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Simon Ash Profile picture
@OBsleepmerchant
Jun 10, 2023 • 20 tweets • 23 min read • Read on X
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Up next: @ValZaph moderates the #OBAnes session on PPH: a focus on coagulation. Dr Karine Doyon and @LorrainechowMD presenting. #CASAM2023 Image
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 ImageImageImage
Causes of coagulopathy in pregnancy - Dr Doyon won’t be discussing inherited disorders. The focus will be on the acquired hemorrhagic disorders. #OBAnes #CASAM2023 ImageImage
The coagulation pathway (she IS a hematologist 😉) Coagulation cascade describes in vitro/ laboratory coagulation. More modern is the cell based model: initiation, amplification and propagation. Natural inhibitors of coagulation exist. Hemodynamic changes in pregnancy =… twitter.com/i/web/status/1… ImageImageImageImage
Let’s discuss coagulation testing in PPH. When? What? If you have POC testing in Canada you’re lucky. Guidelines. Caveat with laboratory testing - turn around time means lots of bleeding BEFORE you get a result. Changes occur LATE. #OBAnes #CASAM2023 ImageImageImage
What of POC testing? Knowing what’s normal is key. Note the FIBTEM in normal pregnancy (it’s not pink) - if FIBTEM looks normal in pregnancy, there’s probably trouble! Caveats to POC testing: misses vWD, insensitive to antiplatelet agents #OBAnes #CASAM2023 ImageImageImageImage
Pathophysiology of coagulopathy during pregnancy. OB DIC: bleeding > thrombosis. DIC score NOT valid in pregnancy - there is a pregnancy specific score (have to look that up). DIC in pregnancy - severe bleeding. Quite a high mortality worldwide - knock on effects abound. AFE and… twitter.com/i/web/status/1… ImageImageImageImage
Pathophysiology of coagulopathy in massive bleeding. Dilutional. Take home message from Dr Doyon, including what the role of a hematologist may be: improve turn around, assist interpretation, inform about latest products. #OBAnes #CASAM2023 ImageImageImage
@LorrainechowMD feeling the pressure of a tall podium and short time. Admits to trying to get AI to create the talk - muppet anesthesiologists cool, it’s approach to managing PPH… we’ll have to wait and see. #OBAnes #CASAM2023 ImageImage
Causes of coagulopathy in PPH: 3 broad categories: late dilutional; early hypofibrinogenemia; and generalized systemic coagulation failure. Management of PPH- key steps: find & treat cause; assess coagulopathy; resuscitate massive hemorrhage. #OBAnes #CASAM2023 ImageImage
Starting with TXA @LorrainechowMD reviews the literature… #OBAnes #CASAM2023 ImageImageImage
… and a few more to generate take home points on TXA. Important to acknowledge the risk of inadvertent administration of TXA neuraxially - high mortality (new case report in latest @CJA_Journal - @DavidGray37 raised the alarm, presenting at #OAA3dc2022 and #OBSIG23SYD #ASM23SYD)… twitter.com/i/web/status/1… ImageImageImage
Moving on to fibrinogen literature… #OBAnes #CASAM2023 ImageImageImage
… and more literature to take home points on fibrinogen. Note special populations! High doses required. #OBAnes #CASAM2023 ImageImageImage
On transfusion: #OBAnes bleeding is not trauma. Lab based transfusion decisions superior to standard 4:4:1 (1:1:1) trauma transfusion. #CASAM2023 ImageImage
What of POC testing? Not much literature. Take home points. Quicker turnaround but probably unwarranted <1500ml. FIBTEM correlates well with Clauss fibrinogen. #OBAnes #CASAM2023 ImageImage
So what was the AI generated algorithm?… hmmm… simplistic? That just won’t do (@LorrainechowMD asked the question several different ways before surrendering to preparing this lecture herself) #OBAnes #CASAM2023 ImageImage
The @LorrainechowMD PPH with coagulopathy algorithm (my name not hers, she appropriately attributes the shoulders upon which she stands).
Quite a straight forward approach. One of first questions - are there risk factors for DIC? If yes fibrinogen early (2-4g is fine) #OBAnes… twitter.com/i/web/status/1… ImageImage
2nd half of algorithm is how to transfuse - traditional lab testing vs POC testing. And don’t forget post PPH care. #OBAnes #CASAM2023 ImageImage
An abbreviated but no less enjoyable discussion before the organizers switched off the lights for the evening: @ValZaph moderating for Dr Karine Doyon & @LorrainechowMD #OBAnes #CASAM2023 Image

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More from @OBsleepmerchant

Simon Ash Profile picture
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
Simon Ash Profile picture
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
Simon Ash Profile picture
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
Simon Ash Profile picture
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
Simon Ash Profile picture
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
Simon Ash Profile picture
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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