Severe pre-eclampsia and hypertensive crises Arulkumaran, N., MRCP; Lightstone, L., PhD
Best practice & research. Clinical obstetrics & gynaecology,
12/2013, Letnik:
27, Številka:
6
Journal Article
Recenzirano
Hypertensive disorders of pregnancy are one of the leading causes of peripartum morbidity and mortality globally. Hypertensive disease in pregnancy is associated with a spectrum of severity, ranging ...from mild pregnancy-induced hypertension to eclampsia. Although most cases of pre-eclampsia may be managed successfully, severe pre-eclampsia is a life-threatening multisystem disease associated with eclampsia, HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, acute kidney injury, pulmonary oedema, placental abruption and intrauterine foetal death. Management of severe pre-eclampsia includes identification of high-risk patients, optimisation of antenatal care, early intervention and the identification and early management of complications. In the first instance, oral anti-hypertensive agents, including labetalol, nifedipine and methyldopa, should be tried. If oral anti-hypertensive agents have failed to adequately control blood pressure, intravenous anti-hypertensives should be considered. Commonly used intravenous anti-hypertensives include labetalol, hydralazine and glyceryl trinitrate. In addition to anti-hypertensive agents, close attention should be given to regular clinical examination, assessment of fluid balance, neurologic status and monitoring of other vital signs. Magnesium sulphate should be considered early to prevent seizures. Delivery of the baby is the definitive management of severe pre-eclampsia.
Videolaryngoscopy (VL) may improve the success of orotracheal intubation compared with direct laryngoscopy (DL). We performed a systematic search of PubMed, Embase, and CENTRAL databases for studies ...comparing VL and DL for emergency orotracheal intubations outside the operating room. The primary outcome was rate of first-pass intubation, with subgroup analyses by location, device used, clinician experience, and clinical scenario. The secondary outcome was complication rates. Data are presented as odds ratio (95% confidence intervals); P-values. We identified 32 studies with 15 064 emergency intubations. There was no difference in first-pass intubation with VL compared with DL OR=1.28, (0.99–1.65); P=0.06. First-pass intubations were increased with VL compared with DL in the intensive care unit (ICU) 2.02 (1.43–2.85); P<0.001, and similar in the emergency department or pre-hospital setting. First-pass intubations were similar with GlideScope®, but improved with the CMAC® 1.32 (1.08–1.62); P=0.007 compared with DL. There was greater first-pass intubation with VL compared with DL amongst novice/trainee clinicians OR=1.95 (1.45–2.64); P<0.001, but not amongst experienced clinicians or paramedics/nurses. There was no difference in first-pass intubation with VL compared with DL during cardiopulmonary resuscitation or trauma. VL compared with DL was associated with fewer oesophageal intubations OR=0.32 (0.14–0.70); P=0.003, but more arterial hypotension OR=1.49 (1.00–2.23); P=0.05. In summary, VL compared with DL is associated with greater first-pass emergency intubation in the ICU and amongst less experienced clinicians, and reduces oesophageal intubations. However, VL is associated with greater incidence of arterial hypotension. Further trials investigating the utility of VL over DL in specific situations are required.
Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed ...therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), 95% confidence intervals (CIs), and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications OR=0.54, (0.38–0.76), P=0.0005 and arrhythmias OR=0.54, (0.35–0.85), P=0.007. GDT was not associated with an increase in acute pulmonary oedema OR=0.69, (0.43–1.10), P=0.12 or myocardial ischaemia OR=0.70, (0.38–1.28), P=0.25. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.
We aimed to identify any association between day and time of admission to critical care and acute hospital outcome.
We conducted a cohort study using prospectively collected data from the national ...clinical audit of adult critical care. We included 195 428 unplanned admissions from 212 adult general critical care units in England, Wales and Northern Ireland, between April 1, 2013 and March 31, 2015 in the analysis.
Hourly admission rates for unplanned admissions varied more than three-fold during the 24 h cycle. Overall acute hospital mortality was 26.8%. Before adjustment, acute hospital mortality was similar between weekends and weekdays but was significantly lower for admissions at night compared with the daytime (−3.4%, −3.8 to −3.0%; P<0.001). After adjustment for casemix, there remained no difference between weekends and weekdays (−0.0%, −0.4 to +0.3%; P=0.87) or between nighttime and daytime (−0.2%, −0.5 to +0.1%; P=0.21). Delays in admission were reported for 4.3% of admissions and were slightly more common during weekdays than weekends and in the daytime than at night. Delayed admission was associated with a small increase in acute hospital mortality, but adjusting for this did not affect the estimates of the effect of day and time of admission.
The day of week and time of admission have no influence on patient mortality for unplanned admissions to adult general critical care units within the UK. Ways to improve critical care and hospital systems to minimize delays in admission and potentially improve outcomes need to be ascertained in future research.
