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Management of Critical Obstetric Cases
Clinical Input
There
are two patients who delivered in quick succession at your
hospital, normally. Both are having PPH. Which of these will you
shift to an ICU?
Detection Of
The Patient Requiring Critical Care
Important signs
of serious injury and illness include
· Low-blood pressure or weak peripheral pulses,
· Cold temperature of extremities, and
· Peripheral cyanosis
· Warning signs include
· Reduced urinary output,
· Dyspnea or hyperpnea,
· High temperature,
· Unexplained fatigue,
· Chest pains, and
· Tachycardia or palpitations.
· Subtle changes in mental status
Clinical Input
I was giving a trial of labour to a previous LSCS scar
attempting a VBAC. Labour did not progress and patient’s general
condition also worsened. I opened her up and found a bad
rupture. First I tried to save the uterus but failed. So I did a
hysterectomy. Patient was shifted to the ward. As the surgery
was prolonged, there was a big back-log in the outdoor. The ward
paramedic staff was providing me with the info on vital
parameters. All seem to be going well. Suddenly the patient
collapsed. What must have happened?
Reply:
After massive hemorrhage, meticulous monitoring of the patient’s
pulse and BP is mandatory. Recognizing shock in an early stage
may be missed otherwise, especially on busy days. Prolonged
surgery or surgery following massive hemorrhage will send the
patient into shock. After hemorrhagic shock has been tackled,
the obstetrician should continue to be vigilant, even after the
vital parameters begin to improve, because, such patients may go
into systemic inflammatory response and subsequent septic shock.
Principles of Management Of A Patient Needing Critical Care
Management of a patient in an ICU should be systematic and
should include
· Clinical monitoring,
· Respiratory support and
· Cardiovascular support, in addition to
· Correction of the cause
Clinical Input
I have observed that patients of obstetric hemorrhage admitted
to ICU with altered sensorium respond poorly to treatment
compared to well-oriented patients. Why so?
Clinical
Monitoring:
Mental status
Altered mental status in a post-hemorrhage patient may indicate
severe shock with a deficit of more than 40% of blood volume.
This may be due to inadequate cerebral perfusion.
Heart rate
Tachycardia generally alerts one to the possibility of
hypovolemia,
But it could also be increased with
· Cardiac impairment,
· Infection,
· Anxiety,
· Fear,
· Fever, or
· Pain and discomfiture.
Clinical Input
I have observed two paradoxical situations at times:
Inspite of “excessive” bleeding many times the BP just remains
fine
Inspite of clinical volume correction, BP doesn’t respond fast
enough
Why so?
Clinical
Monitoring
Blood pressure:
Inspite of “excessive” bleeding many times the BP just remains
fine
· Severely reduced cardiac output for periods of 40
minutes to 2 hours has been demonstrated before a significant
reduction in arterial pressure.
· Depends on the reserve and compensatory response
Inspite of clinical volume correction, BP doesn’t respond fast
enough
· On the other hand, if fluids are used to restore blood
pressure, the cardiac output and oxygen transport may still need
to be corrected even if the blood pressure is normal.
Clinical Input
My Professor during my UG Surgical posting told me that
respiration though shown very prominently in films as an
important parameter, in clinical practice it is not very helpful
in monitoring. I wondered why this great man said so.
Clinical Monitoring
Respiration:
Acute increase in respiratory rate:
· Pulmonary embolism or pneumothorax.
· Pulmonary edema, pneumonia, atelectasis, etc in the
moribund patient.
· Abdominal loading, caused by ascites or pregnancy by
itself could lead to dyspnea.
· Massive hemoperitoneum or collection of pus in the
abdomen could also lead to dyspnea.
· Electrolyte abnormalities, metabolic acidosis and
renal failure may also increase respiratory effort.
Clinical Input
Once while I was about to board my flight on a similar lecture
trip, my registrar from labour room OT put in a frantic call to
me: “Sir all three Pulse-Ox machines are not working”. We have
an LSCS. What should we do?
Electronic
monitoring and invasive hemodynamic monitoring Pulseoximetry:
A reading of 95% SpO2 or less could indicate hypoxia and should
be investigated. SpO2 reading of 90% or less indicates
significant hypoxia and requires immediate action. In severe
shock, if the pulse oximeter shows no reading, it may mean that
there is not adequate flow in the finger capillaries for the
probe to pick up a reading. Pulseoximetry reading may be
incorrect in patients with low perfusion, anemia and increased
venous pulsations.
