CRITICAL-CARE-OBSTETRICS-SRI-SATHYA-SAI-INSTITUTE-…：危重病妇产科赛巴巴所…

1、CRITICAL-CARE-OBSTETRICS-SRI-SATHYA-SAI-INSTITUTE-：危重病妇产科赛巴巴所CRITICAL-CARE-OBSTETRICS-SRIOrganizing a Critical Care Obstetric UnitWHEN TO INTERVENE : CONSULT!Prevalence of obstetric pts in ICU 100-900 per 100,000 gestationsMaternal mortality :55-920 per 100,000 gestations in developing countriesOrga

2、nizing a Critical Care ObsEpidemiology of Critical Illness and Outcomes in Pregnancy -Germain SJ & Nelson-Piercy C. Obstetric admissions to intensive care or obstetric high dependency units in a London tertiary/teaching hospital. Journal of Obstetrics and Gynaecology 2019; 26: S37S38. Number of deli

3、veriesTransfers to ICUICU admission rate per 1000 deliveriesMaternal deathsMaternal deaths to ICU transfer ratiocountryStudy periodReference614351262.111:126Australia1978-1989Stephens et al493492334.781:29USA1991-2019Gilbert et al159 896830.5231:28Canada1988-2019Baskett & OConnell13 333282.121:14Eng

4、land2019-2019Germain &Piercy et alEpidemiology of Critical IllneCritical illnesses in pregnancy and 6 weeks postpartumObstetric hemorrhagePlacental abruption/Placenta previaPreeclampsia, EclampsiaHELLP syndromeChorioamnionitis/Puerperal sepsisAcute fatty liver of pregnancyAmniotic fluid embolismPelv

5、ic thrombophlebitisPeri partum cardiomyopathyConditions unique to pregnancy: account for 50-80% admissions to ICU:Critical illnesses in pregnancCritical illnesses in pregnancy and 6 weeks postpartumInfectionsFalciparum MalariaViral Hepatitis EVaricella pneumoniaH1N1 InfectionRenal acute renal failur

6、e HematologicDIC; Venous thrombosisEndocrine : DM, sheehans syndromeNeurologic intra cranial hemorrhage (ICH)Respiratory -Pulmonary embolism - Venous air mbolism - Mendelson syndromeB. Conditions with susceptibility in pregnancyCritical illnesses in pregnancCritical illnesses in pregnancy and 6 week

7、s postpartumC. Conditions unrelated to pregnancyTrauma, BurnsDiabetic ketoacidosisCytomegalovirus infectionHIVCommunity acquired pneumoniaARDSBronchial asthmaDrug abuseCritical illnesses in pregnancCardiovascularValvular diseaseEisenmengers syndromecyanotic congenital heart diseasecoarctation of aor

8、taPrimary pulmonary hypertensionRenal: - Glomerulonephritis, -Chronic renal insufficiencyHematologic - sickle cell disease, anemiaLiver - CirrhosisCritical illnesses in pregnancy and 6 weeks postpartumD Pre-existing conditions that may worsen during pregnancy:CardiovascularCritical illnessEndocrine,

9、 Diabetes mellitus, prolactinomaReumatologic:Scleroderma, polymyositisRespiratory: cystic fibrosis, lung transplantNeurologicEpilepsyIntracranial tumorsMasthenia gravismultiple sclerosis.Account for 20-50% of admissions to ICUCritical illnesses in pregnancy and 6 weeks postpartumEndocrine, Diabetes

10、mellitus, Respiratory: Airway Management in Critical Illnesskey points in airway intubation of pregnant womenFetal well-being depends on maternal well-being Assess airway even in urgent intubationsAvoid aspiration: elevate head of bed, cricoid pressure, sod citrate, smaller ETT in sizeNeed of Lower

11、dose of sedatives/anestheticsPre-oxygenation Respiratory: Airway ManagementRespiratory: Airway Management in Critical Illness risk of aspiration by manual ventilationFaster occurrence of Hypoxia and hypercapnia in response to apneaLeft lateral decubitus to relieve IVC obstructionReady availability o

12、f Difficult intubation cartIntubation by the most experiencedCXR to confirm ETT placementRespiratory: Airway ManagementAcute Respiratory Failure, ARDSCauses include: ARDS, venous air embolism, Beta-adrenergic tocolytic therapy, Asthma, thromboembolic disease, Pneumothorax, and pneumomediastinum ARDS

13、 complicating pregnancy are sepsis, pneumonia, aspiration of gastric contents, and amniotic fluid embolism. Acute Respiratory Failure, ARTreatment principlesTreat primary problemPhysiological support(lungs & other organs) Avoid complicationsDifferent methods of ventilatory support - Noninvasive Posi

14、tive-Pressure Ventilation - Lung-Protective Conventional Ventilation Advanced options :A airway pressure-release ventilation (APRV)HFOVlung recruitment maneuvers(LRMs) Prone positioningTreatment of Respiratory Failure, ARDSTreatment principlesTreatment Control of Hemorrhage SURGICALBlood universal d

15、onor O neg PRBC.FFP = 10-15 ml/kgPlatelet transfusion 50,000.Cryoprecipitate if fibrinogen con. 7.2, PTT, PT 1.25 times control levels, Platelet count 100,000/mm3, fibrinogen 100 mg/dL. Control of Hemorrhage SURGIComplications of Pre-eclampsia / EclampsiaRefractory hypertension, Pulmonary edema, or

