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Wang Y, Liu D, Wu X, Zheng C, Chen X. Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes. BMC MEDICAL EDUCATION 2023; 23:781. [PMID: 37858188 PMCID: PMC10588008 DOI: 10.1186/s12909-023-04772-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/13/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Emergency caesarean section (ECS) is an effective method for rapid termination of pregnancy and for saving maternal and foetal life in emergencies. Experts recommend that the interval from decision of operation to the decision to delivery interval (DDI) should be shortened as much as possible. Studies have shown that improving communication skills among staff by performing simulation drills shortens DDI, thus reducing the occurrence of adverse obstetric events and protecting maternal and child safety. In situ simulation (ISS) training is a simulation-based training approach for clinical team members conducted in a real-world clinical setting. In August 2020, Anhui Maternal and Child Health Hospital began ISS training on the rapid obstetric response team (RRT) in our hospital area for emergency caesarean section. This study aimed to investigate the effect of implementing in situ simulation training for emergency caesarean section on maternal and child outcomes by comparing maternal and child-related data on emergency caesarean section in two hospital areas. METHODS Data on cases of emergency caesarean delivery implemented in two hospital districts from August 2020 to August 2022 were collected: 19 in the untrained group and 26 in the training group. The two groups were compared concerning the interval from the decision of operation to the decision to delivery interval (DDI), the interval from the decision of operation to the initiation of skin incision, the interval from skin incision to the decision to delivery interval, and the neonatal situation. RESULTS Primary outcome comparison: The training group had a significantly shorter interval between the DDI compared to the untrained group (8.14 ± 3.13 vs. 11.03 ± 3.52, P = 0.006). Secondary outcomes comparison: The training group had a significantly shorter interval between the decision to cut skin compared to the untrained group (6.45 ± 2.21 vs. 9.95 ± 4.02, P = 0.001). However, there was no significant difference in the interval between cutting skin and infant delivery between the two groups (2.24 ± 0.08 vs. 2.18 ± 0.13, P > 0.05). Additionally, the Apgar score at 1 min after birth was higher in the training group compared to the untrained group (7.29 ± 2.38 vs. 6.04 ± 1.46, P < 0.05). CONCLUSIONS The DDI for emergency caesarean section procedures can be significantly shortened, and neonatal Apgar scores at 1 min improved by implementing in situ simulation training for emergency caesarean section in obstetric rapid response teams. In situ simulation training is an effective tool for training in emergency caesarean section procedures and is worth promoting.
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Affiliation(s)
- Yin Wang
- Department of Obstetrics and Gynecology, Anhui Province Maternity and Child Health Hospital, Hefei, China.
- , Anhui, China.
| | - Dehong Liu
- Department of Obstetrics and Gynecology, Anhui Province Maternity and Child Health Hospital, Hefei, China
| | - Xiumei Wu
- Department of Obstetrics and Gynecology, Anhui Province Maternity and Child Health Hospital, Hefei, China
| | - Chenmin Zheng
- Department of Obstetrics and Gynecology, Anhui Province Maternity and Child Health Hospital, Hefei, China
| | - Xianxia Chen
- Department of Obstetrics and Gynecology, Anhui Province Maternity and Child Health Hospital, Hefei, China
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Liggett MR, Amro A, Son M, Schwulst S. Management of the Pregnant Trauma Patient: A Systematic Literature Review. J Surg Res 2023; 285:187-196. [PMID: 36689816 DOI: 10.1016/j.jss.2022.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality. MATERIALS AND METHODS A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations. RESULTS Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs. CONCLUSIONS We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.
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Affiliation(s)
- Marjorie R Liggett
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Ali Amro
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Moeun Son
- Yale University School of Medicine, Obstetrics, Gynecology & Reproductive Sciences, New Haven, Connecticut
| | - Steven Schwulst
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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3
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Surgery in Pregnancy. Am J Gastroenterol 2022; 117:53-59. [PMID: 36194034 DOI: 10.14309/ajg.0000000000001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 12/11/2022]
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Lu MN, Zhang BL, Dai QH, Fu XH. Application of the Plan-Do-Check-Act Cycle in Shortening the Decision to Delivery Interval Time. Healthc Policy 2022; 15:1315-1323. [PMID: 35832904 PMCID: PMC9271685 DOI: 10.2147/rmhp.s362420] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To discuss the application value of the plan–do–check–act (PDCA) cycle in shortening the decision to delivery interval (DDI) time. Methods A total of 106 DDI cases from the Ningbo Women and Children’s Hospital (China) from January 2019 to December 2020 were selected as the subjects of this study. The causes for the prolongation of DDI were analyzed and protocols were developed. Through continuous summaries and improvement, a standardized process was established to direct clinical application, ie, the PDCA cycle. Results The DDI was shortened from 14.26 min in 2019 to 12.18 min in 2020 and the neonatal asphyxia rate significantly decreased from 34.69% in 2019 to 12.50% in 2020 (P < 0.05). Conclusion The PDCA cycle management mode effectively shortened the DDI time and reduced the neonatal asphyxia rate, without increasing adverse maternal outcomes.
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Affiliation(s)
- Ming-Na Lu
- Department of Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, 315012, People's Republic of China
| | - Bai-Lei Zhang
- Department of Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, 315012, People's Republic of China
| | - Qiao-Hong Dai
- Department of Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, 315012, People's Republic of China
| | - Xian-Hu Fu
- Department of Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, 315012, People's Republic of China
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Weißleder A, Beinkofer D, Gässler H, Treffer D, Dargel S, Schleußner E. [Cardiopulmonary resuscitation of pregnant patients in the rescue service]. Notf Rett Med 2022; 25:359-368. [PMID: 35194395 PMCID: PMC8852988 DOI: 10.1007/s10049-022-00979-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/24/2022]
Abstract
Cardiopulmonary resuscitation of a pregnant patient is a rarity in prehospital emergency medicine and an extraordinary challenge for the emergency team. Besides modifications to emergency medical procedures due to physiological changes during pregnancy, specific reversible causes must be considered and psychosocial difficulties must be managed. This article aims to present a standard operating procedure for this special situation. In these circumstances the basics of crew resource management (CRM) are of special interest for the emergency team and are therefore mentioned in this article.
