E70: The Traumatic Airway: A Nightmare Series Podcast

Mechanical Ventilation and ARDS – Podcast Summary and References

This is the sixth of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams as a retrieval OBGYN/MFM and is one of our Assistant Medical Directors for the flight program. 

The topic of this podcast is Mechanical Ventilation and ARDS in pregnancy.  Although respiratory distress requiring intubation and ARDS in pregnancy is not very common, it is more common than some of the other pathologies we have discussed recently.  Mechanical ventilation of the pregnant patient can be intimidating, but rest assured that if you have the capabilities to manage other patients on a vent, you can manage the pregnant patient.  Generally speaking solid outcomes data is sparse and, generally speaking, most guidelines recommend vent management of mechanical ventilation in patients with or without ARDS similarly to non-pregnant patients…with a few exceptions.  This podcast reviews the basics of ARDS and evidence-based management.  It reviews some specific features of obstetric physiology and fetal gas exchange that are important to keep in mind.  Finally, we will review what guidance is available and review general recommendations for managing these patients in transport.

For additional learning and a more in-depth review of the evidence check out this talk on gas exchange and mechanical ventilation in critically ill patients by Dr. Allison Lankford (part of the amazing Maryland CC Project lecture series): http://maryland.ccproject.com/2023/05/30/lankford-gas-exchange-and-pulmonary-ventilation-in-the-critically-ill-obstetric-patient/

