Explore every episode of the podcast Obsgynaecritcare
| Title | Pub. Date | Duration | |
|---|---|---|---|
| 152 Continuous non invasive blood pressure monitoring. | 07 Jul 2026 | 00:40:37 | |
Hypothetical Case: You finish injecting the spinal anaesthetic for your patient who has come for an urgent caesarean section. She has pre-eclampsia and her blood pressure just before you started was 180/100. Just after lying down she starts vomiting and unfortunately the non invasive blood pressure cuff is going up and down but not giving you a number – she is shaking and can’t stop moving around. Is she vomiting because of hypotension, should you give her a bolus of phenylephrine? What if she is actually still hypertensive – you don’t want to push her BP over 200. Wouldn’t it be great if you had a beat to beat continuous display of her BP – maybe you should have placed an arterial line before starting. Are there any other options that might have been helpful??? Hi everyone, This week I am joined by John to discuss continuous non-invasive blood pressure monitoring. Many of these technologies have actually been around for a number of years now, but despite this don’t seem to be in commonplace usage. There does seem to be a recent renewed interest in re-evaluating these technologies. How do these technologies work? How accurate are they? Have there been any improvements? What are the economics and costs? Thanks John for all your hard work researching this topic! Methods References | |||
| 151 Obstetrics in the ANZCA final exam part 1 | 10 Jun 2026 | 00:52:18 | |
Declan and Sarah discuss strategies for obstetric questions in the ANZCA final exam. | |||
| 142 Peripartum cardiomyopathy with Dr Faith Njue | 30 Jun 2025 | 00:54:10 | |
You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn’t get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that “it is much worse”. On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague – who says “subjectively her LV isn’t contracting very well”. Hi everyone, This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease – peripartum cardiomyopathy. (See Faith’s Bio below). Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients. Thanks Faith for a great discussion! Dr Faith Njue – Bio Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK). She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy. She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH. ReferencesBromocriptine: | |||
| 052-Fatigue and burnout with Parvesh Verma | 25 Jun 2019 | 00:28:35 | |
Hi everyone, This week Parvesh and I catch up to discuss some more serious issues – fatigue and burnout. Join us as we discuss these issues, share some anecdotes and even muse about the correct management of snake bites in pregnancy! Useful Articleshttps://academic.oup.com/bjaed/article/17/10/334/3865410 http://www.uapd.com/wp-content/uploads/Maslach-Burnout-Inventory-MBI.pdf https://academic.oup.com/bjaed/article/14/1/18/336242 https://anaesthetists.org/Fatigue Useful Resourcesa checklist that is also used in aviation that has been adapted to anaesthesia: fatigue tool useful at handover:
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| 051 Bullying in healthcare and anaesthesia – Dr Peter Garnett | 04 Jun 2019 | 00:20:56 | |
Hi Everyone, This week I am joined by one of our provisional fellows and we discuss the serious topic of bullying in healthcare and anaesthesia. Unfortunately this sort of behaviour is more common than we appreciate…… Take home messages from Peter’s talk Want to listen to Peter’s department talk as well? Follow the link to our presentation page: https://www.obsgynaecritcare.org/education-presentations/ Linkshttps://www.beyondblue.org.au/ http://www.anzca.edu.au/documents/anzca-policy-on-bullying-discrimination-and-harass.pdf | |||
| 050 – Empiric massive transfusion protocols versus targeted blood product therapy. | 11 Apr 2019 | 00:35:58 | |
Hi everyone, Recently Graeme and I were asked to help run a workshop here in WA for the ANZCA Emergency Response CPD programme – thanks for your help Graeme and Paras. Some of the key concepts were understanding blood products and the strategies / philosophies which have been used when deciding what to give in a major haemorrhage. We decided that this would make a great podcast discussion and so voila – here it is! We discuss: – massive transfusion protocols utilising empiric ratios of blood products (often heavy in FFP / plasma) versus the more targeted approach often based on rapid assessment of haemostasis using viscoelastic tests such as ROTEM / TEG. – the four deficits in haemostasis which can develop; 1 fibrinolysis, 2 fibrinogen deficiency, 3 platelet deficiency, 4 thrombin deficiency. -a description of the types of blood products available their pros / cons. – why the use of large volumes of plasma probably doesn’t make sense and may in fact involve some harm to patients. – an alternative strategy for empiric therapy when rapid tests of coagulation are not available empiric treatment with tranexamic acid and fibrinogen. Thanks for another great dicsussion Graeme! USEFUL LINKS https://www.obsgynaecritcare.org/rotem/ https://www.obsgynaecritcare.org/rotem-real-cases-discussed/ LINKS
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| 048 – After hours critical cases discussion about assembling a good team and communication. | 04 Apr 2019 | 00:32:10 | |
Hi Everyone, This week we have a great four person discussion around the importance of assembling the right team when confronted with a high risk complex case in the after hours period. Interesting points covered include still doing the team huddle and introducing everyone even at midnight, a detailed discussion around manual aortic compression – the IVC, and how to monitor effectiveness – and also using a posterior hysterotomy to deliver the fetus when everywhere else looks bad! Thanks to IKEA for their contribution to our high tech podcast studio! Thanks also Parvesh, Matt Epee-Bekima & Matt Rucklidge for this great discussion. (* The patient discussed in this podcast gave us explicit written consent for her case to be used in this deidentified discussion) High Tech Podcasting Studio (Thanks IKEA for your plastic bin!)Links https://www.obsgynaecritcare.org/017-prof-yee-leung-obstetric-and-surgical-management-of-abnormally-invasive-placenta/ https://www.obsgynaecritcare.org/015-placenta-percreta-perioperative-and-anaesthetic-management/ https://www.obsgynaecritcare.org/041-obstetric-cell-salvage-an-update-what-only-one-suction-no-filter-and-more-with-dr-matt-rucklidge/ https://www.obsgynaecritcare.org/manual-aortic-compression-life-saving-in-massive-obstetric-haemorrhage/ https://www.youtube.com/watch?v=rc9BYcIhamA | |||
| 049 – FOAMed and podcasting with Dr Casey Parker | 03 Apr 2019 | 00:13:49 | |
