Resuscitation of Obstetric Patient

The number of cases of pregnant patients with cardiorespiratory arrest requiring resuscitation has increased worldwide, secondary to the main number of patients with high-risk pregnancies associated with chronic, especially cardiopulmonary, pathologies. The knowledge of the resuscitation algorithms by the health personnel responsible for the care of pregnant patients is mandatory, because due to different physiological and anatomical changes, there are particularities in the management and use of medications. In addition, a detailed description of the steps included in the resuscitation is necessary, where assessment of the airway, ventilation, circulation, and defibrillation determines a step in resuscitation. One of the determining and exclusive events in this type of patients is cesarea perimortem. That is why it includes a concrete description of the time and the indications for its realization. Finally, a list of medicines most used in resuscitation in pregnancy, with its dosage and safety range, is mentioned. The pregnant patient poses a challenge to resuscitation teams. This review refers to the recommendations for establishing “obstetric blue code” protocols at the institutional level

Reversion of Severe Mitral Insufficiency in Peripartum Cardiomyopathy Using Levosimendan

Idiopathic peripartum cardiomyopathy presenting with heart failure is a true diagnostic and treatment challenge. Goal oriented clinical management aims at the relapse of left ventricular systolic dysfunction. A 35-year-old patient on her 12th day post-delivery presents progressive signs of heart failure. Transthoracic echocardiography showed severe mitral insufficiency, mild left ventricular dysfunction, mild tricuspid insufficiency, severe pulmonary hypertension, and right atrial enlargement. With wet and cold heart failure signs, the patient was a candidate for inodilator cardiovascular support and volume depletion therapy. As the patient presented a persistent tachycardia at rest, levosimendan was chosen over dobutamine. Levosimendan was administered at a dose of 0.2 g/kg/min during a period of 24 hours. After inodilator therapy, the patient's signs and symptoms of heart failure began to decrease, showing improvement of dyspnea, mitral murmur grade went from IV/IV to II/IV, filling pressures and systemic and pulmonary resistance indexes decreased, arterial blood gases improved, and an echocardiography performed 72 h later showed non-dilated cardiomyopathy, mild cardiac contractile dysfunction, mild mitral insufficiency, type I diastolic dysfunction and improvement of pulmonary hypertension. Cardiovascular function in peripartum cardiomyopathy tends to go back to normality in 23-41% of the cases, but in a large group of patients, severe ventricle dysfunction remains months after initial symptoms. This article describes the diagnostic process of a patient with peripartum cardiomyopathy and a successful reversion of a severe case of mitral insufficiency using levosimendan as a new therapeutic strategy in this clinical context

The ultrasound-based cardiac output monitoring is a useful tool to define baseline hemodynamic parameters in healthy permanent residents at high altitude: results of a monocentric pilot study

Previous studies on the cardiac data of healthy permanent residents living in high-altitude regions such as Tibet and the Andes have yielded inconsistent findings and significant disparities. These discrepancies can be mainly attributed to the invasive methods conventionally used for parameter evaluation. However, with the introduction of cutting-edge ultrasound technology, there is now an innovative approach to addressing and reconciling these variations. In this pilot study, we employed an ultrasound-based cardiac output monitoring (USCOM) device to evaluate cardiac output and related hemodynamic variables in a group of 20 healthy high-altitude Andean residents (comprising 10 men and 10 women) aged between 26 and 35 years old. The monocentric study was carried out in La Paz, Bolivia, located between at an altitude of 3,600–4,000 m. A total of 60 hemodynamic measurements were evaluated, accounting for three technical replicates per subject. Our results showed strong intrasubject reproducibility and revealed important differences related to both sex and hemodynamic parameters in highlanders compared to individuals residing at sea level. We conclude that USCOM represents a highly reliable technology for performing hemodynamic measurements in high-altitude residents. Our preliminary findings underscore the need for larger studies, encompassing larger sample sizes, specifically tailored to gender considerations, and extendable to broader highland populations. These findings have special significant implications for the management of hemodynamics in intensive care and postoperative settings, warranting further comprehensive research efforts

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Post-cardiopulmonary resuscitation therapeutic hypothermia during the immediate post-partum period in a patient seen at San Jose Hospital in Bogota in 2013: Case Report and review of the literature

