@euklaas from @asznl presents on PDPH: new perspectives at #OAA3dc2022. (As promised by teaser) August Bier = father of PDPH, a surgeon started it not #OBAnes 😉
Current perspective on PDPH. ICHD-3 definition, tied to CSF pressure & volume as is pathophysiology. #OAA3dc2022
New anatomical perspectives challenge the classic CSF hypothesis. Choroid plexus not main site of production, CSF doesn’t circulate unidirectionally.
Bulat-Kiarica-Orešković hypothesis: osmotic & hydrostatic forces are main determinants of CSF movement, pulsates
PDPH presentation: EPiMAP1 (@BJAJournals ) - signs and symptoms (100% headache not too surprising) #OAA3dc2022
NB PDPH is NOT always postural (another poll for @antonchau1 or @emilysharpe or @OAAinfo or @SOAPHQ: how many #OBAnes/ institutional protocols exclude PDPH on basis of postural component?), 39% get headaches postpartum (only 4% PDPH), No CSF. Beware changing picture #OAA3dc2022
Complications of PDPH (neurological): increased SDH rate associated with PDPH (@JAMA_current) postpartum depression, PTSD, chronic headache, chronic backache (@EJA_Journal) #OAA3dc2022
Can #OBAnes prevent PDPH? Lots about needle type and size. (@Anaes_Journal) Sadly probability of PDPH & probability of block failure are “inversely” related; least PDPH: 26A>27A>29C etc, lowest failure: 26A>25C>22C etc. 26G atraumatic = perfect? The std 25G middling? #OAA3dc2022
Pencil point better (except perhaps 29G, how long would you have to wait to CSF return?), 26G seem ideal. If we’re to massively reduce the morbidity burden should 26G pencil point be everywhere? Achieving that worldwide = expensive! Ultrasound has no effect on ADP? #OAA3dc2022
What do you do if you recognize an ADP? Sharon Orbach-zinger et al (incl @noolslucas@MarcVandeVelde6) in @Anaes_Journal - low level evidence for recommendations on intrathecal catheter. Multiple options, variable effficacy. #OAA3dc2022
@NarouzeMD favourite! Fluoroscopically guided vs intranasal LA?
Jespersen et al (@BJAJournals) no significant effect on pain intensity > 30 min vs. placebo. But, pain was reduced & EBP was avoided in 50% patients of both groups, suggesting position NB? #OAA3dc2022
EPiMAP group then proceeded to look at factors associated with failed EBP. Using p<0.01 for significance: migraine Hx, ADP level, time from ADP to EBP. If p<0.05 had been chosen, interesting. No effect volume or level EBP, position during EBP or operator experience! #OAA3dc2022
Factors p<0.01: migraine, timing and ADP level. Relationship between level ADP & level EBP - food for thought, but considering how inaccurately #OBAnes assess level (even with US), either ADP or EBP level may be out? @euklaas how was level assessed? #OAA3dc2022
Summary from @euklaas with QR email code to join research (in fullness of time, don’t flood her inbox [yet]). Prominent QR code for references on first slide (repeated here enlarged) #OAA3dc2022
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
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
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
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023
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…
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023
PPH: a focus on coagulation is kicked off by Dr Karine Doyon (a hematologist). Objectives. Canada ranked 39th in world in maternal mortality - not sure if that’s good. We’re doing better than USA. #OBAnes#CASAM2023
Causes of coagulopathy in pregnancy - Dr Doyon won’t be discussing inherited disorders. The focus will be on the acquired hemorrhagic disorders. #OBAnes#CASAM2023
Pregnancy-associated mortality ≈ maternal mortality. #OBAnes 0.2% - doing well (wonder what the denominator is?), so Elmo could ask why are we worried? #SOAPAM2023