Obsgynaecritcare

What is the EXIT procedure? Who is it used for and how do we do it? In our institution this procedure only occurs on average every 3-4 years. It is an event where a large diverse group of individuals, who often have never met each other, come together for a brief period of time to work as a highly complex team to achieve a great result for both the mother and baby. Join Lloyd and I as we do a deep discussion on this uncommon but challenging multi-disciplinary procedure. References Maternal anesthesia for EXIT procedure: A systematic review of literature. The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure

Hi Everyone, This week Matt and I agreed to get together to do another journal club episode (or more accurately I printed out an article, put it in Matt’s pigeon hole and told him to make himself available or else!). We went to one of our favourite journals IJOA (International Journal of Obstetric Anesthesia), where we chose an article from the latest edition published in May. The article is entitled “A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard Ostheimer lecture.” The background to this article is that every year the north american Society of Obstetric Anesthesia and Perinatology (SOAP) hold an annual conference. One of the highlights of these annual conferences is this lecture which is researched and then presented by a well respected obstetric anesthesiologist from the north american community. The lecture is a narrative review of the previous years published literature highlighting important papers and discussing their importance and relevance particularly in relation to current north american practice. This year’s lecture was presented by Pervez Sultan from Stanford University, and it is drawn from a review of articles published in 2022 from 66 different journals. Over 12 different themes are discussed including (but not limited to) TIVA for GA Caesareans, dexamethasone for post CS analgesia, predicting epidural blood patch success, dural puncture epidurals and a number of other interesting topics. Join Matt and I as we discuss these and muse over what relevance they may have to our current practice here in Western Australia as well as a couple terrible olympic themed dad jokes to close! References / Links A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture  Int J Obstet Anesth 2024 May:58:103973. doi: 10.1016/j.ijoa.2023.103973. Epub 2024 Jan 3.

A maternal death is always a tragic event for the mother, the child, the family and society at large. Unfortunately in some parts of the globe this is still a much too common event. Luckily for those of us living in higher resource countries it has now become relatively rare. This week Matt and I sat down together to discuss the history of maternal mortality reporting, and all the useful knowledge we have been able to learn over the years from these important resources. What are direct, indirect and coincidental maternal deaths? We touch on some aspects of the recent Australian reports and then go into depth on the long history of the UK reports which have many strengths such as their national funding, compulsory reporting, anonymous nature and very long history. Thanks Matt References Maternal Mortality Report Australia Maternal Mortality World Health Organisation WHO MBRRACE-UK Maternal mortality reports UK Signup to receive email notification of each new episode We don’t share email addresses and we don’t send spam (function() { window.mc4wp = window.mc4wp || { listeners: [], forms: { on: function(evt, cb) { window.mc4wp.listeners.push( { event : evt, callback: cb } ); } } } })(); First Name Last Name Email address: Leave this field empty if you're human:

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

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.

You are called to a code blue medical on labour ward – a previously well nulliparous woman has just had a seizure, and now seems confused. Her observations are normal, she is not hypertensive and the CTG appears fine. She is presumed to have had an eclamptic seizure and is given oxygen, magnesium and has some urgent pre-eclampsia bloods and urine sent. The midwife states she has been trying to stay well hydrated with lots of coconut water and has been on oxytocin to augment her labour for a number of hours. Her results are all normal except for a sodium of 111. She suddenly starts to begin seizing again……. Hi everyone, This week I am joined by two guests – Siv our current education fellow and Jess who is a senior ICU trainee working in our department to discuss a very important but perhaps somewhat often overlooked condition – peripartum hyponatraemia. As we acknowledge in the podcast hyponatraemia is a huge topic and in order to make this podcast more manageable and practical we have chosen to focus specifically on peripartum hyponatraemia, it’s common causes, recognition & diagnosis, practical management and how to avoid the harms associated with excessively rapid correction. Thanks Jess! References Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017

