Use of the Sequential Organ Failure Assessment score for evaluating outcome among obstetric patients admitted to the intensive care unit

Lung Protective Ventilation during Pregnancy: An Observational Cohort Study

Objectives  We sought to describe characteristics of mechanically ventilated pregnant patients, evaluate utilization of low-tidal-volume ventilation (LTVV) and high-tidal-volume ventilation (HTVV) by trimester, and describe maternal and fetal outcomes by ventilation strategy. Study Design  This is a retrospective cohort study of pregnant women with mechanical ventilation for greater than 24 hours between July 2012 and August 2020 at a tertiary care academic medical center. We defined LTVV as average daily tidal volume 8 mL/kg of less of predicted body weight, and HTVV as greater than 8 mL/kg. We examined demographic characteristics, maternal and fetal characteristics, and outcomes by ventilation strategy. Results  We identified 52 ventilated pregnant women, 43 had LTVV, and 9 had HTVV. Acute respiratory distress syndrome occurred in 73% ( N  = 38) of patients, and infection was a common indication for ventilation ( N  = 33, 63%). Patients had LTVV more often than HTVV in all trimesters. Obstetric complications occurred frequently, 21% ( N  = 11) experienced preeclampsia or eclampsia, and among 43 patients with available delivery data, 60% delivered preterm ( N  = 26) and 16% had fetal demise ( N  = 7). Conclusion  LTVV was utilized more often than HTVV among pregnant women in all trimesters. There was a high prevalence of maternal and fetal morbidity and fetal mortality among our cohort. Key Points Our center utilized low tidal more often than high-tidal-volume ventilation during all trimesters of pregnancy.Prone positioning can be performed at advanced gestations.Infection is a common cause of antepartum ventilation.

[Maternal mortality due to genital tract infection in France, 2016-2018]

Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.

Prognostic scores for prediction of maternal near miss and maternal death after admission to an intensive care unit: A narrative review

Near miss morbidity and maternal death (defined as severe maternal outcomes - SMO) are the most important adverse outcomes in obstetric settings to assess delays and characteristics of health care management. Intensive care units (ICUs) represent an opportunity of adequate care for women who, in several cases, experienced earlier clinical delays in their maternal health care management. Some prognostic scores widely used in ICU have been useful in characterizing patients in terms of severity of illness in clinical studies, for evaluation of ICU performance, in quality improvement initiatives and for benchmark purposes. Prediction of SMO during the admission to the ICU could greatly improve obstetric care management. We reviewed the feasibility of the existing ICU clinical and obstetric prediction scores in predicting maternal near miss and maternal death.

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BACKGROUND

Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.

AIM

To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.

METHODS

The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.

RESULTS

One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.

CONCLUSION

This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Development of the Sepsis-Associated Adverse Outcomes in Pregnancy Score

OBJECTIVE

This study aimed to develop and evaluate a scoring system-called the Sepsis-Associated Adverse Outcomes in Pregnancy (SAAP) Score-to identify individuals with maternal infection that have composite maternal adverse outcomes (CMAO).

STUDY DESIGN

Using the International Classification of Disease codes, we identified pregnant and postpartum (up to 6 weeks after birth) individuals admitted at our center with a primary diagnosis of infection. The primary outcome was CMAO which included any of the following: maternal intensive care unit admission, surgical intervention, vasopressor use, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, dialysis, organ failure, venous thromboembolism, or maternal death. Regularized logistic regression was used to identify variables that best discriminate CMAO status. Variables were chosen for inclusion following evaluation of statistical and clinical significance. Model performance was evaluated using area under the curve (AUC) with 95% confidence intervals (CIs), sensitivity, specificity, and predictive values.

