As the duty anaesthetist you are called down to the antenatal clinic by the obstetric team to see a pregnant woman with achondroplasia who is booked to deliver in your hospital. What are the anaesthetic issues which can arise in this condition? What evidence is there in the literature for the optimal anaesthetic techniques? What will you discuss with this woman and how will you counsel her? Join Declan and I as we discuss the anaesthetic issues of this relatively rare but sometimes challenging condition... References Dumitrascu CI, Eneh PN, Keim AA, Kraus MB, Sharpe EE. Anesthetic management of parturients with achondroplasia: a case series. Proc (Bayl Univ Med Cent). 2023 Dec 20;37(1):63-68. doi: 10.1080/08998280.2023.2261084. PMID: 38173994; PMCID: PMC10761160. Lange, E.M.S., Toledo, P., Stariha, J. et al. Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism. Can J Anesth/J Can Anesth 63, 945–951 (2016). https://doi.org/10.1007/s12630-016-0671-5 15 Ways Pregnancy Is Different For Little People - Good Lay Person Website

You are called to a code blue on the postnatal ward. A 28 yr old female who is 1 day post a non elective caesarean section has just had a witnessed convulsion lasting 1-2 min. She has now regained consciousness but seems a little confused and is complaining that she "has lost vision in both of her eyes". Her BP is 180/100, and all other vital signs are normal. What is this most likely to be? What is your differential diagnosis (what things do you not want to miss)? What investigations would you like done? This turns out to be an episode of eclampsia and PRES (posterior reversible encephalopathy syndrome). What is PRES? What are it's radiological features and what is the mechanism which leads to this disorder? Join Graeme and I as we discuss this uncommon but fascinating condition. References Gewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep. 2021 Feb 25;25(3):19. doi: 10.1007/s11916-020-00932-1. PMID: 33630183; PMCID: PMC7905767. Marcoccia E, Piccioni MG, Schiavi MC, Colagiovanni V, Zannini I, Musella A, Visentin VS, Vena F, Masselli G, Monti M, Perrone G, Panici PB, Brunelli R. Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol. 2019 Jan 27;2019:9527632. doi: 10.1155/2019/9527632. PMID: 30809401; PMCID: PMC6369475.

Hi everyone, Join us this episode - Declan and I have scoured the literature for a few interesting articles of varying degrees of quality! We had fun discussing these articles and hopefully you will also enjoy our discussion. Hopefully we will make this a regular feature every 3-4 months! Articles Discussed 1 - Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean DeliveryA Randomized Clinical Trial In this RCT published in JAMA - the time to surgical anaesthesia was 4 min faster when topping up a dural puncture epidural in comparison to a standard epidural catheter. 2 - Neuraxial buprenorphine for post-cesarean delivery analgesia: a case series This correspondence from the International Journal of Obstetric Anesthesia (IJOA) this year discussed the experience of a small hospital which decided to use neuraxial buprenorphine when there was a morphine shortage. 3 - There's No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment This classic paper from 2006 is a must read for anyone who is involved in debriefing and simulation in healthcare. 4 - Improving blood product management in placenta accreta patients with severe bleeding: institutional experience This short report from IJOA 2023 describes the experience of blood product management in patients with placenta accreta spectrum disorder in a large tertiary referral hospital in Israel. 5 - Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study This observational study from Analgesia & Anesthesia 2022 examined 70 women with severe PET with lung ultrasound and ECHO to assess diastolic dysfunction.

You are called to labour ward to place an epidural in a nulliparous woman who is obviously extremely distressed in pain. After you sit her up to clean her back you notice she has a long scar running down the middle of her back. Between contractions she tells you she had surgery as a teenager to straighten her back.....what does this mean? Hi Everyone, Graeme regularly teaches this topic to our anaesthesia trainees and I was surprised to realise that we haven't done a podcast on this already. Join us as we discuss scoliosis, spina bifida, spinal surgery and other assorted spinal issues. TRAGIC CASE OF AIRWAY DEATH DUE TO SEVERE KYPHOSCOLIOSIS - FROM WEST AUSTRALIAN