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Affiliation(s)
- Anne Weißleder
- Klinik für Gynäkologie XX, Bundeswehrkrankenhaus Westerstede, Lange Str. 38, 26655 Westerstede, Deutschland
| | - Daniela Beinkofer
- SG VI-2.2 Gesundheitsrisikobewertung/-Information, Kommando Sanitätsdienst der Bundeswehr, Koblenz, Deutschland
| | - Holger Gässler
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin & Schmerztherapie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Dominik Treffer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerzmedizin, Klinikum St. Elisabeth Straubing, Straubing, Deutschland
| | - Susanne Dargel
- Klinik für Geburtsmedizin, Universitätsklinikum Jena, Jena, Deutschland
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Maternal and neonatal outcomes of preeclamptic and normotensive women who underwent cesarean section under spinal anesthesia: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Moors X, Biesheuvel TH, Cornette J, Van Vledder MG, Veen A, de Quelerij M, Weelink E, Duvekot JJ. Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future. Resuscitation 2020; 155:112-118. [PMID: 32745580 DOI: 10.1016/j.resuscitation.2020.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/08/2020] [Accepted: 07/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the recommended guidelines; and to formulate recommendations. METHODS We performed a population-based retrospective cohort study of all consecutive maternal out-of-hospital cardiac arrests that underwent PCD in the prehospital setting between May 1995 and December 2019. Registered data included patient demographics, operator background, advanced life support interventions, and timelines. Resuscitation performance was evaluated according to the 2015 European Resuscitation Guidelines. RESULTS Seven patients underwent a prehospital PCD. Three mothers died on the scene, while four were transported to a hospital but died in the hospital. Seven neonates were born by PCD. One neonate died on the scene and six were transported to a hospital. Three neonates were eventually discharged from the hospital. Among the three surviving neonates, the periods from dispatch to start of PCD were 13, 14, and 21 min. CONCLUSIONS There was a low incidence of maternal perimortem caesarean deliveries in The Netherlands. Only some neonates survived after PCD. It is recommended that PCD be performed as quickly as possible. Due to the delay, the mother has a far lower chance of survival than the neonate. In fatal cases, autopsy is strongly recommended.
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Affiliation(s)
- Xrj Moors
- Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital, Rotterdam, The Netherlands; HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - T H Biesheuvel
- Department of Surgery and HEMS, VU University Medical Center, Amsterdam, The Netherlands
| | - J Cornette
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M G Van Vledder
- HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands; Trauma Research Unit, Department of Surgery ErasmusMC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Veen
- HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M de Quelerij
- Department of Anaesthesiology, Franciscus Hospital Rotterdam, The Netherlands
| | - Eem Weelink
- Department of Anaesthesiology and HEMS, University Medical Center Groningen, University of Groningen, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Taylor JEA, Ngua CW, Carwardine M. Massive pulmonary embolism in pregnancy: intra-arrest thrombolysis and resuscitative hysterotomy. BMJ Case Rep 2020; 13:e234083. [PMID: 32327458 PMCID: PMC7202774 DOI: 10.1136/bcr-2019-234083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2020] [Indexed: 11/03/2022] Open
Abstract
Massive pulmonary embolism (PE) is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy. The case presented is a primigravida in her mid-30s at 28 weeks gestation. The patient presented to the emergency department after out-of-hospital cardiac arrest. Return of spontaneous circulation (ROSC) was achieved but not sustained. Episodic cardiopulmonary resuscitation with epinephrine boluses was required. Resuscitative hysterotomy was performed intra-arrest. Echocardiography revealed a dilated right heart consistent with massive PE and thrombolysis was administered. ROSC was obtained thereafter and output was sustained. Subsequent CT brain revealed irreversible hypoxic injury. Treatment was withdrawn with the support of family. Postmortem examination confirmed massive PE. Thrombolysis can restore and improve cardiovascular status in cardiac arrest caused by massive PE. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.
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Affiliation(s)
| | - Chen Wen Ngua
- Emergency Unit, University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
| | - Matthew Carwardine
- Anaesthetics, Nevill Hall Hospital, Aneurin Bevan University Health Board, Abergavenny, UK
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10
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Uterine Trauma and Intrauterine Fetal Death Caused by Seatbelt Injury. Case Rep Obstet Gynecol 2019; 2019:5262349. [PMID: 31827955 PMCID: PMC6885207 DOI: 10.1155/2019/5262349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/03/2019] [Indexed: 11/24/2022] Open
Abstract
We present a case of uterine trauma and intrauterine fetal death caused by seatbelt injury. A 37-year-old primigravida at gestational week 24 was involved in a single-car accident when traveling as a front-seat passenger and wearing a three-point seatbelt. Fetal heart rate monitoring patterns revealed fetal demise, and computed tomography revealed intraperitoneal bleeding due to damage to the uterine vessels and placental lacerations across the seatbelt-compressed region. Intensive treatment, including transfusion therapy and surgical laparotomy, prevented the loss of her life but not that of the fetus. Seatbelt use can reduce the overall mortality associated with motor vehicle crashes. Pregnant women must be educated on the proper use of restraints while traveling in motor vehicles.
