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Obstatric ICU ain shams university protocol

Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Obstetric
ICU


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Guidelines for ICU Admission, Discharge
Diagnosis Model:
This model uses specific conditions or diseases to determine
appropriateness of ICU admission.
A. Cardiac System
1. Acute myocardial infarction with complications
2. Cardiogenic shock
3. Complex arrhythmias requiring close monitoring and
intervention

4. Acute congestive heart failure with respiratory failure and/or
requiring hemodynamic support
5. Hypertensive emergencies
6. Unstable
angina, particularly with
dysrhythmias,
hemodynamic instability, or persistent chest pain
7. S/P cardiac arrest
8. Cardiac tamponade or constriction with hemodynamic
instability
9. Dissecting aortic aneurysms
10.Complete heart block
B. Pulmonary System:
1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Patients in an intermediate care unit who are demonstrating
respiratory deterioration
4. Need for nursing/respiratory care not available in lesser care
areas such as floor or intermediate care unit
5. Massive hemoptysis
6. Respiratory failure with imminent intubation


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

C- Neurologic Disorders:
1. Acute stroke with altered mental status
2. Coma: metabolic, toxic, or anoxic
3. Intracranial hemorrhage with potential for herniation
4. Acute subarachnoid hemorrhage
5. Meningitis with
compromise

altered

mental

status

or

respiratory

6. Central nervous system or neuromuscular disorders with
deteriorating neurologic or pulmonary function
7. Status epilepticus
8. Brain dead or potentially brain dead patients who are being
aggressively managed while determining organ donation
status
9. Vasospasm
10. Severe head injured patients
D- Drug Ingestion and Drug Overdose:
1. Hemodynamically unstable drug ingestion
2. Drug ingestion with significantly altered mental status with
inadequate airway protection
3. Seizures following drug ingestion
E- Gastrointestinal Disorders:
1. Life threatening gastrointestinal bleeding including
hypotension, angina, continued bleeding, or with comorbid
conditions
2. Fulminant hepatic failure
3. Severe pancreatitis
4. Esophageal perforation with or without mediastinitis
F. Endocrine
1. Diabetic ketoacidosis complicated by hemodynamic
instability, altered mental status, respiratory insufficiency, or
severe acidosis


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Anaesthesia, ICU and Pain management Dep.

2. Thyroid storm or myxedema coma with hemodynamic
instability
3. Hyperosmolar
instability.

state

with

coma

and/or

hemodynamic

4. Other endocrine problems such as adrenal crises with
hemodynamic instability
5. Severe hypercalcemia with altered mental status, requiring
hemodynamic monitoring
6. Hypo or hypernatremia with seizures, altered mental status
7. Hypo or hypermagnesemia with hemodynamic compromise
or dysrhythmias
8. Hypo or hyperkalemia with dysrhythmias or muscular
weakness
9. Hypophosphatemia with muscular weakness
G. Surgical:
Post-operative
patients
requiring
hemodynamic
monitoring/ventilatory support or extensive nursing care
H. Miscellaneous:
1. Septic shock with hemodynamic instability
2. Hemodynamic monitoring
3. Clinical conditions requiring ICU level nursing care
4. Environmental
injuries
hypo/hyperthermia)

(lightning,

near

drowning,

5. New/experimental therapies with potential for complications
Objective Parameters Model:
Objective criteria have been requested, expected and reviewed from
individual hospitals as part of the Joint Commission on Accreditation of
Healthcare Organizations' review process of special care units in the past..
Vital Signs:
 Pulse < 40 or > 150 beats/minute.
 Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the
patient's usual pressure.


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 Mean arterial pressure < 60 mm Hg
 Diastolic arterial pressure > 120 mm Hg
 Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered):








Serum sodium < 110 mEq/L or > 170 mEq/L
Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
PaO2 < 50 mm Hg
pH < 7.1 or > 7.7
Serum glucose > 800 mg/dl
Serum calcium > 15 mg/dl
Toxic level of drug or other chemical substance in a
hemodynamically or neurologically compromised patient

Radiography/Ultrasonography/Tomography (newly discovered):
 Cerebral vascular hemorrhage, contusion or subarachnoid
hemorrhage with altered mental status or focal neurological signs
 Ruptured viscera, bladder, liver, esophageal varices or uterus with
hemodynamic instability
 Dissecting aortic aneurysm
Electrocardiogram
 Myocardial infarction with complex arrhythmias, hemodynamic
instability or congestive heart failure
 Sustained ventricular tachycardia or ventricular fibrillation
 Complete heart block with hemodynamic instability
Physical Findings (acute onset):









