tolerant and at high risk of serious opioid related respiratory adverse effects - how are you going to manage her pain, get her mobilising and avoid any technique that involves a needle in the back! Hi everyone, This week we have an interview with Dr Matt Rucklidge, a colleague and good friend who is also a consultant anaesthetist practicing here in Western Australia. Matt trained in the UK and worked in southern England, one of the pioneering regions, where he first became acquainted with the use of rectus sheath catheters for postoperative analgesia after midline laparotomy. He has helped us successfully introduce this very effective technique into our institution where it has now become the default analgesic technique for the majority of our patients undergoing major intra-abdominal surgery with a midline incision. BJA EDUCATION Article <a href="https://bjaed.org/article/S2058-5349(18)30033-7/abstract" rel="nofollow" target="_blank">https://bjaed.org/article/S2058-5349(18)30033-7/abstract</a> Unfortunately contrary to my comments on the podcast - this article does not appear to be open access and when I tried to access it today it requires an institutional subscription or an individual payment. If you are an employee of a health service / university or a member of a college you may be able to access the article through these channels. Want to know more about the open access debate? See our previous podcast on this here: <a href="https://www.obsgynaecritcare.org/036-sci-hub-earthquakes-listener-mail-pirate-jokes-and-another-quiz/" rel="nofollow" target="_blank">https://www.obsgynaecritcare.org/036-sci-hub-earthquakes-listener-mail-pirate-jokes-and-another-quiz/</a> Instructional Videos <a href="https://youtu.be/Xq-H3SLLwO0" rel="nofollow" target="_blank">https://youtu.be/Xq-H3SLLwO0</a><a href="https://youtu.be/_r_pVQf4C5w" rel="nofollow" target="_blank">https://youtu.be/_r_pVQf4C5w</a>

039 – Rectus sheath catheters for analgesia with Dr Matt Rucklidge

This week Graeme and I take on a big topic! (excuse the pun),You are the anaesthetic consultant on call and you are woken by your registrar at 2am who asks you to come and give them a hand with a difficult patient. They have been asked to come down to labour ward to place an epidural in a supermorbidly obese patient who has arrived and appears to be in established labour. She weighs about 190kg, and has a BMI of over 60. The team have been unable to get intravenous access and they want your help with this too. They are also having trouble measuring her blood pressure accurately because of the shape of her upper arms and she is now getting quite distressed with her pain making it difficult for them to examine her obstetrically and monitor her foetus........There are many difficult aspects to managing the supermorbidly obese patients. In this podcast Graeme and I discuss some practical tips / points on how to navigate the difficulties which they can present.Super morbid obesity is defined as a BMI &gt;50.We hope you will find some of these tips useful if you ever have to care for these women. This is by no means a comprehensive list of tips and we would welcome any other suggestions for tips / techniques you have personally found useful - let us know in the comments below!Practical Tips (in no particular order) 	Blood pressure monitoring - cuffs on the upper arm often struggle to work - consider a standard adult cuff on the forearm or if in theatre put in an arterial line. 	Ultrasound is your friend to get good reliable intravenous access. Two iv's if in theatre as they tissue easily and you want to have a back up in case one stops working halfway through surgery! 	Be VERY CAREFUL with manual handling and positioning issues - use proper epidural positioning devices (not people, chairs or stools). Lots of people to carefully move them. 	Ultrasound is your friend when attempting a neuraxial block! 	Have the long tuohy and spinal handy. 	Consider tunnelling your labour ward epidural to prevent it falling out - if you have learnt this technique. 	Anticipate potential obstructive sleep apnoea &amp; respiratory issues and be very careful with opioids and sedatives - use non sedating regional analgesia / NSAIDs etc. 	General anaesthesia - fraught with danger - beware airway, ventilation (&amp; circulation issues)! - these are not patients you want to crash off to sleep in a hurry even if our obstetric colleagues are concerned about the foetus............Careful positioning (Oxford or Troop devices), apnoiec oxygenation during induction, videolaryngoscopy (e.g. CMAC) and the difficult airway trolley ready to go.Helpful Illustrations:Extra long Tuohy and spinal needlesLarge upper arm BP cuff - often doesn't work well.Use a standard adult BP cuff placed on the forearmEpidural positioning device - much safer than using a chair / stool or partners legsUltrasound guided intravenous cannula placement - often there is a large vein in the mid forearm directly above the radius.ReferencesTunnelling Epidural Catheters: An editorial discussing tunnelling of epidural catheters to prevent accidental catheter migration and Dr Pavy's famous 1994 article! 	Tunnelling epidural catheters: a worthwhile exercise? Editorial N. Kumar W. A. Chambers 	Anaesth Intensive Care. 1994 Dec;22(6):703-5.Tunnelled epidural catheters for routine use: description of a technique. Pavy TJ1.Management of supermorbidly obese parturient with two epidural technique: 	Anaesth Intensive Care. 2007 Dec;35(6):979-83.The management of a super morbidly obese parturient delivering twins by caesarean section.McDonnell NJ1, Paech MJ.