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Abstract
PURPOSE OF REVIEW The review is intended to serve as a practical clinical aid for the clinician called to maternal cardiac arrest. RECENT FINDINGS Anesthesia complications comprise an important cause of maternal cardiac arrest in developed countries Also predominant are hemorrhage and infections. Recent in-depth reports highlight fractionated care for pregnant women with cardiac and also probably neurological comorbidities. Pathology reports reveal a prevalence of thromboembolic phenomena that is higher than previously assumed but still rare. These are accompanied by particularly high mortality rates. The presenting rhythms of cardiac arrest which differ from most cardiac arrest populations, suggest the need for further in-depth investigation of both the causes and management of these cases. Despite these, outcomes are far better than those of most arrests. Key differences in treatment include are consideration of early airway management and possible medication complications. Pulseless electrical activity and VF should always alert to the possibility of hemorrhage. Echocardiography can diagnose thromboembolism. Also different are the need for Left uterine displacement and early delivery within after 4-5 min of initiation of resuscitation effort in cases with suspected compromise of the venous return or a poor likelihood of a good maternal outcome. SUMMARY Maternal cardiac arrest should be managed similarly to other adult cardiac arrests. At the same time its unique reversible causes require a different form of thought regarding diagnosis and treatment during the code.
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Schaap TP, Overtoom E, van den Akker T, Zwart JJ, van Roosmalen J, Bloemenkamp KWM. Maternal cardiac arrest in the Netherlands: A nationwide surveillance study. Eur J Obstet Gynecol Reprod Biol 2019; 237:145-150. [PMID: 31051417 DOI: 10.1016/j.ejogrb.2019.04.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Maternal cardiac arrest is a complex and demanding clinical situation requiring a well-attuned team effort of healthcare workers of multiple disciplines. A recent report on maternal cardiac arrest in the United Kingdom reported a rise in incidence over a span of 10 years, while maternal mortality increased in the United States between 2000 and 2014. However, reported causes of maternal cardiac arrest differed between both countries. OBJECTIVE(S) To determine the incidence, causes and management of maternal cardiac arrest in the Netherlands and compare incidence with previous estimates in the Netherlands and the United Kingdom. STUDY DESIGN Using the Netherlands Obstetric Surveillance System, all Dutch cases of maternal cardiac arrest during a three-year period (2013-2016) were prospectively collected. Complete casefile copies were obtained for analysis. Main outcome measures were incidence of maternal cardiac arrest and cardiac arrest in pregnancy, use of perimortem caesarean section if appropriate and maternal death. RESULTS The monthly card return rate was 97%; 18 women with cardiac arrest during pregnancy and 20 postpartum met the inclusion criteria. Incidence of maternal cardiac arrest was 7.6 per 100,000 pregnancies and 3.6 per 100,000 pregnancies excluding postpartum maternal cardiac arrest. Main causes were pulmonary embolism (n = 9), major obstetric hemorrhage (n = 7) and amniotic fluid embolism (n = 6). Aortocaval compression relief and perimortem caesarean section were performed in 9/14 (29%) and 11/14 (79%) respectively in pregnancies 20 weeks gestational age onwards. Twenty-two women died, representing a case fatality rate of 58% (95% CI 42-72%). CONCLUSION(S) There is a higher incidence of cardiac arrest in pregnancy compared to both previous estimates in the Netherlands and recently established figures in the United Kingdom. Main causes of maternal cardiac arrest are potentially preventable and/or treatable complications of pregnancy. Insufficient use of critical elements of obstetric resuscitation identifies the need for enhanced obstetric emergency training for obstetric and non-obstetric first responders.
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Affiliation(s)
- Timme P Schaap
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Evelien Overtoom
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joost J Zwart
- Department of Obstetrics and Gynaecology, Deventer hospital, Deventer, the Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands; Athena Institute, VU University, Amsterdam, the Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
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Abstract
Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.
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Affiliation(s)
- Philippa N Soskin
- Department of Emergency Medicine, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, Ground Floor CCC Building, Washington, DC 20007, USA
| | - Jennifer Yu
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, 110 Irving Street Northwest, Suite 4B-42, Washington, DC 20010, USA.
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Grooten WJA, Tseli E, Äng BO, Boersma K, Stålnacke BM, Gerdle B, Enthoven P. Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS-aspects of interrater agreement. Diagn Progn Res 2019; 3:5. [PMID: 31093575 PMCID: PMC6460536 DOI: 10.1186/s41512-019-0050-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/23/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many studies have been performed to identify important prognostic factors for outcomes after rehabilitation of patients with chronic pain, and there is a need to synthesize them through systematic review. In this process, it is important to assess the study quality and risk of bias. The "Quality In Prognosis Studies" (QUIPS) tool has been developed for this purpose and consists of several prompting items categorized into six domains, and each domain is judged on a three-grade scale (low, moderate or high risk of bias). The aim of the present study was to determine the interrater agreement of the risk of bias assessment in prognostic studies of patients with chronic pain using QUIPS and to elaborate on the use of this instrument. METHODS We performed a systematic review and a meta-analysis of prognostic factors for long-term outcomes after multidisciplinary rehabilitation in patients with chronic pain. Two researchers rated the risk of bias in 43 published papers in two rounds (15 and 28 papers, respectively). The interrater agreement and Cohen's quadratic weighted kappa coefficient (κ) and 95% confidence interval (95%CI) were calculated in all domains and separately for the first and second rounds. RESULTS The raters agreed in 61% of the domains (157 out of 258), with similar interrater agreement in the first (59%, 53/90) and second rounds (62%, 104/168). The overall weighted kappa coefficient (kappa for all domains and all papers) was weak: κ = 0.475 (95%CI = 0.358-0.601). A "minimal agreement" between the raters was found in the first round, κ = 0.323 (95%CI = 0.129-0.517), but increased to "weak agreement" in the second round, κ = 0.536 (95%CI = 0.390-0.682). CONCLUSION Despite a relatively low interrater agreement, QUIPS proved to be a useful tool in assessing the risk of bias when performing a meta-analysis of prognostic studies in pain rehabilitation, since it demands of raters to discuss and investigate important aspects of study quality. Some items were particularly hard to differentiate in-between, and a learning phase was required to increase the interrater agreement. This paper highlights several aspects of the tool that should be kept in mind when rating the risk of bias in prognostic studies, and provides some suggestions on common pitfalls to avoid during this process. TRIAL REGISTRATION PROSPERO CRD42016025339; registered 05 February 2016.
