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Avila-Hilari A, Tinoco-Solórzano A, Vélez-Páez J, Avellanas-Chavala ML. Critical pregnancy at altitude: A look at Latin America. Med Intensiva 2024; 48:411-420. [PMID: 38704303 DOI: 10.1016/j.medine.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/25/2024] [Indexed: 05/06/2024]
Abstract
Critical pregnancy at high altitudes increases morbidity and mortality from 2500 m above sea level. In addition to altitude, there are other influential factors such as social inequalities, cultural, prehospital barriers, and lack the appropriate development of healthcare infrastructure. The most frequent causes of critical pregnancy leading to admission to Intensive Care Units are pregnancy hypertensive disorders (native residents seem to be more protected), hemorrhages and infection/sepsis. In Latin America, there are 32 Intensive Care Units above 2500 m above sea level. Arterial blood gases at altitude are affected by changes in barometric pressure. The analysis of their values provides very useful information for the management of obstetric emergencies at very high altitude, especially respiratory and metabolic pathologies.
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Affiliation(s)
- Adrián Avila-Hilari
- Unidad de Terapia Intensiva, Hospital Municipal Boliviano Holandés, El Alto, Bolivia
| | - Amilcar Tinoco-Solórzano
- Servicio de Cuidados Intensivos e Intermedios, Seguro Social de Salud (EsSalud), Hospital Nacional Ramiro Prialé Prialé, Huancayo, Perú
| | - Jorge Vélez-Páez
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Quito, Ecuador
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2
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Sodhi A, Cox-Flaherty K, Greer MK, Lat TI, Gao Y, Polineni D, Pisani MA, Bourjeily G, Glassberg MK, D'Ambrosio C. Sex and Gender in Lung Diseases and Sleep Disorders: A State-of-the-Art Review: Part 2. Chest 2023; 163:366-382. [PMID: 36183784 PMCID: PMC10083131 DOI: 10.1016/j.chest.2022.08.2240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023] Open
Abstract
There is now ample evidence that differences in sex and gender contribute to the incidence, susceptibility, presentation, diagnosis, and clinical course of many lung diseases. Some conditions are more prevalent in women, such as pulmonary arterial hypertension and sarcoidosis. Some life stages-such as pregnancy-are unique to women and can affect the onset and course of lung disease. Clinical presentation may differ as well, such as the higher number of exacerbations experienced by women with cystic fibrosis (CF), more fatigue in women with sarcoidosis, and more difficulty in achieving smoking cessation. Outcomes such as mortality may be different as well, as indicated by the higher mortality in women with CF. In addition, response to therapy and medication safety may also differ by sex, and yet, pharmacogenomic factors are often not adequately addressed in clinical trials. Various aspects of lung/sleep biology and pathobiology are impacted by female sex and female reproductive transitions. Differential gene expression or organ development can be impacted by these biological differences. Understanding these differences is the first step in moving toward precision medicine for all patients. This article is the second part of a state-of-the-art review of specific effects of sex and gender focused on epidemiology, disease presentation, risk factors, and management of selected lung diseases. We review the more recent literature and focus on guidelines incorporating sex and gender differences in pulmonary hypertension, CF and non-CF bronchiectasis, sarcoidosis, restless legs syndrome and insomnia, and critical illness. We also provide a summary of the effects of pregnancy on lung diseases and discuss the impact of sex and gender on tobacco use and treatment of nicotine use disorder.
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Affiliation(s)
- Amik Sodhi
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, WI
| | - Katherine Cox-Flaherty
- Division of Pulmonary, Critical Care and Sleep Medicine, Brown University, Providence, RI
| | - Meredith Kendall Greer
- Division of Pulmonary, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Tasnim I Lat
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott & White Health, Temple, TX
| | - Yuqing Gao
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Arizona College of Medicine Phoenix, Phoenix, AZ
| | - Deepika Polineni
- Division of Pulmonary, Critical Care and Sleep Medicine, Washington University at St. Louis, St. Louis, MO
| | - Margaret A Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT
| | - Ghada Bourjeily
- Division of Pulmonary, Critical Care and Sleep Medicine, Brown University, Providence, RI
| | - Marilyn K Glassberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Arizona College of Medicine Phoenix, Phoenix, AZ
| | - Carolyn D'Ambrosio
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT.