Hi Everyone, This week I had the privilege to sit down and chat with Dr Casey Parker (or is that Paraka? – apologies a little inside joke ). Casey works up in Broome as a GP anaesthetist, in emergency medicine, the HDU, is an enthusiast for point of care ultrasound and is involved in FOAMed and a huge number of other educational initiatives. Casey has had his own very successful website / podcast / blog (www.broomedocs.com) for over 7 years and he was one of the original people who encouraged me a few years ago. This week I sat down and quizzed him about his own journey in the FOAMed world, what he has learnt along the way, what his favourite podcasts are and if he has any advice for people out there who are also interested in getting involved. Thanks for sitting down and sharing your wisdom Casey! FOAMed Blogs / podcasts mentioned in our discussionOther Links https://www.nosuchthingasafish.com/
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| 047 – Bedside echocardiography for critical care and perioperative medicine | 29 Mar 2019 | 00:24:15 | |
(*Hypothetical patient) You are called to review a woman who recently arrived in your hospital and is now a few hours postpartum after a pre-term vaginal delivery at 35 weeks. She tells you that she has felt unwell for the last few days with a little bit of vomiting, diarrhoea and her asthma has been playing up and needing quite a few puffs of her ventolin. She went into preterm labour and delivered quickly 2-3 hours ago. She has received 3-4 litres of crystalloid to treat her “dehydration” and the at times non reassuring CTG over the last 24hours. She isn’t febrile, but is tachycardic at 115/min, hypotensive 95/45 and she looks a little short of breath with Sp02 92% on room air and a respiratory rate of 20/min. She can talk in sentences and is walking around her room so you are reassured by this. After taking a history and examining her you decide to have a quick look at her heart and lungs with your USS machine (you have recently completed a point of care ultrasound course so are always looking for an opportunity to put your new skills into practice). To your surprise you discover the apices of both her lungs have a large number of B-lines and then when you throw the probe on her heart and inferior vena cava within a couple of minutes you see she has a large poorly contracting left ventricle and a dilated IVC. You reach over and turn off her iv fluids – this woman doesn’t need anymore rehydration! Hi everyone, This week Parvesh and I follow up on our earlier podcast discussing the utility of point of care lung ultrasound with a discussion about the merits of point of care echocardiography. Join us and as we discuss the pros / cons, share some anecdotes and talk about where we are on our journey learning this incredibly useful new technique. B-Lines on Pulmonary Ultrasound = interstitial fluidMitral Stenosis Links https://www.obsgynaecritcare.org/lung-ultrasound-a-discussion-with-dr-parvesh-verma/ These articles are not free open access – they are available through most university / hospital libraries or your medical college (eg ANZCA). | |||
| 046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge | 06 Mar 2019 | 00:31:23 | |
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 https://www.obsgynaecritcare.org/016-sphenopalatine-ganglion-block-for-postdural-puncture-headache/ | |||
| 045 – Avoiding or managing the accidental dural puncture a discussion with Dr Matt Rucklidge | 19 Feb 2019 | 00:20:54 | |
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 Anesthesiahttp://anesthesiology.pubs.asahq.org/article.aspx?articleid=2028361 | |||
| 044 – Lung ultrasound a discussion with Dr Parvesh Verma | 17 Dec 2018 | 00:16:58 | |
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 & 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 & 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:
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: https://youtu.be/jh7EP7jiW98 https://youtu.be/e_wloEfvs1M | |||
| 043 – Anaphylaxis discussion part 1 with Chong | 03 Dec 2018 | 00:30:12 | |
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? 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 Group Online Courses:For members of ANZCA:
Health Professionals in general:
Members of the general public:
How to use an Epipen properly ! – fast forward to 3:30 to see the injection technique. https://youtu.be/YheJhyQ168Y
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| 141 Uterine inversion with Dr David Owen | 11 Feb 2025 | 00:31:24 | |
Hi everyone, This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion – an acute obstetric emergency. Luckily this condition is relatively rare – however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals. Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required! Thanks again David for your research and preparation for this episode! ReferencesUterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 – 112 Unfortunately (as of Feb 2025) this article is not yet open access – but it is very good if you can get it through your hospital or college library.. | |||
| 042 – Great case discussed – perioperative anaphylaxis | 23 Oct 2018 | 00:20:45 | |
Hi everyone, Anaphylaxis is an unpredictable scary life-threatening condition which unfortunately is more common than we would like. If you work in healthcare chances are you will have seen this condition or perhaps you may even be unlucky enough to have suffered an anaphylaxis yourself. To introduce the topic in this first episode, Graeme and I discuss a life threatening case of perioperative anaphylaxis to intravenous muscle relaxant, which occurred a few years ago. This case was pretty stressful and about as severe as it can get but it demonstrates a number of important aspects of this potentially life-threatening condition. (* The patient involved in this case provided written consent for the details to be used for education – some aspects of this case have also been published in a case report in the International Journal of Obstetric Anaesthesia). Next week we have a detailed discussion including the pathophysiology, talk about the NAP6 national audit into perioperative anaphylaxis in the UK, and of course discuss the management principles and finally offer you some links to important useful education resources. ReferencesNAP6 UK National Audit Project into perioperative anaphylaxis (* The patient involved in this weeks case provided written consent for her case to be used for education – some aspects of this case have also been published in a case report in the International Journal of Obstetric Anaesthesia). Here is the published case report of the case we discussed in this podcast – focusing on the hyperfibrinolysis which occurred: | |||
| 041 – Obstetric cell salvage an update, what only one suction, no filter and more with Dr Matt Rucklidge | 01 Oct 2018 | 00:29:21 | |
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:
Some of his talk is based on the following recent articles: RECENT ARTICLES
https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0 WHAT ABOUT VAGINAL CELL SALVAGE?
National Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/ics Great 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-education 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:
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| 040 – Cell salvage basics for the person holding the sucker – with Cheryl Dane Stewart | 24 Sep 2018 | 00:12:39 | |
Hi Everyone, Welcome to part 1 of a two part series on the use of cell salvage in obstetrics & 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=0 ONLINE EDUCATION RESOURCESNational Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/ics Great 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-education 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: https://www.obsgynaecritcare.org/022-stored-blood-versus-fresh-salvaged-blood/ | |||
| 039 – Rectus sheath catheters for analgesia with Dr Matt Rucklidge | 17 Sep 2018 | 00:25:34 | |
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/abstract 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: https://www.obsgynaecritcare.org/036-sci-hub-earthquakes-listener-mail-pirate-jokes-and-another-quiz/ Instructional Videoshttps://youtu.be/Xq-H3SLLwO0
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| 038 – Simulation in Obstetrics and Gynaecology with Dr Katrina Calvert | 11 Sep 2018 | 00:24:16 | |
Hi Everyone! This week I am joined on the podcast by Dr Katrina Calvert a senior trainee in Obstetrics and Gynaecology here in WA. Katrina has a long career spanning both sides of the globe in medical education and has a real passion for the use of simulation in O&G. We discuss all things simulation:
Thanks Katrina for a very enlightening discussion – we look forward to getting you back on the podcast soon! Links To Courses in AustraliaMaternity Emergency Management: Simulation day for obs emergencies NOVICE – basic skills in O&G for RMO’s PHO’s https://www.matereducation.qld.edu.au/Professional-development-learning/Maternity-Infant-Care
For those interested in developing their sim educator skills, most sim centres offer a basic course, as we do. For those with some skills already, we also regularly host the Harvard team for the “simulation as a teaching tool”, and “advanced debriefing” courses. http://www.promptmaternity.org/au/ https://www.amare.org.au/advanced-life-support-in-obstetrics-also/ | |||
| 037 – Intravenous lidocaine infusions for analgesia with Dr Kevin Chan | 04 Sep 2018 | 00:32:57 | |
(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 Ting ReferencesPodcast with author from the above article: Their experience at Ottawa Hospital | |||
| 036 – Sci hub, earthquakes, listener mail, pirate jokes and another quiz! | 23 Aug 2018 | 00:20:39 | |
Want to put together a tutorial? See someone with an unusual condition in clinic and want to access some up to date knowledge to look after them? The first thing most of us do is search the current literature – but then often we face this – look familiar? What is Sci Hub? If you’re lucky you are an employee of a hospital / university or college that has a subscription and you can usually gain access eventually through these channels. But what if the journal is not included in their bundle or spare a thought for our colleagues living in less affluent conditions – how will they access up to date knowledge and research?? Join Graeme and I this week as we discuss earthquake stories, Sci-hub, open access publishing, pirate jokes, respond to some listener mail and I try out another quiz! This Weeks Quiz Who is this famous person? – I am an obstetrician! Sci-Hub Open Access Related LinksOnline Petition against Elseviers fees > 17200 academics Wikipedia academic publishing page Podcast on the history of scientific publishing interview with Aileen Fyfe Earthquake Related Links
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| 035 – Labour epidural analgesia regimens discussed – Nolan McDonnell | 09 Aug 2018 | 00:38:09 | |
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. | |||
| 034 – Gastric ultrasound in anaesthesia with Dr Mark Sharples | 01 Aug 2018 | 00:16:31 | |
(*hypothetical patient) You have a young woman booked for an emergency D&C for a miscarriage. She is in a lot of discomfort from the misoprostol given earlier that day. She hasn’t eaten for exactly 6 hours but feels a bit nauseated and has had some oxycodone during the day. According to the 6 hour rule you assume she should be fasted – but she has had opioids because of her pain and you wonder whether she does still have solids in her stomach and will it be safe to just use a supraglottic ariway or should you give her an RSI and used a cuffed endotracheal tube? Is there anyway you can get more information to help you make a decision?? Hi Everyone, This week I am joined by Dr Mark Sharples to discuss gastric ultrasound a fascinating technique which could be the new frontier in perioperative aspiration risk assessment. USEFUL LINKSNAP4 – airway audit project in the UK
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| 033 – Perioperative management of tracheostomies with Dr James Anderson | 23 Jul 2018 | 00:34:42 | |
The emergency pager goes off – code blue medical on the gynaecology surgical ward. As you enter the ward a frantic grim faced nurse waves you into the side room where you discover an elderly woman who is obviously cyanosed, not really conscious and struggling vigorously to breath. She has a hudson mask on her face and there is an obvious tracheostomy tube protruding from her neck. One of the nurses tell you she had a laparotomy for ovarian cancer earlier that day and that she has a long term tracheostomy after having had a throat cancer resected 5 years ago….. Hi Everyone, This week I am joined by another anaesthetist, Dr James Anderson to discuss the perioperative management of tracheostomies. Before seeing the light and jumping the drapes to become an anaesthetist James spent a year working as an ENT registrar and now he has an interest in teaching both perioperative and crisis management of patients with tracheostomies. He helps run tracheostomy crisis management courses at Fiona Stanley Hospital and helped author a recent article in the famous ANZCA blue book (see the link below): Unfortunately patients with surgical airways and tracheostomies are not confined to just the ENT wards – they all often have associated comorbidities and medical problems which mean they can be encountered anywhere in the hospital or healthcare settings. Whether we like it or not we could all get called to deal with an emergency – and so we all need to have some basic understanding of tracheostomies and skills in dealing with any crises or problems which could occur! In this episode we discuss the perioperative management and emergency management of these airways. If anyone is keen to attend the FSH tracheostomy crisis management course, James is happy for you to contact him via email at james.anderson@health.wa.gov.au Tracheostomy.org.uk emergency management crisis card: USEFUL LINKSANZCA Blue Book 2017 – http://www.anzca.edu.au/documents/australasian-anaesthesia-2017.pdf https://constitutioncenter.org/blog/the-mysterious-death-of-george-washington | |||
| 140 The Placenta Accreta Spectrum Team at KEMH Part two. | 23 Dec 2024 | 00:53:11 | |
Hi Everyone, Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into:
Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years. References | |||
| 032 – Part 2 perioperative acute pain management tips with Sonya Ting and a second attempt at quiz 4 | 18 Jul 2018 | 00:25:20 | |
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? | |||
| 031 – Perioperative acute pain management advice part 1 with Dr Sonya Ting | 10 Jul 2018 | 00:20:20 | |
Hi everyone, This week I am joined again by my colleague Dr Sonya Ting – where I attempt to pick her brains for some useful advice in managing difficult perioperative pain issues. Sonya’s first episode on the opioid epidemic has already taken first place on the podcast download list as the most popular episode so far! Hypothetical Patient A 50yr old woman is on your list and scheduled to undergo a laparascopic hysterectomy. You see her in the preoperative area: Q – What issues / history should you explore to identify if this patient is at risk of perioperative pain issues? Q – How are you going to explain to her the plan for her perioperative pain management, what are the goals and what strategies fo you use to manage her expectations? Q – What communication strategies can you use, what about non-verbal and verbal communication? Listen to Sonya and I discuss these issues on the podcast – and finally have a crack at the latest instalment of our quiz below: Anaesthetist or Serial Killer? Quiz 4Is the following person an anaesthetist or is he a serial killer (or perhaps is he both!) Massive bonus points available if you can actually name this individual! | |||