You are referred a patient who needs urgent surgery and the obstetrician tells you she has some obscure medical condition which you have never heard of before. Does her condition have any implications for the safe conduct of anaesthesia? How can you find out in a timely manner what the specific anaesthetic issues are and what anaesthetics have been used safely by others in these patients before? Hi everyone, This week I am joined by Siv and Sarah to discuss this tricky situation and to give a free plug for the website orphananesthesia.eu a site started by the German society of anaesthesiology and now contributed to by anaesthesia providers from all over the world to help with these difficult patients. Correction: In the podcast we referred to Stoelting’s textbook – this text is actually titled “Anesthesia and co-existing disease” – but not dedicated specifically to rare or uncommon disorders. A more relevant text would have been Fleischer et al “Anaesthesia and uncommon diseases”. References https://www.orphananesthesia.eu/en/

Arterial lines – let’s face it who doesn’t love them? When you have a truly sick patient these humble and often underrated devices bring so much to the table, precise control of the haemodynamics, assessment of gas exchange, blood sampling to assess coagulation, anaemia and many other parameters. There is nothing more frustrating however when these lines don’t go in easily, malfunction or stop working altogether….. Hi everyone, This week I sit down with Graeme and Siv to dissect & discuss a great review article. The authors do a great job performing a deep dive into almost every imaginable aspect of their use, including insertion techniques, ultrasound, angle of insertion, length, size, site, construction, securement, and more. Join us and no matter what your level of experience I am sure you will learn something new – I know I certainly did! References Preventing radial arterial catheter failure in critical care – Factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med 2022 Aug;41(4):101096. *Unfortunately this is an article in a journal owned by Elsevier (in my humble opinion a company not very supportive of open access) and is behind a pay-wall. You can access this through the ANZCA library or your own institutions library in some cases.

(Hypothetical case) You are called to the PACU to review a patient, who despite face mask oxygen has saturations of only 88%. She is a woman in her 50s who has just undergone a 3 hour laparoscopic hysterectomy for endometrial cancer. She has a BMI of 48, has been a smoker for 30 years, and had a chest infection 3 weeks ago. When she walked into the hospital earlier this morning she was breathing relatively normally. She had a long period of time when we she was steeply head down, there was a pneumoperitoneum of gas pushing on her lung bases and we were positively ventilating her with the anaesthetist choosing what gas mixture, pressures and ventilation modes they used. What has happened during this operation and anaesthetic that now she has serious respiratory dysfunction here only a few hours later in PACU? Are there any strategies that we could have employed intraoperatively to try and minimise or avoid postoperative respiratory problems like this? Join Lloyd and I as we discuss this thorny issue which is not uncommon in gynaecological patients having laparoscopic and open abdominal surgery. Part 1: We discuss post pulmonary dysfunction and consensus statements on the topic. Part 2: We talk about practical intraoperative & postoperative strategies you might consider to try and protect the lungs and prevent any problems. “Lloyd’s Recipe” Check the patient’s oxygen sats whilst supine – pre induction (use to plan target sats intra & post) Individualise FiO2 for pre-oxygenation and not necessarily 100% for most (usually 80%) Have the APL valve at around 5cm H20 when preoxygenating Head-up / ramped (to maintain FRC) Recruitment manoeuvre after intubation and before pneumoperitoneum – use a machine technique not hand recruitment. Start with a PEEP 5-8cm H20, individualise during the case – may need higher whilst head down and pneumoperitoneum. Small Tidal Volumes (TV) 5-8ml/kg of ideal body weight – (obese patients don’t get bigger TV’s) Keep FiO2 < 0.4 I:E ratio 1:1 If disconnection – repeat recruitment maneouvre At emergence / extubation – sitting upright, don’t disconnect to suction ETT, recruit again if laparoscopic procedure or obese. Routinely use NM monitoring – ensure TOFR >0.95 Don’t use 100% O2, Aim FiO2 < 0.8 If breathing on manual ventilation setting have APL valve at 5-10 to maintain PEEP Squeeze bag as extubating Immediately post extubation place face mask with APL still at 5-10 Be cautious / avoid excessive opioids that will suppress respiratory drive in PACU References A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications BJA 2018 May 120(5) Postoperative pulmonary complications BJA: British Journal of Anaesthesia, Volume 118, Issue 3, March 2017, Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis BMJ 2020; 368 Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations BJA 2019 Dec;123(6)

Hi everyone, This week three of us sit down to discuss a great review article (and topic) – the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery. For many the classic technique for a GA caesarean has been thio / sux tube then volatile & nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it’s role for women having caesarean surgery and GA for management of postpartum haemorrhage. Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation). It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know. Informal Twitter Poll result from Parita!: References The role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022 Comments on above article – M.Paech IJOA June 28, 2022