This week Graeme and I take on a big topic! (excuse the pun), You are the anaesthetic consultant on call and you are woken by your registrar at 2am who asks you to come and give them a hand with a difficult patient. They have been asked to come down to labour ward to place an epidural in a supermorbidly obese patient who has arrived and appears to be in established labour. She weighs about 190kg, and has a BMI of over 60. The team have been unable to get intravenous access and they want your help with this too. They are also having trouble measuring her blood pressure accurately because of the shape of her upper arms and she is now getting quite distressed with her pain making it difficult for them to examine her obstetrically and monitor her foetus........ There are many difficult aspects to managing the supermorbidly obese patients. In this podcast Graeme and I discuss some practical tips / points on how to navigate the difficulties which they can present. Super morbid obesity is defined as a BMI &gt;50. We hope you will find some of these tips useful if you ever have to care for these women. This is by no means a comprehensive list of tips and we would welcome any other suggestions for tips / techniques you have personally found useful - let us know in the comments below! Practical Tips (in no particular order) 	Blood pressure monitoring - cuffs on the upper arm often struggle to work - consider a standard adult cuff on the forearm or if in theatre put in an arterial line. 	Ultrasound is your friend to get good reliable intravenous access. Two iv's if in theatre as they tissue easily and you want to have a back up in case one stops working halfway through surgery! 	Be VERY CAREFUL with manual handling and positioning issues - use proper epidural positioning devices (not people, chairs or stools). Lots of people to carefully move them. 	Ultrasound is your friend when attempting a neuraxial block! 	Have the long tuohy and spinal handy. 	Consider tunnelling your labour ward epidural to prevent it falling out - if you have learnt this technique. 	Anticipate potential obstructive sleep apnoea &amp; respiratory issues and be very careful with opioids and sedatives - use non sedating regional analgesia / NSAIDs etc. 	General anaesthesia - fraught with danger - beware airway, ventilation (&amp; circulation issues)! - these are not patients you want to crash off to sleep in a hurry even if our obstetric colleagues are concerned about the foetus............Careful positioning (Oxford or Troop devices), apnoiec oxygenation during induction, videolaryngoscopy (e.g. CMAC) and the difficult airway trolley ready to go. Helpful Illustrations: Extra long Tuohy and spinal needles Large upper arm BP cuff - often doesn't work well. Use a standard adult BP cuff placed on the forearm Epidural positioning device - much safer than using a chair / stool or partners legs Ultrasound guided intravenous cannula placement - often there is a large vein in the mid forearm directly above the radius. References Tunnelling Epidural Catheters: An editorial discussing tunnelling of epidural catheters to prevent accidental catheter migration and Dr Pavy's famous 1994 article! 	Tunnelling epidural catheters: a worthwhile exercise? Editorial N. Kumar W. A. Chambers 	Anaesth Intensive Care. 1994 Dec;22(6):703-5.Tunnelled epidural catheters for routine use: description of a technique. Pavy TJ1. Management of supermorbidly obese parturient with two epidural technique: 	Anaesth Intensive Care. 2007 Dec;35(6):979-83.The management of a super morbidly obese parturient delivering twins by caesarean section.McDonnell NJ1, Paech MJ.