| 030 – Doctor I only have half a heart – the parturient with a Fontan circulation | 04 Jul 2018 | 00:40:36 | |
You are the anaesthetic consultant on call and you are woken (again) at 2am on a Saturday night by your registrar. They tell you they have been asked by the obstetric team to see a pregnant woman who has just arrived in the hospital contracting with ruptured membranes at 30 weeks gestation and is telling everyone “I only have half a heart”! The registrar tells you they have had a look through what they describe as a very large set of patient notes. They tell you it appears that they have been seen by a lot of specialists in the antenatal period but no-one in the overnight team is exactly sure what the plan is for this woman. She is starting to get quite uncomfortable and is asking for some pain relief. The patient herself is not the greatest help – she has told your registrar that she too is confused and that a final decision on how she is going to give birth hasn’t been made yet – but everyone seems to be really worried about it! What is the Fontan circulation and what implications does this have for pregnancy, childbirth and anaesthesia / analgesia? This week I am joined by my colleague Chong to discuss this interesting but very challenging condition. Neither Chong or I consider ourselves to be experts in this condition but we have both come across patients with the Fontan circulation during our careers & we are well aware that we may be expected to look after someone with this condition again!! Please listen to the podcast – we have tried to distil out the important issues and explain them in a sensible manner. If you notice any errors or disagree with any of our content please let us know in a comment! Conditions usually palliated with a Fontan Repair Dr Francis FontanDr Fontan from Bordeaux, first described this palliative surgical procedure in 1971. He sadly passed away at the age of 89 earlier this year (Jan 2018). REFERENCES /ARTICLES
ANZ Fontan Registry – A great website! https://www.fontanregistry.com/ The different types of Fontan procedure: https://www.fontanregistry.com/the-different-fontan-procedures Khan Academy Youtube tutorial – Detailed description of the 3 stage surgical creation of a Fontan circulation in child with hypoplastic left heart syndrome: https://youtu.be/4GUm8ybncWY Layperson description of the Fontan Heart: https://www.youtube.com/watch?v=1bMq2eWfyyw
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| 029 – Great cases discussed crash caesar in a patient with congenital heart disease and another quiz! | 22 Jun 2018 | 00:12:26 | |
Hi everyone, This week Graeme and I discuss an interesting case from the past involving a parturient with a partially corrected congenital heart condition who presented a bit of a conundrum in the middle of the night. Before we get into the case discussion however we unpick the prospects for the football (soccer) world cup and admire the Iceland viking clap. Graeme does a bit of a “trump” when he attempts to bluff his way through our world cup conversation by first deploring the antics of the Italian team attempting to fake fouls and he then even picks the Netherlands to win! – and of course neither of these teams are even at the 2018 world cup! Fake news! QUIZ!Finally to beef up this relatively short episode we have another quiz. Who is the person pictured below and why are they famous in the world of obstetrics? Once again no prizes but we will give you a mention on the next episode for a bit of brief internet fame! | |||
| 028 – The Opioid Epidemic a discussion with Dr Sonya Ting | 04 Jun 2018 | 00:33:59 | |
(*Hypothetical case) You are a busy gynaecologist working in a large public hospital. You are contacted by a GP on the phone about a young 19yr old patient who you operated on 3 weeks ago – she underwent a laparoscopic ovarian cystectomy. The GP tells you that he referred her to your service for investigation of intermittent pelvic pain about 5 months ago and hasn’t seen her since. They inform you that today she turned up for an appointment asking to get a renewal of her Targin 20mg bd which was prescribed by the inpatient team on discharge and which she has been on for the last 3 weeks since leaving hospital. The GP is not very happy! They inform you ” she still has the same pelvic pain but now I also have to manage a 19yr old who is hooked on a fairly decent dose of opioids!”. They rightly point out that she was a bit depressed before they sent her to you but arguably now she is much worse than she was before and they want to know what you are going to do to help…………. What is the “opioid epidemic”? Is this just an issue for North America? How relevant is it to us here in Australia? As health care practitioners what has been our role in contributing to the development of this very serious crisis which is killing more young people than HIV / trauma / guns? This week I interview Dr Sonya Ting – a consultant in anaesthesia and pain medicine. We discuss the opioid epidemic, how it evolved and what we can do as healthcare practitioners. References
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| 027 – LAST – local anaesthetic systemic toxicity | 30 May 2018 | 00:32:59 | |
(*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 & 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
Congratulations to Sneha and Jeremy (a close second). The ABG was of 4 climbers at 8400m just below the summit of Everest & taken from this paper in the NEJM: https://www.nejm.org/doi/10.1056/NEJMoa0801581 The most hypoxic result was that of Dr Dan Martin an anaesthetist from the UK – hear him being interviewed: Click here https://www.topmedtalk.com/the-extreme-everest-oxygen-research-consortium/ The group conducting this research are the Extreme Everest Project – headed by a group of UK investigators with critical care backgrounds. They are hoping this research will help us understand how humans can adapt and cope with hypoxia and that this may translate into common conditions we deal with in the critically ill where patients suffer hypoxic injury. | |||
| 026 – Emergency Vascular Access Options and another quiz! | 23 May 2018 | 00:26:23 | |
(*Hypothetical Case) A 26 yr old woman with a suspected ruptured ectopic pregnancy is rushed to theatre in haemorrhagic shock. The patient has a history of IVDU with a naltrexone implant. The team in the emergency department have been unable to get vascular access. She has a heart rate of 150/min and a BP of 75/45. She is now very distressed and unco-operative from both the abdominal pain but also the repeated painful attempts at vascular access with large needles by lots of different healthcare staff! Join Graeme and I as we discuss the various different options for gaining vascular access to allow resuscitation, but also induction of anaesthesia so definitive surgery can occur. We discuss the following various options:
Graeme even discloses that he has trialled unsuccessful sternal intraosseous placement in the past – sounds like an interesting case we should perhaps delve into more detail on at another time!! Hagen-Pouseille Equation: Bottom line – shorter and wider bore catheters are better for rapid fluid resuscitation. The MAC line – note swan sheath, haemodialysis or other large bore central catheters will also work: Youtube / Podcasts Discussing this topic:
A great course to learn emergency procedures for use in trauma care run by the critical care trauma team at The Alfred in Melbourne. Check out their description of vascular access in particular their detailed description of the technique for emergent placement of the large bore MAC line in the subclavian vein. 2. https://emcrit.org/pulmcrit/hemodynamic-access-for-the-crashing-patient-the-dirty-double/ A great discussion on the placement of large bore femoral catheters. 3. The Rapid IJ – Ultrasound guided placement of a peripheral iv cannula in the internal jugular. https://youtu.be/FjSmbUWXznY References
These are ABG’s from four different individuals? What do these represent? First correct answer gets kudos and a mention on the next podcast!