Hi Everyone, You receive a phone call at 2am from a junior colleague who tells you that they are managing a code blue caesarean section and in the confusion of urgently administering a number of different medications they have just accidentally injected 10ml of cephazolin into the epidural catheter instead of the intravenous tubing. They are understandably upset and worried. (* This is a hypothetical scenario). What are wrong route errors? How common are they? How do they happen? Article from 2012 – “The US Pharmacopeia, the largest information source of tube misconnection related errors, has received 1600 reports of epidural to central or peripheral intravenous misconnections since 1999.” What is NRFIT and how will this help improve patient safety? When is it coming? – It is already here and will probably coming to your health service soon. Many hospitals around the world including all of Japan have already changed over and a few sites in Australia / NZ have also now introduced NRFIT. Join Graeme and I as we discuss the issue of wrong route errors, and what you need to know about NRFIT, as well of course a few bad Xmas jokes! LINKS Reducing Risk of Epidural-Intravenous Misconnections – APSF Newsletter Winter 2012 Challenges when introducing NRFit™ at a tertiary hospital in Japan International Journal of Obstetric Anesthesia, 2022-02-01, Volume 49, Article 103244 . This article is behind Elseviers firewall but you should be able to access it through the ANZCA library or your own hospitals if you are lucky enough to have these available. NRFIT Pajunk Stay connected GEDSA NRFIT website

Your 76 yr old patient is now two days post her laparotomy for ovarian cancer. She looks well, is starting to eat and keen to get up to the shower as well as have all the “annoying lines and tubes removed from my arms!”. Unfortunately she is still on 3ml/hr of a metaraminol infusion and everytime the nurse tries to wean it off her BP drops to 70/45….. Is there anything you can do? Hi everyone, This week Rheily and I discuss the pharmacology of oral midodrine a alpha adrenergic agonist useful as an oral systemic vasoconstrictor. Join us as we discuss the ins and outs of using oral midodrine – please leave us a comment if you have some experience or tips to share! USEFUL LINKS Australasian Anaesthesia 2019 (Blue Book) Article – go to page 101

Welcome to this podcast, the tenth in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Shilpa, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery part 1 10 – Neuraxial anaesthesia for Caesarean Delivery part 2

Welcome to this podcast, the ninth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Shilpa, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery part 1 10 – Neuraxial anaesthesia for Caesarean Delivery part 2 https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/

Hi everyone, This is the second episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary topic of maternal sepsis. Join us as in this second episode where we discuss amongst many things. antibiotics fluids & vasopressors multi-organ dysfunction source control anecdotes & tips Thanks Sneha & Jess! If you haven’t already listen to episode one first: https://www.obsgynaecritcare.org/098-maternal-sepsis-with-jess-and-sneha-part-1/?preview=true LINKS “Sepsis in Pregnancy” Burlinson et al – International Journal of Obstetric Anaesthesia 2018 “Maternal sepsis” Filetici et al – Best Pract Res Clin Anaesthesiol 2022

Hi everyone, This is the first episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary topic of maternal sepsis. Join us as in this first episode where we discuss amongst many things the recent changes in how sepsis is defined detection and recognition in pregnancy common micro-organisms Thanks Sneha & Jess! LINKS “Sepsis in Pregnancy” Burlinson et al – International Journal of Obstetric Anaesthesia 2018 “Maternal sepsis” Filetici et al – Best Pract Res Clin Anaesthesiol 2022

Welcome to this podcast, the seventh in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to general anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). It makes easier listening if you listen to episode one first! Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/

Welcome to this podcast, the sixth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to general anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

Welcome to this podcast, the fifth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss eclampsia, pre-eclampsia, hypertensive disorders and the specific issues relating to provision of obstetric anaesthesia. Thanks Laura, Graeme & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

