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Welcome Suspecting and Treating Sepsis in Maternal Medicine

Welcome Suspecting and Treating Sepsis in Maternal Medicine. Audience Participation. Your Participation. Open your control panel Join audio: Choose “Mic & Speakers” to use computer VoIP Choose “Telephone” and dial using the information provided

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Welcome Suspecting and Treating Sepsis in Maternal Medicine

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  1. WelcomeSuspecting and Treating Sepsis in Maternal Medicine

  2. Audience Participation Your Participation • Open your control panel • Join audio: • Choose “Mic & Speakers” to use computer VoIP • Choose “Telephone” and dial using the information provided • Submit questions and comments via the • Questions panel • Note: Today’s presentation is being recorded and will be provided within 45 days.

  3. Audience Participation Your Participation • Please continue to submit your text questions and comments using the Questions Panel • or • Click Raise Hand button to be unmuted for verbal questions.

  4. Stephen L. Davidow, MBA-HCM, APR Manager, Quality Implementation Programs Society of Critical Care Medicine MountProspect, IL Today’s webcast is funded by a generous grant from the Gordon and Betty Moore Foundation

  5. Save the Date! The Next Surviving Sepsis Campaign Webcast September 19, 2013 Topic: Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care Faculty: Margaret M. Parker, MD, FCCM Professor of Pediatrics, Anesthesia, and Medicine, Stony Brook University Learning objectives: • Apply the key recommendations of the Surviving Sepsis Campaign to the care of the pediatric sepsis patient • Describe the special considerations in the guidelines for care of pediatric sepsis patients and the differences from adult patients • Utilize data from central-line placement to benefit the patient’s care

  6. Jeanne Sheffield, MD Maternal Fetal Medicine University of Texas Southwestern Medical School Dallas, TX

  7. Brenda Downs, MSN, RN, ACNS-BC Program Director, Clinical Performance Improvement Dignity Health Gilbert, AZ

  8. Septic Shock in the Obstetric Patient Jeanne S. Sheffield, M.D. Maternal Fetal Medicine University of Texas Southwestern 2013

  9. I have no conflict of interest related to the content of this presentation.

  10. The microorganisms that seem to have it in for us..turn out..to be rather more like bystanders..it is our response to their presence that makes the disease Lewis Thomas NEJM 1972

  11. Concept of Septic Shock in 2013 • Early in sepsis there is an increase in inflammatory mediators - then SHIFTS • Mid- to late sepsis consistent with immunosuppression • loss of delayed hypersensitivity • inability to clear infection • predisposition to nosocomial infections

  12. Why immune suppression which increases mortality? • Shift to anti-inflammatory cytokines CD4 T cells CD4 T cells ? Pathogen Bacterial inoculum Th1 cells Th2 cells Inflammatory cytokines TNF-a IFN-g IL-2 Anti-inflammatory cytokines IL-4 IL-10

  13. Why immune suppression which increases mortality? • Anergy • Non-responsiveness to antigen • T cells fail to proliferate and secrete cytokines in response to antigen • Death of immune cells • Apoptosis (suicide or programmed cell death) • Decrease in B cells, CD4 T cells and follicular dendritic cells

  14. The normal stress response is activation of anti-inflammatory mechanisms which predominate in sites outside of the affected systems • Not the previously believed uncontrolled hyperinflammatory response • Survival among patients correlates with recovery of inflammatory responses

  15. Definitions • Shock: When the functional intravascular blood volume is below that of the capacity of the body’s vascular bed • Hypovolemic • Hemorrhagic • Cardiogenic ( pump failure) • Neurogenic ( loss of sympathetic control of resistance vessels)

  16. Definitions • Systemic Inflammatory Response Syndrome (SIRS) • Inflammatory process that can be generated by infection or by non-infectious causes (burns, trauma) • Non-pregnant: 2 or more of the following • Temperature >38 C or <36 C • HR > 90 beats/min • RR >20 breaths/min or PaO2 <32 mmHg • WBC > 12,000/mm3, < 4,000/mm3 or >10% bands

  17. Definitions • Sepsis : the systemic inflammatory response syndrome that occurs during infection (Society Critical Care Medicine 2001 consensus statement) • Septic shock: vascular collapse secondary to an infectious process • Usually components of hypovolemic and cardiogenic shock

  18. National Guidelines for the Non-Pregnant Individual • There are several “scoring systems” and national guidelines to help determine admission to the ICU, treatment regimens and predict morbidity and mortality. • Modified Early Warning System • SIRS Criteria • APACHE • Unfortunately not validated for the pregnant and non-pregnant woman

  19. Maternal Sepsis: Incidence • Septic shock: 0.002-0.01% of all deliveries • 0.3-0.6% of all septic patients are pregnant • Has increased over the last decade • Older maternal age at delivery • Obesity, diabetes, CHTN, placental abruption and placenta accreta • ART and multi-fetal gestation • Obesity • HTN, DM, Cesarean, cardiopulmonary complications Burton and Sibai 2012

  20. Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 • Population based epidemiologic study in the United States • Nationwide Inpatient Sample (NIS) 1988-2008 • Hospitalizations for delivery • American College of Chest Physician and Society of Critical care medicine Definitions • Severe sepsis: sepsis with acute organ dysfunction, hypotension or hypoperfusion • Identified independent associations of severe sepsis

  21. Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 • 44,999,260 hospitalizations for delivery • Sepsis complicated 1:3333 deliveries • Severe sepsis 1:10,823 deliveries • Sepsis related death 1:105,384 deliveries • Overall frequency of sepsis stayed the same during the study period • Severe sepsis and death odds increased 10% per year

  22. Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 • Independent risk factors for severe sepsis Age >35 Chronic renal failure AA Race HIV infection Medicaid SLE Retained POCs Multiple gestation PROM Cerclage CHF Chronic liver failure

