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Khan KS, Moore P, Wilson M, Hooper R, Allard S, Wrench I, Roberts T, McLoughlin C, Beresford L, Geoghegan J, Daniels J, Catling S, Clark VA, Ayuk P, Robson S, Gao-Smith F, Hogg M, Jackson L, Lanz D, Dodds J. A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial. Health Technol Assess 2019; 22:1-88. [PMID: 29318985 DOI: 10.3310/hta22020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking. OBJECTIVES To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use. DESIGN Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded. SETTING A total of 26 UK obstetric units. PARTICIPANTS Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated. INTERVENTIONS Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed. MAIN OUTCOME MEASURES Primary - donor blood transfusion. Secondary - units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer-Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes - costs of resources and service provision taking the UK NHS perspective. RESULTS We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at £8110 per donor blood transfusion avoided. CONCLUSIONS The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective. FUTURE WORK Research into risk of alloimmunisation among women exposed to cell salvage is needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN66118656. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Khalid S Khan
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Philip Moore
- Selwyn Crawford Department of Anaesthetics, Birmingham Women's Hospital, Birmingham, UK
| | - Matthew Wilson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Richard Hooper
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | | | - Ian Wrench
- Anaesthetics, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Lee Beresford
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - James Geoghegan
- Selwyn Crawford Department of Anaesthetics, Birmingham Women's Hospital, Birmingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Sue Catling
- Department of Anaesthetics, Singleton Hospital, Swansea, UK
| | - Vicki A Clark
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul Ayuk
- Women's Services, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Stephen Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Fang Gao-Smith
- Perioperative, Critical Care and Trauma Trials Group, University of Birmingham, Birmingham, UK
| | - Matthew Hogg
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Louise Jackson
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Doris Lanz
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Julie Dodds
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center. Obstet Gynecol Sci 2018; 61:209-219. [PMID: 29564311 PMCID: PMC5854900 DOI: 10.5468/ogs.2018.61.2.209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 11/08/2022] Open
Abstract
Objective Reviewing indications and characteristics of obstetric patients admitted to the intensive care unit (ICU) of a tertiary care center, comparing those patients by time period and place of delivery, and to verify clinical utility of acute physiology and chronic health evaluation (APACHE) II score in ICU-admitted women. Methods Retrospective analyses were carried out for parturients admitted to the ICU of our institution from 1994 to 2015. Clinical characteristics were compared between time period (period 1: 1994-2004; period 2: 2005-2015) and place of delivery (our institution and local hospitals). Receiver operating characteristic (ROC) curve analysis was used to evaluate the usefulness of APACHE II score to predict maternal mortality. Results During 22-year period, 176 women required ICU admission, showing the incidence of 2.2 per 1,000 deliveries. The most common reason for ICU admission was postpartum hemorrhage (56.3%), followed by hypertensive disorders (19.3%), sepsis (3.4%), and pulmonary and amniotic fluid embolism (2.3%). Period 2 showed older maternal age (32.7±4.8 vs. 30.8±4.4 years, P=0.006, higher embolization rate (26.4% vs.1.2%, P<0.001), and lower hysterectomy rate (30.8% vs. 49.4%, P=0.012). Cases from local hospitals showed significantly higher proportion of postpartum hemorrhage (84.5% vs. 42.2%, P<0.001). Overall maternal death occurred in 5.1% (9/176) including 6 direct maternal deaths. The APACHE II score showed area under the ROC curve of 0.813 (confidence interval [CI], 0.607-1.000) for prediction of maternal mortality. Conclusion The incidence of obstetric ICU admission was 2.2 per 1,000 deliveries and the most common reason was postpartum hemorrhage followed by hypertensive disorders. APACHE II score could be used to predict mortality in obstetric ICU admission.
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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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Farzi F, Mirmansouri A, Atrkar Roshan Z, Naderi Nabi B, Biazar G, Yazdipaz S. Evaluation of Admission Indications, Clinical Characteristics and Outcomes of Obstetric Patients Admitted to the Intensive Care Unit of a Teaching Hospital Center: A Five-Year Retrospective Review. Anesth Pain Med 2017; 7:e13636. [PMID: 29181330 PMCID: PMC5696879 DOI: 10.5812/aapm.13636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 03/01/2017] [Accepted: 04/22/2017] [Indexed: 11/16/2022] Open
Abstract
Background Care of obstetric patients has always been a challenge for critical care physicians, because in addition to their complex pregnancy-related disease, fetal viability is considered. Objectives The aim of this study was to review the admission indications, clinical characteristics and outcomes of obstetric patients, admitted to the intensive care unit of Alzzahra teaching hospital affiliated to Guilan University of Medical Sciences, Rasht, Iran. Methods This retrospective cohort study was conducted on pregnant /post-partum (up to 6 weeks) patients admitted to the ICU over a 5-year period from April 2009 to April, 2014. Results Data from 1019 subjects were analyzed. Overall, 90.1% of the patients were admitted in the postpartum period. The most common indications for admission were pregnancy related hypertensive disorders (27.5%) and obstetric hemorrhage (13.5%). Epilepsy (5.4%) and cardiac disease (5.2%) were the most common non-obstetric indications. Conclusions Pregnancy-related hypertensive disorders and obstetric hemorrhage were the main reasons for admission, and epilepsy and cardiac disease were the most common non-obstetric indications. Efforts must be concentrated on increasing antenatal care.
