#211 Critical Care in Pregnancy Flashcards
What are the leading causes of ICU admission during pregnancy or postpartum period?
hypertensive disorders and obstetric hemorrhage
In the US, how many obstetric patients out of 1,000 deliveries admitted to the ICU?
1-10 per 1,000
Obstetric patients admitted to the ICU are more likely to be antepartum or postpartum?
Postpartum (63-92%)
What is the maternal death rate after ICU admission in high and low-income countries?
3.3% vs 14% respectively
What are the maternal early warning criteria from the national partnership for maternal safety?
Systolic bp <90 or >160 Diastolic bp >100 HR <50 or >120 RR <10 or >30 O2 sat <95% Oliguria <35cc/hr for 2+ hours Maternal agitation, confusion, or unresponsiveness Pt with PEC w/ non-remitting HA or SOB
What is the definition of sepsis?
Life-threatening organ dysfunction caused by a dysregulated host response to infection. (infection w/ organ dysfunction)
What is septic shock?
Sepsis (infection w/ organ dysfunction) + need for vasopressor to maintain mean arterial pressure greater than 65mmHg and have a serum lactate greater than 2mmol/L after adequate fluid resuscitation.
What is the Quick Sequential Organ Failure Assessment?
Any 2 of the following = pos screen:
- systolic 100mmHg or less
- RR 22 breaths or more
- Altered mental status
What should you do in nonpregnant adults if the Quick Sequential Organ Failure Assessment score is 2 or 3?
Search for signs of organ dysfunction with clinical and laboratory evaluation and consider infection as possible cause
What is the general treatment for sepsis?
Quick recognition, fluid resuscitation, and antibiotic therapy within the first hour
What is acute respiratory distress syndrome, how is it characterized?
Nonspecific response of the lung to a variety of insults, characterized by diffuse inflammation, increased fluid level in the lung d/t increased vascular permeability, and loss of aerated lung units
True or false, pregnant women are at an increased risk for acute respiratory distress syndrome compared to non pregnant women?
True.
In what settings is ARDS more commonly seen in pregnant women?
In setting of sepsis with infections such as influenza and pyelonephritis. Can also been seen as complication of PEC or amniotic fluid embolism
What are criteria for ARDS diagnosis?
Onset of respiratory failure 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.
How is the degree of severity of ARDS determined?
Oxygenation, as measured by the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FIO2) ratio
What type of ventilator setting is used for ARDS?
Low tidal volume ventilation
What is an open ICU model?
When the patient remains the responsibility of her primary or referring team.
What is a closed ICU model?
Patient is transferred to the ICU team, which takes over sole responsibility for managing the patient including writing orders
How does plasma volume/erythrocyte volume change during pregnancy and what effect does this have?
Plasma volume increases by 40-50%, erythrocyte volume increased by 20%. Dilutional anemia, decreased oxygen carrying capacity
How does pregnancy affect the dextrorotation of the heart and what effect does this have?
Increased dextrorotation of the heart. Increased EKG left axis deviation
What does increased estrogen effect on myocardial receptors increase risk of?
Supraventricular arrhythmias
How does supine positioning later in pregnancy affect cardiac output?
Decreases cardiac output by 30 percent
How does pregnancy affect colloid oncotic pressure and what does this put the woman at risk for?
Decreased colloid oncotic pressure. Susceptible to third spacing
How does the pulmonary capillary wedge pressure change in pregnancy and what does this put the woman at risk for?
Decreased pulmonary capillary wedge pressure. Susceptible to pulmonary edema.
How does pregnancy affect tidal volume?
Increased
How does minute ventilation change during pregnancy?
Increases
How is the functional residual capacity affected during pregnancy?
Decreased by 25%
How does serum bicarbonate levels compare to nonpregnant adults? Why?
Decreased, compensated for a respiratory alkalosis
What level is arterial PCO2 in a pregnant woman compared to non pregnant adult (higher, lower, same)?