References

1. Abou-Arab O, Huette P, Debouvries F, Dupont H, Jounieaux V, Mahjoub Y. Inhaled nitric oxide for critically ill Covid-19 patients: a prospective study. Crit Care. Nov 12 2020;24(1):645. doi:10.1186/s13054-020-03371-x
2. Barrantes JH, Ortoleva J, O'Neil ER, et al. Successful Treatment of Pregnant and Postpartum Women With Severe COVID-19 Associated Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation. Asaio j. Feb 1 2021;67(2):132-136. doi:10.1097/mat.0000000000001357
3. Bhatia PK, Biyani G, Mohammed S, Sethi P, Bihani P. Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature. J Anaesthesiol Clin Pharmacol. Oct-Dec 2016;32(4):431-439. doi:10.4103/0970-9185.194779
4. Boelig RC, Saccone G, Bellussi F, Berghella V. MFM guidance for COVID-19. Am J Obstet Gynecol MFM. May 2020;2(2):100106. doi:10.1016/j.ajogmf.2020.100106
5. Campbell LA, Klocke RA. Implications for the pregnant patient. Am J Respir Crit Care Med. Apr 2001;163(5):1051-4. doi:10.1164/ajrccm.163.5.16353
6. Carter AM. Factors affecting gas transfer across the placenta and the oxygen supply to the fetus. J Dev Physiol. Dec 1989;12(6):305-22. 
7. Carter AM. Placental Gas Exchange and the Oxygen Supply to the Fetus. Compr Physiol. Jul 1 2015;5(3):1381-403. doi:10.1002/cphy.c140073
8. Cavalcante FML, Fernandes CDS, Rocha LDS, Galindo-Neto NM, Caetano J, Barros LM. Use of the prone position in pregnant women with COVID-19 or other health conditions. Rev Lat Am Enfermagem. 2021;29:e3494. doi:10.1590/1518-8345.5181.3494
9. Cojocaru L, Turan OM, Levine A, et al. Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19. J Matern Fetal Neonatal Med. Dec 2022;35(25):9043-9052. doi:10.1080/14767058.2021.2013464
10. Cole DE, Taylor TL, McCullough DM, Shoff CT, Derdak S. Acute respiratory distress syndrome in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S269-78. doi:10.1097/01.ccm.0000182478.14181.da
11. D'Souza R, Ashraf R, Rowe H, et al. Pregnancy and COVID-19: pharmacologic considerations. Ultrasound Obstet Gynecol. Feb 2021;57(2):195-203. doi:10.1002/uog.23116
12. Danish MA. Mechanical Ventilation in Critically Ill Obstetric Patient. Principles of Critical Care in Obstetrics. 2016:133-141:chap Chapter 14.
13. Delyoa-Tomas E M-LT, Lopez-Fermin J, Perez-Nieto OR, et al. Consideration for Mechanical Ventilation in the Critically Ill Obstetric Patient. Crit Care Obst Gyne. 2020;6(10):1-8. 
14. Douglass KM, Strobel KM, Richley M, et al. Maternal-Neonatal Dyad Outcomes of Maternal COVID-19 Requiring Extracorporeal Membrane Support: A Case Series. Am J Perinatol. Jan 2021;38(1):82-87. doi:10.1055/s-0040-1718694
15. Ende H, Varelmann D. Respiratory Considerations Including Airway and Ventilation Issues in Critical Care Obstetric Patients. Obstet Gynecol Clin North Am. Dec 2016;43(4):699-708. doi:10.1016/j.ogc.2016.07.002
16. Gattinoni L, Camporota L, Marini JJ. Prone Position and COVID-19: Mechanisms and Effects. Crit Care Med. May 1 2022;50(5):873-875. doi:10.1097/ccm.0000000000005486
17. Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. Jul 2023;49(7):727-759. doi:10.1007/s00134-023-07050-7
18. Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. Dec 22 2005;353(25):2683-95. doi:10.1056/NEJMra051884
19. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. Jun 6 2013;368(23):2159-68. doi:10.1056/NEJMoa1214103
20. Huang C-Y, Tsai Y-L, Lin C-K. The prone position ventilation (PPV) as an approach in pregnancy with acute respiratory distress syndrome (ARDS). Taiwanese Journal of Obstetrics and Gynecology. 2021/05/01/ 2021;60(3):574-576. doi:https://doi.org/10.1016/j.tjog.2021.03.036
21. Khalil M, Butt A, Kseibi E, Althenayan E, Alhazza M, Sallam H. COVID-19-Related Acute Respiratory Distress Syndrome in a Pregnant Woman Supported on ECMO: The Juxtaposition of Bleeding in a Hypercoagulable State. Membranes (Basel). Jul 17 2021;11(7)doi:10.3390/membranes11070544
22. Kodali BS, Wong MJ, Lankford A, Lee K, Bharadwaj S. Effect of Fetal Delivery on Pao2/Fio2 Ratio During Mechanical Ventilation in Parturients With COVID-19: A Case Series. A A Pract. Jul 1 2022;16(7):e01587. doi:10.1213/xaa.0000000000001587
23. Lam GK, Stafford RE, Thorp J, Moise KJ, Jr., Cairns BA. Inhaled nitric oxide for primary pulmonary hypertension in pregnancy. Obstet Gynecol. Nov 2001;98(5 Pt 2):895-8. doi:10.1016/s0029-7844(01)01549-6
24. Lapinsky SE. Acute respiratory failure in pregnancy. Obstet Med. Sep 2015;8(3):126-32. doi:10.1177/1753495X15589223
25. Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients. Crit Care. 2009;13(2):206. doi:10.1186/cc7146
26. Lapinsky SE, Viau-Lapointe J. Mechanical Ventilation and Delivery During Pregnancy. Chest. Mar 2023;163(3):473-474. doi:10.1016/j.chest.2022.10.025
27. Lim MJ, Lakshminrusimha S, Hedriana H, Albertson T. Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment. Seminars in Fetal and Neonatal Medicine. 2023;28(1)doi:10.1016/j.siny.2023.101426
28. Linassi F, Campagnolo M, Busato E, Ortolani V, Peta M. Prolonged prone position in pregnant woman with COVID-19 pneumonia. Journal of Anesthesia, Analgesia and Critical Care. 2022/04/12 2022;2(1):16. doi:10.1186/s44158-022-00044-9
29. Lucarelli E, Behn C, Lashley S, Smok D, Benito C, Oyelese Y. Mechanical Ventilation in Pregnancy Due to COVID-19: A Cohort of Three Cases. Am J Perinatol. Aug 2020;37(10):1066-1069. doi:10.1055/s-0040-1713664
30. Magala Ssekandi A, Sserwanja Q, Olal E, Kawuki J, Bashir Adam M. Corticosteroids Use in Pregnant Wom...