RESULTS

Of the 23,235 deliveries during the study period, 227 (0.9%) individuals met inclusion criteria and among them CMAO occurred in 39.2% (95% CI: 33.1-45.7%). The SAAP score consisted of six variables (white blood cell count, systolic blood pressure, respiratory rate, heart rate, lactic acid, and abnormal diagnostic imaging) with scores ranging from 0 to 11 and a score of ≥7 being abnormal. An abnormal SAAP score had an AUC of 0.80 (95% CI: 0.74-0.86) for CMAO. The sensitivity and specificity of the SAAP score for CMAO was 0.71 (95% CI: 0.60-0.80) and 0.73 (95% CI: 0.64-0.80), respectively. The positive predictive value was 0.62 (95% CI: 0.52-0.72) and negative predictive value was 0.79 (95% CI: 0.71-0.86).

CONCLUSION

Pending external validation, the sixth variable SAAP score may permit early recognition of pregnant and postpartum individuals with infection who are likely to develop adverse maternal outcomes.

KEY POINTS

· Sepsis is a leading cause of maternal morbidity and mortality.. · Early recognition improves maternal sepsis outcomes.. · The SAAP score may permit early recognition of maternal adverse outcomes due to infection..

Comparison of the CIPHER prognostic model with the existing scores in predicting severe maternal outcomes during intensive care unit admission

OBJECTIVE

To compare the performance of the Collaborative Integrated Pregnancy High-Dependency Estimate of Risk (CIPHER) model in predicting maternal death and near-miss morbidity (Severe Maternal Outcome [SMO]) with the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the Simplified Acute Physiology Score (SAPS) III scores.

METHODS

A retrospective and a prospective study was conducted at two centers in Brazil. For each score, area under curve (AUC) was used and score calibration was assessed using the Hosmer-Lemeshow statistic (H-L) test and the standardized mortality ratio (SMR).

RESULTS

A cohort of 590 women was analyzed. A SMO was observed in 216 (36.6%) women. Of these, 13 (2.2%) were maternal deaths and 203 (34.4%) met one or more maternal near-miss criteria. The CIPHER model did not show significant diagnostic ability (AUC 0.52) and consequently its calibration was poor (H-L P<0.05). The SAPS III had the best performance (AUC 0.77, H-L P>0.05 and SMR 0.85).

CONCLUSION

The performance of the CIPHER model was lower compared to the other scores. Since the CIPHER model is not ready for clinical use, the SAPS III score should be considered for the prediction of SMO.

Prognostic Value of an Estimate-of-Risk Model in Critically Ill Obstetric Patients in Brazil

The CIPHER (Collaborative Integrated Pregnancy High-Dependency Estimate of Risk) prognostic model was not predictive of risk of death, prolonged organ support, or lifesaving intervention among critically ill patients in Brazil.

To externally validate the CIPHER (Collaborative Integrated Pregnancy High-Dependency Estimate of Risk) prognostic model for pregnant and postpartum women admitted to the intensive care unit.

Quick Sequential Organ Failure Assessment: Modifications for Identifying Maternal Morbidity and Mortality in Obstetrical Patients

OBJECTIVE

Screening tools, including the Systemic Inflammatory Response Syndrome (SIRS) criteria and Sequential Organ Failure Assessment (SOFA) criteria, have not been validated in the pregnant population. We aimed to determine if pregnancy-specific modifications to the quick SOFA (qSOFA) can improve prediction of severe maternal morbidity in pregnant women with serious infections.

STUDY DESIGN

We performed a retrospective cohort study of pregnant patients with severe infections admitted to a single institution from January 1, 2011, through December 31, 2017. The primary outcome was severe maternal morbidity, defined as a composite of adverse maternal outcomes: intensive care unit (ICU) admission for >48 hours, need for invasive monitoring (central line or arterial line), intubation, pharmacologic hemodynamic support (intravenous vasopressors or inotropes), and/or maternal death. A logistic regression was then applied and the resulting predictors were analyzed individually and in combination with receiver operating characteristic (ROC) curves to modify qSOFA for pregnancy, that is, qSOFA-P.

