maternal collapse and cardiorespiratory arrest...now gaining momentum. there are clear grounds for...
TRANSCRIPT
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Maternal collapse and
cardiorespiratory arrest
Dr David Gabbott
Consultant Obstetric Anaesthetist
Gloucester, UK
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Saving Mothers’ Lives:
Reviewing maternal deaths to
make
motherhood safer – 2006-2008
Tuesday 1st March 2011
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Obesity
Diabetes
Hypertension
PET
Thromboembolism
Wound infection
Cardiac disease
Difficult airway
Venous access
Greater risk of PPH
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More than half of all the women who died from Direct or Indirect causes, for whom information was available, were either overweight or obese.
More than 15% of all women who died from Direct or Indirect causes were morbidly or super morbidly obese.
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Resuscitation in Pregnancy
Two people to resuscitate
Early involvement of obstetrician and neonatologist
Cardiopulmonary arrest from non obstetric causes
- trauma
- cystic fibrosis
- anaphylaxis
- drug overdose
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CNST
Standard
1 2 3 4 5
Criterion
Organisation Clinical Care High Risk Conditions Communication Postnatal and Newborn Care
1 Risk Management Strategy
(Organisation)
Care of Women in Labour Severe Pre-Eclampsia Booking Appointments Referral When a Fetal
Abnormality is Detected
2 Risk Management Strategy
(Leadership)
Auscultation Eclampsia Missed Appointments Neonatal Resuscitation
3 Staffing Levels (Midwifery &
Nursing Staff)
Continuous Electronic Fetal
Monitoring
Operative Vaginal Delivery Clinical Risk Assessment
(Antenatal)
Admission to Neonatal Unit
4 Staffing Levels (Obstetricians) Fetal Blood Sampling Bladder Care Patient Information & Discussion Immediate Care of the Newborn
5 Staffing Levels (Anaesthetists &
Assistants)
Use of Oxytocin Perineal Trauma Maternal Antenatal Screening
Tests
Newborn Feeding
6 Guideline Development Caesarean Section Shoulder Dystocia Mental Health Newborn Security
7 Maternity Records Recovery Obstetric Haemorrhage* Clinical Risk Assessment
(Labour)
Examination of the Newborn
8 Incidents, Complaints & Claims Severely Ill Pregnant Women Venous Thromboembolism Handover of Care (Onsite) Support for Parents
9 Training Needs Analysis High Dependency Care Pre-Existing Diabetes Maternal Transfer Postnatal Care Planning
10 Skills Drills Vaginal Birth after Caesarean
Section
Obesity Admission to Emergency
Department
Postnatal Information
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Maternal Emergency
Resuscitation Course
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Adult ALS
Algorithm
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What is the same as non pregnant…
Rate and depth of chest compression
Drug doses e.g. 1mg adrenaline, 300mg amiodarone
Defibrillation energies
Single shocks
Time cycles
30:2 ratio for chest compression and ventilation
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What is the same as non pregnant…
Rate and depth of chest compression
Drug doses e.g. 1mg adrenaline, 300mg amiodarone
Defibrillation energies
Single shocks
Time cycles
30:2 ratio for chest compression and ventilation
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Forty‐five women consented to
measurement of TTI at term. Post
partum measurements were made 6–8
weeks later on 42 of these women once
physiological changes had resolved.
Mean TTI was 91.3 (15.8) Ω at term and
91.6 (11.8) Ω 6–8 weeks after delivery.
The difference was not statistically
significant.
Do physiological changes in pregnancy change
defibrillation energy requirements?
J. Nanson, D. Elcock, M. Williams and C. D. Deakin
Br J Anaesth 2001; 87: 237–9
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What is the same as non pregnant…
Rate and depth of chest compression
Drug doses e.g. 1mg adrenaline, 300mg amiodarone
Defibrillation energies
Single shocks
Time cycles
30:2 ratio for chest compression and ventilation
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Physiological changes
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Airway
Airway obstruction
Increased risk of regurgitation
Tracheal intubation (difficult):
- large neck
- breast enlargement
- glottic oedema
- mucosal hyperaemia
- full dentition
- poorly applied cricoid
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Prevalence of factors associated with difficult intubation in
early and late pregnancy. A prospective observational study
I Hayes, R Rathore, K Enohumah, N Salah, N Aslani, C McCaul
Dept of Anaesthesia, the Rotunda Hospital, Dublin, Eire
Difficult Airway Society Meeting, Cheltenham, Nov 2010
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Sleep-disordered breathing and upper airway size in
pregnancy and post-partum
B. Izci, M. Vennelle, W.A. Liston et al, Eur Respir J 2006; 27: 321–327
Pregnant females had
significantly smaller upper
airways than nonpregnant
females at the oropharyngeal
junction when seated and
smaller mean pharyngeal
areas in the seated, supine
and lateral postures
compared with the
nonpregnant females.