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Bovbjerg ML, Leitao S, Corcoran P, O'Regan L, Greene RA, Manning E, Byrne B, Cooley S, Daly D, Fallon A, Higgins M, Jones C, Kinsells I, Murphy C, Murphy J, Ni Bhuinneain M. Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014–2016. Eur J Obstet Gynecol Reprod Biol 2022; 279:183-190. [DOI: 10.1016/j.ejogrb.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
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Roberts CM, Williams D, Ceneviva GD, Walter V, Thomas NJ, Krawiec C. Frequency and Results of Pregnancy Screening in Critically Ill Adolescents in Multiple Health Care Organizations. J Adolesc Health 2022; 71:552-558. [PMID: 35715348 DOI: 10.1016/j.jadohealth.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Adolescent females may undergo pregnancy screening while receiving critical care services, but the frequency and results are unknown. The objectives of this study are to evaluate patient characteristics, pregnancy screening frequency, and rate of positive pregnancy screens in adolescent females of childbearing age who require critical care services. We hypothesize that when adolescent pregnancy screening is performed in the critical care setting, it occurs in a higher frequency in older subjects. METHODS This is a multicenter retrospective observational cohort study utilizing TriNetX, an electronic health record database. The following electronic health record data were collected and evaluated in adolescent females aged 12-18 years and billed for critical care services: age, race, ethnicity, diagnostic codes, selected radiology and surgical procedure codes, number of deaths, pregnancy screening laboratory codes, and pregnancy screening results. RESULTS A total of 5,241 subjects (2,242 [42.8%] subjects for whom pregnancy screen was noted and 2,999 [57.2%] subjects for whom it was not noted) were included in this study. Subjects aged 15-18 years (odds ratio = 1.56, 95% confidence interval = 1.38-1.77, p value < .0001) and had Hispanic or Latina ethnicity (odds ratio = 1.46, 95% confidence interval = 1.28-1.66, p value < .0001) had a higher association with pregnancy screening. A positive pregnancy screen was identified in 18 (0.8%) subjects. DISCUSSION In our study, positive pregnancy screens were infrequent, not all subjects were screened, and there was an association between pregnancy screening and ethnicity. Because of the potential for screening bias, this study suggests that clinicians should strongly consider routine pregnancy screening for all females of childbearing age and that hospital policies should require this type of screening.
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Affiliation(s)
| | - Duane Williams
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Gary D Ceneviva
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Vonn Walter
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Neal J Thomas
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania; Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania.
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Maternal Risk Modeling in Critical Care-Development of a Multivariable Risk Prediction Model for Death and Prolonged Intensive Care. Crit Care Med 2021; 48:663-672. [PMID: 31923028 DOI: 10.1097/ccm.0000000000004223] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care. DESIGN We used data from a high-quality prospectively collected national database, supported with literature review and expert opinion. We tested univariable associations between each risk factor and outcome. We then developed two separate multivariable logistic regression models for the outcomes of acute hospital mortality and death or prolonged ICU length of stay. We validated two parsimonious risk prediction models specific for a maternal population. SETTING The Intensive Care National Audit and Research Centre Case Mix Programme is the national clinical audit for adult critical care in England, Wales, and Northern Ireland. PATIENTS All female admissions to adult general critical care units, for the period January 1, 2007-December 31, 2016, 16-50 years old, and admitted either while pregnant or within 42 days of delivery-a cohort of 15,480 women. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care. For the primary outcome of acute hospital mortality, our parsimonious risk model consisting of eight variables had an area under the receiver operating characteristic of 0.96 (95% CI, 0.91-1.00); these variables are commonly available for all maternal admissions. For the secondary composite outcome of death or ICU length of stay greater than 48 hours, the risk model consisting of 17 variables had an area under the receiver operating characteristic of 0.80 (95% CI, 0.78-0.83). CONCLUSIONS We developed risk prediction models specific to the maternal critical care population. The models compare favorably against general adult ICU risk prediction models in current use within this population.