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| 025 – obstetric induced coagulopathy with Nolan McDonnell | 14 May 2018 | 00:30:25 | |
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 2018 If you want to watch the video of this talk with it’s powerpoint slides:
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| 024 – Tips for managing super morbidly obese patients | 02 May 2018 | 00:28:23 | |
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 >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)
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. ReferencesTunnelling Epidural Catheters: An editorial discussing tunnelling of epidural catheters to prevent accidental catheter migration and Dr Pavy’s famous 1994 article!
Management of supermorbidly obese parturient with two epidural technique:
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| 023 – Stored blood versus fresh salvaged blood | 17 Apr 2018 | 00:19:10 | |
Hi Everyone, Congratulations & kudos Jeremy Hickey who correctly identified that this blood gas was a sample from a unit of stored allogeneic blood, sorry we don’t have any actual prize except for getting a mention on the podcast and the glory of seeing your name in print on the website! (If we have any more quizzes we may have to look into this.) Ryan Juniper also deserves a mention for his post on the facebook page which was also very close. What is the storage lesion of blood? What is 2,3 DPG? What happens to red cell deformability? Join Graeme and I for a 15minute discussion around the changes that occur in allogeneic blood when it is stored and why this may affect both it’s function and the undesirable effects this may have on our patients. We also briefly discuss and try to make a case for why salvaging and re-infusing a patients own fresh blood may be a much better option if you can achieve this during surgery – however we will leave a detailed discussion on cell salvage for another episode. Last weeks blood gas – taken from 23 day old stored allogeneic red cells ReferencesClick on these to link to the pubmed article: 4. National Blood Authority video – blood still saving lives but there are risks. | |||
| 139 The Placenta Accreta Spectrum Team at KEMH Part one | 18 Dec 2024 | 00:40:40 | |
Hi Everyone, This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following:
King Edward Memorial Hospital website – The Placenta Accreta Spectrum guideline | |||
| 022 – Medical podcasts and a quiz – a discussion with Graeme | 10 Apr 2018 | 00:14:10 | |
Hi everyone, Join Graeme and I this week where we discuss podcasts for medical education (& recreation). Find out who Alexander Hamilton was and what our favourite medical podcasts are and our personal take on this topic. Want to get into some medical podcasts? Get yourself a good set of earphones, go onto your iphone and into the purple podcast icon (sorry Samsung and Android users Graeme and I can’t help you there): Here are some of our favourite podcasts (in no particular order): EMCRIT – Critical care and emergency medicine from NY City ACCRAC – Anesthesia Critical Care Reviews and Commentary – From John Hopkins in the US COG – conversations in Obstetrics and Gynaecology – From Queensland BBC History – No Medicine here but Graeme loves it. The Curbsiders – Internal Medicine topics in depth from the US EDECMO – Cutting edge use of ECMO for cardiac arrest and critical care Intensive Care Network – From The Alfred Hospital in Melbourne – gold! Obsgynaecritcare – subscribe and give these guys a good review please! To finish the podcast we have a quiz, a blood gas result which is posted below. I asked Graeme to read this out & briefly describe it to listeners – however he gets a little carried away and lets the cat out of the bag so I have had to censor him – I suspect this may not be the last time I have to do this…….
What does this blood gas show? Please send in your comments – the first to correctly guess will get a mention on the show next week! Sorry we don’t have any T-shirts or mugs to give out so the glory of your name in print and on the show will have to do….. See you next week! | |||
| 021 – Uterine rupture in Namibia with Dr Wynand Breytenbach | 05 Apr 2018 | 00:16:49 | |
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 | |||
| 020 – Amniotic Fluid Embolism pathophysiology with Assoc Prof Nolan McDonnell | 28 Mar 2018 | 00:21:31 | |
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
Listen to last weeks fascinating case of AFE: 019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell
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| 019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell | 21 Mar 2018 | 00:17:13 | |
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 https://www.ncbi.nlm.nih.gov/pubmed/17337177
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| 018 – Management of the obstetric patient for whom transfusion is not an option | 14 Mar 2018 | 00:33:42 | |
(*Hypothetical Case) You are an obstetrician (or anaesthetist) and you work in a peripheral hospital in a metropolitan city. You are not on call but despite this you get woken by a phone call at 2am one night. It is a junior obstetric registrar who is very keen for you to come and give them some help. They tell you the on call obstetric consultant is already busy in theatre with an urgent caesarean for fetal distress and isn’t currently available. They are on the labour ward with a women who has just had vaginal delivery of twins following a relatively long labour augmented with oxytocin. She now has an atonic uterus and despite oxytocin / ergometrine has bled about 2 litres – she has just reminded everyone that she is a jehovah’s witness and reiterates that she will not accept blood under any circumstances. Unfortunately she never had any formal antenatal discussion about blood products – this is the first time she has mentioned it! The registrar sounds very scared and they want your advice about what to do next! What are you going to advise over the phone? What should have been done differently in the antenatal period? Join Graeme and I in this podcast. Thanks to Graeme for again being a good sport and agreeing to join in this podcast to make it more of a conversation and easier to listen to! He had to ad-lib, completely off the cuff, without any warning (I literally grabbed him in the corridor). – Tune in to find out where Wangkatjungka community is and why it is relevant to this topic! The Most Important Points to Consider:ANTENATAL
INTRAPARTUM
POSTPARTUM What is they have significant anaemia?
