Resuscitation in pregnancy dr.krushna patel
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Transcript of Resuscitation in pregnancy dr.krushna patel
Dr. Krushna Patel
Postgraduate, MEM
KDAH, Mumbai
17-07-2012
RESUSCITATION IN PREGNANCY
GOALS
1. To understand and perform basic and advance life support in pregnant patients
2. Understand the adaptations of CPR
3. Understand the importance of early defibrillation when appropriate
4. Understand the need to perform perimortem cesarean section
SCOPE OF THE PROBLEM
According to the Confidential Enquiries into Maternal And Child Health (CEMACH) overall maternal mortality rate is 13.95deaths/100,000 maternities (AHA
CIRCULATION :2010)
Out of which 8 are due to cardiac arrest with frequency of 0.05 per 1000 maternities or 1:20,000
Rescuers must provide appropriate resuscitation based on consideration of physiological changes caused by pregnancy.
ANATOMICAL AND PHYSIOLOGICAL CHANGES IN PREGNANCY
CARDIOVASCULAR SYSTEM
Uteroplacental blood flow
Maternal blood volume Arterial pressure
Cardiac output Increases 30 – 45%
20th week of gestation
Maternal heart rate
increases 10- 15 beats/min
SBP and DBP First two trimesters – decreases by 10 – 15 mm hg
Returns to baseline by term
Supine pregnant patient
Gravid uterine pressure
Compression of IVC
Decreased venous return
Decreased cardiac output – 10 – 30%
Poor venous flow
Compromises infradiaphragmatic i.v sites
Femoral / saphenous routes
Not recommended for i.v access
During resuscitation
RESPIRATORY SYSTEM
Increased Tidal Volume
Progesterone stimulated
hyperventilation
Increased minute ventilation
Chronic respiratory
alkalosis
Decreased Functional Residual
Capacity – 20%
Rapid decrease in arterial
oxygen content during arrest
Right side shift of oxyhemoglobin curve during arrest state
Maintain maternal PO2 of >60 mm hg
in arrest state
Delayed Gastric emptying in pregnancy
(progesterone like effects of placental hormones)
Increased acidity of stomach contents
cardiac sphincter relaxation causes
regurgitation of stomach contents
Increased chance of aspiration and vomiting
GASTO-INTESTINAL SYSTEM
AIRWAY AND VENTILATION CONSIDERATION IN PREGNANCY
Decreased tolerance for hypoxia and apnoea
Tongue, mucosa, supraglottic edema & friability
Difficult mask ventilation• Low FRC• Elevated diaphragm• Raised intra-abdominal pressure
Mallampatti class 3 airway
Weight gain & obesity• Increased neck folds• Foreshortened neck
Increased risk of aspiration• Increased gastric emptying time• Decreased lower esophageal sphincter tone
KEY INTERVENTIONS TO PREVENT ARREST
Place the patient in the full left-lateral position to relieve possible compression of the inferior vena cava. Uterine obstruction of venous return can produce hypotension and may precipitate arrest in the critically ill patient.
Give 100% oxygen.
Establish intravenous (IV) access above the diaphragm.
Assess for hypotension : maternal hypotension that warrants therapy has been defined as a systolic blood pressure 100 mm Hg or 80% of baseline.
Maternal hypotension can result in reduced placental perfusion.
In the patient who is not in arrest, both crystalloid and colloid solutions have been shown to increase preload.
Consider reversible causes of critical illness and treat conditions that may contribute to clinical deterioration as early as possible.
RESUSCITATION OF THE PREGNANT PATIENT IN CARDIAC ARREST MODIFICATIONS OF CARDIOPULMONARY
RESUSCITATION
Patient Positioning
Important strategy to improve the quality of CPR and resultant compression force and output.
The pregnant uterus especially of >20 weeks gestation or gravid uterus palpated above the umbilicus, compresses the inferior vena cava, impeding venous return and thereby reducing stroke volume and cardiac output.
In non cardiac arrest parturients left-lateral tilt results in improved maternal hemodynamics of blood pressure, cardiac output, and stroke volume and improved fetal parameters of oxygenation, nonstress test, and fetal heart rate.
Left lateral tilt - 30 degrees using wedge (hard) of predetermined angle. Eg. Cardiff wedge
Manual left uterine displacement, with the patient in supine, also relieves aortocaval compression .
Left uterine displacement - patient’s left side with the 2-handed technique
The patient’s right side with the 1-handed technique , depending on the positioning of the resuscitation team.
If chest compressions remain inadequate after lateral uterine displacement or left-lateral tilt, immediate emergency cesarean section should be considered.
BLS AND ACLS MODIFICATIONS
AIRWAY AND BREATHING
Active airway management is the initial consideration.