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Affiliation(s)
- Wilhelmus Johannes Andreas Grooten
- 0000 0004 1937 0626grid.4714.6Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, SE-141 83 Sweden
- 0000 0000 9241 5705grid.24381.3cAllied Health Professionals Function, Functional area Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, SE-171 76 Sweden
| | - Elena Tseli
- 0000 0004 1937 0626grid.4714.6Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, SE-141 83 Sweden
| | - Björn Olov Äng
- 0000 0004 1937 0626grid.4714.6Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, SE-141 83 Sweden
- 0000 0001 0304 6002grid.411953.bSchool of Education, Health and Social Studies, Dalarna University, Falun, SE-791 88 Sweden
- grid.468144.bCenter for Clinical Research Dalarna - Uppsala University, Falun, SE-791 82 Sweden
| | - Katja Boersma
- 0000 0001 0738 8966grid.15895.30School of Law, Psychology and Social Work, Örebro University, Örebro, SE-701 82 Sweden
| | - Britt-Marie Stålnacke
- 0000 0001 1034 3451grid.12650.30Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, SE-901 87 Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet; Department of Rehabilitation Medicine, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Björn Gerdle
- 0000 0001 2162 9922grid.5640.7Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Paul Enthoven
- 0000 0001 2162 9922grid.5640.7Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
- 0000 0001 2162 9922grid.5640.7Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
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Comito C, Bechi L, Serena C, Checcucci V, Mori E, Micaglio M, Mecacci F, Petraglia F. Cardiac arrest in the delivery room after spinal anesthesia for cesarean section: a case report and review of literature. J Matern Fetal Neonatal Med 2018; 33:1456-1458. [PMID: 30246574 DOI: 10.1080/14767058.2018.1517321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Cardiac arrest in pregnancy is a rare event due to different cause. When it occurs after spinal anesthesia a cause that can explain this event is the Bezold-Jarish Reflex (BJR). A cardiac arrest occurs in a pregnant women after spinal anesthesia admistered for urgent caesarean section. During this event perimortem caesarean delivery (PMCD) is the rapid surgical way that can improve maternal and fetal outcomes. In this situation, it is very important to have a multidisciplinary team of midwives, obstetricians, anesthetists, neonatologists, intensivists that is able to perform perimortem caesarean delivery according to the guidelines.
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Affiliation(s)
- Chiara Comito
- Department of Maternal-Neonatal Care, DAIMI, Careggi University Hospital, Florence, Italy
| | - Lorenzo Bechi
- Department of Maternal Anesthesia, DAIMI, Careggi University Hospital, Florence, Italy
| | - Caterina Serena
- Department of Maternal-Neonatal Care, DAIMI, Careggi University Hospital, Florence, Italy
| | - Vanni Checcucci
- Department of Maternal-Neonatal Care, DAIMI, Careggi University Hospital, Florence, Italy
| | - Emanuele Mori
- Department of Maternal Anesthesia, DAIMI, Careggi University Hospital, Florence, Italy
| | - Massimo Micaglio
- Department of Maternal Anesthesia, DAIMI, Careggi University Hospital, Florence, Italy
| | - Federico Mecacci
- Department of Maternal-Neonatal Care, DAIMI, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Maternal-Neonatal Care, DAIMI, Careggi University Hospital, Florence, Italy
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Lipowicz AA, Cheskes S, Gray SH, Jeejeebhoy F, Lee J, Scales DC, Zhan C, Morrison LJ. Incidence, outcomes and guideline compliance of out-of-hospital maternal cardiac arrest resuscitations: A population-based cohort study. Resuscitation 2018; 132:127-132. [PMID: 30201534 DOI: 10.1016/j.resuscitation.2018.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/20/2018] [Accepted: 09/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Incidence and survival rates after cardiac arrest among pregnant women are reported for in-hospital cardiac arrests; the incidence and outcomes of maternal out-of-hospital cardiac arrest (OHCA) are unknown. Current cardiopulmonary resuscitation guidelines contain recommendations specific to this population; compliance with these has not been investigated. OBJECTIVE To report maternal OHCA incidence, outcomes, and compliance with recommended treatment guidelines. METHODS A population-based cohort study of consecutive maternal OHCAs from 2010 to 2014. Census data of all women of childbearing age provided the comparison. Resuscitation performance was measured against the 2010 American Heart Association (AHA) Guidelines. RESULTS Six maternal OHCAs were identified among 1085 OHCAs occurring in females of child bearing age (15-49) years; Incidence 1.71 per 100,000 pregnant women (95% CI 0.21 to 6.18) vs. 20.18 OHCAs per 100,000 females of child bearing age (95% CI, 18 to 22.62) p < 0.0001. Survival to hospital discharge was 16.7% (95% CI 3.0, 56.4%) after maternal OHCA vs. 6.8% (95% CI 5.4, 8.4) p < 0.0001 after OHCA in all females of childbearing age, and neonatal survival was 33.3% (95% CI 9.7, 70%). CPR quality metric compliance averaged 83% (range 75% to 100%); compliance with pregnancy-specific resuscitation guidelines ranged from 0% (uterine displacement) to 100% (intravenous line insertion above diaphragm and prehospital maternal team activation). CONCLUSION The incidence of maternal OHCA was 1.71:100,000. Survival was higher after maternal OHCA than after OHCA of non-pregnant females of childbearing age. Pregnancy-specific guideline compliance was low suggesting a need for training and better documentation to improve outcomes in these rare events.