024 – Tips for managing super morbidly obese patients

Kevin Chan

(Real Case: De-identified)You receive a call from a frantic ward nurse who tells you they have a 32 yr old woman who had laparoscopic surgery for treatment of endometriosis earlier in the day and she is in severe pain despite having had 3 doses of sublingual buprenorphine and 4 doses of tramadol since theatre 4 hours earlier. You head up to the ward and read her notes - she has had chronic pelvic pain since a teenager, she has been on analgesic drugs chronically for many years and been managed by her GP and a chronic pain service. She has a history of anxiety and depression and sexual abuse as an adolescent. Her current preoperative regimen involved tapentadol SR, amitriptyline, celebrex, pregabalin and prn oxycodone. In theatre she had a volatiel anaesthetic and a number of multi-modal analgesic medications including a small dose of methadone, ketamine, lignocaine. She needed a lot of fentanyl in recovery and since arrival on the ward has been very hard to control. You go and see her, she is definitely not narcosed from all these drugs! She is wide awake, slightly tachycardic (HR 105), restless and complaining of diffuse abdominal pain. She says "Doc it's 11/10" and is asking for you to give her something else to help please!You talk her about your options then decide together to admit her to your HDU for overnight intravenous lidocaine infusion. She has the 100mg loading dose over 10min then is started on a 1mg/kg/hr infusion. Within 2 hours she is asleep and when you see her in the morning she says her pain is only 3/10 and she thanks you profusely....Hi this week on the podcast we are joined by my colleague Dr Kevin Chan and we discuss the pros / cons of intravenous lidocaine infusions and it's increasing use in perioperative pain management!Previous PodcastsThe Opioid Epidemic a discussion with Dr Sonia TingReferencesIntravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education, Volume 16, Issue 9, 1 September 2016, Pages 292–298. Free ArticlePodcast with author from the above article: Their experience at Ottawa HospitalLidocaine Infusions: The golden ticket in postoperative recovery? Australasian Anaesthesia 2017 p 185-196 (e.g. Blue Book article).Perioperative Use of Intravenous Lidocaine. Lauren K. Dunn, M.D., Ph.D.; Marcel E. Durieux, M.D., Ph.D. Anesthesiology 4 2017, Vol.126, 729-737.

(Real Case: De-identified) You receive a call from a frantic ward nurse who tells you they have a 32 yr old woman who had laparoscopic surgery for treatment of endometriosis earlier in the day and she is in severe pain despite having had 3 doses of sublingual buprenorphine and 4 doses of tramadol since theatre 4 hours earlier. You head up to the ward and read her notes - she has had chronic pelvic pain since a teenager, she has been on analgesic drugs chronically for many years and been managed by her GP and a chronic pain service. She has a history of anxiety and depression and sexual abuse as an adolescent. Her current preoperative regimen involved tapentadol SR, amitriptyline, celebrex, pregabalin and prn oxycodone. In theatre she had a volatiel anaesthetic and a number of multi-modal analgesic medications including a small dose of methadone, ketamine, lignocaine. She needed a lot of fentanyl in recovery and since arrival on the ward has been very hard to control. You go and see her, she is definitely not narcosed from all these drugs! She is wide awake, slightly tachycardic (HR 105), restless and complaining of diffuse abdominal pain. She says "Doc it's 11/10" and is asking for you to give her something else to help please! You talk her about your options then decide together to admit her to your HDU for overnight intravenous lidocaine infusion. She has the 100mg loading dose over 10min then is started on a 1mg/kg/hr infusion. Within 2 hours she is asleep and when you see her in the morning she says her pain is only 3/10 and she thanks you profusely.... Hi this week on the podcast we are joined by my colleague Dr Kevin Chan and we discuss the pros / cons of intravenous lidocaine infusions and it's increasing use in perioperative pain management! Previous Podcasts The Opioid Epidemic a discussion with Dr Sonia Ting References Intravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education, Volume 16, Issue 9, 1 September 2016, Pages 292–298. Free Article Podcast with author from the above article: Their experience at Ottawa Hospital Lidocaine Infusions: The golden ticket in postoperative recovery? Australasian Anaesthesia 2017 p 185-196 (e.g. Blue Book article). Perioperative Use of Intravenous Lidocaine. Lauren K. Dunn, M.D., Ph.D.; Marcel E. Durieux, M.D., Ph.D. Anesthesiology 4 2017, Vol.126, 729-737.

