Critical Illness Cases and YG Experience of CIS

1. Critical Illness Cases and YG Experience of CIS Dr Chris Clark Consultant Obstetrician and Gynaecologist

2. Case A 25 year old 3 NVD previously Booked at 10 weeks gestation Fit and healthy BMI 26 Smoked 1-2 per week Pregnancy progressed well under MLC until 35 weeks� gestation Had felt generally unwell for a 2 days 14/04/07 phoned her midwife at 12.30hrs due to increasing SOB

3. Case A Midwife called 999 ambulance which arrived and transported the women to ED Obs in triage 13.13hrs:- T37.2, BP116/58, P131, RR 24, Alert: CIS 5 Complaining shortness of breath and severe left thoracic/lumbar pain on inspiration. Pain score 10/10 O2 sat 97% Triaged Orange and seen by SHO at 13.45hrs Given IV paracetamol for rigor (pink venflon) at 14.00hrs Temp 38.6

4. Case A ECG nil acute FBC, U+E, LFT, CRP, clotting, D-Dimer, urine dipstick done Referred to Obs SHO at 13.45hrs No specific diagnosis Transferred out of ED to antenatal ward at 14.25hrs

5. Case A Seen by midwife who was reassured that ED doctor had assessed this woman Obs on arrival at the ward:- T38.6, BP97/40, P133, RR not done CTG commenced fetal tachycardia, FM noted Seen by Obs SHO, cough productive of white sputum, rigors, left side chest pain, �looks ill�, reduced air entry left base CRP 95, WCC 32.5 IV fluids commenced (1l 8 hrly) Hourly obs requested (T, P, BP)

6. Case A Provisional diagnosis was chest infection and dehydration Cefuroxime 1.5g IV tds prescribed Reg asked to see, but team became busy with C/S Reviewed by Reg at 16.50hrs Asked to attend urgently in view of CTG showing fetal tachycardia of 180bpm with possible decelerations

7. Case A Obs at this point:- T37.5, BP71/41, P129 �Lying very still� due to pain on inspiration VE done as �tightenings� noticed by m/w Transferred to LW Reg opinion was lobar pneumonia and consultant phoned re CTG findings at 17.45hrs IV Hartmanns commenced

8. Case A Consultant�s instructions were:- to ignore CTG Give oxygen Add in Clarithromicin Arrange CXR NOT to perform C/S Involve Medics Wide gauge IV access obtained Consultant arrived at 18.32hrs

9. Case A No antibiotics had been given by then The degree of shock had not been conveyed over the phone Obs at 18.32hrs:- T37.8, BP80/40, P120, RR36/min, alert: CIS 8 �laboured breathing�, unable to speak in sentences, using accessory muscles to breath, in severe pain Anaesthetist called

10. Case A BP unresponsive to 2l Gelofusin O2 therapy Nebulised Salbutamol as wheeze +++ Antibiotics and pyhsio given CXR left lower lobe pneumonia Morphine IV Catheter:- poor urine output: 20ml initially then nil Cap refill 2secs Art line inserted, no HDU/ITU bed available, consultant anaesthetist busy Metaraminol CTG large unprovoked decelerations. Switched off

11. Case A Med reg arrived at 19.35hrs Agreed with all that was occurring Gases on 16/l O2 pH 7.3, pO2 12.7, pCO2 4.1, BXS -9.7, HCO3 15.2 Sats 97% Transferred to ITU at 20.50hrs BP 120/50, P130, RR 40/min Intubated, Noradrenaline, CVP

12. Case A Microbiologist contacted agreed with current antibiotic therapy, acyclovir added as Chicken Pox status unknown Decision taken with added input from another consultant obstetrician and consultant anaesthetist that delivery would only occur for maternal benefit. Fetal consideration was no longer relevant

13. Case A Difficulty maintaining BP overnight Decided to deliver by C/S in main theatre the following morning on ITU bed Stillborn girl delivered Aggressive use of uterotonics to prevent PPH Remained on ITU for a further 9 days