You get called to a code blue medical in the maternofetal assessment unit of your labour ward. A pregnant woman at 35 weeks has presented in severe respiratory distress. Her BP is 220/110, her heart rate 120/min, oxygen sats 88% despite high flow oxygen. She has a history of hypertension, diabetes and amphetamine abuse. You grab the nearby obstetric ultrasound (because it is there) and quickly scan her lungs with the curvilinear probe – all the lung fields are full of B-lines….. Hi everyone join Graeme and I as we discuss the acute management of this condition, variously known as SCAPE (sympathetic crashing acute pulmonary oedema), flash pulmonary oedema, or hypertensive pulmonary oedema. Links Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. J Card Fail. 2016 Aug;22(8):618-27 A critical appraisal of the morphine in the acute pulmonary edema: real or real uncertain? J Thorac Dis. 2017 Jul;9(7):1802-1805.  https://emcrit.org/pulmcrit/scape-2/#:~:text=SCAPE%20%28Sympathetic%20Crashing%20Acute%20Pulmonary%20Edema%29%20is%20a,SCAPE%20in%20articles%20and%20chapters%20about%20heart%20failure.

A pregnant woman at 32/40 weeks gestation is rushed into your theatre for a code blue caesarean because of fetal distress. The team tell you that she has been in hospital for the last 6 weeks with Guillain Barre syndrome and has only just got out of ICU where she needed respiratory support for a number of weeks. What sort of anaesthetic are you going to give? Why is the traditional thio / sux / tube likely to go badly? If you inject local anaesthetics into her neuraxium what response will you expect from her already damaged nervous system? Will the drugs cause any further damage? What about breathing and swallowing problems afterwards? Hi everyone, This week I am joined by Dr Shilpa Desai, an anaesthetic consultant colleague and we discuss how to handle this rare but tricky group of patients and share a few dodgy dad jokes on the way! References https://resources.wfsahq.org/atotw/guillain-barre-syndrome/ Guillain Barre Syndrome – BJA Cardiac arrest after succinylcholine administration in a pregnant patient recovered from Guillain-Barré syndrome

A nulliparous woman is admitted to labour ward in established labour, she is in a lot of pain and asks for an epidural. The team note that a full blood count taken 2 days ago showed a platelet count of 48. Is this a real thrombocytopenia? What are the causes of thrombocytopenia in pregnancy? How are they treated? What about epidural or spinal anesthesia? Will she bleed? What if it falls further and she needs platelets? Hi everyone, This week I have a new guest on the show Dr Simon Kavanagh a consultant haematologist and we do a two part deep dive into thrombocytopenia in pregnancy, what are the causes, what to do and who to call! (hint they specialise in diseases of the blood…..) Thanks Simon! References HOW Collaborative position paper on the management of thrombocytopenia in pregnancy – ANZJOG Jan 2021 This is published by Wiley and you may need to access it via your institution / library

You are called to see a 31 yr old woman on the ward who is 8 hours postop after a diagnostic laparoscopy to investigate her longterm chronic pelvic pain. The nurse treating her is concerned because she is still complaining of pain despite many analgesics, however she is more concerned by the patient’s increasingly erratic behaviour and agitation. Her heart rate is 108/min, NIBP 155/95, she appears sweaty, temp = 38.9C, appears restless and has some noticeable tremor. When you examine her she has very brisk reflexes and three beats of clonus in her ankles. Glancing at her med chart you see she is usually on desvenlafaxine 50mg/day, tramadol 100mg BD, and admits to using methamphetamine recreationally. Join Graeme and I as we discuss a rational approach to this sort of scenario, share some real life anecdotes and trade a few more dodgy dad jokes. Differential diagnoses (don’t miss these) Deeper dive into SS syndrome, and NLMS References Tutorial of the Week 2010 Serotonergic Syndrome Serotonin Syndrome in the Perioperative Period BJA Education 2020

You are called to review a 35yr old woman at 36 weeks in labour ward who has had a couple of “funny turns” in the last 15 minutes where she became unresponsive and then seemed confused for a few minutes after. When you get there they tell you she is being induced with cervidil for premature rupture of membranes but she is not in active labour. Because of the PROM she has been started on erythromycin. She has also been unwell with hyperemesis most of the pregnancy but has been vomiting a lot over the last 2 days and has received a lot of medications to try and get on top of it including, ondansetron, droperidol, famotidine and maxalon – with only limited effect. She looks pretty thin and she says she has had a lot of trouble with her weight / nutrition because of her chronic nausea. The team have done some observations on her – she has a heart rate of 57/min, BP 100/55, she is afebrile and not tachypneic. At this stage the team thinks maybe she is fainting because she is a bit dehydrated but decide to send off some bloods and to do an ECG “to make sure there is nothing else going on”. Her bloods come back and her potassium is only 2.2 and she is anaemic Hb 95. The ECG shows the following – what’s wrong? (Image borrowed from LITFL – Hypokalaemia ECG changes • LITFL • ECG Library) Suddenly she passes out again whilst the ECG is attached, what are you going to do? Image borrowed from LITFL – Polymorphic VT and Torsades de Pointes (TdP) • LITFL Join Graeme and I as we discuss another fascinating topic after having a couple of patients recently with this challenging but fascinating syndrome…..