037 – Intravenous lidocaine infusions for analgesia with Dr Kevin Chan

You are called down to labour ward to put an epidural into a woman who is extremely distressed, in the throes of established labour who is thrashing around the bed in agony. You introduce yourself and she looks up at you and says "you ain't gonna give me a terrible f* headache like that a**** who did ma epidural three years ago are ya?" This week we are joined again but Dr Matt Rucklidge for a discussion on what is arguably still the most common serious problem which continues to plague obstetric anaesthetists. Ever since August Bier and his trusty assistant Hildebrandt inflicted this condition on eachother in the late 1800s when experimenting on themselves at the very birth of spinal anaesthesia we continue to struggle with this important and pressing problem. August Bier - Father of spinal anaesthesia. He also personally experienced a 9 day postdural puncture headache! Interesting Links "What I wish I knew about post-dural puncture headaches before I got an epidural" Todays Parent The Centennial of Spinal Anesthesia

You are called down to labour ward to put an epidural into a woman who is extremely distressed, in the throes of established labour who is thrashing around the bed in agony. You introduce yourself and she looks up at you and says "you ain't gonna give me a terrible f* headache like that a**** who did ma epidural three years ago are ya?" This week we are joined again but Dr Matt Rucklidge for a discussion on what is arguably still the most common serious problem which continues to plague obstetric anaesthetists. Ever since August Bier and his trusty assistant Hildebrandt inflicted this condition on eachother in the late 1800s when experimenting on themselves at the very birth of spinal anaesthesia we continue to struggle with this important and pressing problem. August Bier - Father of spinal anaesthesia. He also personally experienced a 9 day postdural puncture headache! Interesting Links "What I wish I knew about post-dural puncture headaches before I got an epidural" Todays Parent The Centennial of Spinal Anesthesia

045 – Avoiding or managing the accidental dural puncture a discussion with Dr Matt Rucklidge

Parvesh Verma

You are called down to your HDU to review a 81 year old woman who is day one following a major laparotomy for ovarian cancer surgery. The nursing staff are worried because "she is not quite right". She hasn't made much urine over the last 3 hours, her blood pressure is a little low and she has also developed low peripheral oxygen saturations on room air and is now needing 3l/min via nasal prongs. She had a unit of blood earlier this morning and has had 4-5 litres of intravenous fluid now both during and after her operation.What to do?Should you give her a 500ml bolus of fluid to help her urine output and maybe boost her BP a little? But why are her saturations low - what if you push her into florid pulmonary oedema? Why are her sats low? Does she have pleural effusions? atelectasis? early pulmonary oedema? Should you give her a vasopressor? some frusemide? some physio? some more fluids? Aaarrgggh!You get out your stethoscope - her lungs are quiet at the bases and she is slightly breathless but you are still not sure what's going on. You move your stethoscope to teh middle of her chest and you can't hear any murmurs - but this doesn't really tell you that there is nothing wrong with her heart or valves for that matter!. Oh well at least you had a couple of quiet minutes without talking to the patient or nurse to think about what you might do next !Only 10m away in the corner of the unit you spot the portable USS machine, which has a curvilinear and phased array probe. You remember the talk from your colleague last week on point of care USS. They described how in around 5min you could probably confidently answer most of these questions &amp; you make a mental note that you are definitely going to sign up for that course in 2 months time...Hi Everyone,Welcome to this weeks podcast episode where Dr Parvesh Verma and I discuss the pros and cons of lung ultrasound and the vastly under utilised potential of this relatively easy to perform bedside technique. Lung ultrasound is relatively easy to learn, is vastly more accurate than lung auscultation, quite a bit better than CXR and as good as invasive radiation heavy investigations like chest CT.In just about every clinical setting we all have access to an ultrasound machine now. If you ever listen to someone's chest or look after patients with dyspnoea (in hospital or a clinic ) then hopefully this episode will inspire you to go away and learn this incredibly useful skill!Merry Xmas &amp; Happy New Year!  This will probably be the last episode this month - I am keen to get suggestions on topics for future episodes so please send me all your suggestions and great ideas!References / LinksThere are a huge number of free resources out there to introduce you to this topic - please search for them yourself. The links below are not necessarily the best but you might find them useful: 	Practical Guide to Lung Ultrasound BJA Education - free article  	Lung ultrasound compared with chest X‐ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study† 	BMJ - Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction?Youtube TutorialA short video tutorial is one of the best ways to introduce yourself to the basics of lung ultrasound. Therea re a large number of video tutorials on this topic - choose your own favourite! Here are a couple which I thought were good:https://youtu.be/jh7EP7jiW98 https://youtu.be/e_wloEfvs1M

