Simon Ash Profile picture
Oct 19, 2022 15 tweets 20 min read Read on X
Dr Anna Nunokawa presents case of Amniotic Fluid Embolism (#AFE) at @DalAnesthesia grand rounds #OBAnes

(get her on #Medtwitter @garrettsbarry @axe1314 @Ropivacaine @jon_bailey_anes @AnaSjaus @bmacaulay2000 @Dolores_McKeen?) Image
The case: #AFE #OBAnes

Any questions at this point?

(Written consent for case presentation from patient) ImageImageImageImage
A brief discussion of epidemiology and pathophysiology. #AFE is rare, but some retrospective literature suggests up to 45% mortality even in developed world - much higher in developing world #OBAnes ImageImageImage
Risk factors for #AFE

#OBAnes ImageImageImage
Considerations for diagnosis of #AFE: up to 25% will be atypical (not meeting all 4 Clark’s Criteria). A quick refresher on diagnosis of DIC. Other signs include aura in awake patients and seizures/stroke
#OBAnes ImageImageImage
The differential diagnosis of #AFE is necessarily broad. @stanfordanes emergency manual has a list to rule out, although latest version puts AFE under embolism, losing the specific section. Investigations help - including echo
#OBAnes ImageImageImage
On echo in #AFE - what was found in the case (less movement of RV wall, TR, elevated RVSP - all resolved postoperatively
#OBAnes ImageImageImageImage
What does literature say about echo in #AFE? @CJA_Journal case series and review in 2021 - will add reference. LV failure in Acute phase suggests an alternative diagnosis.
#OBAnes ImageImageImage
Principles of management of #AFE - primarily supportive?
#OBAnes Image
Great checklist from @MySMFM guidelines on managing #AFE
#OBAnes ImageImageImageImage
Our outcome was great for this #AFE, able to mobilize a great team (@Dolores_McKeen @OBsleepmerchant @AnaSjaus), but recognize limitations of no POC ABG (@IWKHealth lab against POC), no ROTEM, pumps not set for significant resus. #OBAnes Image
Some discussion points:
* reluctance to use cell salvage in setting of #AFE despite major transfusion (UK/IE/EU experience?) @noolslucas
* REBOA is becoming more useful in #OBAnes setting - definitely consider if surgeons applying aortic compression buys time to stabilize Image
MOST important take home point: we were able to mobilize a team of 3 #OBAnes fellowship trained specialists, and despite a few POC limitations had capacity to access vascular surgery and interventional radiology during the case.
This is NOT the norm in the community hospital.
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More from @OBsleepmerchant

May 9
@SQuashie presents an update on anesthesia for operative delivery. Declarations. Methodology and themes. #OAA24ASM #OBAnes

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Gastric USS. Oral rehydration has benefits over NPO wrt vasopressor use. #siptilsend safe, noting some patients have increased gastric volumes irrespective of starvation status. #OAA24ASM #OBAnes
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@SQuashie continues at a rapid pace. To DPE or not to DPE remains a question - 16min vs 19 min, is that 3 min clinically relevant? Esketamine for supplemental analgesia - >95% had psych effects, read @rjharrison79 editorial. #OAA24ASM #OBAnes
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Read 16 tweets
May 9
@Jamesocarroll presents an Update on Labour and Delivery. Disclosures #OAA24ASM #OBAnes

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How the lecture was put together. Screening. Themes. How to interpret the slides. Very Ostheimer-esque @Jamesocarroll #OAA24ASM #OBAnes


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@Jamesocarroll Clinical practice theme: intrathecal catheters & ADP. Intrathecal catheters: No decrease in PDPH, but reduction in EBP. 10mL intrathecal saline decreased PDPH & need for EBP. Of note, the percentage of epidurals requiring multiple attempts. #OAA24ASM #OBAnes

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Read 17 tweets
May 5
8am-ish in Denver and time for a much anticipated session: PDPH beyond the guidelines. Moderated by Dr Lisa Leffert, featuring @Ropivacaine, @euklaas, @sharonOzynger and @WouterSchievink at #SOAPAM2024 #OBAnes

(HT: @Ropivacaine, bless his heart, he knows I hate missing out)

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Hot off the Press? August 2023! @JAMANetworkOpen with quite an illustrious team including @Ropivacaine @robin_russell1 @KalagaraHari @LimGrapes @claralexlobo @noolslucas @NarouzeMD (please tag others if you have their handles?) #SOAPAM2024 #OBAnes

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Introduction, Methods and the 10 questions. #SOAPAM2024 #OBAnes

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Read 11 tweets
Jun 12, 2023
Next up at #CASAM2023 - fittingly keeping the most important academic session to last: #OBAnes
@ValZaph moderating the Maternal Experience and Outcomes: Improving the care we provide. @DrWesleyEdwards

Bookends the 1st #OBAnes session, on intrapartum pain at cesarean section… twitter.com/i/web/status/1… Image
Dr Christina Lamontagne kicks off the session with: Use of Dexmedetomidine in improving maternal experience and outcomes. Nothing to disclose. Then an important disclosure: All indications discussed are OFF LABEL in Canada. Objectives.
#OBAnes #CASAM2023 ImageImageImageImage
Why does Dr Lamontagne use a lot of dexmedetomidine (not only in #OBAnes mind)? Clinical pharmacology of dexmedetomidine (1): highly selective alpha-2 agonist; sedation WITHOUT amnesia at locus coeruleus. #CASAM2023 ImageImageImage
Read 9 tweets
Jun 11, 2023
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023 ImageImageImage
The opioid crisis isn’t new - China probably remembers the Opium wars that helped establish a British foothold on the continent. Opioids and OUR crisis. Is what we fear the real crisis? Are opioid-related deaths due to surgical prescriptions? No, mostly due to street fentanyl.… twitter.com/i/web/status/1… ImageImageImage
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023 ImageImageImage
Read 11 tweets
Jun 10, 2023
@DrLucieFilteau introduces @CMA_Docs president @AlikaMD for his keynote address at #CASAM2023 Image
@AlikaMD starts with the state of the 🇨🇦 health system, including a little history. #CASAM2023 ImageImage
The 🇨🇦 health system approach to problems, creating new problems as a result with a dangerous lack of interoperability. #CASAM2023 ImageImageImage
Read 12 tweets

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