Caracterización de la materna crítica quirúrgica ingresada en Unidad de Cuidados Intensivos / Characterization of pregnant women in critically surgical state admitted to the Intensive Care Unit / Caracterização da mãe cirúrgica crítica internada na Unidade de Terapia Intensiva

RESUMEN Introducción: La morbilidad obstétrica y la mortalidad materna se definen como la probabilidad que una mujer que ha estado o está embarazada enferme o muera según sea el caso. Objetivo: Caracterizar la paciente obstétrica crítica quirúrgica ingresada en la Unidad de Cuidados Intensivos del Hospital General Docente "Vladimir Ilich Lenin" de provincia Holguín. Método: Se realizó un estudio descriptivo, longitudinal retrospectivo en el período comprendido desde 1 de enero hasta 31 de diciembre de 2021. El universo de estudio lo constituyeron 90 maternas críticas quirúrgicas ingresadas en dicha unidad, (muestra=universo). Se identificaron: edad, estado físico según Sociedad Americana de Anestesiología, enfermedades asociadas, técnica anestésica empleada, diagnóstico al ingreso a la unidad de cuidados intensivos y mortalidad. Los resultados se registraron en una base electrónica de datos y se aplicó estadística descriptiva. Resultados: Las pacientes obstétricas con estado físico II según Sociedad Americana de Anestesiología, entre 20-29 años con antecedentes de hipertensión arterial fueron las más propensas a ingresar en Unidad de Cuidados Intensivos, siendo las causas directas: principalmente la hemorragia obstétrica, secundado por preeclampsia agravada y la sepsis; las causas indirectas: cirugía no obstétrica, como apendicitis aguda. La anestesia general fue la técnica anestésica más empleada. La mortalidad fue baja y de causa indirecta. Conclusiones: Los resultados coinciden con lo publicado por otros autores, donde se muestra la importancia de la atención multidisciplinaria desde la atención primaria de salud hasta la atención secundaria.

ABSTRACT Introduction: Obstetric morbidity and maternal mortality are defined as the probability that a woman who has been or is pregnant will become ill or die. Objective: Characterization of the obstetric patient in critically surgical state admitted to the Intensive Care Unit (ICU) at the Hospital General Docente "Vladimir Ilich Lenin" in Holguín province. Method: A descriptive, longitudinal, retrospective study was conducted from January 1 to December 31, 2021. The universe studied consisted of 90 pregnant women in critically surgical state admitted to the ICU (sample=universe). It was identified: age, physical status according to the American Society of Anesthesiologists, associated diseases, anesthetic technique used, diagnosis on admission to the intensive care unit, and mortality. The results were recorded in an electronic database and the descriptive statistics were applied. Results: Obstetric patients with physical status II according to the American Society of Anesthesiology, between 20 to 29 years of age with a history of arterial hypertension were the most likely to be admitted to the Intensive Care Unit, the direct causes being: mainly obstetric hemorrhage, seconded by aggravated preeclampsia and sepsis; indirect causes: non-obstetric surgery, such as acute appendicitis. General anesthesia was the most commonly used anesthetic technique. Mortality was low and indirect cause. Conclusions: The results agree with those published by other authors, which show the importance of multidisciplinary care from primary health care to secondary care.

RESUMO Introdução: A morbidade obstétrica e a mortalidade materna são definidas como a probabilidade de uma mulher que esteve ou está grávida adoecer ou morrer, conforme o caso. Objetivo: Caracterizar a paciente obstétrica cirúrgica crítica internada na Unidade de Terapia Intensiva do Hospital General Docente "Vladimir Ilich Lenin" na província de Holguín. Método: Estudo descritivo, retrospectivo longitudinal, realizado no período de 1º de janeiro a 31 de dezembro de 2021. O universo de estudo foi composto por 90 puérperas críticas internadas na referida unidade (amostra=universo). Foram identificados: idade, estado físico de acordo com a Sociedade Americana de Anestesiologia, doenças associadas, técnica anestésica utilizada, diagnóstico na admissão na unidade de terapia intensiva e mortalidade. Os resultados foram registrados em banco de dados eletrônico e foi aplicada estatística descritiva. Resultados: As pacientes obstétricas com estado físico II segundo a American Society of Anesthesiology, entre 20-29 anos com histórico de hipertensão arterial, foram as mais propensas a serem admitidas na Unidade de Terapia Intensiva, sendo as causas diretas: principalmente hemorragia obstétrica, secundária à pré-eclâmpsia, agravada e sepse; causas indiretas: cirurgia não obstétrica, como apendicite aguda. A anestesia geral foi a técnica anestésica mais utilizada. A mortalidade foi baixa e de causa indireta. Conclusões: Os resultados coincidem com os publicados por outros autores, onde se mostra a importância da atenção multidisciplinar desde a atenção primária à saúde secundária.