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Koukoubanis K, Prodromidou A, Stamatakis E, Valsamidis D, Thomakos N. Role of Critical Care Units in the management of obstetric patients (Review). Biomed Rep 2021; 15:58. [PMID: 34007451 DOI: 10.3892/br.2021.1434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/19/2021] [Indexed: 11/06/2022] Open
Abstract
Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recommended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives.
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Affiliation(s)
- Konstantinos Koukoubanis
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, 'Alexandra' Hospital, 11528 Athens, Greece
| | - Anastasia Prodromidou
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, 'Alexandra' Hospital, 11528 Athens, Greece
| | - Emmanouil Stamatakis
- Department of Anesthesiology and Pain Management, 'Alexandra' General Hospital of Athens, 11528 Athens, Greece
| | - Dimitrios Valsamidis
- Department of Anesthesiology and Pain Management, 'Alexandra' General Hospital of Athens, 11528 Athens, Greece
| | - Nikolaos Thomakos
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, 'Alexandra' Hospital, 11528 Athens, Greece
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Abstract
Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Aleta S Hong
- Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/hong_aleta
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Shehabi Y, Al-Bassam W, Pakavakis A, Murfin B, Howe B. Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm. Semin Respir Crit Care Med 2020; 42:98-111. [PMID: 32957139 DOI: 10.1055/s-0040-1716736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.
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Affiliation(s)
- Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia.,Prince of Wales Clinical School of Medicine, University of New South Wales, Randwick, New South Wales, Sydney, Australia
| | - Wisam Al-Bassam
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Adrian Pakavakis
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Brendan Murfin
- Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Belinda Howe
- The Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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Patel S, Estevez A, Nedeff N, Gascon J, Lee I. ICU management of the obstetric patient. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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10
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Erel M, Güzel A, Çelik F, Yıldırım ZB, Kavak GÖ. Yoğun Bakım Ünitesinde Yatan Obstetrik ve Obstetrik Olmayan Hastaların Maliyet ve Sağkalım Analizlerinin Karşılaştırılması. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.539976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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11
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Reducing Maternal Mortality and Severe Maternal Morbidity: The Role of Critical Care. Clin Obstet Gynecol 2019; 61:359-371. [PMID: 29629925 DOI: 10.1097/grf.0000000000000370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Throughout most of the 20th century, the risk of maternal mortality in high resource countries decreased dramatically; however, this trend recently has stalled in the United States and appears to have reversed. Equally alarming is that for every reported maternal death, there are numerous severe maternal morbidities or near misses. Shifting maternal demographics (eg, obesity, advanced maternal age, multifetal pregnancies), with attendant significant medical comorbidities (eg, hypertension, diabetes, cardiac disease) and the increase in cesarean deliveries significantly contribute to increased maternal morbidity and mortality. This chapter focuses on the role of critical care in reducing maternal mortality and morbidity.
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12
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Cypher RL. Pulmonary Edema in Obstetrics: Essential Facts for Critical Care Nurses. AACN Adv Crit Care 2019; 29:327-335. [PMID: 30185499 DOI: 10.4037/aacnacc2018958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Pulmonary edema is an acute pregnancy complication that, if uncorrected, can result in increased maternal and fetal morbidity and mortality. Although pulmonary edema is relatively rare in the general obstetrics population, pregnant patients are at increased risk for pulmonary edema because of the physiologic changes of pregnancy. The risk may be exacerbated by certain pregnancy-related diseases, such as preeclampsia. Prompt identification and appropriate clinical management of pulmonary complications is critical to prevent adverse outcomes in pregnant patients. This article reviews the collaborative treatment of pulmonary edema in pregnant women with complex critical illnesses.
