SICS Maternal Critical Care Symposium 2016

 

SICS – Maternal Critical Care Symposium June 2016

Despite the train strikes causing havoc on the roads over a hundred and twenty people made the trip to the Royal College of Surgeons in Edinburgh for the inaugural Scottish Intensive Care Society – Maternal Critical Care Symposium in June. The audience comprised of obstetric anaesthetists, critical care physicians, obstetricians, critical care nurse practitioners and midwives.

Dr Corinne Love, senior Medical Officer for Maternity and Woman’s Health, opened the meeting with her vision for the future of maternal critical care in Scotland.

The morning session was chaired by Kerry Litchfield (obstetric anaesthetist from PRMH Glasgow and OAA MCC board member) and focused on what maternal critical care is, and where we are in terms of need and provision.

Pamela Johnston (obstetric anaesthetist from Ninewells, Dundee and Chair of the Scottish Maternal Critical Care (SMaCC) network) explained that her interest in maternal critical care had started when one of her critical care colleagues had asked her in the early 2000s, “when is the best time to deliver a pregnant woman who has critical oxygenation?” and she didn’t have an answer… there was and remains little information to guide this dilemma.

In England and Wales, the Intensive Care National Audit and Research Centre (ICNARC) have collected data on pregnant critical care patients since the mid-1990s. The Scottish Intensive Care Society Audit Group (SICSAG) only included the question ‘Pregnant/recently pregnant’ to their Ward Watcher data collection set in 2014. She then explained how interest in the provision of maternal critical care has developed in Scotland to date with the development of SMaCC.

Oliver Robinson, a senior Intensive Care Medicine trainee from Edinburgh, presented his 7-year audit of all obstetric patients admitted to the Intensive Care Unit (ICU) at the Royal Infirmary of Edinburgh (RIE):

* 1.89% of ALL patients admitted were admitted for obstetric reasons.

* 30% require level 2 care

* most common cause for the admission of ‘recently pregnant’ women was major Haemorrhage (MOH) and the,

* most common cause of admission of currently pregnant women is a non-obstetric cause, mainly infection due to pneumonia.

Rarer diagnoses included α1-antitrypsin deficiency, requiring a post-natal liver transplant and anaphylaxis. The BMI of patients admitted to ICU varied from 17.2 to 81. Patients with a BMI greater than 30 or age greater than 35 had an increased risk of admission to ICU. The length of stay of patients admitted to ICU varied from 0.2 to 35.4 days with 35% of patients staying greater than 48 hours. Dr Robinson then compared his results to a similar audit carried out at Glasgow Royal Infirmary ICU. He found that RIE had more admissions to ICU but that may be due to the fact that all patients that required critical care were admitted to ICU instead of a High Dependency Unit (HDU) and the fact that RIE has a cardiac surgery unit onsite.

Audrey Quinn, Chair of the Maternal Critical Care subcommittee for the OAA and OAA ICNARC lead, introduced “Enhanced Care of the Sick Mother: Standards for Maternal Critical Care 2016”. This document has been developed by the RCOA, OAA, RCOG, ICS and RCM sets out what is required from all specialities when looking after pregnant or recently pregnant mothers who are critically ill. It also suggests a minimum data set for audit collection and the need for cross speciality training in a multidisciplinary team (MDT) setting.

Rupert Gauntlett, an intensivist and lead for obstetric anaesthesia at the Royal Victoria Infirmary in Newcastle, then spoke about where is the best place to look after the sick obstetric patient – maternity setting where the critical care isn’t readily available or critical care with minimal obstetric input. He illustrated this by presenting a series of complex cases he had come across in his career:

* a “simple case of MOH” illustrated the potential adverse consequences of an admission to a general ICU can be underestimated.

* a patient with severe pre-eclampsia on a general ICU asked the question of who are the right people and what is the right location for the management of patients with obstetric specific conditions and,

* severe respiratory failure whilst pregnant posed questions about location and timing of delivery, and

* a polytrauma patient at term but with need for specialist medical input from a speciality at a distant site, highlighted the need for a functioning MDT to balance opinions between medical specialities.

Last to speak in the morning session were Niki Walker (Cardiologist) and Robyn Smith (Cardiac Anaesthetist) from the Golden Jubilee National Hospital in Glasgow. Dr Walker discussed a case of a peripartum cardiomyopathy which was undiagnosed until after delivery, highlighting the fact that one of the most common causes of indirect maternal mortality is cardiac disease. Dr Smith gave examples of what cardiothoracic input can add in the management of an obstetric patient with cardiac disease up to, and including extra-corporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) as a bridge to recovery or transplant.

The first afternoon session was chaired by Dr Monika Beatty and featured updates on sepsis and case presentations.

Judith Joss, consultant anaesthetist and intensivist from Ninewells, Dundee gave an update on sepsis highlighting the recent change in the classification and definition of sepsis with the introduction of the “qSOFA score” to predict poor outcome. The management of sepsis in the obstetric patient is more challenging and relatively evidence free as most studies have pregnancy as one of their main exclusion criteria. She then went on to describe research being undertaken in Ninewells looking at sepsis inflammatory markers – an inflammatory marker Procalcitonin (PCT) is raised only in the context of sepsis and unaffected by labour.

Case presentations illustrating some of the above issues were then presented by trainees from around Scotland.

* Brian Lafferty (West of Scotland) presented a case of an Amitriptyline overdose in a woman who was 35 weeks gestation with subsequent urgent delivery of the foetus. Discussions concentrated on the timings of interventions and the location of care.

* Sean Keating (South East Scotland) presented a case of acute respiratory failure (H1N1 influenza) in a patient who was 26 weeks gestation who was subsequently delivered in ICU. Timing of delivery and the appropriateness of advanced ventilatory strategies were the points discussed.

* John Smith (East of Scotland) presented a patient pregnant with twins who developed a dilated cardiomyopathy at nearly 30 weeks gestation who was transferred for specialist cardiology input. With this case the diagnosis of cardiac disease in pregnant patients was again highlighted along with discussion regarding the centralising of care for “high-risk” mothers.

The final session of the day was chaired by Dr Arlene Wise and focussed on what happens after intensive care.

Tim Walsh, Professor of Intensive Care Medicine at Edinburgh Royal Infirmary spoke about critical care recovery and follow-up. He discussed “post ICU syndrome” and how it can affect patients in many different ways. The potential support models suggested in the literature and how they may be tailored to obstetric critical care patients including better communication between ICU and maternity services after discharge from critical care. This support is best started before discharge from ICU and would involve critical care staff education on obstetric conditions.

Naz Lone, a senior lecturer in critical care and a critical care consultant at Edinburgh Royal Infirmary continued with critical care outcomes and the long term consequences of maternal critical care. Mortality in the maternal critical care cohort is generally low however survival from ICU is usually associated with an increased use of hospital resources. His research showed that more than 2% of women who had been discharged from ICU experienced an emergency readmission to hospital within the first year of discharge, resulting in a higher burden on the NHS than those women not admitted to ICU.

The closing remarks included the hope that’ Enhanced Care for the Sick Mother’ and the ‘Review of Maternity and Neonatal Services review’ in Scotland would provide a national framework to base the improvement work currently being encouraged nationally and locally by the SMaCC network, and that there would be another Maternal Critical Care Symposium in the not too distant future….

Jen Service

Anaesthetic Specialty Registrar

South East Scotland.

The Presentations

Sepsis; An update Powerpoint presentation

Dr Judith Joss, Consultant Anaesthetist & ICM

Ninewells Hospital, Dundee