RESULTS

Analysis of 104 pregnant patients with severe infections found that the standard qSOFA did not accurately predict severe maternal morbidity (ROC area under the curve [AUC] = 0.54, p = 0.49, sensitivity = 0.38, and specificity = 0.70). Pregnancy-specific modifications or "qSOFA-P" (respiratory rate [RR] ≥ 35 breaths/minute and systolic blood pressure [SBP] ≤ 85 mm Hg) significantly improved prediction of severe maternal morbidity (AUC = 0.77, p < 0.001, sensitivity = 0.79, and specificity = 0.74).

CONCLUSION

The standard qSOFA is a poor screening tool in the prediction of severe maternal morbidity in pregnant patients with infections. A pregnancy-specific screening system, qSOFA-P, improved prediction of severe maternal morbidity in pregnant women with severe infections. Further prospective and large multicenter studies are needed to validate this scoring system in pregnant women.

KEY POINTS

· Validated scoring systems for evaluating pregnant patients with sepsis are needed.. · Modifications to existing systems may improve the evaluation of pregnant patients with sepsis.. · The qSOFA-P (RR ≥ 35 breaths/minute and SBP ≤ 85 mm Hg) includes modifications to qSOFA, and improves the detection of patients who would develop severe maternal morbidity...

Maternal Sepsis: A Review of National and International Guidelines

OBJECTIVE

 Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3).

STUDY DESIGN

 Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language-The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3.

RESULTS

 All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar.

CONCLUSION

 In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations.

KEY POINTS

· Definitions for maternal sepsis and septic shock are varied.. · Maternal sepsis guidelines differ in proposed criteria and tools.. · Maternal sepsis guidelines have similar management recommendations..

Critical care in obstetrics: a strategy for addressing maternal mortality

The acute rise in maternal morbidity and mortality in the United States is in part because of an increasingly medically complex obstetrical population. An estimated 1% to 3% of all obstetrical patients require intensive care, making timely delivery and availability of critical care imperative. The shifting landscape in obstetrical acuity places a burden on obstetrical providers, many of whom have limited experience in identifying and responding to critical illness. The levels of maternal care definitions by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine designate hospitals based on the availability of obstetrical resources and highlight the need for critical care resources and expertise. The growing need for critical care skills in the evolving contemporary obstetrical landscape serves as an opportunity to redefine the concept of delivery of care for high-risk obstetrical patients. We summarized the key tenets in the prevention of maternal morbidity and mortality, including the use of evidence-based tools for risk stratification and timely referral of patients to facilities with appropriate resources; innovative pathways for hospitals to provide critical care consultations on labor and delivery; and training of obstetrical providers in high-yield critical care skills, such as point-of-care ultrasonography. These critical care-focused interventions are key in addressing an increasingly complex obstetrical patient population while providing an educational foundation for the training of future obstetrical providers.

[Maternal deaths due to infections in France 2013-2015]

Over the 2013-2015 period, maternal mortality due to infections accounted for 10 % of direct maternal deaths and 13 % of indirect maternal deaths. Among the 21 deaths from infection, and compared to the last triennium, maternal deaths from genital infection doubled with 11 deaths during the 2013-2015 period. This included 6 cases of puerperal toxic shock syndrome, 4 of which due to Streptococcus A, and 5 cases of sepsis caused by intrauterine infection due to Gram-Negative Bacillus. Indirect maternal deaths due to infections from extragenital sources represented 10 deaths in this triennium, including four influenza infections and three infectious complications of an immunosuppressive state (uncontrolled HIV infection for two patients and CMV encephalitis during an immunosuppressive treatment for one patient). Of these 21 deaths by infectious causes, 6 direct maternal deaths and 9 indirect maternal deaths were considered preventable. The most common preventable factors were those related to medical management (13 times): diagnostic failure or delayed diagnosis leading to a delayed medical treatment, absence of influenza vaccination. The other contributory factors were related to the organization of healthcare (delayed transfer, lack of communication between clincians) as well as factors related to patient social vulnerability.