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Affiliation(s)
- Alain A Lipowicz
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sheldon Cheskes
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara H Gray
- Departments of Emergency Medicine and Critical Care, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Farida Jeejeebhoy
- Department of Medicine, University of Toronto, Department of Medicine, William Osler Health System, Toronto, ON, Canada
| | - Janice Lee
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Department of Medicine, William Osler Health System, Toronto, ON, Canada
| | - Damon C Scales
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Cathy Zhan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Emergency Medicine, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Ng WM, Lee WF, Cheah SO, Chung YEL, Lee CY, Lim BL. Peri-mortem caesarean section after traumatic arrest: Crisis resource management. Am J Emerg Med 2018; 36:2338.e1-2338.e3. [PMID: 30274760 DOI: 10.1016/j.ajem.2018.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022] Open
Abstract
Peri-mortem caesarean section (PMCS) is a very rare procedure performed to improve the chances of survival for both mother and fetus following cardiorespiratory arrest. Non-obstetricians including Emergency Physicians (EPs) are often called upon to perform this procedure under challenging and suboptimal circumstances. We reported a case of PMCS performed timely after traumatic cardiorespiratory arrest that resulted in fetal survival. A 25-year-old primigravida female and six-month pregnant presented to the Emergency Department (ED) of an adult tertiary hospital. She experienced traumatic cardiorespiratory arrest for nearly 27 min following a high-speed motor vehicle crash. Upon ED arrival, she was in pulseless electrical activity. She was immediately intubated with continuation of cardiopulmonary resuscitation. She received bilateral tube thoracostomies as well as intravenous (IV) transfusion of blood products, adrenaline and tranexamic acid. Her fundal height was two centimeters above the umbilicus on palpation. The EP performed a PMCS via a midline laparotomy 3-4 min upon ED arrival. The baby was bradycardic and cyanosed with no spontaneous respiration at birth and was resuscitated by a second EP. She was intubated and the EP gained IV access using a cannula introduced into the umbilical vein. Neonatal hypothermia was avoided using cling wrap. The baby was transported to a nearby neonatal intensive unit. She survived and is currently one year old. The mother, however, did not respond to our resuscitation and succumbed to her multiple injuries. We reviewed the limited literature regarding this potentially life-saving emergency procedure and highlighted the challenges facing our resuscitation team.
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Affiliation(s)
- Wei Ming Ng
- Emergency Department, Ng Teng Fong General Hospital, Singapore.
| | - Wei Feng Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Si Oon Cheah
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | | | - Chan Yu Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Beng Leong Lim
- Emergency Department, Ng Teng Fong General Hospital, Singapore
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18
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Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol 2018; 219:52-61. [PMID: 29305251 DOI: 10.1016/j.ajog.2017.12.232] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/16/2017] [Accepted: 12/27/2017] [Indexed: 02/03/2023]
Abstract
While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Management of maternal cardiac arrest requires an interdisciplinary team familiar with the physiologic changes of pregnancy and the maternal resuscitation algorithm. Interventions intended to mitigate obstacles such as aortocaval compression, which may undermine the success of resuscitation interventions, must be performed concurrent to standard basic and advanced cardiac life support maneuvers. High-quality chest compressions and oxygenation must be performed along with manual left lateral uterine displacement when the uterine size is ≥20 weeks. While deciphering the etiology of maternal cardiac arrest, diagnoses unique to pregnancy and those of the nonpregnant state should be considered at the same time. If initial basic life support and advanced cardiac life support interventions fail to restore maternal circulation within 4 minutes of cardiac arrest, perimortem delivery is advised provided the uterus is ≥20 weeks' size. Preparations for perimortem delivery are best anticipated by the resuscitation team for the procedure to be executed opportunely. Following delivery, intraabdominal examination may reveal a vascular catastrophe, hematoma, or both. If return of spontaneous circulation has not been achieved, additional interventions may include cardiopulmonary bypass and/or extracorporeal membrane oxygenation. Simulation and team training enhance institution readiness for maternal cardiac arrest. Knowledge gaps are significant in the science of maternal resuscitation. Further research is required to fully optimize: relief of aortocaval compression during the resuscitation process, gestational age and timing of perimortem delivery, and other interventions that deviate from nonpregnant standard resuscitation protocol to achieve successful maternal resuscitation. A robust detailed national and international prospective database was recommended by the International Liaison Committee on Resuscitation in 2015 to facilitate further research unique to cardiac arrest during pregnancy that will produce optimal resuscitation techniques for maternal cardiac arrest.
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19
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Chu JJ, Hinshaw K, Paterson-Brown S, Johnston T, Matthews M, Webb J, Sharpe P. Perimortem caesarean section - why, when and how. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/tog.12493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Justin J Chu
- Birmingham Women's Hospital; Edgbaston, Birmingham B15 2TG UK
| | - Kim Hinshaw
- City Hospitals Sunderland NHS Foundation Trust; Sunderland SR4 7TP UK
| | | | - Tracey Johnston
- Birmingham Women's Hospital; Edgbaston, Birmingham B15 2TG UK
| | | | - Julian Webb
- Surrey and Sussex Healthcare NHS Trust; East Surrey Hospital; Redhill RH1 5RH UK
| | - Paul Sharpe
- University Hospitals of Leicester NHS Trust; Leicester Royal Infirmary; Leicester LE1 5WW UK
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20
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21
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Cox TR, Crimmins SD, Shannon AM, Atkins KL, Tesoriero R, Malinow AM. Liver lacerations as a complication of CPR during pregnancy. Resuscitation 2017; 122:121-125. [PMID: 29097198 DOI: 10.1016/j.resuscitation.2017.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/27/2017] [Accepted: 10/29/2017] [Indexed: 11/26/2022]
Abstract
AIM Cardiac arrest in peripartum patients is a rare but devastating event; reported rates in the literature range from 0.019% to 0.0085%. In the general population, a well-described complication of cardiopulmonary resuscitation (CPR), liver laceration and injury, is reported at a rate of between 0.5-2.9% after CPR. Liver laceration rate among peripartum patients receiving CPR has not been well-studied. We sought to find the rate of liver lacerations in the peripartum population associated with CPR, with the hypothesis that the rate would be higher than in the general population. METHODS We identified pregnancies complicated by cardiac arrest by performing a retrospective medical record review from 2011 to 2016 at a single tertiary referral hospital. We then compared the rate of liver lacerations in this group to the rate in the general population as found in the literature. RESULTS Eleven of 9408 women in the peripartum period suffered cardiac arrest. Return of spontaneous circulation occurred in seven of eleven (64%) women. Three of these seven women suffered clinically significant liver laceration (43%). Overall mortality rate among women suffering cardiac arrest was 82% (9/11).Even after return of spontaneous circulation, the mortality rate was 72%(5/7) including two of three women suffering liver laceration. CONCLUSIONS Based on a small retrospective study, liver lacerations requiring intervention occurred in 43% of gravidas patients that survived CPR, and is significantly higher than published rates (0.6-2.1%) for the general patient population. Further studies are indicated to determine the incidence of liver injury after peripartum CPR.