Unequal pupils in an unconscious patient
Burns covering > 10% BSA
Anuria
Airway obstruction
Coma
Continuous seizures
Cyanosis
Cardiac tamponade


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

DISCHARGE CRITERIA
The status of patients admitted to an ICU should be reviewed
continuously to identify patients who may no longer need ICU care. This
includes:
A. When a patient's physiologic status has stabilized and the need for ICU
monitoring and care is no longer necessary
B. When a patient's physiological status has deteriorated and / or become
irreversible and active interventions are no longer beneficial, withdrawal
of therapy should be carried out in the intensive care unit. Patient should
only be discharged to the ward if bed is required.
Discharge will be based on the following criteria:
1. Stable hemodynamic parameters
2. Stable respiratory status (patient extubated with stable
arterial blood gases) and airway patency
3. Oxygen requirements not more than 60%
4. Intravenous inotropic/ vasopressor support and
vasodilators are no longer necessary. Patients on low dose
inotropic support may be discharged earlier if ICU bed is
required.
5. Cardiac dysrhythmias are controlled
6. Neurologic stability with control of seizures for 48 hours.
7. Patients who require chronic mechanical ventilation (e.g.
motor neuron disease, cervical spine injuries) with any of
the acute critical problems reversed or resolved
8. Patients with tracheostomies who no longer require
frequent suctioning


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Acute Pain Management in ICU
Definitions
1. Pain

An unpleasant sensory or emotional experience associated with actual
or potential tissue damage, or described in terms of such damage. Pain
is always subjective and each individual learns the application of the
word through experiences related to injury in early life.
2. Acute Pain
Pain associated with surgery, trauma, medical emergencies or attacks
on top of chronic condition.
Policy
 Doctors as well as nurses should do pain assessment. Clinical
assessment includes the location, severity, radiation, duration,
frequency, characteristics, precipitating factors, alleviating and
allergy status (use of pain score). Assessment should be done by
the ICU nurses upon admission of the patient, in every episode of
vital signs check.
 ICU physician assigned must have at least one rounds per shift for
all patients subjected to pain management.
 Nurses should score for pain with every vital sign episode (fifth
vital sign) or more frequent when indicated.
 Forms for pain, nurses and physician follow up charts are used as
appropriate Pain Rating for all conscious adult and finally
Behavioral Pain Scale for unconscious, intubated or sedated patient
 For pain scores > 4/10 this means inadequate management.
Revision of plan, monitoring the accuracy of pain management
protocol implementation should be done by the pain physician.
 Any patient admitted for pain treatment will have analgesia and
pain management started within 30 minutes.
 They reassess the effectiveness of a given analgesia within thirty
(30) minutes of administration


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Pain Assessment tool
1.

Numerical pain Score

2.

Behavioral Pain Score

To assess pain in ventilated, unconscious and /or sedated patients
CATEGORY

FACIAL
EXPRESSION

UPPER LIMBS

COMPLIANCE
WITH
VENTILATION

DESCRIPTION

SCORE

RELAXED

1

PARTIALLY TIGHTENED (eg. brow
lowering)

2

Fully tightened (eg. eyelid closing )

3

Grimacing

4

No movement

1

Partially bent

2

Fully bent with finger flexion

3

Permanently retracted

4

Tolerating movement

1

Coughing with movement

2

Fighting with ventilator

3

Unable to control ventilation

4

Scoring: 3 = No pain. 4-6 = Mild pain.
7-9= Moderate pain. 10-12= Severe pain.


Obstetric I.C.U
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Anaesthesia, ICU and Pain management Dep.

WONG BAKER PAIN SCALE (non-communicative conscious adults)

0

2

4

6

8

10

Point to each face using the words to describe the pain intensity. Ask the person to choose the face best
describe his/her own pain

Pain protocol
According to the WHO stepladder approach for acute pain management
Step 1(mild pain):
Paracetamol
 Adult: Paracetamol(perfalgan) IV , 1gm/6hrly
NSAIDS if no contraindication


Liomethacine amp IV / 8hrly diluted in 50ml infusion over 30 minutes.