In this episode, we uncover the enigmatic world of refractory shock in prehospital trauma patients. Shock, often recognized as a critical condition, becomes even more complex when it resists conventional treatment. Join Eric as he discusses resuscitation in vasoplegic patients refractory to fluids and blood products. Tune in to "Hidden Harms" and embark on a journey to unveil the complexities of refractory shock in prehospital trauma patients. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 12 years! 

In this episode, we delve into the complexities surrounding a challenging COPD patient scenario, focusing on treatment considerations and the broader scope of mechanical ventilation management. We underscore essential lessons gleaned from this case, emphasizing the significance of adopting an obstructive approach, the nuanced application of I:E ratio, and the comprehensive management strategies for hypercapnic patients. Join us as we navigate through this intricate medical terrain, shedding light on effective approaches and valuable insights crucial for optimizing patient care in similar scenarios. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 12 years! 

This is the fifth of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams as a retrieval OBGYN/MFM and acts as one of our Assistant Medical Directors for the flight program.

The topic of this podcast is Amniotic Fluid Embolism (AFE).  Another rare, but devastating disease that can often progress rapidly to cardiac arrest.  In this podcast, we go through the epidemiology and definition/diagnosis of the disease.  We also go into depth on underlying pathophysiology and the current hypotheses on what causes AFE.  Spoiler alert: it’s not as simple as an embolism of amniotic fluid.   Then we review the management, specifically focusing on the management of acute right heart failure in the setting of abrupt and pronounced pulmonary hypertension. Finally, Dr. Garchar and I deliver some spaced repetition and go over the management of maternal cardiac arrest, in the likely event that AFE progresses to that point.

References

1. Abenhaim HA, Azoulay L, Kramer MS, Leduc L. Incidence and risk factors of amniotic fluid embolisms: a population-based study on 3 million births in the United States. Am J Obstet Gynecol. Jul 2008;199(1):49 e1-8. doi:10.1016/j.ajog.2007.11.061

2. Aissi James S, Klein T, Lebreton G, et al. Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation. Crit Care. Apr 7 2022;26(1):96. doi:10.1186/s13054-022-03969-3

3. Clark SL, Montz FJ, Phelan JP. Hemodynamic alterations associated with amniotic fluid embolism: a reappraisal. Am J Obstet Gynecol. Mar 1 1985;151(5):617-21. doi:10.1016/0002-9378(85)90150-4

4. Clark SL, Romero R, Dildy GA, et al. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol. Oct 2016;215(4):408-12. doi:10.1016/j.ajog.2016.06.037

5. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol. Nov 2009;201(5):445 e1-13. doi:10.1016/j.ajog.2009.04.052

6. Creel-Bulos C, Hassani B, Stentz MJ, et al. Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report. Crit Care Explor. Jul 2020;2(7):e0162. doi:10.1097/CCE.0000000000000162

7. Crissman HP, Loder C, Pancaro C, Bell J. Case report of amniotic fluid embolism coagulopathy following abortion; use of viscoelastic point-of-care analysis. BMC Pregnancy Childbirth. Jan 3 2020;20(1):9. doi:10.1186/s12884-019-2680-1

8. Durgam S, Sharma M, Dadhwal R, Vakil A, Surani S. The Role of Extra Corporeal Membrane Oxygenation in Amniotic Fluid Embolism: A Case Report and Literature Review. Cureus. Feb 26 2021;13(2):e13566. doi:10.7759/cureus.13566