Comparison of Sequential Organ Failure Assessment (SOFA) and Sepsis in Obstetrics Score (SOS) in Women with Pregnancy-Associated Sepsis with Respect to Critical Care Admission and Mortality: A Prospective Observational Study

Objective

We aimed to determine performance of sequential organ failure assessment (SOFA) and Sepsis in Obstetrics Score (SOS), in women with pregnancy-associated sepsis (PAS) with respect to critical care admission and mortality.

Methods

Obstetric patients with PAS fulfilling any 2 of the quick SOFA (qSOFA) criteria were enrolled as cases. The various parameters of SOFA and SOS were recorded at admission and compared for outcomes.

Results

Critical care was required in 32 (50.7%) patients and associated mortality was high (31.7%). For our study population, a threshold of SOFA ≥ 6 had the best combination of sensitivity (84.4%) and specificity (61.3%) for critical care admission. For SOS, a cut-off value of ≥ 6 gave best sensitivity (64%) and specificity (40%) for the same.

Conclusions

SOFA was far more predictive of patient's critical condition as well as mortality compared to SOS. SOFA was superior to SOS in determining critical care admission and mortality for PAS.

Intraabdominal pressure and its relation with organ dysfunction in patients scheduled for elective cesarean section: Effect of supine vs left lateral tilt position

INTRODUCTION

Intraabdominal pressure (IAP) is related to clinical outcome of patients. It is measured as intravesical pressure through a Foley catheter in the supine position. During pregnancy, there are data showing elevated IAP and also a suggestion that it may be a false increase due to pressure on the urinary bladder by the gravid uterus in the supine position. Additionally, it is not known whether the elevated IAP during pregnancy is merely a physiological change or is associated with impairment of organ functions. We thus aimed to establish a normal value of IAP in supine (IAP_supine ) as well as 10° left lateral (IAP_lateral-tilt ) positions, and their association with organ functions as well as certain maternal risk characteristics.

MATERIAL AND METHODS

This prospective cross-sectional cohort study included 100 consenting parturients with term gestation posted for elective cesarean section under single-shot subarachnoid block. IAP was measured via an indwelling Foley catheter with a transducer connected to it, as per the recommended technique. Organ dysfunction was defined as Sequential Organ Failure Assessment (SOFA) subscore ≥1 for the particular system.

TRIAL REGISTRATION

ctri.gov.in (CTRI/2017/11/010527).

RESULTS

The IAP_supine was significantly higher than IAP_lateral-tilt (13.8 ± 2.4 vs 12 ± 2.3 mm Hg) (P < .001). The incidence of intraabdominal hypertension as per conventional definition, that is, IAP ≥12 mm Hg, was also higher in the supine position (77% vs 55%) (P < .001). None of the patients had dysfunction of the cardiovascular, renal or central nervous system. The incidence of respiratory, hepatic and hematologic dysfunction was 2%, 15% and 32%, respectively. Receiver operating characteristic analysis showed insignificant association of IAP_supine and IAP_lateral-tilt with various organ dysfunctions (P > .05). There was a significant correlation of intraabdominal hypertension when considering IAP_supine or IAP_lateral-tilt , with obesity (P = .004 and .000, respectively), as well as preeclampsia (P = .006 and .000, respectively).

CONCLUSIONS

In nonlaboring patients undergoing elective cesarean section, IAP is significantly higher in the supine vs 10° left lateral position. In neither position is IAP significantly associated with organ dysfunction. Thus, the usual recommendation of a supine position for measuring IAP to diagnose intraabdominal hypertension, formulated consequent to its pathological effects on organ functions, may not be applicable to pregnant patients and needs urgent validation studies.

Predictive value of the sequential organ failure assessment (SOFA) score for prognosis in patients with severe acute ischemic stroke: a retrospective study

OBJECTIVE

To identify the risk factors for early death and determine the predictive value of the sequential organ failure assessment (SOFA) score for prognosis of severe acute ischemic stroke (AIS).