Once the patient can eat adequately (commonly after 48hrs) ;
 Paracetamol tablet orally (Adol) 1000mg/6hrly.
 Ibuprofen (brufen) orally 400mg /8hrly (after meals).
Use one of them or you may combine both according to the severity of pain
Step 2 (Moderate pain): (Step 1 + weak opioid)
 Nalbuphine
10 mg/70 kg administered IV, IM, every 6 -8 hours as needed.
Maximum single dose: 20 mg.
Maximum daily dose: 160 mg



Tramadol (tramal) 50-100mg IM /8hrly p.r.n. in the first 48hrs followed by 50 mg oral
tablets 8hrly p.r.n

Step 3 (Severe pain): (Step 1 + storng opioig)
Adult and pediatrics
 Pethidine 1mg/kg (50-100mg for an adult) IM/8hrly,p.r.n.
 Fentanyl 1 mic/ kg
 Morphine 0.1 mg/kg
 Continuous epidural infusion


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Diabetic Emergencies
Diabetic emergencies consist of hyperglycemic conditions such as
diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS)
HHS diabetic state, and hypoglycemic emergencies.
DKA is an acute medical emergency associated with fetal loss rates
in excess of 50%. Maternal mortality rates are generally less than 1%.
DKA in pregnancy most commonly occurs in women with pregestational,
insulin dependent diabetes who are poorly controlled or in women newly
diagnosed with insulin dependent diabetes. DKA may be provoked by an
exposure to a stress such as infection, surgery, or labor
DKA and HHS
Transfer to the ICU may be required if
Severe ketoacidosis (pH < 7.0)
Altered consciousness
More intensive monitoring anticipated (e.g. intercurrent illness)
Step 1: Start initial resuscitation
 Urgently insert two wide-bore intravenous peripheral
catheters for volume infusion.
 A central line is needed in presence of hypotension, lack of
peripheral access, multiple infusions, severe acidosis, and
impaired cardiorespiratory or renal parameters.
 Airway should be maintained as HHS patients could be
obtunded on presentation.
 Hyperventilation is prominent with acidosis and may require
assisted breathing.
Step 2: Take focused history and perform physical examination
 History of insulin omission in a diabetic patient is common
and often points toward a diagnosis of DKA.


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 A thorough physical examination helps in finding a
cause/possible focus of infection which is often a cause for the
hyperglycemic crisis.
Step 3: Send essential investigations
 Serum glucose
 Serum electrolytes, Na, K, chloride, Mg, phosphate (with
calculation of the anion
 gap)
 Blood urea nitrogen and plasma creatinine (may be spuriously
high due to chemical analysis interference with ketones)
 Serum bicarbonate
 Complete blood count with differential count
 Urinalysis and urine ketones by dipstick
 Plasma osmolality
 Serum ketones
 Arterial blood gas
 Electrocardiogram
 Serum amylase, lipase
 Chest X-ray
 Infection screening
 Continuous electronic fetal monitoring (as appropriate based
on gestational age)
Step 4: Infuse fluid
 Initially, give a bolus of 1 L of 0.9% saline or 500 mL of colloid
over 30 min. Subsequently, fluid may be given at rates of 200
mL/h till hypovolemia is corrected.
 Clinical signs such as heart rate, blood pressure, and skin
perfusion may be used as guides to fluid resuscitation. In
patients with HHS, comorbidities like renal and cardiac
dysfunctions warrant more close monitoring of hemodynamics.
 In the non- shocked and hypernatremic patients (after correcting
for high blood glucose) calculate free water deficit to assist


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Anaesthesia, ICU and Pain management Dep.

fluid replacement in patients with hypernatremia and replace
with dextrose or enteral water.
 Replace total body water losses slowly with 5% glucose
solution (50–200 mL/h) once circulating volume and serum
sodium are restored (usually when the blood glucose falls to
<200 mg/dL).
Calculate water deficit
Water deficit (L) =total body water (TBW) x[(measured Na /140)-1]
TBW=body weight (Kg) x “Y”
Y in adult woman = 0.5
Y in elderly woman = 0.45

This can be given as 5% dextrose or free water by the nasogastric
tube or orally.
Rate of correction = 0.5 mEq/h
Insensible water loss (30 mL/h) should be added.
Step 5: Correct electrolyte abnormalities
 Potassium replacement should begin as soon as serum potassium
concentration is less than 5.5 mEq/L. Target potassium
concentration is 4–5 mEq/L.
 Ensure adequate urine output before replacing intravenous
potassium.
 Guideline for replacing potassium is as follows:
 If K is less than 3.5 mEq/L, give K at 40 mEq/h (given
diluted in a liter).
 If K is 3.5–5.0 mEq/L, give K at 20 mEq/h.
 If K is more than 5.0 or anuric, no supplements are required.
 If potassium is less than 3 mEq/L, avoid insulin initially and
replace potassium first.
 Hypomagnesemia occurs early in the course of DKA and requires
correction. Monitor serum magnesium levels.
 Phosphorous depletion is common in DKA. Replacement is
advised when it is severely depressed (<1 mg/dL). Infusion of
potassium phosphate at the rate of 0.1–0.2 mmol/kg over 6 hours
(10 mL of potassium phosphate solution for intravenous use