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Oxygen availability
Oxygen consumption = 250ml/min
Increased by 25% by full term
Available oxygen in non pregnant
Cardiac output x Hb conc x 1.34 x % saturation
5000 x 15/100 x 1.34 x 95/100
Total = 950ml
Approximately 4 minutes
Full term ~ 2-3 minutes
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Apnoeic desaturation in pregnancy
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Rates of neurologically favourable one month survival after chest
compression only CPR and conventional CPR in people with out of
hospital cardiopulmonary arrest witnessed by bystander
Ogawa T et al. BMJ 2011
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Airway
Difficult airway box /
trolley
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Easy to insert
Good seal pressures
Venting of gastric pressure and contents
May allow continuous chest compressions
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The use of ProSeal laryngeal mask airway in caesarean
section – experience in 3000 cases
BK Halaseh, ZF Sukkar, L Haj Hassan, ATH Sia, WA Bushnaq, H Adarbeh
Department of Anaesthesia, Farah Hospital, Amman, Jordan
3000 elective LSCS cases
Modified insertion with cricoid, gastric tube and laryngoscope
No failures
21 sore throat
Anaesthesia and Intensive Care 2010; 38: 1023-1028
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Oesophageal insufflations with different SADs during positive pressure ventilation at (a) 40
and (b) 60 mbar.
Schmidbauer W et al. Br. J. Anaesth. 2012;109:454-458
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Breathing
Diaphragmatic splinting
High inflation pressures may
be required
Reduced FRC and oxygen
reserve
Increased oxygen demand
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Aufderheide, T. P. et al. Circulation 2004;109:1960-1965
Hyperventilation-Induced Hypoperfusion During Cardiopulmonary
Resuscitation
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Coronary
perfusion
pressure
mm Hg
Leaning during chest compressions impairs cardiac output
and left ventricular myocardial blood flow in piglet cardiac
arrest Zuercher, Mathias MD et al. Crit Care Medicine 2010
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Advanced pregnancy
Approximately 45% loss of chest wall
elasticity reduces intrathoracic
negative pressure
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Waveform Capnography in CPR
Quantitative measurement of end tidal
CO2 may be a safe and effective non-
invasive indicator of cardiac output
during CPR and may be an early
indicator of ROSC in intubated
patients.
Low values of end tidal CO2
(<10mmHg) are associated with a low
probability of survival.
CoSTAR 2010
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The use of end-tidal CO2 monitoring
Arrows 1-8 fall in etCO2 as rescuer tires.
At 9 sudden rise indicating ROSC. Kalender Z. Resuscitation 1978;6:259-63
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Circulation
IVC
Supine position causes caval compression
and reduced venous return
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Caval Compression
May occur as early as 5th
month of pregnancy
Multiple pregnancy or
hydramnios increase risk
Even 45 degree tilt does not
relieve compression in all
mothers
30 - 50% of cardiac output via
IVC
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Circulation
Displace uterus using:
- manual displacement
- left lateral tilt
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Circulation
Displace uterus using:
- manual displacement
- left lateral tilt
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Chest compression vs IVC compression
Unless the pregnant victim is on a tilting operating table, left
lateral tilt is not easy to perform whilst maintaining good quality
chest compressions
Start basic life support according to standard guidelines. Ensure
good quality chest compressions with minimal interruptions.
Manually displace the uterus to the left to remove caval compression.
European Resuscitation Council Guidelines for Resuscitation 2010
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Quality of chest compressions performed by inexperienced rescuers in
simulated cardiac arrest associated with pregnancy
Seunghwan Kim, Je Sung You, Hye Sun Lee, Jae Ho Lee, Yoo Seok Park, Sung Phil Chung and Incheol Park
Resuscitation DOI: 10.1016/j.resuscitation.2012.06.003
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Drugs
In light of potential inferior vena cava compression, it is advisable to ensure that venous access during cardiopulmonary resuscitation is above the diaphragm.
The circulation time of drugs given via a cannula placed in the lower limb may be delayed.
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IO access
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Thrombolysis
The use of thrombolysis during
cardiopulmonary resuscitation is
now gaining momentum. There
are clear grounds for the use of
such clot busting drugs in
situations where thrombosis is
the primary cause of the cardiac
arrest e.g. massive pulmonary
thromboembolism (PTE).
