SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023.

BACKGROUND: The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static. AIMS: To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis. MATERIALS AND METHODS: A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement. RESULTS: This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes. CONCLUSION: Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.

Nebulised heparin for patients with or at risk of acute respiratory distress syndrome: a multicentre, randomised, double-blind, placebo-controlled phase 3 trial.

BACKGROUND: Mechanical ventilation in intensive care for 48 h or longer is associated with the acute respiratory distress syndrome (ARDS), which might be present at the time ventilatory support is instituted or develop afterwards, predominantly during the first 5 days. Survivors of prolonged mechanical ventilation and ARDS are at risk of considerably impaired physical function that can persist for years. An early pathogenic mechanism of lung injury in mechanically ventilated, critically ill patients is inflammation-induced pulmonary fibrin deposition, leading to thrombosis of the microvasculature and hyaline membrane formation in the air sacs. The main aim of this study was to determine if nebulised heparin, which targets fibrin deposition, would limit lung injury and thereby accelerate recovery of physical function in patients with or at risk of ARDS. METHODS: The Can Heparin Administration Reduce Lung Injury (CHARLI) study was an investigator-initiated, multicentre, double-blind, randomised phase 3 trial across nine hospitals in Australia. Adult intensive care patients on invasive ventilation, with impaired oxygenation defined by a PaO2/FiO2 ratio of less than 300, and with the expectation of invasive ventilation beyond the next calendar day were recruited. Key exclusion criteria were heparin allergy, pulmonary bleeding, and platelet count less than 50 X 109/L. Patients were randomly assigned 1:1, with stratification by site and using blocks of variable size and random seed, via a web-based system, to either unfractionated heparin sodium 25 000 IU in 5 mL or identical placebo (sodium chloride 0·9% 5 mL), administered using a vibrating mesh membrane nebuliser every 6 h to day 10 while invasively ventilated. Patients, clinicians, and investigators were masked to treatment allocation. The primary outcome was the Short Form 36 Health Survey Physical Function Score (out of 100) of survivors at day 60. Prespecified secondary outcomes, which are exploratory, included development of ARDS to day 5 among at-risk patients, deterioration of the Murray Lung Injury Score (MLIS) to day 5, mortality at day 60, residence of survivors at day 60, and serious adverse events. Analyses followed the intention-to-treat principle. There was no imputation of missing data. The trial is registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612000418875 . FINDINGS: Between Sept 4, 2012, and Aug 23, 2018, 256 patients were randomised. Final follow-up was on Feb 25, 2019. We excluded three patients who revoked consent and one ineligible participant who received no intervention. Of 252 patients included in data analysis, the mean age was 58 years (SD 15), 157 (62%) were men, and 118 (47%) had ARDS. 128 (51%) patients were assigned to the heparin group and 124 (49%) to the placebo group, all of whom received their assigned intervention. Survivors in the heparin group (n=97) had similar SF-36 Physical Function Scores at day 60 compared to the placebo group (n=94; mean 53·6 [SD 31·6] vs 48·7 [35·7]; difference 4·9 [95% CI -4·8 to 14·5]; p=0·32). Compared with the placebo group, the heparin group had fewer cases of ARDS develop to day 5 among the at-risk patients (nine [15%] of 62 patients vs 21 [30%] of 71 patients; hazard ratio 0·46 [95% CI 0·22 to 0·98]; p=0·0431), less deterioration of the MLIS to day 5 (difference -0·14 [-0·26 to -0·02]; p=0·0215), similar day 60 mortality (23 [18%] of 127 patients vs 18 [15%] of 123 patients; odds ratio [OR] 1·29 [95% CI 0·66 to 2·53]; p=0·46), and more day 60 survivors at home (86 [87%] of 99 patients vs 73 [73%] of 100 patients; OR 2·45 [1·18 to 5·08]; p=0·0165). A similar number of serious adverse events occurred in each group (seven [5%] of 128 patients in the heparin group vs three [2%] of 124 patients in the placebo group; OR 2·33 [0·59 to 9·24]; p=0·23), which were a transient increase in airway pressure during nebulisation (n=3 in the heparin group), major non-pulmonary bleeding (n=2 in each group), haemoptysis (n=1 in the heparin group), tracheotomy site bleeding (n=1 in the heparin group), and hypoxaemia during nebulisation (n=1 in the placebo group). INTERPRETATION: In patients with or at risk of ARDS, nebulised heparin did not improve self-reported performance of daily physical activities, but was well tolerated and exploratory outcomes suggest less progression of lung injury and earlier return home. Further research is justified to establish if nebulised heparin accelerates recovery in those who have or are at risk of ARDS. FUNDING: Rowe Family Foundation, TR and RB Ditchfield Medical Research Endowment Fund, Patricia Madigan Charitable Trust, and The J and R McGauran Trust Fund.