Propofol como agente inductor anestésico en la cesárea electiva / Propofol as an anesthetic inducing agent in elective caesarean section

Introducción: La decisión de realizar la inducción anestésica con propofol o tiopental en la paciente obstétrica para operación cesárea es un tema controvertido, con resultados contradictorios entre las investigaciones. Objetivo: Presentar los resultados que se publicaron en la literatura nacional e internacional sobre el uso del propofol como agente anestésico en la inducción de la anestesia general en la operación cesárea electiva. Métodos: Se realizó una revisión no sistemática de la bibliografía basada en artículos que se publicaron en bases de datos indexadas en Infomed como Hinari, Ebsco, Scielo, Pubmed, Cubmed, Cocrhane; en idioma español e inglés, durante los últimos diez años, utilizando palabras clave como: (inducción anestésica OR anestesia general OR) AND (propofol OR) AND (operación cesárea OR cesárea OR). Desarrollo: Se destacaron artículos donde se comparan los resultados del uso del propofol contra el tiopental y otros barbitúricos durante la inducción anestésica en cuanto a variables hemodinámicas, efectos adversos, calidad anestésica y desenlaces neonatales como el estado físico, capacidad de adaptación neurológica y gases arteriales. Conclusiones: El propofol es el agente más común para la inducción anestésica en la paciente obstétrica que necesita cesárea electiva. Este presenta resultados adecuados maternos y fetales, y menor incidencia de efectos adversos(AU)

Introduction: The decision to perform anesthetic induction with propofol or thiopental in obstetric patients for cesarean section is a controversial issue, with contradictory oncomes among investigations. Objective: To present the results published in the national and international literature about the use of propofol as an anesthetic agent in the induction of general anesthesia in elective cesarean section. Methods: A nonsystematic review of the bibliography was carried out, with a focus on articles in Spanish and English published, during the last ten years, in databases indexed in Infomed, such as Hinari, Ebsco, Scielo, Pubmed, Cubmed, Cocrhane, using keywords such as (inducción anestésica [anesthetic induction] OR anestesia general [general anesthesia] OR) AND (propofol OR) AND (operación cesárea [cesarean section] OR cesárea [cesarean] OR). Development: Articles were highlighted if they compared the results of propofol usage against thiopental and other barbiturates during anesthetic induction in terms of hemodynamic variables, adverse effects, anesthetic quality and neonatal outcomes such as physical state, neurological adaptation capacity and arterial gases. Conclusions: Propofol is the commonest agent for anesthetic induction in obstetric patients requiring elective caesarean section. This presents adequate maternal and fetal outcomes, as well as a lower incidence of adverse effects(AU)

Analgesia en trabajo de parto / Analgesia in labour

Resumen: El dolor que experimentan las mujeres durante el trabajo de parto es considerado uno de los dolores más severos e intensos. La Asociación Internacional para el Estudio del Dolor (IASP) declaró al 2007 como el «Año Global Contra el Dolor en la Mujer¼, enfatizando la importancia que tiene el tratamiento del dolor y su impacto en la salud pública si este dolor es mal tratado y descuidado: se ha reportado un incremento alarmante en la incidencia de dolor agudo postparto y postcesárea de moderado a severo, que ha sido asociado con síndrome de estrés postraumático, depresión postparto y dolor persistente con datos de cronificación. El Colegio Americano de Ginecología y Obstetricia (ACOG), la Sociedad de Anestesia Obstétrica y de Perinatología (SOAP), la Sociedad Americana de Anestesiología (ASA) y la Asociación Internacional Para el Estudio del Dolor (IASP) han generado el modelo para manejo de dolor agudo universal (para ver el artículo completo visitehttp://www.painoutmexico.com).