Puerperal sepsis Arulkumaran, N., MRCP; Singer, M., MD
Best practice & research. Clinical obstetrics & gynaecology,
12/2013, Letnik:
27, Številka:
6
Journal Article
Recenzirano
Infections during pregnancy are relatively prevalent, and the majority of cases are managed well in the community. Occasionally, however, infections may be life-threatening. Sepsis may be associated ...with multiple organ dysfunction and a high mortality. The treatment of sepsis is time critical and requires early fluid resuscitation and antibiotics. Early involvement of other specialties and allied health-care professionals to provide a multidisciplinary approach to patient care is important. Continuous monitoring of maternal vital signs and provision of supportive care for multiple organ dysfunction are best done within the intensive care unit. Despite advances in patient care, the mortality rate associated with maternal sepsis remains high. Health-care services in low-income countries face particular problems that account for an increased incidence of puerperal sepsis and maternal mortality. These include lack of access to health care, septic abortions and a greater incidence of human immunodeficiency virus. The key to management of sepsis is early recognition, aggressive resuscitation, antibiotic administration and source control.
Objectives. ANCA-associated vasculitis and interstitial lung disease (ILD) are uncommon conditions. The occurrence of both diseases in the same patient is increasingly recognized. Our aim was to ...ascertain the characteristics and outcomes of patients with ILD and ANCA-associated vasculitis.
Methods. A retrospective observational cohort study was performed. Patients who presented to the Hammersmith Hospital, London, with ANCA-associated vasculitis granulomatosis with polyangiitis (Wegener's), microscopic polyangiitis (MPA) or Churg-Strauss syndrome who also had ILD were included. Following hospital discharge, all patients were followed up in a multi-disciplinary vasculitis clinic. We recorded patient demographics, diagnostic tests, treatment, complications and mortality.
Results. ILD was observed in 2.7% (n = 14) of our patients with ANCA-associated vasculitis (n = 510); all had MPO-ANCA and a clinical diagnosis of MPA, giving a prevalence of 7.2% in patients with MPA (n = 194). There was no significant difference in survival between patients with MPA and ILD and those with MPA alone.
Conclusion. It is important that physicians are aware of this clinical association and the presence of ILD should be considered in all patients with ANCA-associated vasculitis, especially those with MPO-ANCA. The possibility that patients with ILD may subsequently develop features of systemic vasculitis should also be remembered.
The number of patients with end-stage renal disease (ESRD) is increasing worldwide, with a growing demand on healthcare services. A systematic review of the literature was performed to determine the ...requirement for intensive care unit (ICU) services, reasons for admission, predictors of mortality, and short- and long-term outcomes of ESRD patients admitted to ICU. Sixteen studies were identified, comprising 6591 ICU admissions. Cardiovascular disease and sepsis accounted for the majority of admissions. Acute illness severity scores tend to overestimate mortality among ESRD patients. Critical illness associated with acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with significantly higher hospital mortality compared with ESRD patients admitted to the ICU odds ratio (OR) 3.9; 3.5–4.4; P<0.0001. However, hospital mortality of ESRD patients is less favourable compared with matched patients with mild AKI (OR 1.5; 1.4–1.6; P<0.0001). Although the mortality rate remains high shortly after hospital discharge, the duration of increased mortality risk is unclear. Patients with ESRD frequently benefit from ICU admission, despite chronic co-morbidity. Further studies are required to modify and validate existing illness severity scores for ESRD patients admitted to the ICU, and to establish the duration of increased mortality risk after discharge from ICU.
It remains unclear if intubation and ventilation earlier in the disease course confers a survival advantage in acute respiratory distress syndrome. Our objective was to determine whether patients ...with COVID-19 who died following mechanical ventilation were more advanced in their disease compared to survivors. Forty-seven patients admitted directly to our centre received ventilation, of who 26 (57%) patients died. The rate of fall in SpO2:FiO2 ratio (p = 0.478) and increasing respiratory rate (p = 0.948) prior to IMV were similar between survivors and non-survivors. Our data support a trial of continuous positive airway pressure prior to IMV in patients with moderate-to-severe COVID-19 ARDS.
The COVID-19 pandemic increased the use of broad-spectrum antibiotics due to diagnostic uncertainty, particularly in critical care. Multi-professional communication became more difficult, weakening ...stewardship activities.
To determine changes in bacterial co-/secondary infections and antibiotics used in COVID-19 patients in critical care, and mortality rates, between the first and second waves.
Prospective audit comparing bacterial co-/secondary infections and their treatment during the first two waves of the pandemic in a single-centre teaching hospital intensive care unit. Data on demographics, daily antibiotic use, clinical outcomes, and culture results in patients diagnosed with COVID-19 infection were collected over 11 months.
From March 9th, 2020 to September 2nd, 2020 (Wave 1), there were 156 patients and between September 3rd, 2020 and February 1st, 2021 (Wave 2) there were 235 patients with COVID-19 infection admitted to intensive care. No significant difference was seen in mortality or positive blood culture rates between the two waves. The proportion of patients receiving antimicrobial therapy (93.0% vs 81.7%; P < 0.01) and the duration of meropenem use (median (interquartile range): 5 (2–7) vs 3 (2–5) days; P = 0.01) was lower in Wave 2. However, the number of patients with respiratory isolates of Pseudomonas aeruginosa (4/156 vs 21/235; P < 0.01) and bacteraemia from a respiratory source (3/156 vs 20/235; P < 0.01) increased in Wave 2, associated with an outbreak of infection. There was no significant difference between waves with respect to isolation of other pathogens.
Reduced broad-spectrum antimicrobial use in the second wave of COVID-19 compared with the first wave was not associated with significant change in mortality.
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