Transcript role of intensivist in care of critically ill mother

ROLE OF INTENSIVIST IN CARE OF
CRITICALLY ILL MOTHER
Kenyatta National Hospital & UoN, College of Health
Sciences Symposium
Venue: Lecture Theatre III – College of Health Sciences,
University of Nairobi, KNH Campus
Date: 7th February, 2014
By Dr. P.O.R. Olang’
University of Nairobi.
OUTLINE
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Introduction
Challenges
Indications for ICU admission
Recent concepts in critical care management
of obstetric patients with special focus on
ventilatory strategies, treatment of shock and
nutrition
• specific issues of importance in managing
individual critical illnesses.
Introduction
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Definition:
An intensivist is a doctor who provides care to
patients who require intensive care.
Intensive care involves close monitoring and
support for critically ill patients.
The intensivist works alongside other specialists and
specially trained nurses and paramedics in the ICU
The main indication for the critically ill obstetrical
patient's admission to the ICU is respiratory failure
and a need for mechanical ventilation
Introduction…
• A wide gap exists in delivery of obstetrical critical
care between developed and developing nations.
• This gap of quality care delivery between the two
worlds is due to several factors, including clinical
and economical.
• It may be attributable to the lower literacy rates,
paucity of research in obstetrical critical care,
poverty, lack of awareness, and the socio-cultural
and behavioral factors prevalent in developing
nations.
Introduction…
• The commonest indication for Intensive Care Unit (ICU)
admission of obstetric patients is hemorrhage, both
ante-partum and post-partum.
• Hypertensive disorders, pre-eclampsia, and its related
complications are also major contributory factors for
such admissions.
• These reflect the lack of proper antenatal care and
timely management of obstetrical emergencies,
especially in the developing countries
• The obstetrician's involvement is of prime importance
when managing such cases in the ICU
Challenges
• There are no established universal criteria for
the admission of critically ill obstetric patients
to the intensive care unit (ICU).
• Huge variations in the indications of ICU
admission, mortality and morbidity rates, as
well as the demographic characteristics
• Shortage of qualified intensive care specialists
for handling such cases in developing nations
Challenges…
• Economic factors, socio-cultural characteristics,
and different hospital protocols and management
policies, further widen the gap of bringing
uniform admission criteria
• One of the most striking similarities in all such
patients is their young age, which in fact is a good
prognostic indicator, provided they receive timely
interventions for their acute pathologies
Indications for ICU admission
• Conditions related to pregnancy – eclampsia, severe
pre-eclampsia, haemorrhage, amniotic fluid embolism,
acute fatty liver, peri-partum cardiomyopathy,
aspiration syndromes, infections etc.
• Medical diseases that may be aggravated during
pregnancy - congenital heart diseases, rheumatic and
non-rheumatic valvular diseases, pulmonary
hypertension, anemia, renal failure etc.
• Conditions that are not related to pregnancy – trauma,
asthma, diabetes, autoimmune diseases etc.
MONITORING DURING CRITICAL
ILLNESS
• Invasive monitoring is essential in most critically ill
patients both during surgical procedures and during
the ICU stay.
• Central venous pressure monitoring is used to guide
fluid administration
• The pulmonary artery catheter is extremely useful for
measuring central venous pressure (CVP), pulmonary
capillary wedge pressure (PCWP), systemic vascular
resistance (SVR), cardiac output (CO), pulmonary artery
(PA) pressure, and mixed venous oxygen saturation
(SvO₂).
COMORBID DISORDERS
COMPLICATING PREGNANCY
Sepsis:
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Early goal-directed therapy
Tight control of hyperglycemia
Steroid therapy
Protein C
Symptomatic and supportive treatment
COMORBID DISORDERS
COMPLICATING PREGNANCY…
Diabetes
• Tight glycemic control with insulin is
recommended since such control decreases
mortality and morbidity and improves outcome
Cardiac diseases
• The commonest cause of mortality among
pregnant patients admitted in the ICU
• Further potentiated by significant cardiovascular
and physiological changes of pregnancy
COMORBID DISORDERS
COMPLICATING PREGNANCY…
Morbidity is further increased in cardiac pregnant
patients with a potential risk of thromboembolic
phenomenon and influenced by:
A history of heart failure, transient ischemic stroke
or severe arrhythmias
Severe valvular heart disease
New York Heart Association (NYHA) class II and
above
Ejection fraction < 40%
COMORBID DISORDERS
COMPLICATING PREGNANCY…
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Pulmonary diseases
Pulmonary edema, advanced chronic obstructive pulmonary
disease, infections, and pulmonary embolism are among the
major causes for respiratory failure, which necessitate the
admission of pregnant patients to the ICU
Commonest underlying etiology for pulmonary edema
includes cardiac diseases, non-judicious use of tocolytics,
over-enthusiastic use of intravenous fluids, and to some
extent pre-eclampsia.
The most feared complication is ARDS.
Amniotic fluid embolism rapidly increases maternal mortality.
The symptoms include sudden hypoxia, shock, coagulopathy,
and cardiac arrest.
Conclusion
• Intensivists evaluate patients to determine whether or
not they are candidates for the ICU.
• Patients must have treatable conditions;
• an intensivist may believe that the patient is better
served by hospice or other supportive care if there is
no reasonable chance of recovery.
• Management begins with history, clinical examination
with emphasis on individual organ-based approach and
special consideration of gestational age of foetus.
• Intensive care team must involve the obstetricians to
monitor foetal well-being.
THE END
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