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Affiliation(s)
- Timothy R Cox
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Sarah D Crimmins
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Allison M Shannon
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kristin L Atkins
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Howard University School of Medicine, Washington, D.C., United States
| | - Ronald Tesoriero
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Andrew M Malinow
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
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22
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Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines. Emerg Med J 2017; 34:318-325. [PMID: 28264877 DOI: 10.1136/emermed-2016-205978] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 10/14/2016] [Accepted: 10/30/2016] [Indexed: 11/04/2022]
Abstract
This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes.
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Affiliation(s)
- E Battaloglu
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - K Porter
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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23
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Pecher S, Williams E. Out-of-hospital cardiac arrest in pregnancy with good neurological outcome for mother and infant. Int J Obstet Anesth 2017; 29:81-84. [DOI: 10.1016/j.ijoa.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 11/24/2022]
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Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: Challenging the four-minute rule. EBioMedicine 2016; 6:253-257. [PMID: 27211568 PMCID: PMC4856753 DOI: 10.1016/j.ebiom.2016.02.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/29/2016] [Accepted: 02/29/2016] [Indexed: 12/04/2022] Open
Abstract
Introduction The current approach to, cardiopulmonary resuscitation of pregnant women in the third trimester has been to adhere to the “four-minute rule”: If pulses have not returned within 4 min of the start of resuscitation, perform a cesarean birth so that birth occurs in the next minute. This investigation sought to re-examine the evidence for the four-minute rule. Methods A literature review focused on perimortem cesarean birth was performed using the same key words that were used in formulating the “four-minute rule.” Maternal and neonatal injury free survival rates as a function of arrest to birth intervals were determined, as well as actual incision to birth intervals. Results Both maternal and neonatal injury free survival rates diminished steadily as the time interval from maternal arrest to birth increased. There was no evidence for any specific survival threshold at 4 min. Skin incision to birth intervals of 1 min occurred in only 10% of women. Conclusion Once a decision to deliver is made, care providers should proceed directly to Cesarean birth during maternal cardiac arrest in the third trimester rather than waiting for 4 min for restoration of the maternal pulse. Birth within 1 min from the start of the incision is uncommon in these circumstances. Half of maternal/fetal pairs who are delivered by Cesarean birth within 25 min survive without injury. The injury free survival rate for both has a roughly linear decrease as the time interval from arrest to birth increases. Very few babies could be delivered within 1 min of the Cesarean section incision.
This information suggests that the current cardio-pulmonary resuscitation guideline in pregnancy, known as the four-minute rule, needs to be changed. Injury free survival for both mother and baby decreases steadily from the moment of cardiac arrest until cesarean birth. Furthermore, in actual practice, the baby usually cannot be delivered within 1 min of the start of surgery. Once a decision for delivery has been made, Cesarean birth should be initiated promptly without waiting for 4 min. In practice, the recommendation to proceed to cesarean birth without delay is also likely to result in less confusion than the current “Four-Minute rule.”
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Affiliation(s)
- M D Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, NorthShore University Health System and Advocate Condell Medical Center, United States.
| | - A Padovano
- Washington University School of Medicine, United States
| | - G Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, United States
| | - Y Zhou
- Center for Biomedical Research Informatics, NorthShore Research Institute, United States
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25
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Kim GS, Yang M, Chang CH, Lee EK, Choi JY. Management of cardiac arrest in a parturient with Eisenmenger's syndrome and complete atrioventricular block during Cesarean section: a case report. Korean J Anesthesiol 2015; 68:617-21. [PMID: 26634088 PMCID: PMC4667150 DOI: 10.4097/kjae.2015.68.6.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/25/2014] [Accepted: 04/28/2014] [Indexed: 11/15/2022] Open
Abstract
A 26-year-old parturient with Eisenmenger's syndrome and complete atrioventricular block was presented for emergency Cesarean section due to preterm labor. Ventricular tachycardia (VT), which progressed to ventricular fibrillation (VF), started immediately after the incision. Cardiopulmonary resuscitation with electric shocks was given by anesthesiologists while the obstetrician delivered the baby between the shocks. A cardiac surgeon was ready for extracorporeal membrane oxygenation institution in case of emergency but spontaneous circulation of the patient returned after the 3rd shock and the delivery of the baby. The newborn's Apgar score was 4 at 1 minute and 8 at 5 minutes. An implantable cardioverter-defibrillator was inserted before the discharge because the patient had recurrent episodes of VT and VF postoperatively.
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Affiliation(s)
- Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choo Hoon Chang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Yeon Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, Katz VL, Lapinsky SE, Einav S, Warnes CA, Page RL, Griffin RE, Jain A, Dainty KN, Arafeh J, Windrim R, Koren G, Callaway CW. Cardiac Arrest in Pregnancy. Circulation 2015; 132:1747-73. [DOI: 10.1161/cir.0000000000000300] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.
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27
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Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. Am J Obstet Gynecol 2015. [PMID: 26212180 DOI: 10.1016/j.ajog.2015.07.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Even if intrauterine demise has already occurred, maternal resuscitative efforts will typically be markedly improved following delivery with uterine decompression. Consequently we suggest that perimortem cesarean delivery be renamed "resuscitative hysterotomy" to reflect the mutual optimization of resuscitation efforts that would potentially provide earlier and more substantial benefit to both mother and baby.