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contains 30 mmol of phosphorous and 44 mmol of potassium).
Overzealous phosphate replacement may result in hypocalcemia.
Patients who have renal insufficiency and/or hypocalcemia may
need less aggressive phosphate replacement.
 Bicarbonate therapy may be considered in the following situations:
 When pH is 7.0 or less (In pregnancy, the normal PH is 7.47.45).
 When hypotensive shock is unresponsive to rapid fluid
replacement and persistent severe metabolic acidosis
 In severe hyperkalemia
 Bicarbonate may be given as an infusion of 100 mEq over 4 h with
frequent arterial pH monitoring.
Step 6: Start intravenous insulin infusion
 Insulin therapy should be started only after fluid and electrolyte
resuscitation is underway. Specially ensure that the potassium level
is more than 3.5 mEq/L.
 Use regular (rapid acting) insulin as 0.1 U/Kg body weight as a
bolus dose and then 0.1 U/Kg/h as a continuous infusion or 0.14
U/Kg body weight as a continuous infusion without a bolus dose.
 Initially, measure the blood glucose level 1-hourly. If the blood
glucose level does not decrease by 50–75 mg/dL/h, the rate of
insulin infusion should be doubled.
 Titrate the insulin infusion rate to blood glucose levels.
 Once the blood glucose level reaches 250 mg/dL, decrease insulin
infusion to 0.5 IU/Kg/h.
 Remember that intravenous insulin has a half-life of 2.5 min. It is
important that the insulin infusion is not interrupted.
 Rate of reduction of blood glucose should be less than 50–75
mg/dL/h.
Step 7: Monitor effectiveness of therapy clinically and biochemically
• The following features indicate clinical improvement:
– Increased sense of well-being
– Decreased tachycardia
– Decreased tachypnea
– Improved mental status
– Able to take oral food


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The following biochemical parameters should be followed:
 Serum glucose below 200 mg/dL in DKA and below 250–300
mg/dL in HHS.
 Serum bicarbonate more than 18 mEq/L.
 Venous pH more than 7.30.
 Serum anion gap less than 12 mEq/L or delta anion gap/delta
bicarbonate improving—due to sodium chloride resuscitation,
these patients develop non-anion gap metabolic acidosis, so anion
gap may still be falsely high in the patient who is improving.
 Decreasing glycosuria.
 Urine or serum ketones by nitroprusside test are not reliable
parameters to follow as this test predominantly measures
acetoacetate and acetone, whereas b -hydroxybutyrate is the
predominant ketone in severe DKA, which is not measured
usually in the laboratory. There may be a paradoxical rise of
serum or urinary ketones as patients improve due to conversion of
beta-hydroxybutyrate to acetone and acetoacetic acid.
 Stabilizing urea, creatinine.
 Plasma effective osmolality (exclude urea in osmolality
calculation) below 315 mosmol/Kg.
 If patient normoglycemic or becomes hypoglycemic with IV
insulin, do not cease the insulin infusion until acidosis is corrected
(increase in the dextrose infusion rate).
Step 8: Switch to subcutaneous insulin when stable
 Maintain IV insulin until biochemically stable and the patient has
taken at least two meals.
 Switch to subcutaneous regular insulin with half dose of total
intravenous insulin requirement either as a fixed dose or sliding
scale insulin.
 IV infusion should be stopped 2 h after the first dose of
subcutaneous insulin.


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Anaesthesia, ICU and Pain management Dep.

Step 9: Identify precipitating factors
• They should be sought and treated. Common precipitants include the
following:
 Missed insulin therapy
 Infections—pneumonia, sepsis, urinary tract infection
 Trauma
 Pancreatitis
 Myocardial infarction
 Stroke
 Steroid use for fetal lung maturation
 β2 agonists (e.g. salbutamol, terbutaline) for tocolysis
Step 10: Continue supportive care
 Thromboembolic complications are common, and DVT
prophylaxis should be initiated.
 The nasogastric tube: If consciousness is impaired, use it to avoid
aspiration of gastric contents.
 Antibiotics: Keep low threshold for use.
Checklist of DKA management milestones
□ Phase I (0–6 h)

□ Phase II (6–12 h)

□ Perform history and □ Continue biochemical
physical exam and order clinical monitoring
initial laboratory studies