9. Foley MR ST, Garite TJ. Obstetric Intensive Care Manual. 5th ed. McGraw-Hill Education; 2014.

10. Huybrechts W, Jorens PG, Jacquemyn Y, Colpaert C, Vrints C, Conraads V. Amniotic fluid embolism: a rare cause of acute left-sided heart failure. Acta Cardiol. Dec 2006;61(6):643-9. doi:10.2143/AC.61.6.2017964

11. James CF, Feinglass NG, Menke DM, Grinton SF, Papadimos TJ. Massive amniotic fluid embolism: diagnosis aided by emergency transesophageal echocardiography. Int J Obstet Anesth. Oct 2004;13(4):279-83. doi:10.1016/j.ijoa.2004.03.008

12. Lao TT. Acute respiratory distress and amniotic fluid embolism in pregnancy. Best Pract Res Clin Obstet Gynaecol. Dec 2022;85(Pt A):83-95. doi:10.1016/j.bpobgyn.2022.06.004

13. Lockwood CJ, Bach R, Guha A, Zhou XD, Miller WA, Nemerson Y. Amniotic fluid contains tissue factor, a potent initiator of coagulation. Am J Obstet Gynecol. Nov 1991;165(5 Pt 1):1335-41. doi:10.1016/0002-9378(91)90363-v

14. McDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxide in a parturient with amniotic fluid embolism. Int J Obstet Anesth. Jul 2007;16(3):269-73. doi:10.1016/j.ijoa.2006.10.008

15. Moore J, Baldisseri MR. Amniotic fluid embolism. Crit Care Med. Oct 2005;33(10 Suppl):S279-85. doi:10.1097/01.ccm.0000183158.71311.28

16. Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol. Jan 2020;222(1):48-52. doi:10.1016/j.ajog.2019.07.036

17. Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol. Mar 2016;214(3):340-4. doi:10.1016/j.ajog.2015.08.068

18. Shamshirsaz AA, Clark SL. Amniotic Fluid Embolism. Obstet Gynecol Clin North Am. Dec 2016;43(4):779-790. doi:10.1016/j.ogc.2016.07.001

19. Shechtman M, Ziser A, Markovits R, Rozenberg B. Amniotic fluid embolism: early findings of transesophageal echocardiography. Anesth Analg. Dec 1999;89(6):1456-8. doi:10.1097/00000539-199912000-00025

20. Simard C, Yang S, Koolian M, Shear R, Rudski L, Lipes J. The role of echocardiography in amniotic fluid embolism: a case series and review of the literature. Can J Anaesth. Oct 2021;68(10):1541-1548. Le role de l'echocardiographie dans l'embolie de liquide amniotique : une serie de cas et une revue de la litterature. doi:10.1007/s12630-021-02065-4

21. Society for Maternal-Fetal Medicine . Electronic address pso, Pacheco LD, Saade G, Hankins GD, Clark SL. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol. Aug 2016;215(2):B16-24. doi:10.1016/j.ajog.2016.03.012

22. Stanten RD, Iverson LI, Daugharty TM, Lovett SM, Terry C, Blumenstock E. Amniotic fluid embolism causing catastrophic pulmonary vasoconstriction: diagnosis by transesophageal echocardiogram and treatment by cardiopulmonary bypass. Obstet Gynecol. Sep 2003;102(3):496-8. doi:10.1016/s0029-7844(03)00161-3

23. Sultan P, Seligman K, Carvalho B. Amniotic fluid embolism: update and review. Curr Opin Anaesthesiol. Jun 2016;29(3):288-96. doi:10.1097/ACO.0000000000000328

24. Wu HD, Song ZK, Cao HY, et al. Successful treatment of amniotic fluid embolism complicated by disseminated intravascular coagulation with rivaroxaban: A case report. Medicine (Baltimore). Jan 2020;99(4):e18951. doi:10.1097/md.0000000000018951

Disseminated Intravascular Coagulation 

This is the fourth of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport.

