Thread by @OBsleepmerchant

Novel Content No.2 at #SOAPAM2023 virtual #OBAnes highlights Day 2: @DoctorStahl speaks on Obstetric Critical Care #OBCritCare

@DoctorStahl is an intensive care bear, who loves #OBAnes. QR code to references. #OBCritCare #SOAPAM2023

Pregnancy-associated mortality ≈ maternal mortality. #OBAnes 0.2% - doing well (wonder what the denominator is?), so Elmo could ask why are we worried? #SOAPAM2023

Well, 43% of maternal mortality, early #OBAnes involvement in MDT probably could make a difference. Add in other cardiovascular disease where #OBCritCare definitely involved, critical illness accounts for 76% of maternal deaths. #SOAPAM2023

Ohio data surprisingly similar, as is that for Massachusetts and New Jersey. #OBAnes #SOAPAM2023

So critical illness accounts for ~3/4 maternal deaths in USA. #OBAnes have an opportunity to change this. Assumption warning! So how do we prevent death by critical illness in pregnant patients? We have to see the wood for the trees - move away from looking at causes of death,… twitter.com/i/web/status/1…

And if we move away from looking at casual of death we can recognize maternal death as the endpoint of a potentially modifiable continuum of maternal morbidity, with SMM preceding mortality and the final point of #OBCritcare intervention. Blood transfusion seems an appropriate if… twitter.com/i/web/status/1…

@DoctorStahl points out the ever topical significant racial disparities that exist, for SMM and maternal mortality. #OBAnes #SOAPAM2023

So let’s reframe the question - how to prevent death or morbidity by critical illness (accounting for ~75% maternal mortality, possibly more SMM, in USA): understand the causes of death & apply CCM principles to find a solution. #OBAnes #SOAPAM2023

Possibly even simpler than that - BELIEVE women when they say something is wrong. @elsmere_g had some similar key principles at #Anaesthesia2023 (suspect @SusannaStanford may approve of this message) #OBAnes #SOAPAM2023

With the WHY covered, let’s move onto what’s different and the how to’s of #OBCritcare. @DoctorStahl will cover 3 failures: heart, lungs and immune. #OBAnes #SOAPAM2023

Starting with cardiac - let’s break it down: biventricular failure, wildcard (aortic disease), and RV failure. Starting with biventricular failure - the big 3. #OBAnes #SOAPAM2023

Guidelines aren’t particularly pregnancy focused (dearth of literature to blame). A couple of principles. Caveats & system issues - what works in a regular hospital or ICU does not necessarily flow well in a maternity hospital or labour ward. #OBAnes #SOAPAM2023

ROSE - worthwhile #POCUS addition for #OBAnes. #SOAPAM2023

Wildcards are exactly that: wild. RV failure can be subdivided into that with normal RV afterload vs increased RV afterload. #OBAnes #SOAPAM2023

With the considerations of normal or increased RV afterload delineating DDx, the different treatment bundles are clear. MCS = mechanical cardiovascular support (extracorporeal life support)… do it early. #OBAnes #OBCritcare #SOAPAM2023

We need to address the myth of “crashing onto ECMO” there’s no such thing - even experienced prepared units take time. If it’s on the menu, stop and consider transfer to ICU. Veno-Arterial not veno-venous - provides extracorporeal life support. #OBAnes #SOAPAM2023

Does it work? Look at that maternal survival rate (MSR) post intervention. Also consider survival rates for individual diagnoses. #OBAnes #OBCritcare #SOAPAM2023

Veno-Arterial ECLS at the Ohio State - includes peripartum CMO. So, heart failure in pregnancy: optimize preload; use inotropes, control rhythm; reduce afterload and evaluate for MCS. #OBAnes #OBCritcare #SOAPAM2023

What is good in guidelines? Complete cycle of care - early assessment, pre pregnancy planning, monitoring, delivery planning and POSTpartum care (4th Trimester @Rose_Kearsley). @maloumeng’s planning for delivery framework gets the nod of approval. #OBAnes #SOAPAM2023

Anything to add on cardiac arrest? Do what you do for anyone else, and remember Manual Left Uterine Displacement. #OBAnes #SOAPAM2023

Moving on to acute respiratory failure. Really enjoyed the animation (very satisfying, poorly captured in 4 pictures) #OBAnes #SOAPAM2023

Respiratory Failure management - risk mitigation: mechanical ventilation vs NIPPV or HHFNC (HFNO2). Both modalities have their downsides. #OBAnes #SOAPAM2023

Goals with mechanical ventilation - safe securement of airway; prevention of acute lung injury; balancing risk vs benefits. Rule of 6. High normal PEEP. Maintain reasonable SpO2 > 90% (PaO2 perhaps less important) #OBAnes #SOAPAM2023

HHFNC (HFNO2) and NIPPV? 3 classes of indication. Perhaps time to re-frame preoxygenation wrt PERIoxygenation/ apnoeic oxygenation —> reasonable evidence. And COVID? It depends. #OBAnes #SOAPAM2023

If you can’t explain it in emoji’s…

Any Dx getting worse, severe = ETT & ICU

Any Dx unclear trajectory, severe = ETT & ICU

Pulm edema getting better, not too severe (we hope) = NIPPV & ICU

Pulm edema getting better, moderate severity = NIPPV & ICU

#OBAnes #SOAPAM2023

Emoji’s continued…

Asthma getting better, we think it’s okay = NIPPV on L&D

PE/AFE any trajectory, we think it’s okay = HHFNC/ NIPPV initiated on L&D, to transfer to ICU.

PNA, ARDS, aspiration getting better = HHFNC/ NIPPV in ICU

#OBAnes #SOAPAM2023

Take home: if trajectory and severity are 💩 consider ECLS / MCS EARLY #OBAnes #SOAPAM2023

What of VV ECMO? Specific criteria. Absolute contraindications. #OBAnes #SOAPAM2023

Last (not least): Sepsis. Definitions. qSOFA - might over call OB patients due to either changes in physiology (RR) or epidural analgesia (SBP). Therefore OB-modified qSOFA: RR 25 and over, SBP less than or equal 90mmHg. Altered mentation is NEVER normal (unless proven otherwise)… twitter.com/i/web/status/1…

What is different about maternal sepsis? What scares @DoctorStahl? (usually the same as non-pregnant patients). Early warning systems not yet ideal. There’s a spectrum from sick + no infection through maternal sepsis to end organ failure without infection. #OBAnes #SOAPAM2023

Cornerstones of maternal sepsis management. #OBAnes #SOAPAM2023

Summary and references from @DoctorStahl #OBAnes #SOAPAM2023

@DoctorStahl does smile if you ask nicely in the chat box. #SOAPAM2023

@threadreaderapp unroll please