Clinical Input
My medicine teacher told something very pithily; Don’t overload
a patient. A little hypo will not kill but a small hyper-load
can kill! He said to monitor CVP is not that difficult. At the
least you can pass a fine gauge tube in the antecubital vein and
it will give a reasonably good idea.
Electronic monitoring and invasive hemodynamic monitoring:
Central venous pressure (CVP) monitoring
CVP is the pressure of blood in the thoracic vena cava just
before it (blood) enters the heart. Normal values are between 5
to10cm of H2O. It can be measured by inserting a catheter in the
subclavian vein. Measuring CVP alone is useful in detecting
extreme cases of hypervolemia, fluid overload or heart failure.
CVP does not accurately reflect left ventricular filling in
patients with preeclampsia, pulmonary and cardiac disease.
Electronic
Monitoring And Invasive Hemodynamic Monitoring:
Pulmonary
Artery Catheterization:
The Swan-Ganz pulmonary artery catheter introduced into the
pulmonary artery is used to measure, in addition to the
continuous Central Venous Pressure (CVP), the Pulmonary Artery
Pressures and Intermittent Capillary Wedge Pressure (PCWP).
Drugs and fluids used to optimize ventricular preload can be
monitored more accurately if the pulmonary artery pressures are
known in these patients, so as to avoid pulmonary edema.
CLINICAL INPUT
Our surgery examiner veteran loved to ask this question: Which
bare minimum tests would you like to carry out from the blood of
a patient in ICU?
Blood investigations
· Hemoglobin
· Coagulation parameters
· Electrolyte imbalance
· Sodium
· Potassium
· Calcium
Respiratory
Support In The Critically Ill:
Clinical criteria
· Apnea or hypopnea
· Respiratory distress
· Clinically apparent increasing work of breathing
unrelieved by other interventions
· Need for airway protection
Laboratory criteria
· Blood gases
o PaO2 <55 mm Hg
o PaCO2 >50 mm Hg and
o pH <7.32
· Pulmonary function tests
o Vital capacity <10 mL/kg
o Negative inspiratory force <25 cm H2O
o FEV1 <10 mL/kg
Clinical Input
In the institution where I worked for decades, home delivery and
its complications, unsafe abortion practices leading to septic
peritonitis and the like used to be a regular feature. The first
thing our seniors used to brief us about was handling septic
cases. It was a common password as soon as a “septic” patient
was admitted: “Lag gayee”
Septic Shock:
Management
o Any source of infection should be identified and removed.
o Hysterectomy is seldom indicated
o Antibiotics: Choice of antibiotic should be dictated by
hospital data.
o Fluid therapy could be on the same lines as for hemorrhagic
shock.
o Blood transfusion should be cautiously given as it may be
associated with increased mortality.
o Patients can tolerate and may even benefit from hemoglobin
levels lower than the traditional 10 g/dL
o If hypotension and organ hypoperfusion do not respond to
volume infusion, then ionotropic drugs (to improve cardiac
performance) and vasopressor therapy (for hypotension) are
indicated.
Newer modalities of therapy
o Use of steroids in septic shock has been controversial
o A meta-analysis showed that hydrocortisone in doses from
200-300mg for 5 days or more reduced duration of shock, systemic
inflammation, and mortality without causing harm
o Vasopressin replacement therapy in doses ranging from
0.01-0.04IU/min improved hemodynamics and decreased
catecholamine requirements. However, vasopressin might induce
myocardial, cutaneous, or mesenteric vasoconstriction.
o Use of polyvalent intravenous immunoglobulins was found to
reduce mortality in studies, but high quality trials found no
evidence that immunoglobulins were beneficial
Clinical Inputs
One side there is vasoconstriction on the other there is edema.
On one side there is hypertension on the other side there is
shock. On side everyone seems to know its management, on the
other no body knows. That is Hypertensive Crisis in PIH
Pre-Eclamptic Toxemia
In a patient with severe preeclamptic toxemia needing ICU care,
one should be alert to prevent eclampsia, prevent end-organ
damage and maintaining adequate uteroplacental perfusion. If
urgent lowering of blood pressure is required, intravenous
labetalol or intravenous hydralazine or sublingual nifedipine
may be used. Pulmonary edema develops most commonly. Most
patients respond to 10 mg of frusemide administered
intravenously. For patients with oliguria and rising creatinine,
treatment with small fluid boluses (250 mL) may improve urine
output. Fluids should be given with caution to prevent pulmonary
edema.
IN CONCLUSION
Critical care of the high risk patient should be done as a team
effort with the help of an intensivist, but the obstetrician
should be aware of all the treatment and investigative
modalities, by which he/she can actively participate in the ICU
care of the patient.  |