Thread by @OBsleepmerchant

@hnixon147 presents a very important topic - Optimizing Intraoperative Anesthesia: What can we do to improve care? #OBAnes #SOAPAM2023

A case: “Jennifer” 37 week primup, for induction. Receives epidural, works well for 10h, then requires top-up which is successful.

She chuffs along but eventually stalls. A section is called.

In OR, pinprick and Alice test passed. However, she quickly becomes +++ anxious.… twitter.com/i/web/status/1…

The patient is a physician, in same hospital. Feedback given. 9months post partum STILL having flashbacks, PTSD: #OBAnes #SOAPAM2023

This is NOT as rare as we think (see tweets elsewhere). 1 in SEVEN cesarean patients experience intraoperative pain. Poll of audience - many have seen this themselves. #OBAnes #SOAPAM2023

The knowledge that neuraxial fails is NOT new. Pain at cesarean section is a leading cause of litigation. The consequences of intraoperative pain are not insignificant (@SusannaStanford). Why is this common in #OBAnes? #SOAPAM2023

Preop anxiety ≠ pain. However, #OBAnes are very poor at assessing patients pain.

Remembering that as many as 1 in FIVE patients experience intraoperative pain - something that #AnyAnes would never tolerate. @EMARIANOMD @NarouzeMD @KalagaraHari @amit_pawa don’t perseverate when… twitter.com/i/web/status/1…

@hnixon147 suggests that #OBAnes have some required reading to do - most recently @Anaes_Journal contains @OAAinfo led guide for prevention and management of intraoperative pain during cesarean by @BogodDavid @noolslucas @DavidGray37 @robin_russell1 @SusannaStanford et al.… twitter.com/i/web/status/1…

So how do #OBAnes move forward to manage this? AIM bundles - let’s make one? #SOAPAM2023

Readiness. Recognizing spinals can fail, for multiple reasons. CSF is not a 100% fool proof check in #OBAnes #SOAPAM2023

More often we see LOW blocks rather than high blocks. How much is necessary? (@bmacaulay2000 - Prasad Bolleddula’s magic 12mg)

However, is aiming for a dose that’s only effective in 95% of #OBAnes patients? Is it okay to under-dose 5% of patients? Are we setting ourselves up to… twitter.com/i/web/status/1…

Readiness: epidurals. Recognize that they can be inadequate. Do so early - q2h rounding may be hard to do. Epidural space is a bit of a mystery - we cannot see it live. #SOAPAM2023

Epidural catheter failure during labour up to 1 in FOUR. Red = red flags! Why don’t we respond? Even before @SOAPHQ centres of excellence 5% GA section rate, there was the UK standard of <3% GA for Labor Epidurals. Have #OBanes fulfilled Goodhart’s Law? If we’re reliant on… twitter.com/i/web/status/1…

Intrapartum management can make a difference. @hnixon147 colour coded classification of labour analgesia failure - speaking the same language in #OBAnes may help? #SOAPAM2023

So we’re ready (maybe) - how do we recognize and reframe the situation (ala @AmyCEdmondson - see, #OBAnes learn quickly some times 😉) #SOAPAM2023

To adequately recognize #OBAnes have to understand the basics! Different modalities give different levels. #SOAPAM2023

Top tips for testing. @TrChristmas @SusannaStanford @noolslucas @Eltonchris @BogodDavid @robin_russell1 @Anaes_Journal tables rock! #OBAnes #SOAPAM2023

Reframing is important. Phrases to avoid.

Is it JUST pressure? (JUST pressure with a testicular clamp would probably not be ignored).

Is pressure really “normal”?

And for the love of puppies, if “it’s almost over” aren’t we subliminally recognizing it’s traumatic and NOT… twitter.com/i/web/status/1…

@hnixon147 and her #OBAnes dept chart VAS scores q15min during cesarean section so they recognize changes early - once patient frowning, let alone screaming it may be too late?

Back to “Jennifer” - where were my OB’s? Why did NO ONE speak up? OB, nurses etc all saw the problem… twitter.com/i/web/status/1…

Things to remember: #SOAPAM2023

Respond: first acknowledge what’s happening (reframe that we expect every block to fail) - remember ONLY she knows, true block failure isn’t about the block but #OBAnes’ response to it. She’s the only one who knows. (@SusannaStanford multiple editorials in @Anaes_Journal)… twitter.com/i/web/status/1…

STOP surgery - hands up (princess hands?). Monitoring pain scores before there’s a problem allows #OBAnes to act earlier. TEST the block. Look at what the surgeon’s doing? #SOAPAM2023

Respond! I know @DrNickB_ObAnaes is passionate about avoiding exteriorization (included in @SOAPHQ consensus statement and @NICEComms guidelines - it has a place but should NOT be regular practice). Fentanyl is good for visceral pain and titratable, also a good marker of when… twitter.com/i/web/status/1…

@hnixon147 is clear: if you’re using these there’s potentially a problem. GAWA is NOT acceptable, and a fine line before it’s crossed. “Jennifer” hated Ketamine - it did not treat her pain, just made her hallucinate as well. #OBAnes #SOAPAM2023

Something new to consider in your #OBAnes practice or armamentarium #SOAPAM2023

Most importantly - FOLLOW UP! Both with the patient and the team. #OBanes/ OB/ OR nursing team debrief is important. More so is making sure your patient is able to access support, that there is adequate documentation to ensure she isn’t lost in the system. #SOAPAM2023

Report: ensure debriefing after events. Ensure education and coaching occurs. #SOAPAM2023

Make sure #OBAnes are collecting the data (HT: @kkjaermd) and ALL of it (HT: @HofkampMichael) #SOAPAM2023

Report and Review is often neglected. Close the loop! #SOAPAM2023

Homework from @hnixon147.

Papers to read. I strongly recommend the @Anaes_Journal article from @OAAinfo’s own Plaat et al (@SusannaStanford @noolslucas @BogodDavid @DavidGray37 @robin_russell1), I will be reading the other two after #SOAPAM2023.

Review this checklist of “to… twitter.com/i/web/status/1…

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