Airway management is more difficult during pregnancy
Secure airway early in resuscitation
OPTIMAL use of bag-mask ventilation and suctioning, while preparing for advanced airway placement should be done
Use small endotracheal tubes, short laryngoscope handles
Use an ETT 0.5 to 1 mm smaller in internal diameter than that used for a nonpregnant woman of similar size because the airway may be narrowed from edema
Give 100 % oxygen and mainatain good saturation
CIRCULATION
Chest compressions should be performed slightly higher on the sternum than normally recommended to adjust for the elevation of the diaphragm and abdominal contents caused by the gravid uterus.
Position is slightly above the centre of the sternum
Current recommended drug dosages for use in resuscitation of adults can also be used in resuscitation of the pregnant patient in cardiac arrest.
DEFIBRILLATION
Management of ventricular arrhythmias require defibrillation during maternal resuscitation.
There should be no delay if use of defibrillation is indicated
Energy levels are same as ACLS protocol
Before delivering the shock, REMOVE FETAL MONITORING EQUIPMENTS to prevent electrocution injury to patient or rescuer
PREGNANCY-RELATED CAUSES OF MATERNAL CARDIOPULMONARY ARREST
B- Bleeding(haemorrhage)/ DIC
E- Embolism/coronary/pulmonary/amniotic fluid embolism
A- anesthetic complications
U- Uterine atony
C- Cardiac diseases/MI/Ischemia/aortic dissection/cardiomyopathy
H- Hypertension / Preclampsia/ Eclampsia
O- Others / Diff. Diag of standard ACLS guidelines i.e 5H’s and 5T’s
P- Placenta previa/ Abruptio placenta
S- Sepsis
REVERSIBLE CAUSES
Electrolyte abnormalities Tamponade Hypothermia
Hypovolemia Hypoxia Hypomagnesemia
Myocardial infarction
Pulmonary embolism
Tension pneumothorax
HAEMORRAGE
Case of placenta previa/ abruptio placenta, where bleeding is significant
Fluid resuscitation with RL/ NS
Vasopressor agent - Inj. Ephedrine (5mg every 5 mins till response is seen) , if fluids fail to restore adequate blood pressure.
EMBOLISM
Pulmonary embolism• Thromboembolic disease risk
increased• Hypoxic/ hemodynamic unstable• Anticoagulation with heparin –
currently the treatment of choice• Also , adequate oxygenation and
treating hypotension• Elevated D-dimer not a helpful
screen in pregnancy• CT scan or VP scan to confirm
diagnosis on treatment is stated.• Use of thrombolytics reserved when
potential benefits outweighs the risks, emergencies beyond 20 wks gestation, postpartum period
Amniotic fluid embolism
• Dyspnoea, hypotension associated with pt. is labour/ abortion
• Sudden onset breathlessness, air hunger, decreased oxygen saturtion
• Develop cardiac arrest within minutes
• DIC• Multi- organ failure• Treatment tried : cardiopulmonary
bypass, open pulmonary artery thromboembolectomy.
ANESTHETIC COMPLICATION
Bupivacaine induced arrythmia – amiodarone is the primary drugin the ACLS arrythmia algorithm.
Early administration of lipid emulsification (20% intralipid) – used in resuscitation of bupivacaine- induced cardiotoxicity. ( lipid rescue therapy : picard J . Anesthesia 2009)
CARDIAC DISEASE
The most common causes of maternal death from cardiac disease are myocardial infarction, followed by aortic dissection.
Women deferring pregnancy to older ages, increases the chance of having atherosclerotic heart disease.
Fibrinolytics is relative contraindication in pregnancy
PCI is the reperfusion strategy of choice for ST-elevation myocardial infarction.
illnesses related to congenital heart disease and pulmonary hypertension are the third most common cause of maternal cardiac deaths.
PREECLAMPSIA/ECLAMPSIA
Preeclampsia/eclampsia develops after the 20th week of gestation and can produce severe hypertension and ultimately diffuse organ-system failure.
Magnesium sulphate
If untreated, maternal and fetal morbidity and mortality results.
MAGNESIUM SULFATE TOXICITY
Magnesium toxicity present with ECG interval changes: (prolonged PR, QRS and QT intervals) at magnesium levels of 2.5–5 mmol/L
AV nodal conduction block, bradycardia, hypotension and cardiac arrest at levels of 6–10 mmol/L.
Neurological effects : loss of tendon reflexes, sedation, severe muscular weakness, and respiratory depression are seen at levels of 4–5 mmol/L.
Others include: gastrointestinal symptoms (nausea and vomiting), skin changes (flushing), and electrolyte/ fluid abnormalities (hypophosphatemia, hyperosmolar dehydration).
Patients with renal failure and metabolic derangements can develop toxicity after relatively lower magnesium doses.
Iatrogenic overdose is possible in the pregnant woman who receives magnesium sulfate, particularly if the woman becomes oliguric.