Abstract: The pain that women experience during labor is considered one of the most severe and intense pains. The International Association for the Study of Pain (IASP) declared the year 2007 as «The Global Year Against Pain in Women¼, emphasizing the importance of treating pain in pregnant women in relation to its impact on public health if this pain is poorly treated: there is an alarming increase in the incidence of moderate to severe acute pain postpartum and post-cessation that has been associated with in post-traumatic stress syndrome, postpartum depression and pain persistent with data cronification. The American College of Obstetricians and Gynecologist (ACOG), the American Society of Anesthesiologists (ASA), the Obstetric Anesthesia and Society for Obstetric Anesthesia and Perinatology (SOAP) and the International Association for the Study of Pain (IASP) have generated a model for pain management that provides universal standard care (full version visithttp://www.painoutmexico.com ) .

Morbilidad materna extremadamente grave. Un problema obstétrico en la salud pública y la atención al paciente grave / Extremely serious maternal morbidity. An obstetric problem in public health and seriously ill patient care

El concepto morbilidad materna extremadamente grave, se considera de gran utilidad al ser un indicador muy asociado a la muerte materna y un estadio intermedio en prácticamente la totalidad de las fallecidas. Como parte de la primera etapa de un proyecto de investigación se realizó una revisión del tema y se consultaron las bases de datos LILACS, EBSCO e HINARI. Los descriptores que se utilizaron fueron: mortalidad materna, morbilidad y paciente obstétrica grave. Los resultados de la búsqueda se limitaron a los últimos cinco años en idioma inglés, español, francés y portugués. La morbilidad materna extremadamente grave es un indicador muy asociado a la muerte materna y es considerada una alternativa válida para utilizarla como indicador de la calidad de los cuidados maternos. El interés creciente de integrar el análisis de la morbilidad materna extremadamente grave al estudio de la mortalidad materna, permite identificar los factores de riesgo presentes en las gestantes, desde un embarazo sin complicaciones hasta la muerte, pues se presenta en un mayor número de casos, y con el manejo de aquellos que evolucionaron favorablemente después de la gravedad extrema, se pueden evitar nuevas defunciones (AU).

The concept "extremely serious maternal morbidity" is considered very useful because it is an indicator closely associated to maternal death and an intermediate stage in practically the totality of maternal deceases. As a part of the first stage of a research project, a review on the theme was carried out, and LILACS, EBSCO and HINARI data bases were consulted. The used descriptors were: maternal mortality, morbidity and seriously ill obstetric patient. The results of the search were limited to the last five years in English, Spanish, French and Portuguese languages. Extremely serious maternal morbidity is an indicator very frequently associated to maternal death, and it is considered a suitable alternative for using it as an indicator of the maternal care quality. The increasing interest for integrating the analysis of extremely serious maternal morbidity to the study of maternal morbidity allows identifying the risk factors that are present in pregnant women, beginning from a pregnancy without complications and ending with death, because they are found in a bigger quantity of cases, and new deceases could be avoided with the management of those favourably evolving after the extreme seriousness (AU).

Predictors and outcome of obstetric admissions to intensive care unit: A comparative study.

This descriptive observational study was carried out in Guru Teg Bahadur Hospital to identify predictors and outcome of obstetric admission to Intensive Care Unit (ICU). Ninety consecutive pregnant patients or those up to 42 days of termination of pregnancy admitted to ICU from October 2010 to December 2011 were enrolled as study subjects with selection of a suitable comparison group. Qualitative statistics of both groups were compared using Pearson's Chi-square test and Fisher's exact test. Odds ratio was calculated for significant factors. Low socioeconomic status, duration of complaints more than 12 h, delay at intermediary facility, and peripartum hysterectomy increased probability of admission to ICU. High incidence of obstetric admissions to ICU as compared to other countries stresses on need for separate obstetric ICU. Availability of high dependency unit can decrease preload to ICU by 5%. Patients with hemorrhagic disorders and those undergoing peripartum hysterectomy need more intensive care.