http://ajwrb.org/watchtower-approved-blood-transfusions Tranexamic Acid
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5228660/
Hyperbaric Oxygen to treat severe anaemia in a JW after abruption: https://www.ncbi.nlm.nih.gov/pubmed/23380087 Case report of use of hemopure for postpartum anaemia https://www.tandfonline.com/doi/pdf/10.1080/22201173.2009.10872581 Case report of the use of hemopure in severely anaemic JW trauma patient in Melbourne Vaginal Cell Salvage Cell salvage for postpartum haemorrhage during vaginal delivery: a case series http://www.bloodtransfusion.it/articolosing.aspx?id=000944 Is Cell salvaged vaginal blood suitable for reinfusion? https://www.ncbi.nlm.nih.gov/pubmed/25659518 What would you do if you had one of these cases (Apart from call in sick!)Want to test the neurons more?
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| 017 – Prof Yee Leung Obstetric and surgical management of abnormally invasive placenta | 06 Mar 2018 | 00:23:01 | |
Hi everyone, Thanks for joining us again, this week I am joined by my colleague Prof Yee Leung, Head of Gynaecological Oncology in Western Australia, to discuss the obstetric and surgical aspects of managing the patient with an abnormally invasive placenta (accreta / increta / percreta). Please join us, listen to our conversation on the podcast and let us know if you have any comments or questions. Definitions:Accreta = the chorionic villi are in contact with the myometrium (78%) Increta = the chorionic villi invade the myometrium. (17%) Percreta = the chorionic villi penetrate the uterine serosa. (5%) Risk factors:
ACOG RANZCOG Diagnosis – Imaging Modalities:https://radiopaedia.org/articles/placenta-accreta USS or MRI Surgical managementSurgical management of placenta accreta: to leave or remove the placenta? Placenta Accreta: When is the optimal time to deliver? Manual Aortic OcclusionOur podcast discussion on this topic Interventional Radiology3) REBOA during unexpected uterine rupture https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628233/ 2) Comment urging caution before embracing interventional radiology techniques: http://www.obstetanesthesia.com/article/S0959-289X(16)30075-9/pdf Communication and Having an Effective TeamFostering a culture of safety: The OR team huddle Conservative ManagementLeaving the placenta in situ, Methotrexate, En bloc resection, Hysteroscopic resection | |||
| 016 – Sphenopalatine ganglion block for postdural puncture headache | 27 Feb 2018 | 00:19:37 | |
(*Fictitious case) You are called to the postnatal ward by the midwife to review a woman who unfortunately had an accidental dural puncture the day before during her labour. When you see her today she has a classic postural headache – and has been unable to mobilise for more than 10-15 min and has basically confined to bed in a dark room. You take a detailed history and perform a neurological exam and are relatively confident that it is unlikely that she has any other serious pathology and that the headache is secondary to the CSF leak. You explain to her the natural history of the condition, discuss epidural blood patch, or conservative management. The patient tells you she is not very keen on the idea of anyone putting another big needle in her back – “isn’t there anything else we can try?”
This week on the podcast we are joined again by Gareth Ansell to discuss the role of sphenopalatine ganglion block (SPGB) in the management of postdural puncture headache (PDPH). SPGB is useful in reducing post dural puncture headache. It can be used as an alternative or as interim management of PDPH. So far there has been no randomised controlled trials looking at SPGB specifically for PDPH but there have been case series. Cohen et al (1) published in 2009 showed that in their case series of 32 patients, 69% avoided epidural blood patch and another case series by Kent (2) had a 100% success rate in resolution of headache. There is also a systematic review of SPGB for treatment of headaches published in 2017 by Ho (3) and there are RCTs underway. Some patients get permanent resolution of the headache with the a single SPGB, other patients may need repeat SPGB. Remembering that the natural time course of PDPH is that the majority of patients gets better 7-14 days after the dural puncture. Sphenopalatine ganglion lies in the pterygopalatine fossa which lies posterior to the the middle concha. The sphenopalatine ganglion is the largest of the four parasympathetic ganglions associated with the trigeminal nerve. It is postulated to work by blocking the parasympathetic nerve fibres and improving cerebral vasculature reducing the headache. Advantages of the SPGB is that it is less invasive, easier and quicker to perform and has lower risks than and epidural blood patch. As well as an useful alternative to patients who do not want an epidural blood patch or who have contraindications such as bacteraemia or spina bifida The contraindications for performing a SPGB are previous nasal trauma, deviated septum or local anaesthetic allergy. For further information on how to perform a SPGB watch our video tutorial on youtube below. Remember you have to perform the block on both sides. https://youtu.be/ebvS6tvr4Yk References
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| 015 Placenta percreta perioperative and anaesthetic management | 13 Feb 2018 | 00:31:45 | |
(*Fictitious case) You are contacted by the ultrasound department – they have just completed a formal scan on an urgent referral and want to discuss their findings with you urgently. A 34yr old woman was admitted overnight with some PV bleeding at 32 weeks. She has had 2 previous caesareans and on the scan they have found a low lying anterior placenta which overlies the previous scar and concerningly there appears to be ultrasonographic evidence of accreta (vascular lacunae) and possibly doppler evidence of large vessels indicating invasion of the bladder (percreta). This condition quite rightly strikes fear into the heart of surgeon and anaesthetist alike – primarily because of the risk of catastrophic torrential haemorrhage. What are the principles of managing someone with placenta percreta? Hi Everyone, This week on the podcast I am joined again by my Colleague Graeme Johnson where we discuss the perioperative and anaesthetic management of the patient with a morbidly adherent placenta. Useful links: Screencast of presentation on this topic at Dept Anaesthesia Meeting: https://youtu.be/Wg4aH6Z8fmA
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| 014 Diabetic Ketoacidosis in Pregnancy | 29 Jan 2018 | 00:31:39 | |