Administration of calcium gluconate (10 ml of a 10% solution) is the treatment of choice
Empiric calcium administration may be lifesaving
Trauma and drug overdose
Pregnant women are not exempt from the accidents & mental illnesses
Domestic violence also increases during pregnancy; homicide & suicide are one of the causes of mortality during pregnancy
EMERGENCY CESAREAN SECTION IN CARDIAC ARREST
Delivery of the foetus is a part of resuscitation process when applicable.
Despite appropriate modifications – mechanical effect of gravid uterus – decreases venous return from IVC – obstructs blood flow through abd. aorta – decreases thoracic compliance – unsuccessful CPR – increased risk of hypoxia going in for anoxia to mother and foetus BEYOND 4 MINUTES OF ARREST.
WHY PERFORM AN EMERGENCY CESAREAN SECTION IN CARDIAC ARREST?
Emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation or improvement in maternal hemodynamic status only after the uterus has been emptied.
Recent studies indicates ROSC and maternal hemodynamic stability of the mother and normal neurological outcome of the neonate post perimortem casarean.
The critical point to remember is that both mother and infant may die if the provider cannot restore blood flow to the mother’s heart.
THE IMPORTANCE OF TIMING WITH EMERGENCYCESAREAN SECTION
When the maternal prognosis is grave and resuscitative efforts appear futile, moving straight to an emergency cesarean section may be appropriate, especially if the fetus is viable.
If emergency cesarean section cannot be performed by the 5-minute mark, it may be advisable to prepare to evacuate the uterus while the resuscitation continues.
DECISION MAKING FOR EMERGENCY CESAREAN DELIVERY
Gestational age less than 20 weeks
Need not be considered because this size gravid uterus is unlikely to significantly compromise maternal cardiac output
Gestational age approximately 20 to 23 weeks
Perform to enable successful resuscitation of the mother, not the survival of the delivered infant, which is unlikely at this gestational age
Gestational age greater than 24 weeks
Perform to save the life of both the mother & infant
The following can increase the infant’s survival:
Short interval between the mother’s arrest & the infant’s delivery
Perimortem caesarean section to be performed within 4 mins of cardiac arrest and delivery of the foetus within 5 mins.
No sustained pre arrest hypoxia in the mother
Minimal or no signs of fetal distress before the mother’s cardiac arrest
Aggressive & effective resuscitative efforts for the mother
Delivery to be performed in a medical center with easy access to NICU.
PERIMORTEM CESAREAN SECTION
Prognosis for intact survival of infant is best if delivered within 5 mins of maternal arrest.
Goal : to remove foetus and continue resuscitation of both mother and foetus
During the procedure maternal CPR has to be continued.
Vertical midline abdominal incision from 4 -5 cm below xiphoid process to pubic symphysis
Incise through the fascia and muscles into the peritoneum
Vertical uterine incision .
Delivery of the fetus
Manual removal of placenta and its membranes.
Closure of abdomen may be delayed until maternal blood pressure and pulse is restored.
Dilute oxytocin 10 units in 9 ml NS to prevent uterine atony.
INFORMED CONSENT FOR PERIMORTEM CS IS NOT NECESSARY
POST–CARDIAC ARREST CARE
Post–cardiac arrest hypothermia can be used safely and effectively in early pregnancy without emergency cesarean section (with fetal heart monitoring), with favorable maternal and fetal outcome after a term delivery.
No cases in the literature have reported the use of therapeutic hypothermia with perimortem cesarean section.
Therapeutic hypothermia may be considered on an individual basis after cardiac arrest in a comatose pregnant patient based on current recommendations for the nonpregnant patient
During therapeutic hypothermia of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought
SUMMARY
Successful resuscitation of a pregnant woman & survival of the fetus require prompt & excellent CPR with some modifications in techniques
By the 20th week of gestation, the gravid uterus can compress the IVC & aorta, obstructing venous return & arterial blood flow
Rescuers can relieve this compression by positioning the woman on left side or by pulling the gravid uterus to the side
Defibrillation & medication doses used for resuscitation of the pregnant woman are the same as those used for other adults
Rescuers should consider the need for ER Caesarian Delivery as soon as the pregnant woman develops cardiac arrest
Rescuers should be prepared to proceed if the resuscitation is not successful within 4 minutes
SEQUENCE FOR CPR IN PREGNANT PATIENTS
Intubate early
Protect vulnerable airway
Supply oxygen
Tilt the patient
Limit aortocaval compression
Obtain rapid IV access, avoid the femoral and saphenous veins
Follow current ACLS recommendations
Perimortem cesarean section within 5 min of maternal arrest if fetus >20 wk
Consider open chest CPR within 15 min of maternal arrest
Explore differential diagnosis, include iatrogenic causes (e.g., spinal analgesia). Consider cardiopulmonary bypass, if indicated.
REFRENCES
COURTESY : UPDATE JUNE 2012 LITERATURE REVIEW
AHA : CIRCULATION 2010 – CARDIAC ARREST IN PREGNANCY
TINTINALLI 7TH EDITION
THANK YOU