ICU perspectives in Maternity Critical care

Dr..Carl Waldmann Royal Berkshire Hospital

Reading

ICU perspectives in Maternity Critical care

October 5th 2018

Gary Masterson&

Audrey Quinn

8 MILLENIUM DEVELOPMENT GOALS

• Eradicate extreme poverty and hunger• Promote gender equality and empower women• Achieve universal primary education

• Reduce child mortality• Improve maternal health• Combat HIV/AIDS and other diseases• Ensure environmental sustainability• Develop a global partnership for developmentWHO involvement in patient safety starting in ICU

WHO AM I

• Consultant ICM and Anaesthesia

• Dean FICM

• Sat on the Multidisciplinary Group looking

at care for the pregnant and recently

pregnant individuals

• P/T work for Leyton Orient

• ID 10 T tab

ID 10 T

IDIOT

WHERE DO I WORK

Enlightened employersQuakers gained

favour with consumers due to their ethical business practises, Quaker principles

such as truth telling,simplicity and

fair pricing

ROYAL BERKSHIRE HOSPITALREADING

Background• Our ICU until recently– 17 bedded general

unit – Clinical Information

System• Staffing structure

– 10 intensivists5 anaesthetists 5 physicians– Nursing staff work

internal rotation – 24/7 Outreach service– Follow-up Clinic– TCCDG includes

Maternity representation

0 1 2 3 4 5

% ICU bedsin hospital

Denmark

Switzerland

Belgium

Holland

Germany

France

Sweden

Spain

Austria

UK

Critical insight – ICS 2003 (1999 data)

Not always enough ICU beds

Reading

ICM ALSO REFERRED TO AS CRITICAL CARE MEDICINE, IS A BODY OF SPECIALIST KNOWLEDGE AND PRACTICE RECOVERING FROM POTENTIALLY LIFE-THREATENING FAILURE OF ONE OR MORE OF THE BODY’S ORGAN SYSTEMS. IT INCLUDES END-OF-LIFE CARE, AND THE SUPPORT OF FAMILIES. IT INCLUDES OUTREACH AND POST-INTENSIVE CARE REHABILITATION

WHAT IS INTENSIVE CARE

LEVELS of CAREIntensive Care Society © 2009

• ICU HDU

• Now Level 0 1 2 3

Dr J Eddleston

Dr D Goldhill

Dr J Morris Chair

Not terribly useful in

Obstetrics

Maternal Critical Care

• ICNARC data has until recently not been sensitive enough to tell the story

• Big Issue

The Big Issue

Admission Diagnoses Reading ICU27 cases

• PPH 14

• APH 1

• RUPTURED UTERUS 1

• SEPSIS 1

• HELLP 4

• ECLAMPSIA 4

• FATTY LIVER 2

51 days total ICU care

Interventional

radiology

FLU H1N1

• The BMJ(2010;340:c1279) published the results of a study of women who were more than 20 weeks pregnant and suffering from 2009 H1N1 influenza in Australia and New Zealand.

• 13 times more likely to become critically ill

HONG KONG ICM exam

Long case was on Obstetric

haemorrhage

Florence Nightingale 1863

“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose…. If obtained…they would show subscribers how their money was spent…..’’

21

Manual flowsheet documentation

MBRRACE-UK

Conclusions

• “Equity of Care (2011)” Recommendations have failed to be implemented.

• Some patients cannot be moved to critical care

• Midwives not trained in critical care, directentry to Midwifery Training

• General view that most delivery suites cannot currently deliver level 2 care

• Obstetricians don’t do critical care

• Obstetric Anaesthetists do maternal critical care and need to keep up skills

• Need a flexible solution – one size won’t fit all

• Solution should be competency based rather than speciality based

Conclusions 2

KEY PUBLICATIONS IN 2017 INTENSIVE CARE is now a speciality in its own right.

What is happening in ICU ?

• Population Elderley, OBESE, EoL care

• Sepsis & Bundles

• Thromboprophylaxis v Bleeding

• TECHNOLOGY

• Winter pressure, Terrorism

• REHABILITATION & FOLLOW-UP

• Critical Futures FACULTY

• GIRFT GPICS HBN 04-02

• Maternity Critical Care

• Consultantreview in 14hours

• Formal handovers

• Access to Critical Care

• 24/7 Outreach

The Angel Catheter

Pregnancy increases the risk of VTE by 5 times

PPH and APH

Postpartum haemorrhage

Ratio of products 1:1:1

Tranxemic Acid

Fibrinogen

> 3-4 g litre

rFVIIaIntraoperative cell salvage

Interventional radiology

Surgical intervention

Audrey Quinn

Case JM• LSCS uneventful

• At end of procedure she failed to stabilise fluids.Bleeding Major Haemorrhage.