The topic of this podcast is Disseminated Intravascular Coagulation (DIC) in the pregnant patient.  Although very rare, this disease carries a high morbidity and mortality.  The key features are the disease are diffuse and dysregulated coagulation that causes consumption of clotting factors (resulting in a paradoxical coagulopathic state), widespread endothelial damage, and is essentially always the result of some other disease process.  In this podcast we go over how critical care transport crews can recognize DIC and identify the underlying process causing it.  In addition, Dr. Garchar and I review the management in the transport environment and pearls regarding treating coagulopathy. 

In the podcast we give a shout out to a phenomenal OB Critical Care course that is put on by Banner University Medical Center and the Society for Maternal Fetal Medicine.  Unfortunately, it’s a little late to sign up for this year’s session (November 2023), but put it on your radar for next year!  Here is a link to the brochure and conference content to give you an idea.  There is also a healthy component of simulation education.  I have no conflict of interest with this course at all…it’s just a phenomenal educational opportunity.

https://s3.amazonaws.com/cdn.smfm.org/media/1807/Brochure-Banner(FINAL).pdf

References

1.          Erez O. Disseminated intravascular coagulation in pregnancy: New insights. Thrombosis Update. 2022;6doi:10.1016/j.tru.2021.100083

2.          Erez O, Novack L, Beer-Weisel R, et al. DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9(4):e93240. doi:10.1371/journal.pone.0093240

3.          Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med. 2022;13:21-44. doi:10.2147/JBM.S273047

4.          Foley MR, Strong TH, Garite TJ. Obstetric Intensive Care Manual. 5th ed. McGraw-Hill Education; 2014.

5.          Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost. Jun 1998;79(6):1111-5. 

6.          Kadikar SK, Divan FJ, Topiwala U, Agasiwala S. Study of pregnancy with disseminated intravascular coagulation. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2021;10(11)doi:10.18203/2320-1770.ijrcog20214335

7.          Krikun G, Huang ST, Schatz F, Salafia C, Stocco C, Lockwood CJ. Thrombin activation of endometrial endothelial cells: a possible role in intrauterine growth restriction. Thromb Haemost. Feb 2007;97(2):245-53. 

8.          Levi M, Scully M. How I treat disseminated intravascular coagulation. Blood. Feb 22 2018;131(8):845-854. doi:10.1182/blood-2017-10-804096

9.          Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. Apr 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x

10.        Papageorgiou C, Jourdi G, Adjambri E, et al. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost. Dec 2018;24(9_suppl):8S-28S. doi:10.1177/1076029618806424

11.        Rabinovich A, Abdul-Kadir R, Thachil J, Iba T, Othman M, Erez O. DIC in obstetrics: Diagnostic score, highlights in management, and international registry-communication from the DIC and Women's Health SSCs of the International Society of Thrombosis and Haemostasis. J Thromb Haemost. Sep 2019;17(9):1562-1566. doi:10.1111/jth.14523

12.        Rattray DD, O'Connell CM, Baskett TF. Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009). J Obstet Gynaecol Can. Apr 2012;34(4):341-347. doi:10.1016/S1701-2163(16)35214-8

13.        Taylor FB, Jr., Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. Nov 2001;86(5):1327-30. 

14.        Toffaletti JG, Buckner KA. Use of Earlier-Reported Rotational Thromboelastometry Parameters to Evaluate Clotting Status, Fibrinogen, and Platelet Activities in Postpartum Hemorrhage Compared to Surgery and Intensive Care Patients. Anesth Analg. Mar 2019;128(3):414-423. doi:10.1213/ane.0000000000003499

