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
@mentions@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
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
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
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
@matmedicine presents the first NOVEL content session of #SOAPAM2023 virtual #OBAnes highlights: Trauma in Pregnancy for the Non-Obstetric Provider. Objectives. Goals. All live from Italy - somewhat jealous @matmedicine
Physiological changes during pregnancy (1): Cardiac/ hemodynamic changes. Haematological changes. Are these protective? #OBAnes#SOAPAM2023
Physiological changes during pregnancy (2): Respiratory effects - displacement of diaphragm is key? ABG changes important - lactate the same in pregnant and non-pregnant @matmedicine? #OBAnes#SOAPAM2023