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Affiliation(s)
- Rebecca L Cypher
- Rebecca L. Cypher is a Perinatal Nurse Practitioner and Consultant, 7814 108th St NW, Gig Harbor, WA 98332
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13
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Viau-Lapointe J, D'Souza R, Rose L, Lapinsky SE. Development of a Core Outcome Set for research on critically ill obstetric patients: A study protocol. Obstet Med 2018; 11:132-136. [PMID: 30214479 DOI: 10.1177/1753495x18772996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/13/2018] [Indexed: 11/16/2022] Open
Abstract
Background Current data on critical illness during pregnancy are insufficient for evidence-based decision making. Core outcome sets are promoted to improve reporting of outcomes important to decision makers. We aim to develop a Core Outcome Set for research on critically ill obstetric patients (COSCO study). Methods We will perform a systematic review of studies on critical illness in pregnancy and focus groups or interviews with women who were critically ill while being pregnant. These data will inform an international Delphi survey where stakeholders will rank proposed outcomes. Selected outcomes will be brought forward to a consensus meeting where core outcomes will be defined. We will then complete a second consensus process to define measures for each core outcome. Conclusion The Core Outcome Set on Critically ill Obstetric patients study aims to develop a set of core outcomes to be part of all studies on critically ill obstetric patients. Implementation of this core outcome set will help improve future research efforts.Trial registration: This study is registered on the COMET-initiative website (COS #916). This systematic review is registered on PROSPERO (CRD #42017071944).
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Affiliation(s)
- Julien Viau-Lapointe
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Louise Rose
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College, London, UK
| | - Stephen E Lapinsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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14
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A Standardized Approach to Electronic Fetal Monitoring in Critical Care Obstetrics. J Perinat Neonatal Nurs 2018; 32:212-221. [PMID: 29965826 DOI: 10.1097/jpn.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From the periphery, pregnancy is a common event in women of childbearing age. Normal anatomic and physiologic adaptations occur and, in most cases, will result in ideal maternal-fetal outcomes. Yet, every day, obstetric clinicians are facing complex pregnancies with complicated life-threatening conditions or coexisting medical and surgical problems that not only alter maternal physiology but also impact fetal survival. A challenge in this population is individualizing maternal-fetal care in critical care women while integrating medical-surgical specialties in creating an interdisciplinary team with similar management goals. Questions frequently arise concerning admission criteria, location of care, as well as type and mix of personnel. Furthermore, how to simultaneously manage a critically ill parturient while monitoring a viable fetus is often obscured. This article focuses on crucial fetal monitoring concepts using a standardized approach to interpretation and management in pregnancies managed in an intensive care environment. Application of fetal monitoring during surgical procedures, during perimortem cesarean birth, and in women who have irreversible loss of brain function is included.
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15
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Özçelik M, Turhan S, Bermede O, Yılmaz AA, Ünal N, Bayar MK. Outcomes of Antepartum and Postpartum Obstetric Admissions to the Intensive Care Unit of A Tertiary University Hospital: An 8-Year Review. Turk J Anaesthesiol Reanim 2017; 45:303-309. [PMID: 29114416 DOI: 10.5152/tjar.2017.56323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/28/2017] [Indexed: 12/29/2022] Open
Abstract
Objective Although their rates are decreasing, pregnancy-related mortality and morbidity are problems worldwide. In this study, we aimed to review the characteristics, diagnoses, required interventions and outcomes of obstetric patients admitted between 2006 and 2014 to the Intensive Care Unit (ICU) of a tertiary university hospital to provide an indicator for improving the management of critically ill obstetric patients. Methods A retrospective study of hospital records of obstetric admissions to the ICU was conducted. Results The pregnancy-related ICU admission rate was 0.21% among all deliveries during the study period. Nine antepartum (mean gestational age: 23 weeks) and 48 postpartum (mean gestational age: 34 weeks) obstetric ICU admissions were included. Most obstetric patients admitted antepartum were primiparous (88.8%), whereas those admitted postpartum were multiparous (64.6%). The mean ICU stay was 7 days among the patients admitted antepartum and 6 days among those admitted postpartum. Common medical reasons for ICU admission were respiratory failure and HELLP syndrome in both groups; DIC and eclampsia were also medical reasons causing ICU admission among the postpartum patients. Mechanical ventilation and blood derivative transfusion were the most common interventions required during the ICU stay of the obstetric patients. Maternal death was unique to the patients admitted postpartum (6 patients, 12.5%). Conclusion We reviewed obstetric admissions to our institution over an 8-year period. We believe that a nationwide study in Turkey that provides an indicator of the frequency, reasons of ICU admission and outcome of obstetric patients is required to improve the quality of intensive care.
