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Risks of central venous cannulation include pneumothorax, arterial puncture, thrombosis, and catheter-related infection. Ultrasonography is commonly used to guide vascular insertion.
The subclavian or internal jugular vein is preferable to femoral access in a pregnant patient Arterial cannulation is indicated when instantaneous BP monitoring is needed, as in shock or with vasoactive medications, or when frequent sampling of arterial blood gases is needed.
The radial artery is most commonly accessed, but any easily accessible artery other than the carotid artery can be used.
In a pregnant patient, the femoral site should be avoided. There is a risk of ischemia distal to the cannulated site; other risks are infection and thrombosis The pulmonary artery catheter or Swan—Ganz catheter is an invasive monitor inserted through the central venous circulation, past the right atrium and right ventricle, and floated into the pulmonary artery It can be used to directly measure pressure in the right atrium and the pulmonary artery, and indirectly measure pressure further downstream eg, the pulmonary capillary wedge pressure or pulmonary artery occlusion pressure.
Known risks of the device include cardiac arrhythmias, pulmonary hemorrhage, pulmonary artery rupture or thrombosis, balloon rupture and embolization, intracardiac catheter knotting, and vascular infection For many years, the pulmonary artery catheter was widely used in critical care medicine.
However, its use was not associated with decreased mortality 54—59 , and it has largely been replaced by minimally invasive monitoring Using minimally invasive monitoring, cardiac output can be determined by pulse contour analysis obtained from a peripheral arterial catheter.
Since a relationship is known or can be computed between the pressure in the peripheral artery and the aorta, aortic pressure can then be calculated.
Some devices then infer cardiac output from heart rate, mean arterial pressure, age, height, and weight. There are noninvasive systems that have been used in obstetrics in cesarean delivery and management of preeclampsia and perform well when compared with measurements of cardiac output derived from the pulmonary artery catheter 60, However, given that cardiac output measurements are based on proprietary algorithms that incorporate patient biometric variables, it will be important to ensure that algorithms and specific monitoring systems continue to be validated in pregnancy.
Point-of-care ultrasonography has become increasingly important in critical care medicine 62, It is used to guide procedures eg, vascular access, paracentesis, and thoracentesis ; establish, confirm, or exclude diagnoses eg, ascites, mechanical reasons for acute renal failure, and lower extremity deep venous thrombosis ; and direct therapies.
It can be used to predict fluid responsiveness by measuring the diameter or collapsibility of the inferior vena cava rather than using central venous pressure , to assess left ventricular systolic and diastolic function, quickly ascertain causes of hemodynamic instability and shock so that the correct treatment can be implemented, and as an adjunct to resuscitation in conditions such as pulseless electrical activity.
This technology is rapidly replacing many of the older tools of critical care medicine. It should be noted that there is limited information on using point-of-care ultrasonography in the critically ill pregnant patient; more research is needed.
Cardiac arrest in pregnancy is treated with the same ratio of chest compressions to breaths, respiratory support, drugs, and defibrillation as for any adult in cardiac arrest.
It is important to achieve left uterine displacement during cardiopulmonary resuscitation in order to alleviate aortocaval compression.
The American Heart Association recommends manual uterine displacement, rather than tilting the patient, because it allows for more effective chest compressions and better access for airway management and defibrillation If efforts to resuscitate a pregnant woman in cardiac arrest have been unsuccessful, resuscitative hysterotomy eg, perimortem cesarean delivery is recommended for maternal benefit in women with a uterine size at or above the umbilicus 20 weeks of gestation or more Resuscitative hysterotomy may help permit the return of spontaneous circulation by emptying the uterus and alleviating aortocaval compression and thereby increasing cardiac output, which may improve the efficacy of cardiopulmonary resuscitation.
In addition, it may aid fetal survival despite the woman's death. Consideration of resuscitative hysterotomy should occur as soon as there is a maternal cardiac arrest and preparations should begin in the event that return to spontaneous circulation does not occur within the first few minutes of maternal resuscitation.
Once the decision is made to perform a resuscitative hysterotomy, there is no reason to move a patient to an operating room or undertake extensive preparations.
The operative area can be splashed with an antiseptic if available. The only essential instrument in this setting is a scalpel.
Although the conventional teaching is that resuscitative hysterotomy should be undertaken after 4—5 minutes of arrest without return of spontaneous circulation 67, 68 , obstetricians should be aware that there is no obvious threshold for death or damage at 4—5 minutes; instead there is a progressive decrease in the likelihood of injury-free survival for women and fetuses with lengthening time since cardiac arrest However, more rapid resuscitative hysterotomy has been associated with improved survival 66 , and the procedure should be considered as soon as initial resuscitative measures are unsuccessful.
High-intensity ICU staffing, which mandates intensivist involvement for all patients admitted to the ICU through the closed model or through a mandatory consultation model, is associated with better mortality outcomes and is, therefore, recommended over lower-intensity approaches, such as the open unit with elective consultation 8, However, the supply of intensivists has not kept up with demand, which has led to a search for solutions.
Proposals have been made to augment the critical care workforce with highly trained physician assistants and nurse practitioners collaborating with physicians who often have to supervise units from a distance Tele-intensive care units allow intensivist consultation, collaboration, and supervision of care in facilities that do not have high-intensity intensivist staffing.