Rapid response team calls to obstetric patients in a busy quaternary maternity hospital.

AIMS: There is limited published information regarding intensive care unit (ICU) led rapid response team (RRT) calls to obstetric patients. We examined the characteristics of RRT calls to obstetric patients at a tertiary teaching hospital. METHODS: Details of calls to pregnant and postpartum patients between October 2010 and June 2014 were obtained from the hospital RRT database. Each was retrospectively examined for data on patient demographics, call trigger, interventions and outcomes. Local obstetric-specific escalation practices (Code Pink/Green) for obstetrical concerns (not mandating maternal instability/involvement of the ICU team), were excluded. RESULTS: There were 106 RRT calls logged during 43 months, and 97 had data available for analysis. Women currently pregnant accounted for 33% of calls and postpartum women 67%, with nearly half of these occurring more than 24 h post-delivery. The most common reason (29% of calls) for calling the RRT was hypotension, followed by 'concern about patient' (21%) and decreased Glasgow Coma Score (GCS) (17%). An escalation in the environment of care occurred after 32% of calls, with approximately 11% of calls necessitating direct ICU admission. Twenty-three percent of all calls were to women who had an ICU admission during their hospital stay. Among the cohort who received an RRT call, there was one maternal and three neonatal deaths. CONCLUSION: At our institution generic RRT calls are called to both pregnant and postpartum women, and frequently result in an escalation in the care environment. Further study is required to understand better the specific needs of this important population.

SOMANZ guidelines for the investigation and management sepsis in pregnancy.

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

General Care of the Pregnant Patient in the Intensive Care Unit.

Pregnant women represent a small subset of all intensive care unit (ICU) admissions and may require intensive care for "obstetric" or "nonobstetric" reasons. Women may be admitted to the ICU at any stage of pregnancy or in the postpartum period. Pregnancy may be discovered at the time of admission to the ICU. Pregnancy impacts on ICU care in a variety of ways and requires a multidisciplinary approach to management. Pregnancy is associated with considerable physiological changes that affect most organ systems, including an expansion in blood volume, an increase in minute ventilation, and an increased risk of thrombosis. The enlarging uterus may be associated with mechanical complications due to compression and displacement of other structures. The growing fetus places considerable demands upon the mother, being reliant on maternal systems for oxygenation, nutrition and disposal of carbon dioxide, and other waste products. This "second patient" must be considered when managing the pregnant woman. Optimal management of the mother usually constitutes best treatment for the fetus. Maternal shock and physiological disturbance, medications, and ionizing radiation from diagnostic imaging may have harmful effects on the unborn child. Delivery of the fetus for either maternal or fetal indications may be necessary and should be planned for, even if considered unlikely to be required. Care of the postpartum woman has its own challenges, including managing lactation and facilitating mother/infant contact. In this article, the general care aspects of ICU treatment of the pregnant woman will be discussed, including monitoring, physiological target setting, and general supportive care.

Haemodynamic assessment in pregnancy and pre-eclampsia: A Guytonian approach.