You are called down to your HDU to review a 81 year old woman who is day one following a major laparotomy for ovarian cancer surgery. The nursing staff are worried because "she is not quite right". She hasn't made much urine over the last 3 hours, her blood pressure is a little low and she has also developed low peripheral oxygen saturations on room air and is now needing 3l/min via nasal prongs. She had a unit of blood earlier this morning and has had 4-5 litres of intravenous fluid now both during and after her operation. What to do? Should you give her a 500ml bolus of fluid to help her urine output and maybe boost her BP a little? But why are her saturations low - what if you push her into florid pulmonary oedema? Why are her sats low? Does she have pleural effusions? atelectasis? early pulmonary oedema? Should you give her a vasopressor? some frusemide? some physio? some more fluids? Aaarrgggh! You get out your stethoscope - her lungs are quiet at the bases and she is slightly breathless but you are still not sure what's going on. You move your stethoscope to teh middle of her chest and you can't hear any murmurs - but this doesn't really tell you that there is nothing wrong with her heart or valves for that matter!. Oh well at least you had a couple of quiet minutes without talking to the patient or nurse to think about what you might do next ! Only 10m away in the corner of the unit you spot the portable USS machine, which has a curvilinear and phased array probe. You remember the talk from your colleague last week on point of care USS. They described how in around 5min you could probably confidently answer most of these questions &amp; you make a mental note that you are definitely going to sign up for that course in 2 months time... Hi Everyone, Welcome to this weeks podcast episode where Dr Parvesh Verma and I discuss the pros and cons of lung ultrasound and the vastly under utilised potential of this relatively easy to perform bedside technique. Lung ultrasound is relatively easy to learn, is vastly more accurate than lung auscultation, quite a bit better than CXR and as good as invasive radiation heavy investigations like chest CT. In just about every clinical setting we all have access to an ultrasound machine now. If you ever listen to someone's chest or look after patients with dyspnoea (in hospital or a clinic ) then hopefully this episode will inspire you to go away and learn this incredibly useful skill! Merry Xmas &amp; Happy New Year!  This will probably be the last episode this month - I am keen to get suggestions on topics for future episodes so please send me all your suggestions and great ideas! References / Links There are a huge number of free resources out there to introduce you to this topic - please search for them yourself. The links below are not necessarily the best but you might find them useful: 	Practical Guide to Lung Ultrasound BJA Education - free article  	Lung ultrasound compared with chest X‐ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study† 	BMJ - Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction? Youtube Tutorial A short video tutorial is one of the best ways to introduce yourself to the basics of lung ultrasound. Therea re a large number of video tutorials on this topic - choose your own favourite! Here are a couple which I thought were good: <a href="https://youtu.be/jh7EP7jiW98" rel="nofollow" target="_blank">https://youtu.be/jh7EP7jiW98</a> <a href="https://youtu.be/e_wloEfvs1M" rel="nofollow" target="_blank">https://youtu.be/e_wloEfvs1M</a>