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Eclampsia
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Magnesium overdose
Hypotension from vasodilatation
Reduced muscle power because of its effect at the neuromuscular junction
Uterine relaxation - bleeding
Reduced respiratory rate
Absent deep tendon reflexes
ECG changes e.g. prolonged P-R interval, wide QRS complex, conduction defects
Cardiac and respiratory arrest
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Magnesium overdose
Treatment of magnesium overdose causing cardiac or respiratory arrest
Standard ALS procedures should be followed.
Calcium chloride 1g (10ml 10%) or calcium gluconate (30ml 10%)
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Local anaesthetic toxicity
‘Hospital trust to pay £100,000 after
new mother died when painkiller was
attached to drip by mistake’
‘NHS trust facing prosecution after
new mother killed by epidural
anaesthetic mistakenly attached to
drip’
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In severe LA toxicity, the mother may have:
Sudden loss of consciousness
Convulsion
Cardiovascular collapse due to
- sinus bradycardia
- conduction blocks
- ventricular tachyarrhythmias
- asystole
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Treatment
Start CPR using standard protocols
Treat arrhythmias using standard protocols but recognize that they may be very refractive to treatment
Prolonged CPR may be necessary; consider a cardiopulmonary bypass (if available) and early use of lipid emulsion
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Lipid emulsion
CEMACH
AAGBI
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Use of an ultrasound
machine if available is to
be encouraged. This will
allow determination of
concealed haemorrhage,
placental site, exclusion of
twins and visualisation of
foetal and maternal heart.
In skilled hands other
pathology may be
identified e.g. PE
Ultrasound in resuscitation
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Course objectives
To achieve 4 standard TTE
views:
Parasternal long axis (PLAX)
Parasternal short axis (PSAX)
Apical 4 chamber (A4Ch)
Subcostal (SC)
Perform focused
echocardiography in an ALS
compliant manner
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Perimortem LSCS
‘Perimortem caesarean
section is part of the
resuscitation procedure
in any woman who has
a cardiac arrest in the
second half of
pregnancy’.
CEMACH 2008
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Greatly facilitates maternal resuscitation
Removes IVC compression
May allow the foetus to survive
Timing is essential (within 5 minutes of the
arrest)
May allow aortic compression / clamping
May allow internal cardiac massage by
surgeon
A Perimortem LSCS is performed because it:
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Perimortem Caesarean delivery
Summary of postmortem caesarean
sections reported between 1900 and 1985
93% (57 /61) of surviving neonates were
born within 15 minutes of maternal death
70% of survivors were delivered within 5
minutes
Only 2 had neurological deficits
Katz et al Obstet Gynaecol 1986
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Perimortem Caesarean section
Review 1985 until 2004 of perimortem
cesarean delivery:
38 cases
34 infants survived (3 sets of twins, 1 set
of triplets);
4 other infants survived initially, but died
several days after the deliveries from
complications of prematurity and anoxia.
Katz V.et al. Perimortem cesarean delivery: were our assumptions correct?
Am J Obstet Gynecol. 2005 Jun;192(6):1916-20
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Perimortem Caesarean section
Time of delivery after maternal cardiac arrest was
available for 24 of 34 neonatal survivors.
n minutes
11 < 5
4 6 to 10
2 11 to 15
7 > 15
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Woman Suspected of Cutting Baby
From Massachusetts Mom's Womb
Held on $2M Bail
Baby cut from murdered mother’s
womb found alive
Associated Press
Thursday, 30 July 2009
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CMACE 2011 – perimortem CS
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Maternal cardiac arrest and perimortem
caesarean delivery: Evidence or expert-
based?
Sharon Einav, Nechama Kaufman and Hen Y. Sela
Resuscitation
Volume 83, Issue 10, Pages 1191-1200 (October 2012)
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94 reported cases (1980 – 2010)
Average age 30 yrs
Average gestational age 33 weeks
67% in hospital, 89% witnessed
54% (51/94) survived to discharge
Common causes - Trauma
- Cardiac disease
- Pre-eclampsia
- Amniotic fluid embolism
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PMCS performed in 76/86 viable pregnancy
Average time 16 minutes
4/76 within ‘5 minute’ rule
PMCS maternal survivors ~10 min
Non-survivors ~22 min
More ROSC and SHD with no PMCS
compared to those with PMCS (15/16 vs
39/72)
Neonatal survival 60% - mean time 14
minutes
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Shockable
17.3%
Asystole
24.0%
PEA
474%
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