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Affiliation(s)
- Menekşe Özçelik
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Sanem Turhan
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Onat Bermede
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Abbas Yılmaz
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Necmettin Ünal
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Kemal Bayar
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
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Escobar MF, Carvajal JA, Nieto AJ, Messa A, Burgos JM, Echavarría MP, Granados M. Model of obstetric attention based on critical care in Latin America. J Matern Fetal Neonatal Med 2017; 31:3139-3146. [PMID: 28782392 DOI: 10.1080/14767058.2017.1365128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Report the results obtained following the implementation of an OCC (Obstetric Critical Care) model. MATERIALS AND METHODS This is an observational prospective study in obstetric population with high complexity illness attended in a safety and quality model of attention in a specific unit supporting the concept of obstetric critical care. Records were used as the primary source for collecting information, using the standards of the Center for Clinical Research. RESULTS In a 5-year period, 10,956 patients were admitted. About 51% had diseases that were not exclusive to pregnancy, 91% were admitted while pregnant and, from all births, 46% were by vaginal delivery. 1685 (19%) patients met the criteria for Near Miss Maternal Mortality (NMMM). Forty-three patients died, which represented a mortality rate of 0.49% of the total of hospitalized patients. CONCLUSIONS The implementation of an OOC model, security models, and an institutional support system improve the quality of care in the obstetric services of reference hospitals in developing countries.
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Affiliation(s)
- María F Escobar
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Javier A Carvajal
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Albaro J Nieto
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Adriana Messa
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Juan M Burgos
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Maria P Echavarría
- a Department of Gynecology and Obstetrics , Fundación Clínica Valle del Lili , Cali , Colombia
| | - Marcela Granados
- b Department of Internal Medicine , Fundación Clínica Valle del Lili , Cali , Colombia
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Neurologic complications in critically ill pregnant patients. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190440 DOI: 10.1016/b978-0-444-63599-0.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.
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Oud L. Epidemiology of Pregnancy-Associated ICU Utilization in Texas: 2001 - 2010. J Clin Med Res 2017; 9:143-153. [PMID: 28090230 PMCID: PMC5215018 DOI: 10.14740/jocmr2854w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND ICU admission is uncommon among obstetric patients. Nevertheless, the epidemiology of ICU utilization is considered to be a useful proxy for study of severe maternal morbidity and near-miss events. However, there is paucity of population-level studies in obstetric patients in the United States. METHODS The Texas Inpatient Public Use Data File and state-based reports were used to identify pregnancy-associated hospitalizations and those involving admission to ICU (n = 158,410) for the years 2001 - 2010. The clinical characteristics, outcomes, and the overall incidence and temporal trends of ICU admission were examined and stratified analyses of pregnancy outcomes were performed in specific categories of pregnancy-associated hospitalizations. In addition, ICU utilization among hospitalizations with maternal complications and organ dysfunction was evaluated. RESULTS Chronic comorbidities (9.7%) and presence of organ dysfunction (6.2%) were uncommon among ICU admissions, with 26.5% having high severity of illness. The incidence of ICU admission was 39.0 per 1,000 pregnancy-associated hospitalizations-years. Marked variability was found in ICU admission both across pregnancy outcomes (ranging from 0.6 per 1,000 abortions-years to 85.9 per 1,000 stillbirths-years) and categories of pregnancy-associated hospitalizations (ranging from 32.1 per 1,000 delivery hospitalizations-years to 144.8 per 1,000 postpartum hospitalizations-years). The incidence of ICU admission rose 68% among pregnancy-associated hospitalizations and for all examined subgroups, except abortion. Preeclampsia/eclampsia (23.3%) and obstetric hemorrhage (6.9%) were the most common maternal complications among ICU admissions. Four hundred fourteen women (0.3%) died, while 97.6% were discharged home. CONCLUSIONS This study documents the highest incidence of ICU utilization in obstetric patients in the US to date. The findings suggest low threshold for obstetric ICU admissions in the state and do not support comparative use of ICU utilization as surrogate measure for populations' burden of severe maternal morbidity and near-miss events. Nevertheless, the demonstrated tremendous heterogeneity in ICU utilization across examined subgroups identifies new high-risk groups of obstetric patients that would benefit from heightened clinician vigilance and timely ICU triage and care. Further studies are needed to inform reduction in avoidable variability in ICU utilization to both enhance maternal, fetal, and neonatal outcomes and to improve resource allocation.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA.