Analysis of risk factors associated with acute renal failure in critically ill obstetric patients in intensive care unit / 中国中西医结合急救杂志

Objective To analyze the risk factors associated with acute renal failure (ARF) in critically ill obstetric patients in intensive care unit (ICU).Methods A retrospective analysis of 192 critically ill obstetric patients admitted to the ICU for postpartum complications was conducted. There were 10 patients excluded because 3 died of amniotic embolism with massive hemorrhage in ICU and 7 had incomplete records, therefore, only 182 critically ill obstetric patients were enrolled in this study. According to the occurrence of ARF or not, the patients were divided into ARF group (68 cases) and non-ARF group (114 cases). The indicators of preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, thrombocytopenia), acute fatty pregnancy liver, postpartum hemorrhage, sepsis were collected in the two groups. The main drugs used in the 4 days after delivery were as follows: ① plasma volume expanders: fluids (crystalloids, artificial colloids, hypertonic albumin and 4% serum albumin) and blood products (packed red cells, concentrated platelets, fibrinogen, fresh frozen plasma and activated factor Ⅶ); ② antifibrinolytic drug: tranexamic acid; ③ anti-hypertensive drugs: angiotensin-converting enzyme inhibitors (ACEI), diuretics; ④ nephrotoxic drugs: aminoglycosides, contrast agent. The above indexes were firstly analyzed by the univariate method, and the risk factors with statistical significance were further analyzed by multivariate logistic regression method to screen out the independent risk factors of developing ARF in critically ill obstetric patients in ICU.Results Univariate analysis showed that HELLP syndrome, tranexamic acid and hypertonic albumin infusion used in 4 days after delivery were the risk factors of ARF (χ2 value was 4.92, 4.29, 5.53, respectively, allP < 0.05). The multivariate logistic regression analysis showed: HELLP syndrome [odds ratio (OR) = 10.478, 95% confidence interval (95%CI) was 1.248 - 17.953,P = 0.030] and hypertonic albumin infusion used in 4 days after delivery [OR = 6.632, 95%CI was 1.211 - 16.328,P = 0.029] were the independent risk factors to develop ARF.Conclusions The occurrence of ARF in a critically ill obstetric patient in ICU is a process involving multiple factors, therefore, it is necessary to fully recognize the risk factors influencing the development of this disease; the presence of HELLP syndrome and hypertonic albumin infusion used in 4 days after delivery are the independent risk factors of developing ARF. Thus, particular attention should be paid to those patients with such high risk factors to decrease the incidence of ARF.

Fallo renal agudo en la paciente obstétrica gravemente enferma / Acute renal failure in the severely ill obstetric patient

Introducción: el fracaso renal agudo en el embarazo puede ser inducido por las mismas causas que afectan a la población general, sin embargo existen complicaciones de cada trimestre del embarazo que pueden resultar en fallo renal. Objetivo: reconocer las principales características clínicas y terapéuticas de la insuficiencia renal aguda en la obstétrica grave. Métodos: se realizó la caracterización clínica del fallo renal agudo en la obstétrica gravemente enferma en la sala de cuidados intensivos, a través de un estudio observacional transversal durante 2 años, sobre 12 pacientes portadoras, de un total de 96 obstétricas graves que ingresaron en la unidad. Resultados: el 12, 5 por ciento de las pacientes ingresadas desarrollaron esta entidad con mortalidad del 16,6 por ciento. La causa más frecuente de fallo renal agudo fue la enfermedad hipertensiva del embarazo y predominó el fallo parenquimatoso (necrosis tubular aguda). Se emplearon métodos depuradores en 7 pacientes (58,3 por ciento) y predominó la hemodiafiltración continua entre las técnicas empleadas aunque el tratamiento médico fue importante. El fallo renal agudo se asoció a la disfunción/fracaso multiorgánico en el 83,3 por ciento con mortalidad del 20 por ciento. Conclusión: la paciente obstétrica es una población de alto riesgo para el desarrollo del fallo renal