• Laparotomy- haemoperitoneum

• Packs, Clotting factors, Tr Acid

• Rusch Balloon,

• Interventional Radiology, Splenic Artery Aneurysm. Over weekend 2 more visits to Xray.

IT

Data for obstetrics is lacking

The pressures in critical care are intense across the board,” said Dr Gary Masterson, president of the

Intensive Care Society. “This is a bad winter, it’s the worst since 2010 when we had the H1N1 (swine flu) outbreak

There is more to life than measuring death

King’s Fund Report

Q O L REHABILITATION

PSYCHOLOGICAL

PHYSICAL

o

C I PCritical Illness Polyneuropathy

Rehabilitation in ICU

Sarah Eli, Royal Berkshire Hospital

4

12

5

3

0

CPAX Eve Corner

Getting It Right First Time

ACCPs

Diurnal rythmsSleep deprivation

BABY FRIENDLY!!

Key Messages

• Working in Teams

• Enhanced maternal care

• Education and training

• Early Warning score modified for obstetrics

• Where care is delivered

• Care on ICU rapid access to Obstetric expertise

• Follow up

• Dataset for QI project

Roto-Rest ™130 degrees total arc

65 degrees per side

ROTOPRONE

0

5

10

15

20

25

30

35

40

6 ml/kg

12 ml/kg

% M

ort

ality

ARDSnet mechanical ventilation protocol

results: mortality

Adapted from Figure 1, page 1306, with permission from The Acute Respiratory Distress

Syndrome Network. N Engl J Med 2000;342:1301-1378

PROTECTIVE VENTILATION

STRATEGY

CT

• 29 year old female

• PMH: 2009 stillborn was suing RBH

• Seen in antenatal clinic at Basingstoke

• Vaginal delivery at 40 +1

• Labour from 02.00

• Delivered 05.50

• Placenta 06.30 “ragged”

CT

• Bleeding++PV 13.15• 13.30, collapsed, midwife arrives at 13.50• 999 at 13.57 • At scene 14.03 – PEA→VF →ALS• Arrived at hospital at 14.35 in A&E• ROSC 14.48• Gas at 14.43: pH 6.3/ pO2 9.98/ pCO2 4.37/ Lac 23/

HCO3 1.9/ Hb 5• Placenta evacuated & manual compression

3rd degree tear sutured & Rusch balloon

CT

• To theatre →Subtotal hysterectomy 18.30

• Total: 25 units RBC, FFP 12 units, cryo 8 units and platelets 2 units

• Transferred to ICU post op at 19.30

• High dose inotropes

• Certified dead at 21.17

Summary

• Get patients the right care, at the right time, delivered by the right people in the right place

• Maternity Team (particularly obstetric anaesthetist) & Critical Care work together

• Enhance care on Delivery Suite (particularly for midwives) with EMC

• Crit Care input for non-EMC patients

27.09.18

Carter: ‘Vital’ improvements to tech,

fleets needed to save £50m

PneuX Pneumonia Prevention System

ORIGINAL ARTICLEVentilation with Lower Tidal Volumes as

Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome

The Acute Respiratory Distress Syndrome NetworkN Engl J Med 2000; 342:1301-1308May 4, 2000

VV CO2 removal

PRONE

Evidence

GPP Recommended good practice based on the clinical experience of the multidisciplinary working group

Recommendations

1.1 Obstetric units appoint lead clinician for the care of critically ill women.

1.2 Establish training resources to enable staff to achieve and maintain skills in EMC.

1.3 Women should have access to healthcare professionals who are EMC competent

1.4 The individual competence required should be recorded by the maternity team

1.5 The lead clinician participates in the hospital’s critical care delivery group

1.6 Escalation to critical care clearly defined, includes multidisciplinary discussion.

1.7 Outreach available and provides support and education delivering EMC.

1.8 Obstetric units should be part of the regional maternal critical care network .