METHODS

A total of 110 patients with severe AIS were enrolled and divided into the non-survivor (n = 34) and survivor groups (n = 76). Logistic regression analysis was conducted to identify risk factors for early death, while the receiver operator characteristic (ROC) curve was used to determine the predictive effect of the SOFA score on prognosis.

RESULTS

Logistic regression analysis showed that urinary tract infection (odds ratio [OR] = 17.364, 95% confidence interval [CI]: 1.903-158.427), mechanical ventilation (OR = 1.754, 95% CI: 1.648-2.219), and osmotic therapy (OR = 2.835, 95% CI: 1.871-5.102) were significantly correlated with early death of severe AIS. ROC curve analysis of the area under the curve after hospitalization showed that the maximum SOFA and ΔSOFA scores exceeded 0.7.

CONCLUSION

Our study shows that urinary tract infection, mechanical ventilation, and osmotic therapy are risk factors for early death of severe AIS. The SOFA score has good predictive value for prognosis of severe AIS. These findings may provide a guideline for improving clinical outcome.

Comparison of four prognostic scales for predicting mortality in patients with severe maternal morbidity

OBJECTIVE

To compare the prognostic validity of the APACHE II-M and O-SOFA scales versus the APACHE II and SOFA to predict mortality in patients with severe maternal morbidity.

DESIGN

A retrospective, longitudinal and analytical cohort study was carried out.

SETTING

Medical-surgical intensive care unit (ICU) of a tertiary hospital.

PATIENTS

Pregnant or puerperal patients of any age admitted to the ICU.

INTERVENTIONS

Calculation of prognostic scores upon admission.

VARIABLES OF INTEREST

APACHE II, SOFA, APACHE II-M and O-SOFA scores and maternal mortality.

RESULTS

A total of 141 patients were included. The majority (70.2%) were puerperal. The most frequent diagnosis was gestational hypertensive disease (50 cases). The discrimination of each prognostic model was estimated with the area under the ROC curve (AUC-ROC). The calibration was estimated using the mortality ratio and the Hosmer-Lemeshow statistic. The four scales discriminated between survivors and non-survivors with areas under the curve >0.85. The APACHE II-M model was the predictive model with the highest discrimination and calibration. In the Hosmer-Lemeshow regression analysis, mortality as predicted by the APACHE II and O-SOFA was significantly different from the observed mortality.

CONCLUSIONS

The APACHE II-M exhibited the greatest prognostic validity in predicting maternal mortality. This difference was given by its improvement in calibration.

Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale

Objective To evaluate the characteristics of obstetric admissions to an intensive care unit (ICU) and assess the utility of Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and the Glasgow Coma Scale (GCS). Methods This study is consisted of 160 patients admitted to an ICU during the antenatal period or within 7 days at the postpartum period. Clinical characteristics and ICU scores were evaluated. Results The rate of admission to the ICU was 7.8/1000 deliveries. Four cases ended with maternal mortality (2.5%). The most common hospitalization indications were hypertensive disorders of pregnancy, cardiovascular disorders and obstetric hemorrhage, at 40 (25%), 34 (21.2%), and 31 (19.3%) cases, respectively. The receiver operating characteristics (ROC) curve analysis for prediction of maternal mortality revealed area under curve (AUC) values as 0.971 both for APACHE II and predicted mortality rate (PMR), and 24.5 and 47.1 were determined as the cut-offs with sensitivities of 100%. AUCs were also 0.901 and 0.929 for the initial and worst SOFA score, respectively. The cut-off value for the initial and worst SOFA score was 3.5, with a sensitivity of 100%, and was 10 with a specificity of 98.9%, respectively. Conclusion APACHE II and PMR overpredict maternal mortality, but those higher scores predict maternal mortality. Higher SOFA scores are related with maternal mortalities with high specificity.

Intraabdominal pressure in non-laboring preeclamptic vs normotensive patients undergoing cesarean section: A prospective observational study

INTRODUCTION

It is hypothesized that increased intraabdominal pressure (IAP) may be a cause of preeclampsia. There is, however, a paucity of clinical data regarding IAP in preeclamptics. We evaluated and compared the IAP and its effects on organ functions, in normotensive and preeclamptic patients.