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Affiliation(s)
- Farnoush Farzi
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Mirmansouri
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding author: Ali Mirmansouri, Anesthesiology Research Center, Velayat Hospital, Guilan University of Medical Sciences, Rasht, Guilan, Iran. Tel: +98-9111315314, E-mail:
| | - Zahra Atrkar Roshan
- Department of Statistically, Guilan University of Medical Sciences, Rasht, Iran
| | - Bahram Naderi Nabi
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Gelareh Biazar
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Shima Yazdipaz
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Bentata Y, Madani H, Berkhli H, Saadi H, Mimouni A, Housni B. Complications and maternal mortality from severe pre-eclampsia during the first 48hours in an intensive care unit in Morocco. Int J Gynaecol Obstet 2015; 129:175-6. [PMID: 25638711 DOI: 10.1016/j.ijgo.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/01/2014] [Accepted: 01/13/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Yassamine Bentata
- Department of Nephrology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco.
| | - Hamid Madani
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Hayat Berkhli
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Hanane Saadi
- Department of Obstetrics and Gynecology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Ahmed Mimouni
- Department of Obstetrics and Gynecology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Brahim Housni
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
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Orsini J, Butala A, Diaz L, Muzylo E, Mainardi C, Kastell P. Clinical Profile of Obstetric Patients Admitted to the Medical-Surgical Intensive Care Unit (MSICU) of an Inner-City Hospital in New York. J Clin Med Res 2012; 4:314-7. [PMID: 23024733 PMCID: PMC3449428 DOI: 10.4021/jocmr1079w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pregnancy is associated with physiological and anatomical changes that usually occur uneventfully in majority of women. However, these changes can cause major maternal morbidity with potential catastrophic consequences. The purpose of this study is to evaluate the clinical characteristics of obstetric patients admitted to the MSICU of an inner-city hospital in New York. METHODS A prospective, observational study was conducted among all the obstetric patients admitted to the MSICU between June 1, 2009 and June 30, 2012. RESULTS A total of 19 obstetric patients were admitted to the MSICU between June 1, 2009 and June 30, 2012. The most common comorbidity on admission was hypertensive disorder. Hemodynamic unstability and shock was the most common admission diagnosis. The mean length of stay was 3.5 days. One patient died. CONCLUSIONS Obstetric hemorrhage and pregnancy-induced hypertensive disorders remains as the most common entities requiring intensive care unit (ICU) admission among obstetric patients. A multidisciplinary team involvement is essential in the management of these patients.
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Affiliation(s)
- Jose Orsini
- Department of Medicine, New York University School of Medicine at Woodhull Medical and Mental Health Center, 760 Broadway, Brooklyn, New York, USA
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Rojas-Suarez J, Vigil-De Gracia P. Pre-eclampsia-eclampsia admitted to critical care unit. J Matern Fetal Neonatal Med 2012; 25:2051-4. [PMID: 22468797 DOI: 10.3109/14767058.2012.678432] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate women with hypertensive disorder admitted to critical care unit. METHODS This study was carried out in Cartagena, Colombia, between January 2006 and December 2009. Patients were divided into 4 groups; severe pre-eclampsia, eclampsia, HELLP syndrome and HELLP with eclampsia (HEEH). RESULT A total of 217 cases were admitted. The admitting diagnoses were severe pre-eclampsia without HELLP syndrome (39.2%), HELLP syndrome without eclampsia (33.6%), eclampsia without HELLP syndrome (20.3%) and Eclampsia with HELLP syndrome or HEEH (6.9%). Groups were similar with respect to parity (p = 0.25), gestational age (p = 0.11), cesarean section (p = 0.58), mechanical ventilation (p = 0.54), level of systolic (p = 0.48) and diastolic blood pressure (p = 0.15) and inotropic support (p = 0.32). Average total duration of hospitalization was significantly different among groups, more time in women with HEEH (p = 0.001). Multiple organ dysfunctions was diagnosed > 70% of all women admitted to intensive care, but was significantly more frequent in patients with HELLP syndrome and HEEH (p = 0.001). There were 5 maternal deaths (2.3%). Causes of maternal death were intracranial hemorrhage (3), intra-abdominal bleeding (1) and pulmonary complications (1). CONCLUSION Women with HELLP syndrome with or without eclampsia are associated with major morbidity and mortality. Therefore, the maternal outcome in eclampsia is influenced for HELLP syndrome.
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Affiliation(s)
- José Rojas-Suarez
- Critical Care Unit, Clínica de Maternidad Rafael Calvo, Grupo de Investigación en Cuidados Intensivos y Obstetricia, Universidad de Cartagena, Cartagena, Colombia
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