“Doctor did you know your next patient is a micro alert ?” What does this mean? Do we have to suit up as if there has been an outbreak of Ebola? Will Cefazolin 2g suffice? I just pushed in the vancomycin as recommended – why is the patient now on noradrenaline????? This week I am joined by Jodie Jamieson – an anaesthetic colleague and Claire Kendrick a pharmacist here at KEMH. We discuss the most commonly encountered microbiology alerts, especially MRSA and important safety points concerning some of the less commonly encountered antibiotics. Thanks Jodie and Claire! Note these are the microbiology alerts used in Western Australia – they will not be the same in other parts of the world! USEFUL LINKS Therapeutic Guidelines – https://www.tg.org.au KEMH Clinical Guidelines for health professionals – https://www.kemh.health.wa.gov.au/For-health-professionals/Clinical-guidelines/OG

Hypothetical Case: A gynaecologist contacts you as the duty anesthetist to book an emergency laparoscopic oophorectomy. They tell you that the patient is a young woman who is currently intubated and ventilated on the intensive care unit after presenting 2 days earlier with a complex neurological syndrome, complicated by seizures requiring intubation. The surgeon tells you the ICU team have done some investigations, including an ultrasound demonstrating a complex ovarian mass, and CSF on a lumbar puncture positive for anti-NMDA receptor antibodies. What is Anti-NMDA receptor encephalitis? Why is it associated with gynaecology? When & how was it first discovered? Join Graeme and I as we discuss the ins/outs of this fascinating condition and share a few personal anecdotes of patient’s we have encountered with this project. LINKS Pregnancy outcomes in anti-NMDA receptor encephalitis Acute psychiatric illness in a young woman: an unusual form of encephalitis MJA 2009 Josep Dalmau: exploring the paraneoplastic syndromes An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models

Hi everyone, A few weeks ago I sat down again with one of current trainees Sneha to discuss the interesting subject of the use smartphone applications in anaesthesia, and her latest offer to star in Survivor! LIST-OF-ANAESTHESIA-APPSDownload

Hi Everyone, After over 2 months off Graeme and I back for our first podcast of 2021. In this episode we discuss some news and then dissect the recently published study which analysed the narrative descriptions of the 483 maternal deaths which occurred in the WOMAN study. The WOMAN trial was a large randomised study of 20000 women suffering postpartum haemorrhage comparing tranexamic acid and placebo published in 2017. There were 483 maternal deaths in this study and each death was accompanied with a short narrative description of the circumstances surrounding the death. This study discusses some of the common themes which are encountered frequently in these narratives. LINKS The WOMAN Study 2017 – Lancet website The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries

Hi everyone, Graeme and I recorded this episode way back just before Christmas but because of technical issues here it is a little bit late! Disclaimer neither Graeme or I have any claim to being experts in exam technique but we hope that you find our opinions / advice of some use. Also my answers to these questions were easier for me than real life vivas because I knew in advance what the questions were going to be! Good luck to everyone sitting exams in 2021!

