Philippines Maternal Mortality rate is 224: 100,000

Philippines Maternal Mortality rate is 224: 100,000

D’ Angelo R. Anesthesiology 2014;120:1505-12

What We Already Know about This TopicThe incidences of serious complications related to obstetric anesthesia are unknownWhat This Article Tells Us That Is NewThe Serious Complication Repository Project of the Society for Obstetric Anesthesia and Perinatology captured data on approximately 257,000 parturients administered neuraxial or general anesthesia at 30 institutions between 2004 and 2009Serious anesthesia related complications were reported for 85 (1 of 3,000) patientsThe most common serious complications were high neuraxial block, respiratory arrest in labor suite, and unrecognized spinal catheter

D’ Angelo R. Anesthesiology 2014;120:1505-12

What We Already Know about This TopicThe incidences of serious complications related to obstetric anesthesia are unknownWhat This Article Tells Us That Is NewThe Serious Complication Repository Project of the Society for Obstetric Anesthesia and Perinatology captured data on approximately 257,000 parturients administered neuraxial or general anesthesia at 30 institutions between 2004 and 2009Serious anesthesia related complications were reported for 85 (1 of 3,000) patientsThe most common serious complications were high neuraxial block, respiratory arrest in labor suite, and unrecognized spinal catheter

D’ Angelo R. Anesthesiology 2014;120:1505-12

Resuscitation in the Parturient

Grace Anne B. HerbosaProfessor in AnesthesiologyUniversity of the Philippines College of MedicinePhilippine General HospitalManila

REFERENCES

I. History of CPR in pregnancy

II. challenges

III. Controversies of CPR in pregnancy

IV. Checklists, drills, quality improvement

1966^: 1st published AHA guidelines

1974: 2nd AHA guidelines

1980 & 1986*: Adult, Pediatrics, Neonatal Care

^Safar P, Brown T, Holtey W, Wilder R. Ventilation and circulation with closed chest cardiac massage in man. JAMA 1961;176:574-6

*Katz Obstet Gynecol

1992:

1st to mention pregnancy

4 paragraphs; 8 references

Caval decompression; delivery within 5 minutes

2000: 3 pages (two tables, figure, 9 references)

“The critical point is you will lose both mother and infant if you cannot restore blood flow to the mother’s heart.”

“Fetal-centric”: deliver “within 4-5 mins if BLS/ ACLS fail and…some chance…fetus is viable.”

2005: >3 pages (table, 31 references)

Consider emergency cesarean delivery as soon as woman develops cardiac arrest

Decision making:<20 weeks, 20-23, >24 to 25

“Importance of advance preparation…in collaboration with obstetric and pediatric services.”

2010

“Bundled maternal and neonatal?

Standard team vs “Code OB”

Emergency access barriers?

Lipman et al.Am J Ostet Gynecol 2010;203(2):179.e1-5Lipman et al. Ostet Gynecol 2011;118(5):1090-4

AHA 2010 Guidelines. Circulation2010;122:S829-S861Cheskes et al. Circulation 2011;124(1):58-66

Depth- 5cm 100/min (intubated) Perishock pause <5 seconds No pulse check after defibrillation (not intubated) 30 compressions : 2 breaths 3rd trimester- hand placement 2-3 cm higher on the

sternum vs. non pregnant

Eckstein et al. Prehosp Disaster Med 2011;26(3):148-50Einav et al. Acad Emerg Med. 2011;18(5):468-75Pokorna et al. J Emerg med. 2010;38(5):614-21

>20 weeks gestational size or uterus is palpable or visible

Vanden Hoek. Circulation 2010;122:S861

Left uterine Displacement- 2 Handed Technique

Left Uterine DisplacementOne handed Technique

Ueland AJOG 1969 versus McLennan AJOG 1943

Cardiac outputLiters/min

supine

side

sitting

Gestational age-weeks

Ueland K et al AJOG 1969 july 15: 104(6): 856-64

20-24 28-32 38-40

6

7

5

Effect of gestational age and maternal posture on cardiac output

McLennan CE. Antecubital and femoral venous pressure in normal and toxemic pregnancy. American Journal of Obstetrics and Gynecology. 1943;45(4):568–591.

McLennan CE. Antecubital and femoral venous pressure in normal and toxemic pregnancy. American Journal of Obstetrics and Gynecology. 1943;45(4):568–591.

