Cardio-pulmonary Resuscitation in Pregnancy 4’ Maternal code – Are you ready? Sunil T Pandya Head of the Dept. Anaesthesia, Pain & Critical Care PRERNA ANAESTHESIA AND CRITICAL CARE SERVICES, HYD. Why do we need to discuss? • Pregnant patients are different….two lives are at stake! • Maternal physiological changes in pregnancy DEMANDS modifications during CPR • Pregnancy specific causes: BEAU CHOPS CPR in PREGNANCY • Relatively rare: 1 / 30,000 • Despite pregnant women being younger than the traditional cardiac arrest patient, the survival rates are poorer, depending upon the etiology Causes of Cardiac Arrest in Pregnancy: H’s and T’s • • • • • • • • • B - Bleeding E – Embolism, AFE, Air A – Anaphylaxis, Anaesthesia – LAST, TS, SD U – Uterine atony C - Cardiac H – Hypertension, HELLP O - Others P – Pulmonary Thromboembolism S - Sepsis Causes of Cardiac Arrest in Pregnancy Near miss spectrum – Cardiac Arrest! CPR in pregnancy – Factors to be considered! • Uterine blood flow: Non pregnant state: 2-3% • Ut.-placental blood flow in pregnancy: 30% • Pregnancy represents high CO and low SVR state • CO increases by 50% to satisfy the increased needs from fetus, placenta and mother! Cardiol Clin 30 (2012) 453–461 CPR in pregnancy – Factors to be considered! Utero-placental blood flow in pregnancy: • 30% reduction in supine position • Enlarged uterus also obstructs forward blood flow making chest compressions less effective! • Blood is sequestered by the low-resistance, high volume utero placental unit, hindering effective CPR….delay in establishing ROSC, needing PMCS! Cardiol Clin 30 (2012) 453–461 Supine Hypotensive Syndrome Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984 LUD: Specific to Pregnancy CPR in pregnancy – Factors to be considered! • Progesterone induced increase in MV • Maternal respiratory alkalosis enhances fetal CO2 extraction • Maternal CA leads to Fetal acidosis…further compounded by reduced Ut. – placental blood flow CPR in Pregnancy: Modifications • Heimlich maneuver is contraindicated in later pregnancy; chest thrusts may be necessary • LUD • Aggressive airway management with early intubation • Vascular access always in the UL! • Do not use NaHCO3 – Aim at achieving ROSC Shields A, Fausett MB. Cardiopulmonary resuscitation • PMCS in pregnancy. In: Belfort M, Saade G, Foley M, et al, editors. Critical care obstetrics. 5th edition. West Sussex: Wiley-Blackwell; 2010. p. 93–107 CPR in PREGNANCY Outcome depends on: Underlying cause of arrest (BEAU CHOPS) Speed of resuscitation….chain of survival Set of coordinated life saving actions EARLY ACCESS IMMEDIATE RECOGNITION & EARLY ACTIVATION OF EMS EARLY CPR EARLY CPR WITH EMPHASIS ON CHEST COMPRESSIONS EARLY DEFIBRILLATION RAPID DEFIBRILLATION EARLY ACLS CARE EFFECTIVE ADVANCED CARDIAC LIFE SUPPORT INTEGRATED POST CARDIAC ARREST CARE 14 15 Basic Life Support To restore adequate coronary and cerebral blood flow Parturient collapses! Basic Life Support Check for Responsiveness & Breathing Parturient collapses! Basic Life Support Check for Responsiveness & Breathing NO RESPONSE Call for HELP / Defib - AED Parturient collapses! Basic Life Support Check for Responsiveness & Breathing NO RESPONSE C:Check for Circulation Palpate Carotids Call for HELP / Defib - AED Position - LUD Parturient collapses! Basic Life Support Check for Responsiveness & Breathing NO RESPONSE C:Check for Circulation Call for HELP / Defib - AED Position - LUD Palpate Carotids Give 30 chest compressions Parturient collapses! Basic Life Support Check for Responsiveness & Breathing NO RESPONSE C:Check for Circulation Call for HELP / Defib - AED Position - LUD Palpate Carotids Give 30 chest compressions AB: Open Airway & Give 2 Breaths Parturient collapses! Basic Life Support Check for Responsiveness & Breathing NO RESPONSE C:Check for Circulation Call for HELP / Defib - AED Position - LUD Palpate Carotids Give 30 chest compressions 30 chest compressions,+ 2 breaths CYCLE AB: Open Airway & Give 2 Breaths Continue Cycle of 30 compressions + 2 breaths Effective Chest Compressions  Push HARD and deep  Push FAST : rate of 100/min  Allow the chest to RECOIL  Minimize interruptions Perform high quality chest compressions Place your hand slightly above mid sternum Effective Chest Compressions  Push HARD and deep  Push FAST : rate of 100/min  Allow the chest to RECOIL  Minimize interruptions Perform high quality chest compressions Place your hand slightly above mid sternum Effectiveness of chest compressions Effective resuscitative force of chest compression is 67% of rescuer’s body weight in Supine 