Data are still limited regarding outcomes under this model, and interpretation of results is confounded by varying definitions of tele-intensive care unit and by study design There are data in the neuro critical care literature that support the utility of a telemedicine model for reduction of unnecessary transfers, decreased cost of care, and faster access to subspecialist interpretation of imaging Similarly, in the pediatric literature, telemedicine reduced admissions to the pediatric ICU and improved health care provider-reported accuracy of patient assessment Extrapolation of these findings to the obstetric population would suggest that smaller facilities may benefit from establishing a relationship for teleconsultation with a larger center with full-time intensivists and maternal—fetal medicine specialists.
However, data are needed to establish the effect of telemedicine on obstetric critical care before making more specific recommendations.
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients.
You may view these resources at www. These resources are for information only and are not meant to be comprehensive.
Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource.
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Please try after some time. Published online on April 23, Background The leading causes of ICU admission during pregnancy or the postpartum period are hypertensive disorders and obstetric hemorrhage 1, 2.
Knowledge Base The critical care physician workforce has traditionally been drawn from surgery, anesthesiology, internal medicine and, more recently, emergency medicine.
Admission to Intensive Care Intensive care unit beds are a scarce resource with an eightfold difference among high-income countries ranging from three ICU beds per , population in the United Kingdom to 25 ICU beds per , in Germany, with the United States having approximately 20 ICU beds per , population.
Box 1. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence. Level C—Recommendations are based primarily on consensus and expert opinion.
Considerations in Transfer If a pregnancy is complicated by a critical illness or condition, the woman should be cared for at a hospital with obstetric services, an adult ICU, advanced neonatal care services, and appropriate hospital services such as a blood bank.
Common Causes of Maternal Intensive Care Unit Admission Massive obstetric hemorrhage and hypertensive disorders of pregnancy are common causes of ICU admission in pregnancy or immediately postpartum.
Acute Respiratory Distress Syndrome Acute respiratory distress syndrome is a nonspecific response of the lung to a variety of insults, characterized by diffuse inflammation, increased fluid level in the lung due to increased vascular permeability, and loss of aerated lung units Transfer Within the Hospital If a pregnant patient or a patient who has given birth is to be transferred from the obstetric department to an ICU within the same hospital, communication between the obstetrician—gynecologist and critical care services is crucial.
Role of the Obstetrician—Gynecologist When an Obstetric Patient Is in the Intensive Care Unit Knowing the ICU model and type will help to define the obstetrician's role in patient care, which may be as the primary physician or as a consultant to the intensivist team.
Table 1. Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med ;— Systematic Review Cited Here.
Retrieved November 28, Level II-3 Cited Here. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital.
Characteristics, outcomes, and predictability of critically ill obstetric patients: a multicenter prospective cohort study.
Crit Care Med ;— Level II-2 Cited Here. Intensive care unit admission of obstetric cases: a single centre experience with contemporary update.
Hong Kong Med J ;— Severe maternal morbidity: screening and review. Obstetric Care Consensus No.
Obstet Gynecol ;e54— Murthy S, Wunsch H. Clinical review: International comparisons in critical care—lessons learned. Crit Care ; ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research.
A blueprint for obstetric critical care. Am J Obstet Gynecol ;—6. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy.
Am J Obstet Gynecol ; Internal validation of the sepsis in obstetrics score to identify risk of morbidity from sepsis in pregnancy.
Obstet Gynecol ;— American Hospital Association. Fast facts on U. Society of Critical Care Medicine. Critical care statistics. Levels of maternal care.
Chronic hypertension in pregnancy. Obstet Gynecol ;e26— Gestational hypertension and preeclampsia. Obstet Gynecol ;e1— Postpartum hemorrhage.
Practice Bulletin No. JAMA ;— Pregnancy-related mortality in the United States, Severe maternal sepsis in the UK, a national case-control study.
United Kingdom Obstetric Surveillance System. PLoS Med ;e Maternal deaths due to sepsis in the state of Michigan, Early goal-directed therapy in the treatment of severe sepsis and septic shock.
N Engl J Med ;— Level I Cited Here. A randomized trial of protocol-based care for early septic shock.
Goal-directed resuscitation for patients with early septic shock. Trial of early, goal-directed resuscitation for septic shock. Acute respiratory distress syndrome: the Berlin Definition.
Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes. Obstet Gynecol ;—4.
Severe H1N1 influenza in pregnant and postpartum women in California. Severity of pandemic influenza A H1N1 virus infection in pregnant women.
Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Adult respiratory distress syndrome in pregnancy.
Am J Obstet Gynecol ;—7. Maternal mortality associated with adult respiratory distress syndrome. South Med J ;—4. Severe maternal morbidity in Canada, to surveillance using routine hospitalization data and ICDCA codes.
J Obstet Gynaecol Can ;— Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
N Engl J Med ;—8. Lactic acid measurement to identify risk of morbidity from sepsis in pregnancy. Am J Perinatol ;—6.
Guidelines for perinatal care. Transfer of the critically ill obstetric patient: experience of a specialist team and guidelines for the non-specialist.
Int J Obstet Anesth ;—9. Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: why are there no births in flight?
Greene MJ. Air Med J ;— Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No.
American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol ;].
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