15.        Veronika A L, John V, Xuezhi J. Disseminated Intravascular Coagulation due to Amniotic Fluid Embolism in an Early Molar Pregnancy. Clinical Medical Reviews and Case Reports. 2018;5(1)doi:10.23937/2378-3656/1410199

16.        Walker J, Bonavia A. To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise. Case Rep Anesthesiol. 2020;2020:9642438. doi:10.1155/2020/9642438

17.        Zhao Z, Zhang J, Li N, et al. Disseminated intravascular coagulation associated organ failure in obstetric patients admitted to intensive care units: a multicenter study in China. Sci Rep. Aug 12 2021;11(1):16379. doi:10.1038/s41598-021-95841-7

Join Eric and Will Heuser, PharmD, discussing "The Influence of Low pH on Efficacy of Critical Care Pharmacology."

Changes in acid-base balance have a profound influence on many aspects of the action of drugs. This is illustrated by data on the absorption of drugs from the stomach and intestine, changes in the distribution of drugs between plasma and cells, and the effect of changes in pH. Join us as Will breaks down the pathophysiology and decision-making in these low pH states. When do we deploy sodium bicarbonate? Is there a trade-off?  How is pharmacology affected by low pH states?  This episode is a can't-miss, with the brilliant Will Heuser, PharmD, BCCCP, MS, EMT-P, FP-C. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 11 years!

Contact Info:
Will Heuser, PharmD, BCCCP, MS, EMT-P, FP-C
wheuser@northwell.edu

Since the 2012 Berlin Definition of the Acute Respiratory Distress Syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen (HFNO), expanding the use of pulse oximetry in place of arterial blood gases, use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Join Eric as he dives into the previous ARDS definitions, the pathophysiology around "PseudoARDS," and the new global definition. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 11 years!

New Global Definition for Acute Respiratory Distress Syndrome

This is the third episode of a special podcast series on obstetric critical care.  Although I am the sole host of this podcast, the content was reviewed and edited by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport.

The topic of this podcast is peripartum cardiomyopathy.  Acquired cardiac conditions in otherwise healthy pregnant patients can be a serious and life-threatening condition.  Sometimes, critical care transport crews are called to transport pregnant or recently postpartum females with severe, acquired cardiomyopathy or in frank cardiogenic shock.  This podcast reviews the presentation, underlying pathophysiology, and management of this patient population.  

References

 1.          Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. Apr 5 2016;133(14):1397-409. doi:10.1161/CIRCULATIONAHA.115.020491

2.          Cherubin S, Peoples T, Gillard J, Lakhal-Littleton S, Kurinczuk JJ, Nair M. Systematic review and meta-analysis of prolactin and iron deficiency in peripartum cardiomyopathy. Open Heart. Oct 2020;7(2)doi:10.1136/openhrt-2020-001430

3.          Cooper LT, Mather PJ, Alexis JD, et al. Myocardial recovery in peripartum cardiomyopathy: prospective comparison with recent onset cardiomyopathy in men and nonperipartum women. J Card Fail. Jan 2012;18(1):28-33. doi:10.1016/j.cardfail.2011.09.009

4.          Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol. Jan 21 2020;75(2):207-221. doi:10.1016/j.jacc.2019.11.014

5.          Dinic V, Markovic D, Savic N, Kutlesic M, Jankovic RJ. Peripartum Cardiomyopathy in Intensive Care Unit: An Update. Front Med (Lausanne). 2015;2:82. doi:10.3389/fmed.2015.00082

6.          Djordjevic I, Rahmanian P, Zeriouh M, et al. Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center. J Card Surg. Jan 2020;35(1):254-257. doi:10.1111/jocs.14324

7.          Elkayam U, Akhter MW, Singh H, et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. Apr 26 2005;111(16):2050-5. doi:10.1161/01.CIR.0000162478.36652.7E

8.          Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. Apr 13 2000;342(15):1077-84. doi:10.1056/nejm200004133421502