  23. Pathophysiology of Septic Shock Decreased functional intravascular blood volume Decreased BP and tissue perfusion Cellular acidosis and hypoxia End-organ tissue dysfunction and death

  24. Bacterial Infections in Obstetrics • Postpartum endometritis • Cesarean delivery 15-87 % • Vaginal delivery 1-4 % • Lower tract UTI 1-4 % • Septic abortion 1-2 % • Pyelonephritis 1-2 % • Chorioamnionitis 0.5 - 1 % • Necrotizing fasciitis < 1 % • Toxic shock syndrome < 1 Creasy, Resnick and Iams 2010

  25. Escherichia coli Group B streptococci Bacteroides spp. Peptostreptococcus Peptococcus spp. Clostridium perfringens Group A streptococci Entercoccus spp. Staphylococcus aureus Listeria monocytogenes Klebsiella pneumoniae Pseudomonas aeruginosa Enterbacter spp. Proteus spp. Common BacterialIsolates from OB Patients with Septic Shock

  26. Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 • 1680 Women with severe sepsis had a ICD9 code for a known organism • E. coli septicemia 27% • Staphylococcal septicemia 22% • Streptococcal septicemia 20% • Gram negative septicemia 19% • Pneumococcal speticemia 4% • Pseudomonal septicemia 2.4% • Anaerobic septicemia 2%

  27. Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 • Concurrent infections in women with severe sepsis • Pneumonia 30% • GU infections 30% • Chorioamnionitis 18% • Endometritis 9% • Pyelonephritis 6% • Wound Infection 5% • Endocarditis 2 % • Meningitis 1%

  28. Lower Mortality in the Obstetric Patient • 0-28 % versus 10-81% in the non-pregnant population • Factors associated with the decreased mortality • Younger age • Types of organisms • Overall healthy population • Pelvis amenable to surgical and medical intervention • Transient bacteremia Creasy, Resnick and Iams 2008

  29. Clinical Manifestations • Early stages • RECOGNITION KEY TO SUCCESSFUL TREATMENT • Shaking chills, fever (most common in pregnancy), tachycardia, flushing • Warm extremities, nausea, vomiting, diarrhea • Subtle changes in mental status • May be difficult to diagnose early in pregnant women, particularly in labor

  30. Clinical Manifestations • Laboratory findings • mild leukopenia or leukocytosis, hyperglycemia • early DIC : thrombocytopenia, decreased fibrinogen, increased PTT and PT • transient respiratory alkalosis with increasing metabolic acidosis • Increased serum lactate • Low arterial pH • Increased base deficit

  31. Courtesy of Dr. Robert S. Munford

  32. Clinical Manifestations • Later stages • Generalized vasoconstriction - cold extremities • oliguria, peripheral cyanosis • tachycardia, severe hypotension • Depressed cardiac output, low SVR • Laboratory findings • profound metabolic acidosis • electrolyte imbalance • generalized DIC • Multiple end-organ failure

  33. Multiple Organ Effects with Sepsis and Shock • CNS Effects : Confusion, coma,s omnolence, fever • Cardiovascular: Hypotension, increased CO, myocardial depression tachyarrhythmia • Pulmonary: Hypoxemia, diffuse infiltrates • Renal: Hypoperfusion, acute tubular necrosis • Hematologic: Thrombocytopenia, leukocytosis, consumptive coagulopathy

  34. Complete blood count differential and platelets Coagulation profile PT,PTT,FSP,Fibrinogen Electrolytes, glucose Creatinine and blood urea nitrogen Urinalysis and culture Blood culture and gram stain Cultures of infected sites Chest X-ray CT, ultrasound, MRI to localize infectious etiology Laboratory Evaluation

  35. Why do women die from septic shock? • Myocardial depression : Cardiac output usually maintained due to tachycardia and cardiac dilitation • ARDS : death rare from hypoxemia or hypercarbia • Renal failure : dialysis will prevent death • Liver dysfunction : hepatic encephalopathy rare • ???

  36. Management of Septic Shock • Overall goals • Treat the mother! • Resuscitating the mother will resuscitate the fetus • Delivery attempts increase maternal and fetal mortality assuming the source is not intrauterine • Improve functional intravascular volume • Establish and maintain an adequate airway • Determine the septic foci • Empiric antibiotic therapy : know the most common pathogens Creasy and Resnick 2008

  37. Management of Septic Shock • Volume resuscitation • Aggressive therapy will optimize afterload, preload and cardiac contractility • Normalize mixed venous oxygen saturation, lactate concentrations, base deficit and pH • Blood products, colloid, crystalloid • Central venous access recommended • Pulmonary artery catheter may cause more harm

  38. Williams Obstetrics 2010

  39. Management of Septic Shock • Oxygenation/Ventilation • Mechanical ventilation usually required • ARDS : hypoxemia, normal PCWP, diffuse infiltrates and decreased pulmonary compliance • PEEP • Keep at or above 96% if possible during pregnancy • Blood transfusion can increase O2 content : keep Hgb ~ 10 g/dl

  40. Management of Septic Shock • Inotropic agents • Dopamine hydrochloride (a-adrenergic and b- adrenergic effects) • Dobutamine • Norepinephrine – now considered first line therapy • Increases mean arterial pressure • Can reduce uterine artery blood flow • Isoproterenol

  41. Management of Septic Shock • Empiric antibiotic therapy • Find the underlying etiology of the sepsis • Start broad spectrum antibiotics immediately after drawing cultures • Penicillin (if Staphylococcus aureus suspected, consider Vancomycin) or derivative PLUS aminoglycoside PLUS Clindamycin • Vancomycin and Piperacillin/Tazobactam • Alter regimen as culture and sensitivity results available

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