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Jun 4, 2023 35 tweets 38 min read Read on X
Novel Content No.2 at #SOAPAM2023 virtual #OBAnes highlights Day 2: @DoctorStahl speaks on Obstetric Critical Care #OBCritCare ImageImage
@DoctorStahl is an intensive care bear, who loves #OBAnes. QR code to references. #OBCritCare #SOAPAM2023 ImageImageImage
Pregnancy-associated mortality ≈ maternal mortality. #OBAnes 0.2% - doing well (wonder what the denominator is?), so Elmo could ask why are we worried? #SOAPAM2023 ImageImageImage
Well, 43% of maternal mortality, early #OBAnes involvement in MDT probably could make a difference. Add in other cardiovascular disease where #OBCritCare definitely involved, critical illness accounts for 76% of maternal deaths. #SOAPAM2023 ImageImageImage
Ohio data surprisingly similar, as is that for Massachusetts and New Jersey. #OBAnes #SOAPAM2023 ImageImageImageImage
So critical illness accounts for ~3/4 maternal deaths in USA. #OBAnes have an opportunity to change this. Assumption warning! So how do we prevent death by critical illness in pregnant patients? We have to see the wood for the trees - move away from looking at causes of death,… twitter.com/i/web/status/1… ImageImageImage
And if we move away from looking at casual of death we can recognize maternal death as the endpoint of a potentially modifiable continuum of maternal morbidity, with SMM preceding mortality and the final point of #OBCritcare intervention. Blood transfusion seems an appropriate if… twitter.com/i/web/status/1… ImageImageImage
@DoctorStahl points out the ever topical significant racial disparities that exist, for SMM and maternal mortality. #OBAnes #SOAPAM2023 ImageImage
So let’s reframe the question - how to prevent death or morbidity by critical illness (accounting for ~75% maternal mortality, possibly more SMM, in USA): understand the causes of death & apply CCM principles to find a solution. #OBAnes #SOAPAM2023 Image
Possibly even simpler than that - BELIEVE women when they say something is wrong. @elsmere_g had some similar key principles at #Anaesthesia2023 (suspect @SusannaStanford may approve of this message) #OBAnes #SOAPAM2023 Image
With the WHY covered, let’s move onto what’s different and the how to’s of #OBCritcare. @DoctorStahl will cover 3 failures: heart, lungs and immune. #OBAnes #SOAPAM2023 ImageImageImageImage
Starting with cardiac - let’s break it down: biventricular failure, wildcard (aortic disease), and RV failure. Starting with biventricular failure - the big 3. #OBAnes #SOAPAM2023 ImageImageImage
Guidelines aren’t particularly pregnancy focused (dearth of literature to blame). A couple of principles. Caveats & system issues - what works in a regular hospital or ICU does not necessarily flow well in a maternity hospital or labour ward. #OBAnes #SOAPAM2023 ImageImageImage
ROSE - worthwhile #POCUS addition for #OBAnes. #SOAPAM2023 Image
Wildcards are exactly that: wild. RV failure can be subdivided into that with normal RV afterload vs increased RV afterload. #OBAnes #SOAPAM2023 ImageImage
With the considerations of normal or increased RV afterload delineating DDx, the different treatment bundles are clear. MCS = mechanical cardiovascular support (extracorporeal life support)… do it early. #OBAnes #OBCritcare #SOAPAM2023 ImageImageImageImage
We need to address the myth of “crashing onto ECMO” there’s no such thing - even experienced prepared units take time. If it’s on the menu, stop and consider transfer to ICU. Veno-Arterial not veno-venous - provides extracorporeal life support. #OBAnes #SOAPAM2023 ImageImageImageImage
Does it work? Look at that maternal survival rate (MSR) post intervention. Also consider survival rates for individual diagnoses. #OBAnes #OBCritcare #SOAPAM2023 ImageImage
Veno-Arterial ECLS at the Ohio State - includes peripartum CMO. So, heart failure in pregnancy: optimize preload; use inotropes, control rhythm; reduce afterload and evaluate for MCS. #OBAnes #OBCritcare #SOAPAM2023 ImageImage
What is good in guidelines? Complete cycle of care - early assessment, pre pregnancy planning, monitoring, delivery planning and POSTpartum care (4th Trimester @Rose_Kearsley). @maloumeng’s planning for delivery framework gets the nod of approval. #OBAnes #SOAPAM2023 ImageImage
Anything to add on cardiac arrest? Do what you do for anyone else, and remember Manual Left Uterine Displacement. #OBAnes #SOAPAM2023 Image
Moving on to acute respiratory failure. Really enjoyed the animation (very satisfying, poorly captured in 4 pictures) #OBAnes #SOAPAM2023 ImageImageImageImage
Respiratory Failure management - risk mitigation: mechanical ventilation vs NIPPV or HHFNC (HFNO2). Both modalities have their downsides. #OBAnes #SOAPAM2023 ImageImage
Goals with mechanical ventilation - safe securement of airway; prevention of acute lung injury; balancing risk vs benefits. Rule of 6. High normal PEEP. Maintain reasonable SpO2 > 90% (PaO2 perhaps less important) #OBAnes #SOAPAM2023 ImageImageImage
HHFNC (HFNO2) and NIPPV? 3 classes of indication. Perhaps time to re-frame preoxygenation wrt PERIoxygenation/ apnoeic oxygenation —> reasonable evidence. And COVID? It depends. #OBAnes #SOAPAM2023 ImageImageImageImage
If you can’t explain it in emoji’s…

Any Dx getting worse, severe = ETT & ICU

Any Dx unclear trajectory, severe = ETT & ICU

Pulm edema getting better, not too severe (we hope) = NIPPV & ICU

Pulm edema getting better, moderate severity = NIPPV & ICU

#OBAnes #SOAPAM2023 ImageImageImage
Emoji’s continued…

Asthma getting better, we think it’s okay = NIPPV on L&D

PE/AFE any trajectory, we think it’s okay = HHFNC/ NIPPV initiated on L&D, to transfer to ICU.

PNA, ARDS, aspiration getting better = HHFNC/ NIPPV in ICU

#OBAnes #SOAPAM2023 ImageImage
Take home: if trajectory and severity are 💩 consider ECLS / MCS EARLY #OBAnes #SOAPAM2023 Image
What of VV ECMO? Specific criteria. Absolute contraindications. #OBAnes #SOAPAM2023 ImageImage
Last (not least): Sepsis. Definitions. qSOFA - might over call OB patients due to either changes in physiology (RR) or epidural analgesia (SBP). Therefore OB-modified qSOFA: RR 25 and over, SBP less than or equal 90mmHg. Altered mentation is NEVER normal (unless proven otherwise)… twitter.com/i/web/status/1… ImageImageImageImage
What is different about maternal sepsis? What scares @DoctorStahl? (usually the same as non-pregnant patients). Early warning systems not yet ideal. There’s a spectrum from sick + no infection through maternal sepsis to end organ failure without infection. #OBAnes #SOAPAM2023 ImageImageImage
Cornerstones of maternal sepsis management. #OBAnes #SOAPAM2023 Image
Summary and references from @DoctorStahl #OBAnes #SOAPAM2023 ImageImage
@DoctorStahl does smile if you ask nicely in the chat box. #SOAPAM2023 ImageImage
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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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