Hi Everyone, Whole blood, freeze dried plasma, refrigerated or frozen platelets.... On Oct 31st - Nov 3 Graeme, Emelyn and I attended the THOR - THUNDER conference hosted here in Perth at the Rendezvous Hotel in Scarborough. Who is THOR? In their own words: The THOR (trauma haemostasis oxygenation resuscitation) organization is a resuscitation and blood network, originating in Norway a decade ago, and now boasting global reach. It has built an avid following of both civilian and military resuscitation clinicians and scientists, covering both pre-hospital and hospital management of critically unwell patients. The THOR vision is to improve outcomes from traumatic haemorrhagic shock by optimising the acute phase of resuscitation. The mission is to develop and implement the best practices for haemorrhagic shock resuscitation from pre-hospital care right through to the completion of the acute phase of hospital resuscitation. Thor group website: Trauma Hemostasis and Oxygenation Research Network (rdcr.org) We sat down to reflect on the different topics that were presented at this fascinating conference. A big shout out to Tania Rogerson for organising such an amazing bunch of speakers. It was great to hear how resuscitation of major haemorrhage is done in other parts of the globe and to be educated about some different resuscitation products that are not available here in Australia. If you also want to hear a great deep dive into the scientific evidence base for the management of massive haemorrhage then I highly recommend listening to Casey Parker and Justin Morgenstein discussing this topic here (thanks for a great balanced summary of the evidence): Massive Haemorrhage: Science and Practice - Broome Docs - Nov 2023 Massive hemorrhage: a very deep dive - First10EM - Nov 2023 References Evaluation of freeze dried plasma for use in NSW - https://aci.health.nsw.gov.au/networks/trauma/resources/freeze-dried-plasma There has even been a pilot study comparing whole blood for use in accrete spectrum surgery in San Antonio: Whole blood transfusion reduces overall component transfusion in cases of placenta accreta spectrum: a pilot program.J Matern Fetal Neonatal Med 2022 Dec;35(25):6455-6460. The Use of Whole Blood Transfusion in Trauma - Curr Anesthesiol Rep Jan 2022 Warming Up to Cold-stored Platelets Anesthesiology December 2020, Vol. 133, 1161–1163.

Hi everyone, Welcome to part 3 of a 3 part series we have put together – 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia. These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years! We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening – thanks Anastazia and Nolan for giving up a few hours to put these together!

Hi everyone, Welcome to part 2 of a 3 part series we have put together – 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia. These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years! We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening – thanks Anastazia and Nolan for giving up a few hours to put these together!

Hi everyone, Welcome to part 1 of a 3 part series we have put together - 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia. These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years! We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening - thanks Anastazia and Nolan for giving up a few hours to put these together! Reference - Fishbane Reaction Safety of Intravenous Iron Following Infusion Reactions Stojanovic et al The Journal of Allergy and Clinical Immunology: In Practice Volume 9, Issue 4, April 2021: 1660-1666 - A great paper discussing the different types of reactions to i.v. including the Fishbane reaction and how they were managed in over 13000 iron infusions at the Alfred Hospital in Melbourne. Unfortunately it is an Elsevier publication and you will need some sort of institutional access to read it in full. Where is the iron in our body?

You are phoned and asked to review the venous blood gas from a woman who has just given birth in labour ward. She had a long and difficult labour and eventually required an instrumental delivery. The RMO tells you also that she was very difficult to take blood from and the tourniquet was on her arm for quite a long time. Her results show that she has a lactate of 2.5. Does this result mean she has maternal bacterial sepsis? Does this mean she is in shock, not perfusing her organs properly and they are using anaerobic metabolism? Unfortunately it's not that simple but these are common misconceptions that we might encounter when interpreting raised lactate levels. What is lactate? How does the body handle it? What are the different conditions which can raise your lactate levels? If you want to know this and more listen in to our fascinating discussion this week. Hi everyone, This week I am joined by two new guests, Tim Marmion one of our talented junior registrars and Declan Sharp the new education fellow here at KEMH. This week Tim kindly agreed to give us a talk he recently wrote whilst working in ICU, on the challenges of lactate interpretation. I cornered him after the talk and he kindly agreed to share it with us on the podcast. Thanks Tim and Declan for a fascinating and educational topic! References How should we interpret lactate in labour? A reference study S.Dockree et al BJOG. 2022 Dec; 129(13): 2150–2156. Blood Lactate Measurements and Analysis during Exercise: A Guide for Clinicians Matthew Goodwin et al J Diabetes Sci Technol. 2007 Jul; 1(4): 558–569. https://resus.me/understanding-elevated-lactate/ https://youtu.be/TuvKcplVQLg

Hi Everyone, "Three minutes after the administration on the spinal anaesthetic they became restless and complained of severe pain in both lower limbs and back. Their heart rate and blood pressure increased to 130bpm and 160/100 mmHg. A rapid survey of previously administered medications revealed tranexamic acid 300mg was accidentally injected into the subarachnoid space instead of 15mg of hyperbaric bupivacaine." - case report 2021 Graeme and I sit down to do a deep dive on the serious topic of accidental neuraxial administration of tranexamic acid which may have up to 50% mortality. We discuss two papers which summarise over 40 published case reports of spinal administration and one case report of accidental epidural administration. Join us as we discuss the pharmacological mechanism of toxicity, proposed treatments and methods to minimise the risk of this occurring in the first place. References Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. S. Patel, B. Robertson, I. McConachie Anaesthesia. 2019 Jul;74(7):904-914. - Open access Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports. S. Patel Eur J Anesthesiol 2023 May 1;40(5):334-342. - This article is not open access. Accidental administration of tranexamic acid into the epidural space: a case report. C. Pysyk, L Filteau Can J Anaesth 69, pages 1169–1173 (2022) - open access Tranexamic acid-associated seizures: Causes and treatment. I.Lecker et al. Ann Neurol 2016 Jan;79(1):18-26.