044 – Lung ultrasound a discussion with Dr Parvesh Verma

Cheryl Dane Stewart

Hi Everyone,Welcome to part 1 of a two part series on the use of cell salvage in obstetrics &amp; gynaecology!This week Part 1 focuses on the basics of how cell salvage works and what the staff in the surgical field (nursing and surgical) need to know to do it properly!Next week we hear from Dr Matt Rucklidge who discusses all the latest controversies and developments in the arena of cell salvage during obstetrics - can we use a single suction, what about amniotic fluid in the collection system, do we always need a leukodepletion filter and how can we organise our practice so that we utilise cell salvage during those unexpected emergency cases?These two episodes are audio extracts taken from a great combined presentation given at our local department meeting here in August. The audio from these presentations are great but for those of you who are interested in viewing a video version of this talk where you can also see the slides and images referred to in the talk feel free to watch using the link below:VIDEO VERSION OF THIS TALKhttps://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0ONLINE EDUCATION RESOURCESNational Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/icsGreat resource from the UK pdfs and free slides on all the various aspects of cell salvage: https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-educationWHY SHOULD WE USE CELL SALVAGE?If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode:https://www.obsgynaecritcare.org/022-stored-blood-versus-fresh-salvaged-blood/

Hi Everyone, Welcome to part 1 of a two part series on the use of cell salvage in obstetrics &amp; gynaecology! This week Part 1 focuses on the basics of how cell salvage works and what the staff in the surgical field (nursing and surgical) need to know to do it properly! Next week we hear from Dr Matt Rucklidge who discusses all the latest controversies and developments in the arena of cell salvage during obstetrics - can we use a single suction, what about amniotic fluid in the collection system, do we always need a leukodepletion filter and how can we organise our practice so that we utilise cell salvage during those unexpected emergency cases? These two episodes are audio extracts taken from a great combined presentation given at our local department meeting here in August. The audio from these presentations are great but for those of you who are interested in viewing a video version of this talk where you can also see the slides and images referred to in the talk feel free to watch using the link below: VIDEO VERSION OF THIS TALK <a href="https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0" rel="nofollow" target="_blank">https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0</a> ONLINE EDUCATION RESOURCES National Blood Authority guidelines for intraoperative cell salvage: <a href="https://www.blood.gov.au/ics" rel="nofollow" target="_blank">https://www.blood.gov.au/ics</a> Great resource from the UK pdfs and free slides on all the various aspects of cell salvage: <a href="https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education" rel="nofollow" target="_blank">https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education</a> WHY SHOULD WE USE CELL SALVAGE? If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode: <a href="https://www.obsgynaecritcare.org/022-stored-blood-versus-fresh-salvaged-blood/" rel="nofollow" target="_blank">https://www.obsgynaecritcare.org/022-stored-blood-versus-fresh-salvaged-blood/</a>

040 – Cell salvage basics for the person holding the sucker – with Cheryl Dane Stewart

Scenario:You are called by a midwife to review a patient on the ward who had a vaginal delivery yesterday with an epidural for pain relief and now she has a bad headache. They are concerned that maybe she has a postdural puncture headache.Join Matt and Roger again as this week they discuss the management of a patient with possible or proven post-dural puncture headache.Links"What I wish I knew about post-dural puncture headaches before I got an epidural" Todays ParentPostpartum headache: diagnosis and management BJA Education 2011 Free articlehttps://www.obsgynaecritcare.org/016-sphenopalatine-ganglion-block-for-postdural-puncture-headache/

Scenario: You are called by a midwife to review a patient on the ward who had a vaginal delivery yesterday with an epidural for pain relief and now she has a bad headache. They are concerned that maybe she has a postdural puncture headache. Join Matt and Roger again as this week they discuss the management of a patient with possible or proven post-dural puncture headache. Links "What I wish I knew about post-dural puncture headaches before I got an epidural" Todays Parent Postpartum headache: diagnosis and management BJA Education 2011 Free article <a href="https://www.obsgynaecritcare.org/016-sphenopalatine-ganglion-block-for-postdural-puncture-headache/" rel="nofollow" target="_blank">https://www.obsgynaecritcare.org/016-sphenopalatine-ganglion-block-for-postdural-puncture-headache/</a>