16、cardiovascular decompensation.Oliguria , acute renal failure in severe cases. HELLP syndrome in 2-12% casesRupture of the subcapsular liver hematomaPul. Aspiration due to eclamptic seizureHypertensive encephalopathy, or cerebral edema. DIC, multiorgan failure in severe cases Effective management pla

17、n for delivery and postpartum care.Complications of Pre-eclampsiaSepsis and septic shockCauses:Pyelonephritis,ChorioamnionitisSeptic abortionPP endometritis,Pelvic thrombophlebitis.No single definition Early Goal directed therapy & tenets of SSCRole of steroids, APCEarly antibiotic use & aggressive

18、source control Intensive insulin therapy Sepsis and septic shockCauses:Necrotizing fasciitis after LSCS32 yr old Iraqi women2nd PO pyrexiaDistension Abd , resp distressWound dehiscence NF with L pusARDS on 5th dayARF 7th day CVVHFVentilated, prone position, PCTDischarged from ICU 3rd week after succ

19、essful recoveryNecrotizing fasciitis after LS Cr= serum creatinine; UO= urine output;GFR = glomerular filtration rate; ESKD = end stage kidney disease. Risk of Renal Failure, Injury to Kidney, Failure of Kidney Function, Loss of Kidney Function,End -Stage Renal Failure (RIFLE) Criteria: GFR criteria

20、 Cr 1.5X baseline Or GFR 25%Urine output criteriaUO 50%UO 75% or Cr 4.0mg/dlUO 80% parturients experience cardiopulmonary arrest. Coagulopathy resembling DIC Rx. MV with 100% oxygen, Inotropic support as guided by CVP / PA monitoring, correction of coagulopathyAnaphylactoid Syndrome of PregMaternal

21、heart disease Apprx 1.6% of all e.g.: mitral, aortic valve diseases, TOF; Coarctation of the aorta 2nd trimester, :- in blood volume in labor and delivery, cardiac output due to cardiovascular sympathetic stimulation fr. Pain decompensation immediately postpartum, due to large in venous return after

22、 delivery of the placenta no invasive monitoring in the absence of cardiac symptomsMaternal heart disease AppPeri-partum CardiomyopathyLVF late in pregnancy & 6wks PPDue myocarditis/autoimmunepreload optimization; afterload reduction & improvement of myocardial contractility require anticoagulation

23、Collaboration among the obstetrician, cardiologist, and criticalist Cardiac transplantation If supportive measures fail* Ray p, Murphy G J et al. Recognition and management of maternal cardiac disease in pregnancy. British Journal of Anaesthesia 2019 93(3):428-439 Peri-partum CardiomyopathyLVF ANTIP

24、HOSPHOLIPID SYNDROMEPresence of two autoantibodies, lupus anticoagulant and anticardiolipin antibody Associated with thrombotic events, both arterial and venous Improved fetal survival if Rx with low-dose aspirin, high-dose corticosteroids, heparin. Eg: Young radiologist with IUD ANTIPHOSPHOLIPID SY

25、NDROMEPreseAcute Fatty Liver of Pregnancy3rd trimester 1 in 11,000 pregnancies, maternal mortality 0% to 18%; fetal mortality 47%. S/S : rt upper quadrant pain, nausea, vomiting, proteinuria, edema, mild hypertension, jaundice, coagulapathy, encephalopathy, hypoglycemia, NH3HELLP (vs) AFLP basing on

26、 histopathology, with microvesicular fatty infiltration Supportive therapy : Vit K, Glucose, lactulose, coagulopathy correction , and airway protection in comaAcute Fatty Liver of PregnancyTRAUMA and PREGANACY- INCIDENCE The Leading cause of non-obst. mortality - 46% Trauma during pregnancy - 7% Cau

27、ses of Trauma MVA 54.6 %Domestic abuse & Assault 22.3 %Falls21.8 %Penetrating injury1.3 % 20 wksTRAUMA aNd PREGANACY ATLS ProTRAUMA IN PREGNANCYRememberWhat is Best for the Mother is Best for the Fetus!TRAUMA IN PREGNANCYRememberWGoals of Treatment of the Severely Injured Pregnant Patient Goal 1 Goa

28、l 2 SAVE THE MOTHER; Save the Fetus if possible Goals of Treatment of the Seve 200 successful cases reported in literature 20 minutes, fetal survival unlikelyPerimortem Cesarean Section 4 Minute Rule: Maternal CPR for 4 minutes, Infant should be delivered by the 5th minute. 200 successful cases repo

29、rte Burns and burn injuries7% of women of reproductive age 5 factors size of burn, depth of burn, part of body burned, concurrent injuries, & past medical historyCritical, 40% TBSA burnt Inhalation of CO in a closed fire Freely crosses the placenta Produce fetal cardiac edema. Burns and burn injurie

30、s7% of Burns and burn injuries Oxygenation, ventilation with 100% O2 Electrical burns, fetal mortality - 73% Maintenance of a normal intravascular vol, Avoidance of hypoxia, prevention of inf correction of electrolyte imbalance Debridement & cleaning of Burned areas Povidine-iodine influences fetal

31、ThyroidSilver sulphadizine cause kernicterus Burns and burn injuries OxygeCPR IN PREGNANCYRequire prompt and excellent CPR with some modifications in basic and advanced cardiovascular lifePrimary ABCD Survey Airway & Breathing : no modificationsCirculation: wedge under the womans right side Defibrillation No modifications in dose or pad position., shocks transfer no significant current to the fetus. Remove any fetal or uterine monitors before shock delivery._Circulation. 2019;112:IV-150-IV-153.) 2019 A