Hi Everyone, This week I am joined again by Mike and we discuss this fascinating syndrome of pregnancy, the management of which many of us have had drilled into us for many decades. Although this is a real syndrome which has been recognised for many years and has many serious potential consequences there are many controversies regarding it’s physiology and treatment. In recent years advances in imaging technology and recent studies have questioned some of practices which were taught as if they were dogma…… How far can we tilt the operating table in theatre and does it really help? Compression of the aorta – really? Thanks Mike LINKS The Aortocaval Compression Conundrum – Analgesia and Anesthesia 2017 https://youtu.be/Y2T4MLiQTrM

Hi Everyone, This week I am joined on the show with a new guest, consultant anaesthetist Dr Chris Mitchell. Chris is a colleague who also used to work with us at our women’s hospital and is already famous for his range of USS regional anaesthesia needles (now manufactured by pajunk). Today we discuss the issue of the adverse environmental effects of our profession. In particular we focus on anaesthetic gases and what we can do to make a difference. LINKS British Journal of Anaesthesia 2020 – Environmental sustainability in anaesthesia and critical care

Hi Everyone, Thanks to Mason Habel from Northern Health in Victoria, who contacted us a few months ago and suggested this topic to us. Join Graeme and I as we try to tackle this topic in a comprehensible manner. We do jump around a little bit, chasing anecdotes, interesting historical facts and the occasional dodgy dad joke but hopefully we get there in the end! LINKS 054 – Neurological injuries after childbirth and neuraxial anaesthesia. 053 – Complications after central neuraxial blocks in obstetric anaesthesia a discussion with Graeme 046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

Hypothetical case: You are called to a code blue medical on the gynaecology ward. A patient in her late 60s has collapsed in the bathroom. You are told she was admitted earlier that day for investigation of a probable pelvic cancer. She is conscious, has a heart rate 130/min, NIBP 90/45, SPO2 94% on hudson mask, and is mildly SOB with a respiratory rate 30/min. This patient undergoes investigation and is diagnosed with a large pulmonary embolism. She deteriorates suddenly with the following vitals: groaning, HR 145/min, NIBP 60/35, SpO2 85%, Respiratory rate 35/min. What is the physiology and what are the principles behind the resuscitation of a patient with an acute right ventricular emergency like this? Fluids? Vasopressors? Inotropes? Thrombolysis? Intubation? Pulmonary vasodilators? Join Graeme and I as we discuss this particularly challenging scenario which can be both hard to diagnose and resuscitate. There are some important and critical differences to other common causes of deterioration, and serious traps to be aware of and avoid. Whilst educating myself on this topic I realised that I wasn’t as up to speed on this as I thought I was! Thanks to the following resources which I have listed below which I strongly recommend: USEFUL LINKS EMCrit 272 – Right Heart Failure with Sara Crager PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Hi everyone, This week I am joined by Matt & Graeme to discuss induction drugs and adjuncts used in general anaesthesia for caesarean delivery, with a few obligatory dad jokes thrown in at the end if you make it that far! Hypothetical cases we discuss: 1 – Healthy woman rushed to theatre with cord prolapse and fetal compromise 2 – A woman with severe preeclampsia needs urgent caesarean delivery because of fetal compromise. She has a platelet count of 18, and a BP of 210/120. 3 – A woman ruptures her uterus attempting a VBAC and arrives in theatre with a heart rate of 170/min and BP of 60/40 USEFUL LINKS The future of general anaesthesia in obstetrics BJA Education 2016

Hypothetical patient: You get called by an anaesthetic registrar to come and help them with a woman in labour ward. They tell you that they have been struggling for a number of hours now to get a woman comfortable. They have placed three epidurals and topped them up aggressively with generous doses of the usual bupivacaine and fentanyl medications but none of them seem to have been effective. The woman told them that she has had similar problems in the past with dental procedures and minor skin procedures when younger – she also states she has Ehlers-Danlos syndrome. Hi Everyone, This week I am joined by Fionn – a WA anaesthetic trainee currently working with us here. We discuss the fascinating (but distressing) syndrome of resistance to local anaesthetics. Is it real? (yes) How common is it – and what do we know about it? LINKS https://www.bbc.com/future/article/20170106-the-people-who-cant-go-numb-at-the-dentists https://www.hypermobility.org/local-anaesthetic Resistance to local anesthesia in people with the Ehlers-Danlos Syndromes presenting for dental surgery

You receive a call from an obstetrician: “I have a term patient booked for induction of labour this morning. She had an MRI of her brain 4 years ago after a car accident and was told she has an Arnold-Chiari malformation. She is very keen to have an epidural – can she have one?” Hi everyone, This week Graeme is back and we sit down to discuss Arnold – Chiari malformations and having a baby – why all the fuss and controversy? References Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia https://www.orphananesthesia.eu Ghaly Chiari malformation decision guide – see article above