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Affiliation(s)
- Carl H Rose
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
| | - Arij Faksh
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Kyle D Traynor
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | - Brian C Brost
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC
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Holmes S, Kirkpatrick ID, Zelop CM, Jassal DS. MRI evaluation of maternal cardiac displacement in pregnancy: implications for cardiopulmonary resuscitation. Am J Obstet Gynecol 2015; 213:401.e1-5. [PMID: 25981849 DOI: 10.1016/j.ajog.2015.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/22/2015] [Accepted: 05/10/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to determine, with the use of cardiac magnetic resonance imaging, whether there is vertical displacement of the heart during pregnancy. Cardiopulmonary resuscitation guidelines during pregnancy recommend placing the hands 2-3 cm higher on the sternum than in nonpregnant individuals. This recommendation is based on the presumption that the heart is displaced superiorly by the diaphragm during the third trimester. Whether there is true cardiac displacement because of the expanding uterus in pregnancy remains unknown. STUDY DESIGN A total of 34 healthy female volunteers 18-35 years old were enrolled prospectively from 2010-2012 at 2 tertiary care centers. The conditions of all participants were evaluated with cardiac magnetic resonance imaging in the one-half left lateral decubitus position during the third trimester of pregnancy and again at a minimum of 3 months after delivery (surrogate for the nonpregnant state). Superior displacement of the heart was determined by measurement of the distance between the inferior aspect of the clavicular heads and the coronary sinus at both time points. RESULTS The study population included 34 women (mean age, 29 ± 3 years; body mass index, 24 ± 4 kg/m(2)). The mean gestational age at third-trimester imaging was 237 ± 16 days (34 weeks ± 16 days); the mean number of days for postpartum imaging (baseline) was 107 ± 25 days (16 weeks ± 25 days). There was no statistical difference between the cardiac position at baseline (10.1 ± 1.2 cm) and during the third trimester (10.3 ± 1.1 cm; P = .22). CONCLUSION Contrary to popular assumption, there is no significant vertical displacement of the heart in the third trimester of pregnancy relative to the nonpregnant state. Accordingly, there is no need to alter hand placement for chest compressions during cardiopulmonary resuscitation in pregnancy.
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Maternal collapse: Training in resuscitation. Best Pract Res Clin Obstet Gynaecol 2015; 29:1058-66. [PMID: 26277335 DOI: 10.1016/j.bpobgyn.2015.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/09/2015] [Indexed: 11/23/2022]
Abstract
The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) of South Africa has recommended in the Sixth Saving Mothers Report that health-care professionals (HCPs) training in managing obstetric emergencies be improved. One such measure is to ensure that the Essential Steps in Managing Obstetric Emergencies (ESMOE) with its Emergency Obstetric Simulation Training (EOST) be rolled out to every HCP working in the obstetric environment. The programme has been strengthened and rolled out in the province of KwaZulu-Natal, South Africa. This review focuses on the various teaching methods used to improve maternal resuscitation training in a South African context. Evidence-based interventions in maternal resuscitation will be highlighted, and recommendations for clinical practice will be suggested. Common causes of maternal collapse will be explored, and measures to improve training in these areas will be outlined. In order to ensure sustainability, quality improvement measures need to be introduced and evaluated.
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30
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The pregnant heart: cardiac emergencies during pregnancy. Am J Emerg Med 2015; 33:573-9. [DOI: 10.1016/j.ajem.2015.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 11/23/2022] Open
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Benzidi Y, Jourdain M. Complications cardiovasculaires de la grossesse et du peripartum. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1042-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Burrage PS, Shernan SK, Tsen LC, Fox JA, Wilusz K, Eltzschig HK, Hilberath JN. Emergent transesophageal echocardiography in hemodynamically unstable obstetric patients. Int J Obstet Anesth 2015; 24:131-6. [PMID: 25683381 DOI: 10.1016/j.ijoa.2014.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 11/29/2014] [Accepted: 12/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The obstetric population has an increasing incidence of comorbid conditions. These, coupled with the possibility of acute embolic events involving air, amniotic fluid, and thrombus, increase the likelihood of hemodynamic instability. Although the utility of transesophageal echocardiography to guide management in cardiac and high-risk, non-cardiac surgical populations has been well established, the emergent use in critically-ill parturients has not been comprehensively evaluated. METHODS Using our departmental transesophageal echocardiography database of 28 293 examinations, parturients were identified who underwent emergent transesophageal echocardiography for evaluation of hemodynamic instability, including cardiac arrest, between January 1999 and March 2014. Transesophageal echocardiography findings and their impact on patient management were analyzed. RESULTS Ten peripartum patients were evaluated. Six patients became unstable during dilation and evacuation procedures; one after a forceps delivery; one during and one after cesarean delivery; and one during a postpartum laparotomy. Six patients proceeded to cardiac arrest; however, all women survived their initial operation and resuscitation. Transesophageal echocardiography was instrumental in determining the etiology and guiding resuscitation in all 10 patients including emergent cardiac surgical intervention with cardiopulmonary bypass (n=2). Seven patients survived to hospital discharge, but three died after experiencing neurologic complications. CONCLUSIONS Severe hemodynamic instability and cardiac arrest can occur in previously healthy parturients in pregnancy. Our data suggest that emergent transesophageal echocardiography is a valuable tool in determining the etiology and directing therapy of refractory hypotension or cardiac arrest in obstetric patients.
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Affiliation(s)
- P S Burrage
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - S K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - K Wilusz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - H K Eltzschig
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, CO, USA
| | - J N Hilberath
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Critical Care Medicine, Eberhard Karls University, Tübingen, Germany.