Oxygenate and VentilateFirst responders without advanced airway experience

Jaw thrust, oral airway, bag mask ventilationUnwavering focus on aspiration prevention= fixation

error Cricoid efficacy and effect on ventilation and laryngoscopy

unclear AHA 2010 guidelines do not recommend in non pregnant

patients AHA 2010 Guidelines: Circulation 2010; 122:S829-S861 Fenton et al Int J Obstet Anesth 2009;18(2);106-10 Smith et al. Anesthesiology 2003;99(1);60-4 Boet et al. J Emerg Med. 2010;42(5):606-11

Obtaining IV or intraosseous access above the diaphragm is recommended to avoid the potentially deleterious effects of vena caval compression increase time required for fluids or administered drugs to reach the heart or even prevent their circulation altogether.

Standard resuscitative medications: none contraindicated & no dose alterations

Lipid emulsion if LA toxicity, consider ECMO or bypass if refractory

Consider CV effects of oxytocinAHA 2010 Guidelines:Circulation

2010;122:S829-S861Bern, Weinberg. Curr Op in

Anaesth2011:24(3)262-67Dyer et al. Curr Opin Anaesthesiol

2011:24(3):255-61

Vaginal delivery possible?

Caval compression +4 min since arrest?

No response to ACLS- final pulse check?

Katz (38 cases): 12 of 20 cases had ROSCEinav (76 of 91 cases had CS): 32% benefitted

Delivery within 5 min: only 4 of 76 (7%)MATERNAL STATUS DID NOT DETERIORATE

WITH CESAREAN DELIVERY IN ANY CASE

Katz et al. Am j Obstet Gynecol 2005; 192(6): 1916-20Einav et al. Resuscitation 2012; 83(10): 1191-200

Milestone Labor Room(n=7)

OR( n=7)

P value

CPR resumed

3: 01(2:53 – 3:17)

4:20(3:20- 6:53)

0.030*

Intubation 4: 05(3:22-4:18)

4:48(4:19- 5:54)

0.064*

Incision 4:25(3:59 - 4:50)

7:53(7:18- 8:57)

0.004*

Values are median (IQR) times in min: secLipman, Daniels, Cohen, Carvalho. Obstet Gynecol 2011;118:1090-4

Point of Care ChecklistAdapted from OBSim and OBLS, Center for Advanced Pediatric and Perinatal Education, Stanford University

CALL FOR HELP!START CHEST COMPRESSIONS

C CIRCULATION

A AIRWAY

B BREATHING

D DEFIBRILLATE

E EXTRACT FETUS

Call “OB Code” Call neonatal team Adult Code Cart Adult airway equipment Scalpel/cesarean pack Assign timer/documenter

Immediate BLS Backboard Left uterine displacement Hands mid-sternum 100 compressions/min PUSH HARD! PUSH FAST! Change compressors every 2 min Obtain IV access above diaphragm

100% oxygen Chin Lift/ Jaw Thrust Oral airway, mask ventilate or Intubate early with 6.0 ETT or Supraglottic airway (LMA with gastric port) DO NOT INTERRUPT CHEST COMPRESSIONS!

If intubated:10 breaths / min (500-700ml/breath) If not intubated: 30 compressions to 2 breaths Use self inflating bag Administer each breath over 1 second

Pads front and back AED: Analyze/defibrillate every 2 min Immediately resume CPR for 2 min Prepare for delivery

Aim for incision by 4 min Aim for fetal delivery by 5 min

OBLS: ARREST IN A PREGNANT PATIENTCALL FOR HELP: EMERGENCY CORD/ BUTTON

CCIRCULATION

Backboard Manual Left uterine

displacemeny 100 compressions/min Push HARD, Push FAST Change compressors q i-2 min

AAIRWAY

Ventilate &OxygenateConsider:Chin liftOral AirwayAmbu BagSuctionMask ventilateIntubate or other device

BBREATHING

If intubated- Breathe q 6 sec (10/min)

If not intubated- 30 compressions:2 breaths- consider 2 handed mask ventilation

DDEFIBRILLATE AND

DELIVER FETUS

- Remove fetal monitors- Apply pads front and back- Analyze/defibrillate via AED- Immediately resume CPR X2min- Prep for PERIMORTEM

DELIVERY- DELIVERY within 5 min

Recommended by AHA 2010. Katz V et al

Different provider? Prepare SGA(LMA) Continue bag mask PPV

Place SGA (LMA etc) Utilize VA device (glidescope etc) Continue with bag mask PPV