Objetivo: reportar el caso de una paciente que presentó paro cardiaco en su posparto inmediato, la cual fue manejada con hipotermia terapéutica posreanimación con resultados neurológicos favorables, y realizar una revisión de la literatura publicada acerca de hipotermia posreanimación en el embarazo. Materiales y métodos: se presenta el caso de una paciente con embarazo de 37 semanas, quien es remitida por preeclampsia severa a una institución privada de cuarto nivel de complejidad ubicada en Bogotá (Colombia). La paciente es llevada a cesárea, y en el alumbramiento desarrolla eclampsia, con deterioro respiratorio, hipoxemia y bradicardia que progresa a ritmo de paro en asistolia, con recu15peración del ritmo sinusal luego de 15 minutos de reanimación cardiopulmonar (RCP), pero con criterios para un estado de coma residual. Se establece entonces un protocolo de neuroprotección con hipotermia sostenida a 33 grados durante 24 horas y posterior recalentamiento gradual. El desenlace final fue favorable, con recuperación del estado de conciencia y mínimas secuelas motoras. Para la revisión del tema se realizó una búsqueda en las bases de datos de la literatura especializadas en medicina (Medline vía PubMed, Embase) con los términos MESH: “hipotermia terapéutica”, “embarazo”, “paro cardiaco”, sin restricción de idioma o de tiempo. Resultados: en PubMed se encontraron cuatro estudios con los criterios de búsqueda, y en Embase siete se referían al tema, los cuales incluían los cuatro reportes de casos ya encontrados en PubMed, dos reportes de casos adicionales y una revisión de paro cardiaco materno que discute en sus apartes el tema de hipotermia terapéutica en esta población. En la revisión de referencias bibliográficas se identificó una guía de práctica clínica y un artículo de revisión. Conclusiones: en la literatura publicada se describe la hipotermia terapéutica como una terapia benéfica para la paciente gestante, que podría ser considerada como parte de los cuidados posparo cardiaco como medida de protección neurológica. Se requieren estudios que incorporen mayor número de pacientes, y estudios controlados que evalúen la efectividad y seguridad de la técnica para la madre y el feto.Objective: To report the case of a patient who went into cardiac arrest in the immediate post-partum period and was managed with post-resuscitation therapeutic hypothermia with a favourable neurologic outcome; and to conduct a review of the published literature on post-resuscitation hypothermia in pregnancy. Materials and methods: We present the case of a patient in her 37th week of gestation, referred because of severe pre-eclampsia to a private, level IV institution in Bogotá, Colombia. The patient underwent cesarean section and during childbirth she developed eclampsia with respiratory distress, hypoxemia and bradycardia that progressed to cardiac arrest in asystole. Sinus rhythm returned after 15 minutes of cardiopulmonary resuscitation (CPR) but the patient was in a status consistent with residual coma. A neuroprotection protocol was initiated with hypothermia, maintained at 33 degrees over a 24- hour period, and then followed by gradual warming. The final outcome was favourable, with recovery of consciousness and negligible motor sequelae. For the review of the literature, a search was conducted in Medline via the PubMed and Embase databases using MESH terms for the key words therapeutic hypothermia, pregnancy, cardiac arrest, with no restriction of language or time.Results: Overall, 4 studies that met the search criteria were found in PubMed. In Embase, 7 referred to the topic, including the 4 case reports already found in PubMed plus two additional case reports and a review of maternal cardiac arrest that discusses therapeutic hypothermia in this population. The review of the bibliographic references resulted in the identification of a clinical practice guideline and one additional review article. Conclusions: Therapeutic hypothermia is described in the published literature as a beneficial therapy that could be considered part of postcardiac arrest care as a measure of neurological protection in the pregnant patient. Studies with larger numbers of patients and controlled trials to assess the effectiveness and safety of the technique for the mother and the foetus are needed

Pancreatic pseudocyst infected by Shewanella putrefaciens: A case report

n Shewanella putrefaciens es un bacilo gramnegativo, no fermentador, oxidasa positivo, productor de sulfato de hidrógeno, que de manera inusual causa cuadros infecciosos en humanos. Este germen oportunista produce infecciones en pacientes inmunosuprimidos y/o con antecedente de exposición a comida o agua de mar contaminados con el germen. A continuación presentamos un reporte de caso de un paciente con una infección del páncreas por este germenShewanella putrefaciens is a rare Gram-negative bacillus, non-fermenting, oxidasepositive, and a hydrogen sulfide producer, which infrequently causes human infections. This opportunist germ causes infections in immunosuppressed people and in those with a history of contact with seawater or food contaminated with the microbe. We present a case of a patient with a pancreatic infection caused by this microb

Thromboelastographyguided transfusion therapy in a pregnant patient with hemorrhagic dengue fever hospitalized in icu. Case report

Dengue fever is the biggest public health issue in tropical countries. A significant percentage of patients who suffer from this disease require admission to the intensive care unit (ICU) due to the severity of the clinical picture. This case reports the clinical evolution of an eight-week pregnant woman with dengue fever associated with thrombocytopenia and leukopenia. The patient comes from an endemic area for tropical diseases, fact that led to diagnose dengue fever with hemorrhagic characteristics. During her stay in the ICU, the patient presented with first trimester bleeding and placental hematoma. Therefore, and considering the pregnancy and the risk of loss, the hematological function was monitored through thromboelastography. The transfusion of blood products was decided according to the specific findings. Controlling and reversing the obstetric bleeding process was possible, the patient condition evolved favorably, and she was subsequently discharged from the ICU. This article reports on the usefulness of dynamic monitoring the hematological function using thromboelastography in patients with hemorrhagic dengue fever and special conditions such as pregnancy