Introduction: the acute renal failure during pregnancy may be induced by the same causes affecting to the general population, however, there are complications of each trimester of pregnancy that may become a renal failure. Objective: to recognize the main clinical features in the severe obstetric patient. Methods: a clinical characterization of acute renal failure was made in the severely ill obstetric patient admitted in the intensive care unit (ICU) by means of a cross-sectional and observational study over two years in 12 carrier patients from a total of 96 severe obstetric patients admitted in that unit. Results: the 12.5 percent of patients admitted developed this entity for a mortality of 16.6 percent. The more frequent cause of acute renal failure was the hypertensive disease of obstetric with predominance of parenchymatous failure (acute tubular necrosis). Authors used depurative methods in 7 patients (58.3 percent) with predominance of a continuous hemofiltration among the techniques used although the medical treatment was important. The acute renal failure was associated with the dysfunction/multi-organ failure in the 83.3 percent for a mortality of 20 percent. Conclusion: The obstetric patient is a group with high risk for development of renal failure

Caracterización de pacientes obstétricas críticas / Characterization of critical obstetrical patients

Introducción: la paciente obstétrica plantea consideraciones únicas para la atención crítica, por lo que los miembros del equipo deben tener conocimientos de esta área. Estas pacientes pueden beneficiarse con la tecnología y la experiencia de la obstétrica crítica. Objetivo: caracterizar a la paciente obstétrica crítica atendida en el Hospital Militar Central Dr. Luis Díaz Soto. Métodos: se realizó un estudio descriptivo transversal en pacientes obstétricas críticamente enfermas en el Hospital Militar Central Dr. Luis Díaz Soto desde enero de 2006 hasta junio de 2008. Se incluyeron todas las embarazadas y puérperas admitidas en la Unidad de Cuidados Intensivos. Para el análisis se utilizó la tasa de ingreso de pacientes obstétricas en la Unidad de Cuidados Intensivos y la prueba chi cuadrado para determinar la asociación estadística entre las variables. Los datos recogidos fueron procesados en SPSS y llevados a tablas de frecuencia. Resultados: se estudiaron 26 pacientes obstétricas críticas, donde el grupo de edades más frecuente estuvo entre los 31 y 35 años. La neumonía complicada y la atonía uterina ocuparon las primeras causas de ingreso en la Unidad de Cuidados Intensivos (15,6 y 11,6 por ciento respectivamente). El 23 por ciento requirió ventilación mecánica y el shock hipovolémico fue la principal complicación presentada (15,4 por ciento). La estadía media fue de 7 días. Conclusiones: la incidencia de ingresos de pacientes obstétricas críticas en la Unidad de Cuidados Intensivos se comporta de forma irregular, y las causas no obstétricas fueron las que con mayor frecuencia motivaron la admisión en esta unidad

Introduction: the obstetrical patient proposes unique considerations for the critical care, thus, the staff members must to have knowledges on this area. These patients may benefit with the technology and the experience of the critical obstetrics. Objective: to characterize the critical obstetric patient seen in the Dr. Luis Díaz Soto Central Military Hospital. Methods: a cross-sectional and descriptive study was conducted in critically ill obstetric patients seen in the Dr. Luis Díaz Soto Central Military Hospital from January, 2006 to June, 2008 including the pregnant and puerperal patients admitted in the Intensive Care Unit (ICU). For analysis authors used the admission rate of obstetric patients in the ICU and the Chi² test to determine the statistical association among variables. Data collected were processed in SPSS and showed in frequency tables. Results: twenty six critical patients were studied where the more frequent age group was that between 31 and 35 years. The complicated pneumonia and the uterine atony were the leading causes of admission in ICU (15.6 and 11.6 percent, respectively). The 23 percent need mechanical ventilation and the hypovolemic shock was the major complication present (15.4 percent). The mean stay was of 7 days. Conclusions: admission incidence of critical obstetric patients in ICU behaves in an irregular way and the non-obstetric causes were those with more frequency lead to admission in this unit