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Jeejeebhoy F, Windrim R. Management of cardiac arrest in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:607-18. [DOI: 10.1016/j.bpobgyn.2014.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 03/14/2014] [Indexed: 10/25/2022]
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Lipman S, Cohen S, Einav S, Jeejeebhoy F, Mhyre JM, Morrison LJ, Katz V, Tsen LC, Daniels K, Halamek LP, Suresh MS, Arafeh J, Gauthier D, Carvalho JCA, Druzin M, Carvalho B. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy. Anesth Analg 2014; 118:1003-16. [DOI: 10.1213/ane.0000000000000171] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Laher A, Goldstein L, Wells M, Mahomed Z, Gihwala R, Moodley P. Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy. Afr J Emerg Med 2013. [DOI: 10.1016/j.afjem.2013.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abstract
An emergent cesarean delivery is performed to immediately intervene to improve maternal or fetal outcome for such indications as fetal distress, prolapsed cord, maternal hemorrhage from previa or trauma, uterine rupture, and complete placental abruption. It is paramount to reduce morbidity and mortality by preparing health care providers for special precautions.
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Managing maternal cardiac arrest in Canada:--we're doing OK, but we can do better. Can J Anaesth 2013; 60:1041-6. [PMID: 24026580 DOI: 10.1007/s12630-013-0027-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022] Open
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Maternal cardiac arrest: a practical and comprehensive review. Emerg Med Int 2013; 2013:274814. [PMID: 23956861 PMCID: PMC3730371 DOI: 10.1155/2013/274814] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/09/2013] [Indexed: 12/02/2022] Open
Abstract
Cardiac arrest during pregnancy is a dedicated chapter in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; however, a robust maternal cardiac arrest knowledge translation strategy and emergency response plan is not usually the focus of institutional emergency preparedness programs. Although maternal cardiac arrest is rare, the emergency department is a high-risk area for receiving pregnant women in either prearrest or full cardiac arrest. It is imperative that institutions review and update emergency response plans for a maternal arrest. This review highlights the most recent science, guidelines, and recommended implementation strategies related to a maternal arrest. The aim of this paper is to increase the understanding of the important physiological differences of, and management strategies for, a maternal cardiac arrest, as well as provide institutions with the most up-to-date literature on which they can build emergency preparedness programs for a maternal arrest.
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Ip JK, Campbell JP, Bushby D, Yentis SM. Cardiopulmonary resuscitation in the pregnant patient: a manikin-based evaluation of methods for producing lateral tilt. Anaesthesia 2013; 68:694-9. [DOI: 10.1111/anae.12181] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2013] [Indexed: 11/28/2022]
Affiliation(s)
- J. K. Ip
- Chelsea and Westminster Hospital; London; UK
| | | | - D. Bushby
- Chelsea and Westminster Hospital; London; UK
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Kohama H, Komasawa N, Ueki R, Yamamoto N, Tashiro C, Kaminoh Y, Nishi SI. Utility of the Pentax-AWS Airwayscope and Macintosh laryngoscope for airway management during chest compressions in 27° left-lateral tilt: a manikin simulation study of maternal cardiopulmonary resuscitation. J Anesth 2013; 27:671-5. [DOI: 10.1007/s00540-013-1619-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/12/2013] [Indexed: 11/29/2022]
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Butwick A. What’s New in Obstetric Anesthesia in 2011? Reducing Maternal Adverse Outcomes and Improving Obstetric Anesthesia Quality of Care. Anesth Analg 2012; 115:1137-45. [DOI: 10.1213/ane.0b013e31826af982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Smith A, Edwards S, Siassakos D. Effective team training to improve outcomes in maternal collapse and perimortem caesarean section. Resuscitation 2012; 83:1183-4. [DOI: 10.1016/j.resuscitation.2012.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 07/06/2012] [Indexed: 10/28/2022]
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Hards A, Davies S, Salman A, Erik-Soussi M, Balki M. Management of simulated maternal cardiac arrest by residents: didactic teaching versus electronic learning. Can J Anaesth 2012; 59:852-60. [DOI: 10.1007/s12630-012-9752-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 06/21/2012] [Indexed: 10/28/2022] Open
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Abstract
The International Liaison Committee on Resuscitation advocates for rapid implementation of critical interventions to provide the best chance of survival for patients experiencing a cardiac arrest. Standard educational programs do not include population-specific interventions or modifications. This article provides information regarding how to use an established Advanced Cardiovascular Life Support program as the foundation on which to build a population-specific course. The purpose of creating this blended program is to meet the learning needs of the obstetric healthcare provider and standardize care across all settings, particularly in the perioperative and postanesthesia areas.
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Vencken PM, van Hooff MH, van der Weiden RM. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training. Am J Obstet Gynecol 2012; 206:e4; author reply e5. [PMID: 22182682 DOI: 10.1016/j.ajog.2011.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/22/2011] [Indexed: 11/28/2022]
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Baugher KM, Mattu A. Ten rules to assess and manage the acutely deteriorating patient: a practical mnemonic. Patient Saf Surg 2011; 5:29. [PMID: 22085469 PMCID: PMC3248865 DOI: 10.1186/1754-9493-5-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/15/2011] [Indexed: 11/10/2022] Open
Abstract
The acutely deteriorating patient is a challenge to even the most seasoned provider. The ability to diagnosis the underlying condition quickly and accurately is vital to a successful outcome. We present a review of 10 critical aspects in the management of the crashing patient, based on up-to-date guidelines and organized as an easily remembered mnemonic. The A-A-B-B-C-C-D-D-E-E's of the deteriorating patient address many key pearls and current recommendations to give physicians an added advantage in the moment of crisis.
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Affiliation(s)
- Katherine M Baugher
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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King SE, Gabbott DA. Maternal cardiac arrest—Rarely occurs, rarely researched. Resuscitation 2011; 82:795-6. [DOI: 10.1016/j.resuscitation.2011.03.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 03/27/2011] [Indexed: 11/24/2022]
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