(*Fictitious case) A 32 yr old pregnant woman with insulin dependent diabetes presents to a regional hospital in WA at 27 weeks gestation, with probable premature rupture of her membranes, threatened preterm labour and a low grade fever. She is given a dose of celestone (betamethasone) intramuscularly, some nifedipine for tocoloysis and has an urgent areomedical transfer organised. During the flight she has a salbutamol infusion to provide further tocolysis and minimise the risk of delivery of a 27 week foetus in the back of the plane which the retrieval team are very keen to avoid! On arrival at your tertiary hospital she is febrile (T 38.4) but the most striking thing noted is the fact she is breathing very heavily but yet has clear lungs and normal SpO2 of 99%. The team assessing her do some blood tests including an arterial blood gas and obtain the following results: pH 7.26, pCO2 16, pO2 128, HCO3 7.5, Na 141, K 4.8, Cl 101, Gluc 19.0, Urea 8.1, Crn 0.09 Urine analysis: Glucose 4+, Ketones 1+ What is going on? How are you going to manage this patient? This week I am joined by my colleague Dr Graeme Johnson and we discuss the ins / outs of DKA during pregnancy. Diabetes is an increasingly common condition both in the general population but also in pregnancy. DKA is an important and life threatening critical illness which can develop in any pregnant unwell diabetic patient. All healthcare workers who may be involved in the care of a diabetic pregnant patient will benefit from understanding the basic physiological process which leads to DKA, how to recognise it, and the principles of management. Join Graeme and I as we discuss a hypothetical case. You can listen to the audio only on the blubrry podcast or if you prefer follow along with us watching the screencast which has the slides containing visual aids & diagrams. This does probably make it somewhat easier to follow the discussions we have about the metabolic pathways & ketone production. Screencast: https://youtu.be/dAGb6lEgsnk Here are the links to the two main articles used in putting together this weeks podcast: The Management of DKA References A Hallett, A Modi, N Levy; Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists, BJA Education, Volume 16, Issue 1, 1 January 2016, Pages 8–14, https://doi.org/10.1093/bjaceaccp/mkv006 Mohan M, Baagar KAM, Lindow S. Management of diabetic ketoacidosis in pregnancy. The Obstetrician & Gynaecologist 2017;19: 55–62. http://onlinelibrary.wiley.com/doi/10.1111/tog.12344/pdf
Want to Brush up on Arterial Blood Gas Analysis? Check out these amazing sites: 1 – Kerry Brandis’ amazing Acid Base textbook available here on the anaesthesiamcq site: http://www.anaesthesiamcq.com/AcidBaseBook/ABindex.php 2 – For those of you who like the super deep dive into a topic, I recommend Alex Yartsev’s super detailed discussions on metabolic syndromes and blood gas analysis on his great ICU website below: http://www.derangedphysiology.com/main/core-topics-intensive-care/arterial-blood-gas-interpretation
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| 013 Intraoperative and intrapartum strategies to decrease blood loss – anaesthesia, coagulation and pharmacology | 18 Jan 2018 | 00:16:42 | |
Hi everyone, This weeks post is part 2 of the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage – this week focussing on anaesthetic / pharmacological and coagulation management strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the “sweet spot” for most of us. So based on that this talk is only meant to be a summary – I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built whole careers around some of these different techniques / strategies! I will hopefully come back at some stage and do a “deep dive” to delve into aspects of some of these in greater detail! (e.g. cell salvage – I have you in my sights Dr Rucklidge!). Screencast of this talk: https://youtu.be/EMg4IngN0Ds
References / Resources: Blog discussion on permissive hypotension on Life in The Fast Lane https://lifeinthefastlane.com/ccc/permissive-hypotension/ Previous Blog on this site: https://www.obsgynaecritcare.org/oxytocin-use-in-labour-increases-postpartum-haemorrhage-due-to-uterine-atony/ | |||
| 138 Journal club with Graeme IJOA Nov 2024 | 09 Dec 2024 | 00:32:24 | |
Hi Everyone, Join Graeme and I as we discuss two articles chosen from last months edition of IJOA (International Journal of Obstetric Anesthesia). In the first we discuss an article exploring whether the use of intermittent calf compression can reduce hypotension and vasopressor use in women undergoing caesarean section under spinal anaesthesia. The second article looks at the utility of preoperative electrical stimulation of acupressure points prior to caesarean section reduces postoperative pain and improves the quality of maternal recovery. There’s a sprinkling of our usual dad jokes at the end. For regular listeners to the show join us again later this month when we hopefully will have a couple of episodes dedicated to the management of placenta accreta spectrum and an interview with the founders of the placenta accreta service setup 7 years ago here at KEMH – see you then! References | |||
| 012 Fibrinogen concentrate in major haemorrhage – interview with Dr Hamish Mace | 04 Jan 2018 | 00:19:50 | |
You phone goes off – you roll over it is 2am – when you pick up it is a theatre nurse calling to ask if you can urgently come to the hospital immediately – the team are too busy to talk to you. The nurse tells you a woman has just arrived via ambulance from another small peripheral hospital. She had an emergency caesarean about 6 hours ago and hasn’t stopped bleeding since. She has had 4 units of red cells and 4-5 litres of saline but nothing else. When you arrive 15min later surgery is underway but the surgical team tell you “everything we touch is bleeding” and you notice that she is even bleeding from the skin around her iv…… The anaesthetic registrar turns to you and says – “lets give her the fibrinogen concentrate – we need to get on top of this coagulopathy right now!……” (*Fictitious case example) Hi Everyone, This week we are joined by a colleague and a great friend of mine Dr Hamish Mace, one of the co-authors of an article in the 2017 edition of Australasian Anaesthesia (aka the Blue Book) entitled “Fibrinogen concentrate for the treatment of acquired hypofibrinogenaemia”. Hamish is a consultant anaesthetist working in Western Australia – he works at Fiona Stanley Hospital a large tertiary centre in metropolitan Perth – but has also worked in the past in remote regional centres in WA, in retrieval medicine for the RFDS (Royal Flying Doctor Service) and spent time on fellowship in Toronto Canada. Hamish co-ordinates the preoperative anaemia correction service, is on the hospital transfusion committee, has a strong interest in many aspects of patient blood management. In the interview we briefly discuss the role of fibrinogen in the acquired coagulopathy that often develops during major haemorrhage, the historical treatments used (FFP, cryoprecipitate), the history of fibrinogen concentrate and where we think fibrinogen concentrate might fit into the current management of major haemorrhage – both in tertiary but also remote, regional and retrieval situations. For those of you who are interested in reading on this topic in detail here is the link to the ANZCA website page where you can access the article written by Hamish and Mansi – the article itself has many great references. Their article is in the 2017 edition. Check out all the other great critical care and anaesthesia articles in this book – a quick shout out to Richard Riley the editor of this great biannual publication. http://www.anzca.edu.au/resources/college-publications In the interview we also talk about the value of measuring fibrinogen an coagulation rapidly with point of care viscoelastic tests. Check out our ROTEM learning package right here on this website (of which Hamish was also a co-author). Advice on mixing and administering fibrinogen concentrate: https://youtu.be/7UP2Y1dH9QI
