Exploring clinical conundrums in obstetric anesthesia through interactive polls and panel discussion: insights from Canadian obstetric anesthesiology experts.

PURPOSE: This Special Article aims to synthesize the results of a live audience poll and practice tips from Canadian obstetric anesthesiology experts during a panel session at the Canadian Anesthesiologists' Society 2024 Annual Meeting (Victoria, BC, Canada). We explored six hypothetical case scenarios, each representing a clinically plausible situation that lack a definitive management approach. These scenarios highlight areas where no consensus exists and no single "correct" solution has been established.

SOURCE: We gathered live poll data about six case scenarios from participants who attended the session and chose to submit a response. The expert panel provided decision analysis of each case.

PRINCIPAL FINDINGS: The literature and expert panel suggest that 0.5% isobaric bupivacaine and 0.5% hyperbaric ropivacaine may be appropriate alternatives during shortages of 0.75% hyperbaric bupivacaine. Both combined spinal epidural and standard epidural techniques are effective first choices for rescuing a failed single-shot spinal anesthesia during elective Cesarean delivery. A decision aid may be helpful when converting an epidural for surgical anesthesia. Epidural dexmedetomidine has been used off-label in some centres to enhance the quality of labour analgesia. Nevertheless, owing to limited data in the literature, its routine use for labour analgesia or Cesarean delivery is not currently recommended. In cases of febrile labouring patients, the expert panel advocates initiating antibiotics before epidural placement as a prudent precaution despite the lack of robust contemporary evidence. An obstetric patient with thrombocytopenia may generally undergo neuraxial techniques if the platelet count exceeds 70 × 109·L-1. The risks and benefits should be carefully considered when the platelet count is between 50 × 109·L-1 and 69 × 109·L-1, taking into account potential changes in platelet quality due to conditions such as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. If an accidental dural puncture occurs during an epidural blood patch procedure, a cautious approach would involve abandoning the procedure and reattempting after 24 hr to minimize the risk of blood translocation leading to arachnoiditis. Conversely, a pragmatic approach would involve immediately reattempting the procedure at another level, although there is no consensus on the most appropriate course of action.

CONCLUSIONS

The range of participant responses highlighted various clinical challenges in obstetric anesthesia where evidence is still limited or inconclusive. Three experts in obstetric anesthesia shared their insights, detailing their decision-making processes and how they would approach each case scenario. They also provided key references, offering valuable take-home messages for anesthesiologists practicing obstetric anesthesia.