046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

Hi everyone!Better late than never. This week Chong and I have finally got around to our discussion on anaphylaxis.What are the common causes of anaphylaxis?How is the severity of anaphylaxis graded?How / when should we administer adrenaline and what are the pitfalls of this drug which has a  narrow therapeutic window?We focus mainly on discussing the common causes in hospital and particularly the peri-operative setting. Peri-operative anaphylaxis is now the leading cause of direct anaesthetic related death in Australia / NZ.We do offer a few quick thoughts on the common causes and management of anaphylaxis in the community (how many of you have been asked to help manage these reactions for example on a plane at a school or community event - where invariably someone says get so and so they're a doctor / nurse!). If you haven't I suspect it will only be a matter of time before someone ingests a peanut on a flight you're on! Do you know how to use an epi-pen? They are pretty straight forward but nice to know what to do without having to read the instructions on the device mid flight when it's handed to you by a flight attendant!A big shout out to the ANZAAG special interest group at ANZCA who have put together an amazing online learning package and who are the true experts in the area of peri-operative anaphylaxis management. I strongly recommend those listeners who are members of the anaesthesia community log onto to the ANZCA networks website and complete this online learning package which also satisfies the CPD emergency response requirement for members of the ANZCA college.LinksNAP6 - UK national audit project on perioperative anaphylaxis examining over 3 million anaesthetics.ANZAAG - Australia and NZ Anaesthetic Allergy Testing GroupOnline Courses:For members of ANZCA: 	We highly recommend that you complete this perioperative anaphylaxis online course  available through the ANZCA Networks site: https://networks.anzca.edu.auHealth Professionals in general: 	ASCIA health professional anaphylaxis e-learning course:   https://etraininghp.ascia.org.au/Members of the general public: 	ASCIA community anaphylaxis e-training  https://www.allergy.org.au/patients/anaphylaxis-e-training-first-aid-communityYOUTUBEHow to use an Epipen properly ! - fast forward to 3:30 to see the injection technique.https://youtu.be/YheJhyQ168Y

Hi everyone! Better late than never. This week Chong and I have finally got around to our discussion on anaphylaxis. What are the common causes of anaphylaxis? How is the severity of anaphylaxis graded? How / when should we administer adrenaline and what are the pitfalls of this drug which has a  narrow therapeutic window? We focus mainly on discussing the common causes in hospital and particularly the peri-operative setting. Peri-operative anaphylaxis is now the leading cause of direct anaesthetic related death in Australia / NZ. We do offer a few quick thoughts on the common causes and management of anaphylaxis in the community (how many of you have been asked to help manage these reactions for example on a plane at a school or community event - where invariably someone says get so and so they're a doctor / nurse!). If you haven't I suspect it will only be a matter of time before someone ingests a peanut on a flight you're on! Do you know how to use an epi-pen? They are pretty straight forward but nice to know what to do without having to read the instructions on the device mid flight when it's handed to you by a flight attendant! A big shout out to the ANZAAG special interest group at ANZCA who have put together an amazing online learning package and who are the true experts in the area of peri-operative anaphylaxis management. I strongly recommend those listeners who are members of the anaesthesia community log onto to the ANZCA networks website and complete this online learning package which also satisfies the CPD emergency response requirement for members of the ANZCA college. Links NAP6 - UK national audit project on perioperative anaphylaxis examining over 3 million anaesthetics. ANZAAG - Australia and NZ Anaesthetic Allergy Testing Group Online Courses: For members of ANZCA: 	We highly recommend that you complete this perioperative anaphylaxis online course  available through the ANZCA Networks site: <a href="https://networks.anzca.edu.au" rel="nofollow" target="_blank">https://networks.anzca.edu.au</a> Health Professionals in general: 	ASCIA health professional anaphylaxis e-learning course:   <a href="https://etraininghp.ascia.org.au/" rel="nofollow" target="_blank">https://etraininghp.ascia.org.au/</a> Members of the general public: 	ASCIA community anaphylaxis e-training  <a href="https://www.allergy.org.au/patients/anaphylaxis-e-training-first-aid-community" rel="nofollow" target="_blank">https://www.allergy.org.au/patients/anaphylaxis-e-training-first-aid-community</a> YOUTUBE How to use an Epipen properly ! - fast forward to 3:30 to see the injection technique. <a href="https://youtu.be/YheJhyQ168Y" rel="nofollow" target="_blank">https://youtu.be/YheJhyQ168Y</a>

043 – Anaphylaxis discussion part 1 with Chong

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