You are called to a code blue medical on labour ward. A woman who has been in labour attempting a VBAC has just collapsed whilst pushing during the second stage. She is unresponsive, not breathing and looks “bad”. This week I am joined by my two colleagues, also consultant anaesthetists, Dr Emelyn Lee and Dr Lip Ng. Join us for this interesting conversation where we discuss all things relating to cardiac arrest in pregnancy! Links https://resus.org.au/

Hi Everyone, This week I sit down again with Graeme. We discuss WA’s isolation & covid bubble, exchange a few crap jokes and have a go at the thorny topic of shivering under neuraxial anaesthesia. Big thanks to everyone who helped with the OSCAR trial all those years ago, Yelena for teaching me a new trick to stop shivering and to Dr Tim Pavy for giving me two weeks leave to write up my thesis on shivering! LINKS The OSCAR trial – prophylactic ondansetron does not prevent or decrease the severity of shivering under spinal for Caesarean.

Hi Everyone, This week on the podcast I am joined by Dr Andi Atkinson one of the obstetric and gynaecology trainees here in WA. A few years ago Andi took time off during her training to spend time working in Africa for MSF on two separate occasions and we sat down to record an interview where she explains the processes involved in working with MSF and reflects on some of her experiences during her missions. Andi is still training here in WA but tells me she intends to work again for MSF sometime in the near future. Thanks for sharing your stories Andi! Links MSF Australia https://msf.org.au/

A 28 yr old woman at 36/40 G2P1 presents with a few days history of mild headache, nausea, anorexia, and some upper right abdominal pain. You do some observations and some blood testing and find she has a BP 150/95, mildly hyperreflexic and bloods showing a Hb107, Plts 88, schistocytes on the film, raised AST / ALT /LDH and bilirubin. Hi Everyone, Acknowledging that we are still in the midst of a world wide pandemic we hope you are all safe. This week we thought it would be nice to take a break from COVID related matters (which we are sure like us has invaded most of your minds over the last few months) and turn to a fascinating obstetric critical illness. Join Graeme and I as we discuss this interesting and serious pregnancy related condition. What causes this condition?What do they die from? What are the important differential diagnoses? How do we manage them? We also share a few sh***e dad jokes, reminisce about ANZAC Day, the COVID pandemic and have another crack at one of our quizzes! Doctor or serial killer? Is This Person a Doctor or Serial Killer?? Leave a comment below Bonus Points available if you can tell us their name!

Join Matt and I as we discuss some of the issues we have been grappling with in our planning for how to manage obstetric patients suspected of or known to have COVID-19. Is pregnancy a risk factor for worse disease severity? What is the appropriate PPE for women in active labour? Is active labour an aerosol generating procedure? What about the use of inhaled (and therefore exhaled) nitrous oxide in these women? What about the need for emergency or urgent procedures such as caesarean sections or post partum haemorrhage – how do we get them safely around the hospital? LINKS https://soap.org/education/provider-education/expert-summaries/interim-considerations-for-obstetric-anesthesia-care-related-to-covid19/ https://www.oaa-anaes.ac.uk/OAA_COVID19_Resources

(*Hypothetical Case) A woman is brought into your emergency dept by her husband at 14 weeks gestation. He tells you that she has been “really sick” for almost two months now. He states that they have seen their GP multiple times and have “tried almost everything”. This is the second time they are presenting to your ED – they came 2 weeks ago where he recounts she was given some IV fluids and antiemetics before going home – but they were reluctant to come back because a member of staff was quite dismissive to them last time apparently she told them that if she ate ginger and sipped water she should be fine and “it all stops at 15 weeks anyway so not to worry it will be over soon”. This time he tells you that she has practically eaten nothing in the last 4 weeks and she is now having trouble getting out of bed, because of almost 4 weeks of continuous vomiting. He thinks she has probably lost at least 8-10kg since becoming pregnant. He is “super-worried” and “she is just not herself anymore – please do something”. She appears listless, drowsy and distracted when you try to question her directly, and she tells you she is thirsty, nauseated and has had enough – she even asks you as you take some bloods and place an iv whether it is permissible to get a termination for untreatable nausea. Bloods: pH 7.58 HCO3 28, PCO2 56, Na 126, K2.3, Gluc 8, LFTs normal Urinary Ketones +++, no glucose How would you approach the management of this woman? Join Graeme and I as we discuss this under appreciated & poorly understood yet potentially catastrophic condition…… USEFUL TREATMENT GUIDELINE https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf LINKS Profound Hypokalaemia Resulting in Maternal Cardiac Arrest: A Catastrophic Complication of Hyperemesis Gravidarum? Wernicke’s encephalopathy in hyperemesis gravidarum: A systematic review. http://www.hyperemesis.org/ Pregnancy sickness can kill – why are doctors so uninformed about it? Why are Women Still Dying from Nausea and Vomiting of Pregnancy? http://theconversation.com/when-nausea-from-pregnancy-is-life-threatening-46709