OBJECTIVES: Hypertensive disorders of pregnancy continue to be amongst the leading causes of maternal morbidity and mortality. There is debate about the optimal monitoring and treatment for these women, particularly in regard to circulatory and fluid management. A restrictive fluid strategy is advocated, which conflicts with the prevailing view that the circulating volume is contracted in pre-eclampsia. This belief has been erroneously reinforced by use of the central venous pressure (CVP) as a measure of the volume state. METHODS: We used a Guytonian model of the circulation involving the mean systemic filling pressure (Pms) to review published data using a cohort of normal pregnant/post partum women and a pre-eclamptic cohort. The Pms is the pressure left in the circulation when the heart is stopped, arguably the true volume state measure. An analogue of the Pms (Pmsa) can be calculated using commonly measured haemodynamic variables. RESULTS: Our results show the Pmsa to be elevated in normal pregnancy versus post partum (10.79 vs. 9.58, a 12.6% difference) and elevated further in pre-eclamptic pregnancy (13.86, 29% higher than the normal pregnant group). CONCLUSIONS: There is scope to challenge the long held belief that the volume state is contracted in pre-eclampsia. This approach indicates that the maternal volume state in pre-eclampsia is often elevated. When viewed in combination with recent echocardiographic insights this model helps to explain some of the haemodynamic management paradoxes that these women present. Most importantly, it provides a sound physiological basis for the restrictive fluid strategy that is currently recommended.

Measuring visceral fat, subcutaneous fat and skeletal muscle area changes by computed tomography in acute pancreatitis: a retrospective, single-centre study.

OBJECTIVE: To show that body composition of intensive care unit patients can be analysed with existing computed tomography (CT) images. We planned to describe changes in visceral fat area (VFA), subcutaneous fat area (SFA) and muscle area (MA) on analysis of specific CT images during acute pancreatitis requiring an ICU admission. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of body composition using existing CT images, in an ICU of a tertiary university-affiliated hospital 2005-2010, examining 21 patients with acute pancreatitis and CT imaging on two separate occasions within their hospital admission. MAIN OUTCOME MEASURES: VFA, SFA, VFA:SFA ratio and MA. Medical records were hand searched to identify ICU and hospital mortalities and other clinical outcomes. RESULTS: Three women and 18 men had 84 CT scans analysed, from the level of the right renal hilum and L3 vertebra. The median patient age was 52 years. The median time between CT scans was 9.4 days and the mean Acute Physiology and Chronic Health Evaluation II score was 20.2. ICU mortality was 9%. Analysis showed a decrease in VFA from a median of 229.2 cm2 to 202.1 cm2 (P < 0.01) and a decrease in VFA:SFA ratio from a median of 1.20 to 1.05 (P < 0.01) during the acute illness. MA did not change significantly. CONCLUSIONS: The body composition of ICU patients can be analysed through existing CT images. Pancreatitis requiring ICU admission causes a 12% decrease in VFA.

Acquired bloodstream infection in the intensive care unit: incidence and attributable mortality.

INTRODUCTION: To estimate the incidence of intensive care unit (ICU)-acquired bloodstream infection (BSI) and its independent effect on hospital mortality. METHODS: We retrospectively studied acquisition of BSI during admissions of >72 hours to adult ICUs from two university-affiliated hospitals. We obtained demographics, illness severity and co-morbidity data from ICU databases and microbiological diagnoses from departmental electronic records. We assessed survival at hospital discharge or at 90 days if still hospitalized. RESULTS: We identified 6339 ICU admissions, 330 of which were complicated by BSI (5.2%). Median time to first positive culture was 7 days (IQR 5-12). Overall mortality was 23.5%, 41.2% in patients with BSI and 22.5% in those without. Patients who developed BSI had higher illness severity at ICU admission (median APACHE III score: 79 vs. 68, P < 0.001). After controlling for illness severity and baseline demographics by Cox proportional-hazard model, BSI remained independently associated with risk of death (hazard ratio from diagnosis 2.89; 95% confidence interval 2.41-3.46; P < 0.001). However, only 5% of the deaths in this model could be attributed to acquired-BSI, equivalent to an absolute decrease in survival of 1% of the total population. When analyzed by microbiological classification, Candida, Staphylococcus aureus and gram-negative bacilli infections were independently associated with increased risk of death. In a sub-group analysis intravascular catheter associated BSI remained associated with significant risk of death (hazard ratio 2.64; 95% confidence interval 1.44-4.83; P = 0.002). CONCLUSIONS: ICU-acquired BSI is associated with greater in-hospital mortality, but complicates only 5% of ICU admissions and its absolute effect on population mortality is limited. These findings have implications for the design and interpretation of clinical trials.