Decreased
How is GI motility affected in pregnancy?
Decreased
How is the gastroesophageal sphincter tone affected in pregnancy?
Decreased
Should indicated delivery in the late preterm period be delayed for administration of steroids?
No
In the ICU, even in a situation which delivery may not be possible, why would fetal heart rate monitoring be useful?
Changes in baseline variability or new onset of decelerations may reflect worsening maternal end-organ function. Can be used to help optimize perfusion.
Where in the hospital has the highest rate of health care-associated infections?
ICU
What is a normal arterial pH in a non pregnant patient and in a first trimester patient?
Nonpregnant = 7.4
First trimester = 7.42-7.46
What is a normal arterial pH in a nonpregnant woman and in third trimester?
Nonpregnant = 7.4
Third trimester = 7.43
What is a normal arterial PaO2 (mmHg) in a nonpregnant patient and in a first trimester patient?
Nonpregnant = 93
First trimester = 105-106
What is a normal arterial PaO2 (mmHg) in a nonpregnant patient and in a third trimester patient?
Nonpregnant = 93
Third trimester = 101-106
What is a normal arterial PaCO2 (mmHg) in a nonpregnant patient and in a first trimester patient?
Nonpregnant = 37
First trimester = 28-29
What is a normal arterial PaCO2 (mmHg) in a nonpregnant patient and in a third trimester patient?
Nonpregnant = 37
Third trimester 26-30
What is a normal arterial serum HCO3 (mEq/L) in a nonpregnant patient and in a first trimester patient?
Nonpregnant = 23
First trimester = 18
What is a normal arterial serum HCO3 (mEq/L) in a nonpregnant patient and in a third trimester patient?
Nonpregnant = 23
Third trimester = 17
Why does a pregnant woman become hypoxemic quickly after apnea (compared to nonpregnant)?
The increased minute ventilation and decreased functional residual capacity mean that hypoxemia occurs quickly after apnea
What is the risk of failed intubation in obstetrics? How many times higher or lower than general population?
As high as 1 in 224. Eight times higher than gen pop.
What are risks associated with central venous catheters?
Pneumothorax, arterial puncture, thrombosis, and catheter-related infection
What is central venous pressure an index for?
Preload.
What are risks of the pulmonary artery catheter?
Cardiac arrhythmias, pulmonary hemorrhage, pulmonary artery rupture or thrombosis, balloon rupture and embolization, intracardiac catheter knotting, and vascular infection
True or false, use of a pulmonary artery catheter is associated with decreased mortality?
False. Has largely been replaced by minimally invasive monitoring. The PAC, however, has a role in the diagnosis and operative management of patients with pulmonary hypertension and acute right ventricular failure.
Do ratio of chest compression to rescue breaths, respiratory support, drugs, or defibrillation during cardiac arrest in pregnancy change compared to nonpregnant adults?
No, same
What is the American Heart Association’s recommendation regarding uterine displacement in pregnant patients? Why?
Manual displacement rather than tilting, because it allows for more effective chest compressions and better access for airway management and defibrillation.
At what gestational age is a resuscitative hysterotomy recommended for pregnant women in cardiac arrest with unsuccessful resuscitation efforts?
Uterine size at or above umbilicus (20weeks of gestation or more)
Telemedicine covers what % of ICU adult beds in the US?
11%
Should you withhold necessary medications or diagnostic imaging from a pregnant women due to fetal concerns?
No, although attempts should be made to limit fetal exposure to ionizing radiation and teratogenic medications when feasible
How long after maternal cardiac arrest should you perform resuscitative hysterotomy?
Immediately start preparations in case return to spontaneous circulation does not occur within the first few mins of maternal resuscitation. Traditional teaching is to cut at 4 mins.
Is there a benefit to resuscitative hysterotomy after 5 minutes of maternal cardiac arrest?
Yes. Survival curves for women and neonates have shown 50% injury-free survival rate with perimortem cesarean delivery as late as 25 mins.