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Ayala Quintanilla BP, Taft A, McDonald S, Pollock W, Roque Henriquez JC. Social determinants and maternal exposure to intimate partner violence of obstetric patients with severe maternal morbidity in the intensive care unit: a systematic review protocol. BMJ Open 2016; 6:e013270. [PMID: 27895065 PMCID: PMC5168548 DOI: 10.1136/bmjopen-2016-013270] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Maternal mortality is a potentially preventable public health issue. Maternal morbidity is increasingly of interest to aid the reduction of maternal mortality. Obstetric patients admitted to the intensive care unit (ICU) are an important part of the global burden of maternal morbidity. Social determinants influence health outcomes of pregnant women. Additionally, intimate partner violence has a great negative impact on women's health and pregnancy outcome. However, little is known about the contextual and social aspects of obstetric patients treated in the ICU. This study aimed to conduct a systematic review of the social determinants and exposure to intimate partner violence of obstetric patients admitted to an ICU. METHODS AND ANALYSIS A systematic search will be conducted in MEDLINE, CINAHL, ProQuest, LILACS and SciELO from 2000 to 2016. Studies published in English and Spanish will be identified in relation to data reporting on social determinants of health and/or exposure to intimate partner violence of obstetric women, treated in the ICU during pregnancy, childbirth or within 42 days of the end of pregnancy. Two reviewers will independently screen for study eligibility and data extraction. Risk of bias and assessment of the quality of the included studies will be performed by using the Critical Appraisal Skills Programme (CASP) checklist. Data will be analysed and summarised using a narrative description of the available evidence across studies. This systematic review protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. ETHICS AND DISSEMINATION Since this systematic review will be based on published studies, ethical approval is not required. Findings will be presented at La Trobe University, in Conferences and Congresses, and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER CRD42016037492.
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Affiliation(s)
- Beatriz Paulina Ayala Quintanilla
- The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
- Mercy Hospital for Women, Melbourne, Victoria, Australia
- Peruvian National Institute of Health, Lima, Peru
| | - Angela Taft
- The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Susan McDonald
- The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
- Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Wendy Pollock
- The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
- Mercy Hospital for Women, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
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Zieleskiewicz L, Chantry A, Duclos G, Bourgoin A, Mignon A, Deneux-Tharaux C, Leone M. Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy. Anaesth Crit Care Pain Med 2016; 35 Suppl 1:S51-S57. [PMID: 27386763 DOI: 10.1016/j.accpm.2016.06.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed.
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Affiliation(s)
- Laurent Zieleskiewicz
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France.
| | - Anne Chantry
- Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France; École de sages-femmes Baudelocque, université Paris Descartes, DHU Risques et grossesse, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - Gary Duclos
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Aurelie Bourgoin
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Alexandre Mignon
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Catherine Deneux-Tharaux
- Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France
| | - Marc Leone
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
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