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

1、CRITICAL-CARE-OBSTETRICS-SRI-SATHYA-SAI-INSTITUTE-：危重病妇产科赛巴巴所pWHEN TO INTERVENE:CONSULT!pPrevalence of obstetric pts in ICU 100-900 per 100,000 gestationspMaternal mortality:55-920 per 100,000 gestations in developing countries-Germain SJ&Nelson-Piercy C.Obstetric admissions to intensive care or obs

2、tetric high dependency units in a London tertiary/teaching hospital.Journal of Obstetrics and Gynaecology 2019;26:S37S38.Critical illnesses in pregnancy and 6 weeks postpartumpObstetric hemorrhagepPlacental abruption/Placenta previapPreeclampsia,EclampsiapHELLP syndromepChorioamnionitis/Puerperal se

3、psispAcute fatty liver of pregnancypAmniotic fluid embolismpPelvic thrombophlebitispPeri partum cardiomyopathyA.Conditions unique to pregnancy:account for B.50-80%admissions to ICU:Critical illnesses in pregnancy and 6 weeks postpartumInfectionsnFalciparum MalarianViral Hepatitis EnVaricella pneumon

4、ianH1N1 InfectionpRenal acute renal failure pHematologicnDIC;Venous thrombosispEndocrine:DM,sheehans syndromepNeurologic intra cranial hemorrhage(ICH)pRespiratory -Pulmonary embolism -Venous air mbolism -Mendelson syndromeCritical illnesses in pregnancy and 6 weeks postpartum.Conditions unrelated to

5、 pregnancypTrauma,BurnspDiabetic ketoacidosispCytomegalovirus infectionpHIVpCommunity acquired pneumoniapARDSpBronchial asthmapDrug abuseCardiovascularnValvular diseasenEisenmengers syndromencyanotic congenital heart diseasencoarctation of aortanPrimary pulmonary hypertensionpRenal:-Glomerulonephrit

6、is,-Chronic renal insufficiencypHematologic-sickle cell disease,anemiapLiver -CirrhosisCritical illnesses in pregnancy and 6 weeks postpartumpEndocrine,Diabetes mellitus,prolactinomapReumatologic:Scleroderma,polymyositispRespiratory:cystic fibrosis,lung transplantpNeurologicnEpilepsynIntracranial tu

7、morsnMasthenia gravisnmultiple sclerosis.Critical illnesses in pregnancy and 6 weeks postpartumRespiratory:Airway Management in Critical IllnessRespiratory:Airway Management in Critical IllnesspCauses include:ARDS,venous air embolism,p Beta-adrenergic tocolytic therapy,p Asthma,thromboembolic diseas

8、e,p Pneumothorax,and pneumomediastinum pARDS complicating pregnancy pare sepsis,pneumonia,aspiration of gastric contents,and amniotic fluid embolism.Treatment of Respiratory Failure,ARDSp Control of Hemorrhage SURGICALpBlood universal donor O neg PRBC.pFFP=10-15 ml/kgpPlatelet transfusion 50,000.pCr

9、yoprecipitate if fibrinogen con.7.2,PTT,PT 1.25 times control levels,Platelet count 100,000/mm3,fibrinogen 100 mg/dL.Complications of Pre-eclampsia/EclampsiapRefractory hypertension,p Pulmonary edema,or cardiovascular decompensation.pOliguria,acute renal failure in severe cases.pHELLP syndrome in 2-

10、12%casespRupture of the subcapsular liver hematomapPul.Aspiration due to eclamptic seizurepHypertensive encephalopathy,or cerebral edema.pDIC,multiorgan failure in severe cases pEffective management plan for delivery and postpartum care.pPyelonephritis,pChorioamnionitispSeptic abortionpPP endometrit

11、is,pPelvic thrombophlebitis.qNo single definition q Early Goal directed therapy&tenets of SSCqRole of steroids,APCqEarly antibiotic use&aggressive source control qIntensive insulin therapy p32 yr old Iraqi womenp2nd PO pyrexiapDistension Abd,resp distresspWound dehiscence NF with L puspARDS on 5th d

