Thread by @OBsleepmerchant

@DrWesleyEdwards chair of @CAS_OBSection introduces the first #OBAnes session of #CASAM2023.
Speakers: @SusannaStanford @ammunro2 @Ropivacaine

@SusannaStanford starts off with the importance of having a talk with the word “failure” in it. #OBAnes #CASAM2023

I have not asked permission to share @SusannaStanford’s whole lecture video today, and it’s 20minutes long. However, see the following links:

oaawebcast.info/susanna

#OBAnes #CASAM2023

Updated @SusannaStanford talks after lots of advocacy at @OAAinfo below:



#OBAnes #CASAM2023

And let’s not forget her editorials in @Anaes_Journal:

…-publications.onlinelibrary.wiley.com/doi/abs/10.111…

#OBAnes #CASAM2023

… and in @IJOA_Journal with @BogodDavid

obstetanesthesia.com/article/S0959-…

#OBAnes #CASAM2023

Culminating in Dr Felicity Plaat @SusannaStanford @noolslucas @robin_russell1 @DavidGray37 @queenielokwan @BogodDavid guidelines in @Anaes_Journal on block testing & management of intraoperative pain at cesarean section.

…-publications.onlinelibrary.wiley.com/doi/full/10.11…

#OBAnes #CASAM2023

Next up is @ammunro2 on cesarean pain: Reducing the Harm - ensuring an adequate block & managing the consequences of block failure. Objectives. #OBAnes #CASAM2023

A case, not as uncommon as we think. Easy to google. Also see patient stories in my timeline in the run up to #SOAPAM2023 at beginning of May 2023. #OBAnes #CASAM2023

@PervezSultanMD & group’s review article in @Anaes_Journal showed up to 1 in 4 failed neuraxial anesthesia. Preoperative consultation can be fraught. It should be tailored to individual patients. GA should be suggested as a primary alternative. #OBAnes #CASAM2023

Why do we choose the dermatome level to block - above T5 more likely to have no pain. However, #AnyAnes aren’t particularly good at telling where T5 is. #OBAnes #CASAM2023

Recognize that ED95 of hyperbaric bupivacaine is 11.0+/- 0.95mg - so at 12mg we’re still potentially allowing a dose inadequate for 5% of patients. Surreal to be tweeting my own tweets. Adding fentanyl or sufentanil optimizes quality, and increases efficacy. #OBAnes #CASAM2023

Optimizing neuraxial anesthesia: adjust dose for extremes of height/ weight, use the optimal drug, use the optimal mixture. #OBAnes #CASAM2023

Testing blocks - objective assessment a challenge, with significant variation and no standardization. The Plaat et al guidelines (@Anaes_Journal @noolslucas @SusannaStanford @robin_russell1 @queenielokwan @BogodDavid @DavidGray37). Hierarchy of modality testing. Light touch… twitter.com/i/web/status/1…

Modalities. How to ask the questions - two different levels: when first feel and when it feels same. TOP tip - the patient is the BEST judge of the block. Don’t test too soon, but BEFORE skin incision. #OBAnes #CASAM2023

Cold tests much higher than light touch. Bromate scale is sometimes confusing - even bromate mixes things up. #OBAnes tend to use straight leg raise. Light touch best modality, prone to error, tricky to do. #CASAM2023

If you can raise leg - unsuitable block. Normal ankle movement with epidural - sacral sparing. Autonomic testing not in guideline but most vulnerable to LA, confirms bilateral spread. No autonomic block, no sensory block. Be comprehensive in documentation. #OBAnes #CASAM2023

Consequences are NOT innocuous. 11% women undergoing cesarean section have persistent pai. At 12 months. Important to recognize chronic pain follows inadequate labour analgesia as well. Acute pain also associated with increased risk depression & pain at 8 weeks. #OBAnes… twitter.com/i/web/status/1…

Postpartum depression / maternal mental health a significant issue. Suicide risk. Reduction of these is very much a 4th trimester function - follow-up & support are essential. 3% develop PTSD. #OBAnes #CASAM2023

Summary slide from @ammunro2 #OBAnes #CASAM2023

@Ropivacaine starts his talk off with an attempt to lower expectations after the excellent @SusannaStanford & @ammunro2 (does thank @DrWesleyEdwards, also a Glasgow alumnus @ajrmacfarlane @rjharrison79 @KalagaraHari, for the invite.

@Ropivacaine presents: Cesarean Pain: Reducing the Harm. @CJA_Journal editor. Objectives. #OBAnes #CASAM2023

Recent work from @Dolores_McKeen @ammunro2 @Ropivacaine in @IARS_Journals demonstrated 4.1% spinal failure rate. Factors associated. 2012 work from @MelissaEBauer1 @JAKountanis @JillMhyre looked at failed conversion of epidural and factors associated. #OBAnes #CASAM2023

The Lucas classification of cesarean section urgency (@noolslucas). Practice standards aligned with GA section rate. Some essential reading: the French practice bulletin and obviously the @Anaes_Journal Plaat et al guidelines.#OBAnes #CASAM2023

Prevention and management starts at the beginning - BEFORE skin incision. Elective case - lots of options. Urgent - fewer. Emergent - GA. Manage pain and distress (pressure can be painful - testicular clamp analogy omitted by @Ropivacaine). STOP surgery while address. Do not… twitter.com/i/web/status/1…

Postoperative analgesia is important too. Only 6.1% of patient in Reed et al @IARS_Journals study received recommended pain regimen. #OBAnes #CASAM2023

@SOAPHQ recommendations for intraoperative and postoperative analgesia (Bollag et al, @IARS_Journals). PROSPECT guidelines includes IV dexamethasone (@MarcVandeVelde6 & PROSPECT working group in @Anaes_Journal). Dexamethasone has postoperative pain benefits (Stubbs & Levy in… twitter.com/i/web/status/1…

ITM the holy grail FOUND in #OBAnes? However, it does not prevent chronic pain (Subedi et al. @BJAJournals). Table worried @Ropivacaine - statistically significant vs clinically? If no ITM, TAP blocks work (@Ropivacaine @garrettsbarry in @CJA_Journal) #CASAM2023

A plug for #CASAM24. And on to a engaging panel, with @SusannaStanford on @DrWesleyEdwards’ WhatsApp to answer questions. #OBAnes #CASAM2023