9.          Gorog DA, Vilahur G. Peripartum cardiomyopathy: can the link between prolactin and PAI-1 provide a clue? Cardiovasc Res. Sep 1 2020;116(11):1791-1793. doi:10.1093/cvr/cvaa109

10.        Habedank D, Kuhnle Y, Elgeti T, Dudenhausen JW, Haverkamp W, Dietz R. Recovery from peripartum cardiomyopathy after treatment with bromocriptine. Eur J Heart Fail. Nov 2008;10(11):1149-51. doi:10.1016/j.ejheart.2008.09.001

11.        Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J. May 7 2015;36(18):1090-7. doi:10.1093/eurheartj/ehv009

12.        Hilfiker-Kleiner D, Kaminski K, Podewski E, et al. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell. Feb 9 2007;128(3):589-600. doi:10.1016/j.cell.2006.12.036

13.        Iorgoveanu C, Zaghloul A, Ashwath M. Peripartum cardiomyopathy: a review. Heart Fail Rev. Nov 2021;26(6):1287-1296. doi:10.1007/s10741-020-10061-x

14.        Kim MJ, Shin MS. Practical management of peripartum cardiomyopathy. Korean J Intern Med. May 2017;32(3):393-403. doi:10.3904/kjim.2016.360

15.        Kumar A, Ravi R, Sivakumar RK, et al. Prolactin Inhibition in Peripartum Cardiomyopathy: Systematic Review and Meta-analysis. Curr Probl Cardiol. Feb 2023;48(2):101461. doi:10.1016/j.cpcardiol.2022.101461

16.        Maning J, Ebner B, Vincent L, et al. Abstract 15717: Impact of Mechanical Circulatory Support on Outcomes and In-hospital Mortality of Peripartum Cardiomyopathy Patients With Cardiogenic Shock: An Analysis of the Nis Database. Circulation. 2020;142(Suppl_3)doi:10.1161/circ.142.suppl_3.15717

17.        Metz TD, Khanna A. Evaluation and Management of Maternal Cardiac Arrhythmias. Obstet Gynecol Clin North Am. Dec 2016;43(4):729-745. doi:10.1016/j.ogc.2016.07.014

18.        Sieweke JT, Pfeffer TJ, Berliner D, et al. Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy. Eur Heart J Acute Cardiovasc Care. Mar 2020;9(2):173-182. doi:10.1177/2048872618777876

19.        Sliwa K, Blauwet L, Tibazarwa K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation. Apr 6 2010;121(13):1465-73. doi:10.1161/CIRCULATIONAHA.109.901496

20.        Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary Management of Cardiogenic Shock During Pregnancy. J Card Fail. Feb 2023;29(2):193-209. doi:10.1016/j.cardfail.2022.09.014

21.        Triebel J, Clapp C, Martinez de la Escalera G, Bertsch T. Remarks on the Prolactin Hypothesis of Peripartum Cardiomyopathy. Front Endocrinol (Lausanne). 2017;8:77. doi:10.3389/fendo.2017.00077

In this episode, Eric looks at warm fluids... or lack thereof in resuscitation. We will cover the current evidence around hypothermia in resuscitation secondary to the infusion of cold IV fluids. We discuss current strategies in warming fluids before administration in warm and cold ambient environments and the impact on body systems that ultimately contribute to increased mortality. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 11 years! 

This is the second of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport.

The topic of this podcast is maternal cardiac arrest.  This is, possibly, one of the most stressful clinical encounters we can have as flight crew.  Critical care transport crews are masters of ACLS and resuscitation during cardiac arrest, but what do you do if the patient is pregnant?  Often crews have questions: Can we use the same drugs?  Do you change the dose of different ACLS drugs?  Can you defibrillate a pregnant patient?  Do we change hand position for chest compression?   In this podcast, Dr. Garchar and I go over the recommendations and guidelines from major organizations and clarify some of these important questions.  

References

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28.        Zelop C, Einav S, ...