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| 011 Hyperkalaemic crisis in the pre-eclamptic patient | 26 Dec 2017 | 00:19:07 | |
Merry Xmas! This weeks post was inspired by a recent unexpected case of severe hyperkalaemia in a severe pre-eclamptic – I have put together a fictitious case which is a little more severe in order to illustrate the principles of managing hyperkalaemia – I hope you enjoy & take it easy over Xmas! CASE HISTORY (*A fictitious patient history ) Your pager goes off – code blue medical labour ward! On arrival you are told the patient for whom the code was called has just arrived following an urgent transfer from another hospital. She presented to their service at 31 weeks with a headache, BP 190/100, proteinuria and mildly raised creatinine. She was diagnosed with severe pre-eclampsia, given labetalol, nifedipine and then transferred. She now appears confused with the following vital signs: HR 33/min, BP 74/55, SpO2 92%, RR 17/min (*Image courtesy www.lifeinthefastlane ) An immediate venous blood gas shows the following result: Na 139, K 8.4, pH 7.23, pCO2 37, pO2 63, Lactate 1.8 How are you going to manage this patient?
Immediate Standard Mgmt 1 – Is it real? Common causes of high potassium includes hemolysis of red cells from the sampling and handling process. Always do an ECG whilst awaiting a repeat result – if the patient is compromised and the ECG is abnormal / consistent with hyperkalaemia then assume it is real and don’t delay your treatment! The quickest way to get a repeat sample is usually a VBG this usually only takes a few minutes and will also give you the glucose and pH – important values to know for both mgmt and diagnosis. 2 – Prevent an arrhthymia Immediate mgmt – stabilise the cardiac membrane with intravenous calcium. Most guidelines recommend calcium if there are ECG changes or the absolute K level is over 7mmol/L. *Calcium chloride has 3 times more calcium than calcium gluconate. 3 – Shift K intracellularly a) Insulin / Glucose. Usual dose 10units actrapid + 25-50ml 50% Dextrose
b) Salbutamol
c) NaHCO3 (if acidotic)
4 – Eliminate K from the body (usually renal) – Enhance renal elimination – diuretics (e.g. frusemide), K free crystalloid (if indicated – saline) or both! – Dialysis – institute early in patients with complete renal failure – GI exchange resins (eg resonium) most guidelines now consider they have no role in the acute management. 5 – Identify and treat the cause! – You need to address this issue to stop if from recurring!
BUT
Cardiac Arrest Secondary to Hyperkalaemia Adrenaline (beta agonist) – will move K into cells, NaHCO3, Calcium and more calcium! Important principle: Never stop resuscitation until the potassium is normalised (much like in hypothermic arrest – they are not dead until they are warm and dead!) There are successful case reports of dialysis or ECMO being used during refractory arrest with good neurological outcomes. Hyperkalaemia and PET 1 – Beware: Intravenous Ca is a mild vasoconstrictor and can worsen the hypertension transiently – this is what we observed in a recent case I was involved in. 2 – Beta blockers can contribute to / cause hyperkalaemia (the same mechanism but opposite effect of the use of salbutamol / beta2 agonists ) – labetalol is commonly used in these patients – consider changing to another antihypertensive like hydralazine and/or diuretics if the patient remains severely hypertensive (note loop diuretics will also help excrete K!)
3 – Nifedipine is a ca antagonist (altho less cardiac specific) – does this have implications for the effectiveness of Ca? Will these increase the toxicity of the hyperkalaemia? 4 – Diuretics – these are ok in PET and pregnancy as long as there is a good indication – severe hyperkalaemia (and hypertension) is! What are the ECG changes you see with hyperkalaemia? Remember, hyperkalaemia is the syphilis of the ECG world – it can be a very sneaky mimic!
Drugs Known to Cause / Contribute to hyperkalaemia
Great description here on LITFL: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/ Links / References: Great Podcasts: https://emcrit.org/emcrit/hyperkalemia/ https://emergencymedicinecases.com/emergency-management-hyperkalemia/ LITFL management principles: https://lifeinthefastlane.com/ccc/hyperkalaemia-management/ Causes of hyperkalaemia: Precious Bodily Fluids – the musings of a salt whisperer. Possibly the best website / resource for electrolytes anywhere – full stop. Check out their free 500+ page textbook here: http://pbfluids.com/the-electrolyte-book/
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| 010 Intraoperative and intrapartum surgical / physical / radiological techniques to minimise blood loss | 15 Dec 2017 | 00:10:49 | |
Hi everyone, This weeks post is the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage. After sitting down to put this section together I soon realised that there is actually a lot more to discuss than I anticipated – so I have decided to split this into two parts – surgical / physical and radiological techniques and then another one on anaesthetic / pharmacological and transfusion strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the “sweet spot” for most of us. So based on that this talk is only meant to be a summary – I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built whole careers around some of these different techniques / strategies! I will hopefully come back at some stage and do a “deep dive” to delve into aspects of some of these in greater detail! (e.g. cell salvage – I have you in my sights Dr Rucklidge!). Here is the screencast: https://youtu.be/rNfqlaL64qg Here are some useful resources: If anyone knows of any other great websites / references please let us all know in the comments! Overview of topical haemostatic agents for O&G surgery: Youtube Uterine Artery Ligation: (Can any obstetricians out there let me know if these videos are any good – if you can find any better teaching videos let me know!) https://youtu.be/KUePaQUHJYE https://youtu.be/0T7mo9GIX_Y Links to previous PBM posts:
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