36% in complete lateral position With 270 wedge: Maximum resuscitative force achieved is 80% of that in supine Mallampalli A, Powner DJ, Gardner MO. Cardiopulmonary resuscitation and somatic support of the pregnant patient. Crit Care Clin 2004;20:747–61. Compression – Ventilation Ratio  One Rescuer CPR  Two Rescuer CPR 30:2 One Cycle of CPR  2 breaths  30 compressions 30:2 Has been removed from 2010 guidelines! D Defibrillation  Monophasic : 360 Joules  Bi - phasic : 150 - 200 Joules  Automated Electrical Defibrillator Rhythms you need to know…  Two Shockable – Ventricular Tachycardia : VT – Ventricular Fibrillation : VF Rhythms you need to know…  Two NON Shockable • Asystole • Pulseless Electrical Activity D Defibrillation  Followed by immediate CPR  Rhythm Check after  Five cycles of CPR  2 minutes 33 Advanced  HIGH QUALITY BLS Cardiac  HIGH QUALITY ACLS  Advanced airway devices Life  Medications Support  TCP Post Resuscitation Care (CPCSR) Advanced Cardiac Life Support Advanced Airway Devices Cricoid pressure is not recommended! Avoid hyperventilation (LMA / ETT) 100 : 10 Monitoring you need to perform… Monitor: EtCO2, Art. Trace, CVO2 End-tidal CO2 High quality chest compressions 60 mm Hg 40 > 10 mm Hg 20 0 60 40 < 10 mm Hg Ineffective chest compressions 20 10 0 Time 37 Arterial blood pressure trace High quality chest compressions 12 0 80 mm Hg 40 0 > 20 mm Hg Ineffective chest compressions 12 0 80 < 20 mm Hg 40 20 0 Time 38 Physiologic parameters End-tidal CO2 > 30% Central venous oxygen saturation > 10 mm Hg Arterial > 20 mm blood Hg pressure 39 End-tidal CO2 and ROSC Abrupt rise in EtCO2 >40mmHg 50 1min 25 0 Increase in EtCO2 > 40 mm Hg ROSC 40 Drugs you need to know…  Adrenaline  Vasopressin  Amiodarone  Intra lipid!! Atropine is not recommended! Dosages one needs to know…  Adrenaline 1 mg 1 ampoule IV bolus 3 - 5 minutes  Vasopressin 40 u IV 2 Ampoules Single dose 1st / 2nd dose Dosages one needs to know…  Amiodarone 300 mg / IV 1st Dose 150 mg / IV 2nd Dose Dosages one needs to know…  LAST Lipid Rescue 20% Intralipid 1.5ml/Kg  Magnesium Toxicity Calcium gluconate Advanced Cardiac Life Support IDENTIFY CAUSES • Hypoxia • Hypovolemia • Hypothermia • H+ ion excess • Hypoglycemia • Hyperkalemia • Hypokalemia • Tamponade • Toxins • Tension pn. thorax • Thrombus (MI, VTE) Algorithm : NonShockable Rhythms A / PEA A / PEA A / PEA • ADRENALINE • VASOPRESSOR • ADRENALINE • ??ATROPINE Advanced Cardiac Life Support Algorithm : Shockable Rhythms VF / VT • 1st SHOCK • 200 j / 360 j VF / VT • 2nd SHOCK • VASOPRESSORS VF / VT • 3rd SHOCK • ANTI ARRYTHMIC DRUGS LA ST • 20% Lipid Emulsion A B C L L S S Patients reach a point of ACLS only if they receive Effective and Correct BLS Remember all this has to be achieved in 4 minutes…. • If ROSC cannot be achieved….perform PMCS 4’ MATERNAL CODE: Are you ready to perform PMCS? • PMCS performed at the site of CA….ED / LW / ICU OT shifted to ICU! Severe ARDS as defined by Berlin’s criteria PaO2 / FiO2: 44mmHg SpO2: 86% FiO2: 100% PEEP: 16CM H2O P.Peak: 42mmHg Maternal & Fetal survival Katz et al, AJOG, 2005: 192 Maternal & Fetal survival Katz et al, AJOG, 2005: 192 When to stop CPR? • Ethical considerations…..! • One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review; BMC Med. 2010; 8: 74. • organ donation of a brain dead pregnant patient! A B C L L S S Cardio Pulmonary Resuscitation Timing is Everything  Early Chest Compressions  Early Defibrillation  Aggressive Airway Mx  Perimortem Caesarean Section Dijkman A, Huisman CM, Smit M, Schutte JM, Zwart JJ, van Roosmalen JJ, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG.2010;117:282–287 Be Familiar with Resuscitation Equipment & Hospital Protocols CPR in PREGNANCY • Substandard care • Poor resuscitation skills `Have been repeatedly identified as contributory factors to maternal mortality and morbidity’ A survey of labour ward clinicians’ knowledge of maternal cardiac arrest and resuscitation. Einav S et al. Int J Obstet Anesth 2008; 17: 238–42 CPR in PREGNANCY Highlighted the need for more training in life support amongst obstetric caregivers! A survey of labour ward clinicians’ knowledge of maternal cardiac arrest and resuscitation. Einav S et al. Int J Obstet Anesth 2008; 17: 238–42 Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(suppl 3): S829 –S861 . BLS - ACLS in PREGNANCY `The Best Hope of Fetal Survival is Maternal Survival ’ High quality CPR in PREGNANCY Death is always cruel; when it is untimely it is doubly! Synchronized multidisciplinary effort with Anaesthesiologist as the lead person and timing is critical