14. Case A Has subsequently had NVD of boy, complicated by PPH 2.5l earlier this year Has not smoked again

15. Thinking about CIS Several other very ill pregnant ladies came through the unit around this time 2 DKA, 3 pyelonephritis,1 appendicitis, 1 pancreatitis Looked into CIS at this point but found nothing validated for pregnancy Medical and midwifery staff were sent on ALERT courses CEMACH published Saving Mothers� Lives 2003-2005 in Dec 2007 Recommended using some form of CIS because of unrecognised critical illness contributed to several of the deaths in that report

16. Thinking about CIS CEMACH gave an Example (non-validated)

17. Thinking about CIS And we found out LWH had their version which included an escalation policy (also non-validated)

18. Thinking about CIS So a final year student Shoned Jones and I looked at applying these two scores as well as a score for non-pregnant women both retrospectively (on 7 women) and prospectively on 10 antenatal women Not possible to tell which the best but cut off for systolic BP on the non-pregnancy score was inappropriate

19. Thinking about CIS So we chose LWH version because it was similar to the others in use at YG and had a clear escalation policy (which we modified a bit!)

20. CIS in use at YG currently

21. Case B 18 year old primip Booked at 10 weeks gestation on 28/1/08 Generally fit and healthy Past history of cannabis use and drug overdose Non-smoker BMI 19

22. Case B Booked for MLC Pregnancy progressed well until 20 weeks gestation Saw her community m/w on 20/04/08 c/o left sided loin pain and vomiting for 3/7 Felt very unwell and unable to tolerate food or fluid BP 100/60 urine +++ protein ++++ketones Referred into YG

23. Case B Seen on ward by registrar Abdominal pain less Complaining of vomiting and headache T 36.4, BP 90/55, P 87, RR 16, alert CIS 0 No specific clinical signs Provisional diagnosis of viral illness IV fluids commenced, MSSU sent CRP 171, Hb 9.8, WCC 17.4, U+E, LFT, amylase normal 4 hourly obs planned

24. Case B Stable overnight CIS remained 0 Seen by consultant on ward round next day Further loin pain, bilateral Urine microscopy WCC 180/mm3 Diagnosis altered to pyelonephritis and Cefuroxime 750mg tds IV and Cyclizine IM commenced

25. Case B Later that day had increasing loin pain requiring morphine for analgaesia 16.20hrs noted by midwife to look flushed and unwell Decided to do obs T39.4, BP 88/41, P 109, RR 17, alert, good urine output, CIS 5 Middle grade obstetrician called

26. Case B No alteration of diagnosis, though IV Cefuroxime increased to 1.5g tds, IV fluids increased FBC, CRP, Blood cultures taken Obs increased to 2 hourly Consultant obstetrician summoned CRP 112, WCC 10.8 Examined swabs done (later chlamydia +ve) No alteration of diagnosis, IV Metronidazole 500mg tds added

27. Case B CIS reduced to 1 but overnight gradual increase T 38.3, BP 85/40, P119, RR 23, alert, no comment re urine output, CIS 5 And was transferred to LW for HDU type observation Seen by anaesthetic middle grade Thorough examination, sats 93% on air

28. Case B Gases pH 7.42, BXS -6.0, pO2 9.7, pCO2 3.42, HCO3 16.4 Diagnosis sepsis secondary to pyelonephritis O2 commenced and catheterised Colloids given Microbiologist consulted Cefuroxime changed to Ceftazidime 2g tds IV If no improvement to commence Gentamicin

29. Case B Remained on LW as stabilised and no requirement for invasive monitoring CIS varied between 1-6 Hb had dropped to 7.5 Abdominal USS arranged (N but small pleural effusions noted) CXR L consolidation Benzyl penicillin added Urine grew Gram �ve organism

30. Case B Slow but gradual improvement over next 5 days Considerable input from Anaesthetics, Respiratory Physician, Microbiologist, Phsiotherapy Had transfusion, continuing O2 therapy and level 2 type care on LW, no HDU bed available Discharged to ward 7 days after admission to LW Pregnancy progressed well NVD on 10/9/08

31. And so�.. CIS probably lead to earlier recognition of serious illness Debatable whether this improved the outcome (other factors would contribute) Midwifery/junior medical staff felt very pleased with the introduction of CIS because it helps identify the seriously unwell patient and the escalation policy empowered the summoning of various grades and specialties of medical staff It continues to be used