MATERIAL AND METHODS

Previously healthy non-laboring patients with a singleton pregnancy scheduled for elective cesarean section under subarachnoid block were enrolled (preeclamptic and normotensive; n = 29 each). IAP was measured using an indwelling Foley catheter, and compared in both cohorts at four predefined time points: just before subarachnoid block, immediately after the onset of sensory block to T₆ dermatomal level, just after surgery, and 2 hours later. In addition, the presence of organ dysfunction for respiratory, cardiovascular, renal, hepatic, hematopoietic and central nervous systems were evaluated for association with IAP.

RESULTS

Although age, body mass index, gravidity, parity, serum bilirubin, serum creatinine, PaO₂ /FiO₂ ratio and Glasgow coma score of the preeclamptic and normotensive patients were similar, the mean blood pressure was significantly higher (P < 0.001), the period of gestation less (P = 0.003) and the platelet count lower (P = 0.020) in the former. The IAP was significantly higher in the preeclamptic group at all four time points: respectively, 15.1 (1.0) vs 14.2 (0.9) mm Hg (P = 0.002); 14.9 (0.9) vs 14.1 (1.0) mm Hg (P = 0.002), 10.4 (1.0) vs 9.5 (1.3) mm Hg (P = 0.008) and 10.2 (0.8) vs 9.2 (1.2) mm Hg (P = 0.001). There was no correlation between the IAP and various organ dysfunctions.

CONCLUSIONS

Preeclampsia is associated with a significantly higher IAP in patients undergoing a cesarean section. The clinical relevance of this finding needs further investigation.

Prediction of Severe Maternal Outcome Among Pregnant and Puerperal Women in Obstetric ICU

OBJECTIVE

World Health Organization recommends the use of maternal near miss as a tool to monitor and improve quality of obstetric care. Severe maternal outcome corresponds to the sum of maternal near miss and maternal death cases. This study was aimed at validating Acute Physiology and Chronic Health Evaluation II and IV, Simplified Acute Physiology Score III, and Sequential Organ Failure Assessment in pregnant and postpartum women in predicting severe maternal outcome.

DESIGN

A retrospective cohort study.

SETTING

Obstetric ICU in a tertiary care hospital in Brazil.

PATIENTS

Pregnant and postpartum women admitted to the obstetric ICU during a 3-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 279 women were admitted to ICU, an admission rate of 34.6/1,000 live births, and the mortality index to severe maternal outcome (maternal death/maternal near miss + maternal death) was 7.7%. Total Sequential Organ Failure Assessment had a better overall performance than remaining scores for total hospitalizations (area under the curve, 0.86; standardized mortality ratio, 0.96; 95% CI, 0.74-1.22), for hypertensive direct causes (area under the curve, 0.81; standardized mortality ratio, 0.73; 95% CI, 0.31-1.43), and indirect causes (area under the curve, 0.89; standardized mortality ratio, 0.85; 95% CI, 0.59-1.19). The Acute Physiology and Chronic Health Evaluation II had a better overall performance than total Sequential Organ Failure Assessment for hemorrhagic causes (area under the curve, 0.75; standardized mortality ratio, 1.0; 95% CI, 0.61-1.54).

CONCLUSIONS

Total Sequential Organ Failure Assessment may be used to predict severe maternal outcome in obstetric populations admitted to ICU. The Acute Physiology and Chronic Health Evaluation II may be applied to predict severe maternal outcome in hemorrhagic complications. We do not recommend Acute Physiology and Chronic Health Evaluation IV and Simplified Acute Physiology Score III for the prediction of severe maternal outcome.

Lactate on emergency department arrival as a predictor of in-hospital mortality in necrotizing fasciitis: a retrospective study

Background

Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients.

Method

A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed.

Result

Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2–4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30–1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07–1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11–1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l.

Conclusion

In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality.

