211 - Critical Care in Pregnancy Flashcards
Rate of maternal admission to ICU per 1000 deliveries? what % are post-partum?
1-10/1000 63–92% are postpartum
What is the Sepsis in Obstetrics Score?
Scoring system for pregnant women with suspected infection who are being evaluated in the emergency department that predicts the need for ICU admission.
What are the maternal vitals that should trigger bedside evaluation per the National Partnership for Maternal Safety
What are the two most common causes for maternal ICU admission?
Massive obstetric hemorrhage and hypertensive disorders of pregnancy
What is sepsis?
“life-threatening organ dysfunction caused by a dysregulated host response to infection
What is SIRS and severe sepsis?
Old terms!
We now classify as infection (no organ dysfunction), sepsis (organ dysfunction), or septic shock (organ dysfunction necessitating pressors to keep MAP >65 OR lactate 2mmol/L AFTER fluid recussitation)
what is qSOFA? what are the parameters?
Quick Sequential Organ Failure Assessment
- use to stratify patients with infection
- 2+ findings = positive screen –> indicate a need for further assessment
systolic blood pressure (BP) 100-mm Hg or less; respiratory rate 22 breaths per minute or more; or an altered mental status
qSOFA and pregnancy?
Not validated for obstetric patients
What is ARDS?
diffuse inflammation, increased fluid level in the lung due to increased vascular permeability, and loss of aerated lung units
onset of respiratory failure must be within 1 week of a known clinical event with evidence of bilateral opacities on chest imaging, and no other identifiable etiology such as cardiac failure or fluid overload
What maternal conditions place patients at increased risk of ARDS?
- influenza
- pyelonephritis
- Preeclampsia
- amniotic fluid embolism
What is the mortality rate of obstetric ARDS?
What is the ARDS prevalence in maternal deaths?
Mortality: old literature 22-44%, recent data from Canada = 3%
One study showed 33% of maternal deaths had ARDS
How do you classify ARDS?
mild, moderate, severe
based on oxygenation as measured by the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FIO2) ratio
What is optimal ventilatory supports for ARDS:
- oxygen high or low
- PPV high or low
low/low
(not validated in ob patients)
what are general parameters that may trigger ICU transfer?
instability (hypotension, hypoxemia)
high risk of deteriorization (increased work of breathing)
needs specialized ICU care (i.e. vent)
What should you have during hospital-to-hospital transfer of critically ill mother?
- continuous cardiac rhythm and pulse oximetry monitoring
- regular assessment of vital signs
- Venous access
- Left uterine displacement
- If there is a high probability that intubation and mechanical ventilation will be needed during transport, it should be accomplished before departure
What should you have during within-hospital transfer of critically ill mother?
- be able to assess BP, heart rate, and oxygenation status.
- cardiac monitor with defibrillator
- airway management equipment
- oxygen
- basic resuscitation medications.
- At least two health care professionals should accompany the patient (also to imaging, and in ICU in case emergent need to go back to L+D)
CC and respiratory physiologic changed of pregnancy that affect resuscitation
GI, uteroplacental, breast, and renal/urinary physiologic changed of pregnancy that affect resuscitation
What is the importance and utility of EFM in critically ill patients?
Needs of mom > baby
EFM can give you cues about moms status (even if you wont change delivery plans based on it)
Which artery to avoid in A-lines on pregnant patients?
Femoral due to risk of ischemia distal to cannulated site
What is the role of resuscitative hysterotomy in the setting of maternal cardiopulmonary arrest? Who is a candidate? What are the 3rd trimeter outcomes for mom and baby?
Consider it as soon as there is a maternal cardiac arrest (get supplies), do it if recussitative efforts are failing.
Used to say 4-5 mins, data shows 50% injury-free survival rate as late as 25 minutes
>20wks (at or above umbilicus)
One study showed:
- mom: 45% died, 45% lived and ok, 10% lived with significant morbidity
- babies: 23% died, 57% lived and ok, 19% lived with significant morbidity
How to do CRP on pregnant patients?
MANUAL left tilt of uterus (keep patient on her back for optimal compressions)