Airway ControlledAirway Controlled Secure ETT / LMA 10 breaths per min 1 breath every 6 seconds Delegate PPV to another provider

Secure ETT / LMA 10 breaths per min 1 breath every 6 seconds Delegate PPV to another provider

A Anesthetic complications (high block; loss of airway; aspiration; respiratory depression, hypotension, local anesthetic toxicity)

B Bleeding* (DIC or coagulopathy, uterine atony, placenta accreta, abruption, previa, uterine rupture, trauma, transfusion reaction

C Cardiac cause (cardiomyopathy, myocardial infarction, aortic dissection, arrhythmias)

D Drugs (illicit; drug error, magnesium, narcotic, insulin or oxytocin overdose, anaphylaxis)

E Embolic (pulmonary embolus, amniotic fluid (AFE); air)

F Fever* (Infection, Sepsis)

G General non obstetric causes of cardiac arrest (Hs and Ts)**

H Hypertension* (preeclampsia/eclampsia/HELLP, intracranial bleed)

*Often diagnosis is apparent or predicted from pre-arrest condition

Refractory to resuscitation interventions (no ROSC), the use of ECMO/cardiac bypass

Correct reversible etiologies of arrest Manage uterine bleeding in the post-arrest patient?Therapeutic hypothermia has been reported in several

women who had a cardiac arrest during the first half of pregnancy. No adverse fetal effects resulted, except in one case. (stillbirth) birth.

98 deaths reviewed 77% related to healthcare professional

Delays or inadequacies in dx/ txIneffective treatmentMisdiagnosis

The California Pregnancy Associated Mortality Review. Report from 2002 and 2003 Maternal Death reviewsSacramento:California Department of Public Health, Maternal Child and Adolescent Health Division;2011

Institutional preparednessPeriodic emergency drills or simulationsDebrief to analyze individual (behavioral,

cognitive, technical) and systems issues; operationalize solutions

Hui. Obstet Gynecol Can 2011;33:858-63

Cohen. Int J Obstet Anesth 2008;17:20-25Lipman. Semin Perinatol 2011;35(2):74-9Dijkman. BJOG 2010;117:282-87

Q&A: CAB or ABC? C-A-B sequence (AHA) Note: respiratory maternal collapse (e.g., Mg/ opioid

overdose, high neuraxial block, hypoventilation after eclamptic seizure, failed intubation/ventilation), cardiac arrhythmias may develop

Parturients develop hypoxia/ acidosis rapidly during apnea (high basal metabolic rate, decreased FRC, and fetal O2 requirements.

Q&A: CAB or ABC? C-A-B sequence (AHA) Note: respiratory maternal collapse (e.g., Mg/ opioid

overdose, high neuraxial block, hypoventilation after eclamptic seizure, failed intubation/ventilation), cardiac arrhythmias may develop

Parturients develop hypoxia/ acidosis rapidly during apnea (high basal metabolic rate, decreased FRC, and fetal O2 requirements.

✓Prompt provision of high quality chest compressions with minimal interruptions+ Adequate ventilation initiated ASAP, in parallel with defibrillation.

Q&A:Manual Left Uterine Displacement vs Tilt?

Tilt has mechanical disadvantage for chest compression- transmission forces are no longer perpendicular to the thorax.

A study in healthy pregnant women undergoing CS : manual LUD decreased spinal hypotension compared to use of a 15° L table tilt.

Q&A:Manual Left Uterine Displacement vs Tilt?

Tilt has mechanical disadvantage for chest compression- transmission forces are no longer perpendicular to the thorax.

A study in healthy pregnant women undergoing CS : manual LUD decreased spinal hypotension compared to use of a 15° L table tilt.

✓Effective LUD best achieved with manual displacement. Kundra P, Khanna S, Habeebullah S, Ravishankar M. Anesthesia 2007;62:460–5

Q&A: PMCD - Transport to OR?

Simulation studies on maternal cardiac arrest and PMCD: transport from LR to the OR delayed uterine incision. Median times from maternal arrest to “incision” were 4 and 8 min (LR vs OR)

Transport- more interruptions and degradation in the quality of chest compressions.

Lipman S, Daniels K, Cohen SE, Carvalho B. Obstet Gynecol 2011;118:1090–4

Q&A: PMCD - Transport to OR? Simulation studies on maternal cardiac arrest and

PMCD: transport from LR to the OR delayed uterine incision. Median times from maternal arrest to “incision” were 4 and 8 min (LR vs OR)

Transport- more interruptions and degradation in the quality of chest compressions.