Risk prediction models for maternal mortality: A systematic review and meta-analysis

PURPOSE

Pregnancy-related critical illness leads to death for 3-14% of affected women. Although identifying patients at risk could facilitate preventive strategies, guide therapy, and help in clinical research, no prior systematic review of this literature exploring the validity of risk prediction models for maternal mortality exists. Therefore, we have systematically reviewed and meta-analyzed risk prediction models for maternal mortality.

METHODS

Search strategy: MEDLINE, EMBASE and Scopus, from inception to May 2017. Selection criteria: Trials or observational studies evaluating risk prediction models for maternal mortality. Data collection and analysis: Two reviewers independently assessed studies for eligibility and methodological quality, and extracted data on prediction performance.

RESULTS

Thirty-eight studies that evaluated 12 different mortality prediction models were included. Mortality varied across the studies, with an average rate 10.4%, ranging from 0 to 41.7%. The Collaborative Integrated Pregnancy High-dependency Estimate of Risk (CIPHER) model and the Maternal Severity Index had the best performance, were developed and validated from studies of obstetric population with a low risk of bias. The CIPHER applies to critically ill obstetric patients (discrimination: area under the receiver operating characteristic curve (AUC) 0.823 (0.811-0.835), calibration: graphic plot [intercept-0.09, slope 0.92]). The Maternal Severity Index applies to hospitalized obstetric patients (discrimination: AUC 0.826 [0.802-0.851], calibration: standardized mortality ratio 1.02 [0.86-1.20]).

CONCLUSIONS

Despite the high heterogeneity of the study populations and the limited number of studies validating the finally eligible prediction models, the CIPHER and the Maternal Severity Index are recommended for use among critically ill and hospitalized pregnant and postpartum women for risk adjustment in clinical research and quality improvement studies. Neither index has sufficient discrimination to be applicable for clinical decision making at the individual patient level.

Exploring Epidemiological Aspects, Distribution of WHO Maternal Near Miss Criteria, and Organ Dysfunction Defined by SOFA in Cases of Severe Maternal Outcome Admitted to Obstetric ICU: A Cross-Sectional Study

Objective

To explore the epidemiological aspects, to describe the frequency and distribution of WHO maternal near miss (MNM) criteria and the presence of organ dysfunction and failure measured by the maximum SOFA (Sequential Organ Failure Assessment) score (SOFA max) in cases of severe maternal outcome (SMO).

Methods

In an observational cross-sectional study performed between January 2013 and December 2015, 279 pregnant or postpartum women were admitted to an obstetric ICU (intensive care unit) in Brazil. MNM, maternal death (grouped as SMO), and potentially life-threatening conditions (PLTC) were defined according to WHO criteria. For categorical variables, a descriptive analysis was carried out. Frequency and distribution of WHO criteria, organ dysfunction, or failure defined by SOFA max were performed.

Results

WHO criteria identified 65 SMO and 214 PLTC. Management criteria were present in 58/65 (89.2%) while 61/65 (93.8%) of SMO cases had dysfunction or failure by SOFA.

Conclusions

The systematic evaluation of the organic function by SOFA max score identified the presence of organic dysfunction or failure in almost all SMO cases. Management criteria were present in all MD cases. Our results indicate the need for new studies evaluating the parameterization of the WHO laboratory criteria for values compatible with the definition of organic dysfunction by the SOFA to identify MNM.

Diagnostic Performance of Initial Serum Albumin Level for Predicting In-Hospital Mortality among Necrotizing Fasciitis Patients