12、aypARF 7th day CVVHFpVentilated,prone position,PCTpDischarged from ICU 3rd week after successful recovery 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-Sta

13、ge Renal Failure Criteria:GFR criteria Cr 1.5X baseline Or GFR 25%Urine output criteriaUO 50%UO 75%or Cr 4.0mg/dlUO 80%parturients experience cardiopulmonary arrest.vCoagulopathy resembling DIC Rx.MV with 100%oxygen,Inotropic support as guided by CVP/PA monitoring,correction of coagulopathyMaternal

14、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 delivery

15、of the placenta no invasive monitoring in the absence of cardiac symptomsPeri-partum Cardiomyopathy late in pregnancy&6wks PPpDue myocarditis/autoimmuneppreload optimization;afterload reduction&improvement of myocardial contractility prequire anticoagulation pCollaboration among the obstetrician,car

16、diologist,and criticalist pCardiac 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 ANTIPHOSPHOLIPID SYNDROMEvPresence of two autoantibodies,lupus anticoagulant and

17、 anticardiolipin antibody vAssociated with thrombotic events,both arterial and venous vImproved fetal survival if Rx with low-dose aspirin,high-dose corticosteroids,heparin.vEg:Young radiologist with IUD Acute Fatty Liver of Pregnancyq3rd trimester 1 in 11,000 pregnancies,q maternal mortality 0%to 1

18、8%;fetal mortality 47%.qS/S:rt upper quadrant pain,nausea,vomiting,proteinuria,edema,mild hypertension,jaundice,coagulapathy,encephalopathy,hypoglycemia,NH3qHELLP(vs)AFLP basing on histopathology,with microvesicular fatty infiltration qSupportive therapy:Vit K,Glucose,lactulose,coagulopathy correcti

19、on,and airway protection in comaTRAUMA and PREGANACY-INCIDENCEp The Leading cause of non-obst.mortality-46%p Trauma during pregnancy-7%p Causes of Trauma nMVA 54.6%nDomestic abuse&Assault 22.3%nFalls21.8%nPenetrating injury1.3%p 20 wks p 200 successful cases reported in literaturep 20 minutes,fetal

20、survival unlikelyp 4 Minute Rule:Maternal CPR for 4 minutes,Infant should be delivered by the 5th minute.p7%of women of reproductive age p5 factors size of burn,depth of burn,part of body burned,concurrent injuries,&past medical historypCritical,40%TBSA burntp Inhalation of CO in a closed firep Free

21、ly crosses the placenta pProduce fetal cardiac edema.q Oxygenation,ventilation with 100%O2q Electrical burns,fetal mortality-73%q Maintenance of a normal intravascular vol,q Avoidance of hypoxia,prevention of inf q correction of electrolyte imbalance q Debridement&cleaning of Burned areasq Povidine-

22、iodine influences fetal ThyroidqSilver sulphadizine cause kernicterusRequire prompt and excellent CPR with some modifications in basic and advanced cardiovascular lifePrimary ABCD Survey pAirway&Breathing:no modificationsCirculation:wedge under the womans right side Defibrillationp No modifications

23、in dose or pad position.,shocks transfer no significant current to the fetus.p Remove any fetal or uterine monitors before shock delivery._Circulation.2019;112:IV-150-IV-153.)2019 American Heart Association._Circulation.2019;112:IV-150-IV-153.)2019 American Heart Association.Secondary ABCD Survey Ai

24、rway A Insert an advanced airway early in resuscitation to reduce the risk of regurgitation&aspiration.Airway edema,small diameter ETT,Effective preo-O2 Rapid sequence intubation,deep sedation to minimize hypotension.Breathing avoid esophageal device to confirmCirculation Follow standard ACLS recomm

25、endations Do not use femoral veins D/D:Decisions Decide whether to perform emergency hysterotomy.Identify and treat reversible causes of the arrest.vsmall but important group of patients vUnique problems and need specialized attention vconfounded by physiologic changes in pregnancy.vbetter outcomes vapproach requires good communication and collaboration between the obstetrician and intensivist