(* Hypothetical Case) You are asked to see a pleasant 31 yr old woman in the antenatal clinic who is pregnant for the first time because as an adolescent she had an extensive scoliosis repair and now has Harrington Rods in her lumbar and thoracic spine. She tells you that she “is worried about being in a lot of pain during labour” and she wants to know what her options are. Hi everyone, This week three of us sat around our new AV equipment (thanks Trilby) to discuss the interesting and somewhat controversial topic of remifentanil PCA use for analgesia in labour. We discuss the history, the concerns regarding safety especially respiratory depression or apnoea, efficacy and some of the new evidence recently published. Links The RESPITE study in Lancet 2018 : Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial IJOA August 2019 Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands IJOA August 2019 Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015) BMC Pregnancy and Childbirth 2013 Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”

Hi Everyone, This week I am joined by Prof Mike Paech, Mike has dedicated most of his career to both the research and practice of obstetric anaesthesia. Join us in this podcast where we sat down to discuss the myriad of changes he has witnessed in Obstetric Anaesthesia over his career. We have now started an interactive poll where you the listeners can make suggestions to us about topics you would like to hear discussed! At this stage we are not making any guarantees but if there are certain topics that seem to be very popular and if we can find someone who feels empowered enough to talk on the topic we will see if we can make it happen! (If you can also supply someone to talk – even better – send us a separate email). Go to the home screen and scroll down to find the poll – see link below: https://www.obsgynaecritcare.org/

“Where the f**k is the anaesthetist! I asked for the epidural 45min ago, those obstetric doctors took five goes to put in my drip, the midwife has turned up the hormone drip and now I am going crazy! Aaarghhhh!” Seem familiar? Hi everyone, Welcome back this week I am joined by long time listener and first time interviewee – Dr Sneha Neppali who sits down with me to discuss a couple of projects she has recently completed – epidural analgesia response times and the use of abbreviations in healthcare – specifically obs / gynae ones used during her recent time here at our women’s hospital. How many of these abbreviations do you know? Want to see how Sneha faired on her recent TV appearances follow the links below: The Chase  https://www.youtube.com/watch?v=tEG7JZUTgyk&feature=youtu.be&fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63A Millionaire Hot Seat https://www.youtube.com/watch?v=DcVJyd5j_9A&feature=youtu.be&fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0

You are the duty anaesthetist and you receive a phone call from a midwife on the postnatal ward asking if you can come and review a woman who gave birth yesterday. She is 29 years old, with a BMI of 39 and gestational diabetes. She had an epidural placed in labour ward for analgesia – which she describes as being a difficult and unpleasant procedure. Following a prolonged and difficult labour she was taken to theatre and required an instrumental delivery in theatre under epidural – this too was difficult and she was in the lithotomy position for well over an hour for both the delivery and then the subsequent perineal repair. Today she is complaining of a “numb left leg”. She and the midwife are concerned she has a nerve injury from the epidural. What should be your approach to this difficult situation? Hi everyone, Join Graeme and I for the second part in our series on complications of central neuraxial blockade and postpartum neurological injuries. We will discuss the specific issue of neurological problems – with the take home point being that in fact the underlying cause of the majority of these are related to the process of childbirth and not a direct injury from the epidural / spinal itself. There are however a few rare serious neurological conditions that need rapid diagnosis and treatment in order to avoid what could lead to catastrophic irreversible neurological injury. REFERENCES Neurologic Deficits and Labor Analgesia Cynthia A Wong M.D. Regional Anesthesia and Pain Medicine Vol 29, 4, 2004: pp341-351