✓PMCD be performed at the bedside whenever possible in any pregnant patient >20 weeks’ gestation who sustains a cardiac arrest.

Lipman S, Daniels K, Cohen SE, Carvalho B. Obstet Gynecol 2011;118:1090–4

Case Scenario Q&A

Laboring patient found in cardiac arrest 7 min after the last recording of a low BP. Immediate chest compressions started upon discovering the patient. The code team arrived shortly thereafter. When should the baby be delivered?

Case Scenario- Timing of delivery?

2010 AHA: (1)”Emergency cesarean section may be considered at 4 minutes after onset of cardiac arrest if there is no ROSC,” and (2) “if no ROSC by 4 minutes of resuscitative efforts, consider immediate emergency CS: Aim for delivery within 5 minutes of onset of resuscitative efforts”

✓In the above scenario, chest compressions/ BLS/ACLS continued while preparations are made for an immediate delivery in the LR, but not necessary to wait additional 4 min before delivery.

Q&A: Why are AEDs recommended over manual defibrillators?

AHA 2010: “Despite limited evidence, AEDs may be considered for the hospital setting, especially in areas where staff have no rhythm recognition skills or defibrillators are used infrequently.”

Q&A: Should family members stay in the room during maternal CPR?

Some favor escorting family members out of the room during CPR, medico-legal liability family members becoming

traumatized/distresseddisrupting/delaying critical, life-saving

interventions.

Jabre P, et al. N Engl J Med 2013;368:1008–18

Q&A: Should family members stay in the room during maternal CPR?

✓AHA, the Emergency Nurses Association and public opinion- favor allowing family members to remain close to the patient during CPR. Family members view it as a right rather than a privilege to be with a loved one during their last moments..

facilitate the grieving process study found that relatives who did not witness CPR

experienced symptoms of post- traumatic stress disorder, anxiety and depression more frequently than those who did witness CPR.

Jabre P, et al. N Engl J Med 2013;368:1008–18

Q&A: Is it important to remove fetal monitors before delivery of shock?

Fetal monitors are electrical contact points – If present during maternal defibrillation, there is the potential for arcing or electrical burns. (risk is theoretical and defibrillation should never be delayed)

2 types of monitors of fetal heart rate: external and internal(FSE)

Katz VL, Dotters DJ, Droegemueller W.Obstet Gynecol 1986;68:571–6 Katz V, Balderston K, DeFreest M. Am J Obstet Gynecol 2005;192:1916–20

Q&A: Is it important to remove fetal monitors before delivery of shock?

Fetal monitors are electrical contact points – If present during maternal defibrillation, there is the potential for arcing or electrical burns. (risk is theoretical and defibrillation should never be delayed)

2 types of monitors of FHR: external and internal (FSE)

✓Removal of either external/ internal fetal monitors is recommended if the situation permits but should never delay defibrillation.

Katz VL, Dotters DJ, Droegemueller W.Obstet Gynecol 1986;68:571–6 Katz V, Balderston K, DeFreest M. Am J Obstet Gynecol 2005;192:1916–20

Q&A: Where do you place the hands higher on the sternum during chest compressions ?

gravid uterus displace the contents of the thorax cephalad shift in pregnant patients who are near term.

✓To be effective- hands should be placed 2-3 cm above usual sternal level under which the heart is likely to be located.

Q&A: If one suspects LA-induced cardiac arrest should lipid emulsion be administered, as in a nonpregnant patient?

Pregnancy -enhanced sensitivity to LAST, and cardiac toxicity resulting from high LA plasma concentrations. Dosing/ timing of lipid emulsion during resuscitation of pregnant patients follow standard algorithms used in nonpregnant patients

Bern S, Weinberg G. Curr Opin Anaesthesiol 2011;24:262–7 Neal JM, Mulroy MF, Weinberg GL; ASRA checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8

Q&A: Use of checklists to improve team performance during a maternal cardiac arrest is recommended. Why?

Checklists - integral part of the culture of safety in other highly dynamic, high-stakes domains. Ex. aviation industry- pre-flight safety checklist,

and emergent situations preprocedure/preincision surgical time-outs

Simulation studies suggest checklists help medical teams perform optimally during emergencies; periodic training is necessary. Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg 2013;117:1162–71

*Institutional preparedness, implementaion strategies before event!

BEAUCHOPS

REFERENCES

Thank you!