Background: Hypoalbuminemia is known to be associated with adverse outcomes in critical illness. In this study, we attempted to identify whether hypoalbuminemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF). patients. Method: A retrospective cohort study of hospitalized adult patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and serum albumin levels were determined. We evaluated the predictive value of serum albumin level at ED presentation for in-hospital mortality. All collected data were statistically analyzed. Result: Of the 707 NF patients, 40 (5.66%) died in the hospital. The mean serum albumin level was 3.1 ± 0.9 g/dL and serum albumin levels were significantly lower in the non-survivor group than in the survivor group (2.8 ± 0.7 g/dL vs. 3.5 ± 0.8 g/dL). In the multivariable logistic regression model, albumin was significantly associated with in-hospital mortality (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.88–0.96, p < 0.001). The area under-the-receiver-operating-characteristic curve (AUC) for in-hospital survival was 0.77 (95% CI 0.72–0.82) and corresponding sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 66%, 74%, 33%, 88%, 2.25, and 0.48, respectively. High sensitivity (96%) for survival was shown at albumin level of 4.0 g/dL and high specificity (91%) for mortality was shown at a level of 2.5 g/dL. Conclusion: Initial serum albumin levels strongly predicted in-hospital mortality among patients with necrotizing fasciitis. NF patients with hypoalbuminemia on ED arrival should be closely monitored for signs of deterioration and early and aggressive intervention should be considered to prevent mortality.

Sepsis in pregnancy and the puerperium

Sepsis remains a leading cause of maternal morbidity and mortality. Recognition and treatment of maternal sepsis are often delayed due to the physiological adaptations of pregnancy and vague or absent signs and symptoms during its initial presentation. Over the past decade, our understanding of sepsis has evolved and maternal early warning systems have been developed in an effort to help providers promptly identify and stratify parturients who are at risk. In addition, new consensus definitions and care bundles have recently been published by the World Health Organization and the Surviving Sepsis Campaign to facilitate earlier recognition and timely management of sepsis. In this narrative review, we summarize the available evidence about sepsis and provide an overview of the research efforts focused on maternal sepsis to date. Controversies and challenges surrounding the anesthetic management of parturients with sepsis or at risk of developing sepsis during pregnancy or the puerperium will be highlighted.

COMPARISON OF PATIENTS' ADMISSION, MEAN AND HIGHEST SOFA SCORES IN PREDICTION OF ICU MORTALITY: A PROSPECTIVE OBSERVATIONAL STUDY

Background:

Use of valid criteria for evaluation of patients admitted to intensive care unit (ICU) is essential to assess the quality of services provided. This study was conducted to evaluate admission, mean and the highest Sequential Organ Failure Assessment (SOFA) scores in predicting mortality and outcome of patients admitted to the ICU.

Methods:

This prospective observational study was conducted on 300 patients admitted to the ICU of Imam Khomeini Hospital, Sari, Iran, in 2015. The SOFA tool was applied at the beginning of the admission of patients in the ICU and then every 24 hours. Functions of six vital organs were recorded on a daily basis for scoring with SOFA. Demographic profile, the main diagnosis leading to hospitalization in the ICU, previous interventions, complications and hospital outcomes were recorded for each patient. The patients’ admission, mean and highest SOFA scores were also evaluated and recorded during the study period. These scores were compared between deceased and survived patients. ROC curve determined the best cut-off point of score calculated.

Results:

Among all 300 patients who were enrolled in the study, 189 (63%) cases were males. Trauma was the most common cause of hospitalization and mortality. Thirty point seven percent of 92 deceased patients needed to intubation. Mean length of ICU and hospital stay were significantly longer for deceased patients than the survivors (P <0.001). The admission, mean and highest SOFA scores were 11.72, 16.38 and 16.45 in deceased patients, as well as 6.52, 5.82 and 6.5 in survived patients, respectively. The area under the curve (AUC) for the admission, mean and highest SOFA scores were 0.875, 0.988 and 0982, respectively. All three models were able to predict the outcome of patients significantly (P <0.0001). The cut-off point of 10.6 for the mean SOFA had the highest sensitivity and specificity in predicting mortality.

Conclusion:

The results of this study showed that the mean SOFA score had the highest sensitivity and specificity in prediction of ICU mortality. Therefore, this criterion is a valuable indicator to better predictions of mortality and morbidity rate in the ICU patients, which can lead to appropriate health care and therapeutic interventions in these patients.