□ Phase III (12–24 h)
and □ Continue biochemical and
clinical monitoring

□ Implement monitoring □ calculate free water deficit in □ Adjust therapy to avoid
plan (biochemical and patients with hypernatremia and complications
clinical)
replace with dextrose or enteral
water
□ Give intravenous bolus □ If glucose is <200–250 mg/dL, □ Address
of isotonic fluids
add dextrose to intravenous fluids
factors

precipitating

□ Start insulin therapy □ Adjust insulin infusion rate as □ If DKA resolved, stop
(after fluids started and needed
intravenous insulin and start
only if K >3.3 mmol/L)
subcutaneous insulin
□ Maintain K at 3.3–5.3 mmol/L
range


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Hypoglycemia
Impaired consciousness in diabetic patients is most commonly due
to hypoglycemia that is most often drug-induced. Symptoms of
hypoglycemia are nonspecific, and this can masquerade as
cardiorespiratory, neurological, and even psychiatric problems.
A low threshold for checking blood sugar in all diabetic patients to
exclude hypoglycemia is warranted as it is an imminently treatable
condition and if left unattended leads to mortality and severe morbidity.
Step 1: Promptly identify clinical features of hypoglycemia
 Features of hypoglycemia could be neurogenic such as diaphoresis,
tremor, anxiety, palpitation, hunger, paranesthesia, and tachycardia
caused by sympathetic stimulation.
 These may be absent in patients with autonomic neuropathy or on b
-blockers.
 In some patients, neuroglycopenic features such as drowsiness,
behavioral abnormalities, coma, and seizures predominate.
Step 2: Check blood glucose immediately
• Urgent capillary sugar should be checked with the bedside glucometer.
If possible, a simultaneous venous sample should be sent to the laboratory
for glucose analysis. Point of care glucometers generally overestimate
glucose values in the lower range. • Administration of dextrose should not
be delayed if blood glucose checking cannot be done immediately.
• If the blood glucose level is less than 70 mg/dL and symptoms improve
with glucose administration, then patient symptomatology may be
attributed to hypoglycemia.
Step 3: Give intravenous dextrose
 Reverse hypoglycemia rapidly with 50 mL of 25–50% glucose
given intravenously.
 Check blood glucose after dextrose infusion and repeat the
injection till the glucose is above 70 mg/dL for at least two
consecutive readings and the patient is asymptomatic.


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

 Start intravenous dextrose infusion 6-hourly with frequent blood
glucose monitoring in patients on long-acting insulin, oral
hypoglycemic drugs, or renal impairment as they are prone to
recurrent hypoglycemia.
Step 4: Consider alternative agents in specific circumstances
 Injection octreotide 25–50 mcg may be given subcutaneously or as
an intravenous infusion in patients with resistant hypoglycemia,
sulfonylurea-induced hypoglycemia, or hypoglycemia induced by
drugs like quinine or quinidine.
Step 5: Consider precipitating factors of hypoglycemia in diabetic
patients
• Missed meals/inadequate food intake
• Insulin overdose
• Change of therapy/dosage of hypoglycemic drugs or insulin
• Concomitant ingestion of drugs causing hypoglycemia
• Presence of hepatic or renal failure
Causes of hypoglycemia in the ICU
Insulin
Oral hypoglycemic agents
Sepsis (including malaria)
Hepatic failure
Alcohol
Adrenal crisis (including steroid withdrawal)
Drugs


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Drugs associated with hypoglycemia
Insulin
Oral hypoglycemic agents
Gatifloxacin
Quinine
Artesunate derivatives
Pentamidine
Lithium
Propoxyphene

References:



Joint British Diabetes Societies. Inpatient Care Group. The Management of
Diabetic Ketoacidosis in Adults. Second Edition. 2013
Sandhya Talekar and Jayant Shelgaonkar, Diabetic Emergencies. ICU
Protocols. A Stepwise Approach. 2012


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Antibiotic Therapy Protocol
Disease

Empiric antibiotic therapy

Community Acquired Pneumonia
(Treatment duration at least 5 days
with 48-72 hrs afebrile and no more
than 1 sign of clinical instability
1Elevated temperature
2- Elevated heart rate
3- Elevated respiratory rate
4- Decreased systolic blood pressure
5- Decreased arterial ox/gen
saturation
Hospital Acquired Pneumonia
Treatment duration 7 or 8 days
14 days if pneumonia secondary to
Pseudomonas
Aeruginosa

Oral: Azithromycin 500 mg on day
1 followed by 250 mg once daily +
Ceftriaxone I.V. 2 g/day

Acute cystitis in pregnancy

Uncomplicated cystitis:
Cephalexin oral 500 mg q 12 hrs

Treatment duration 7 days

Preferred if patient is renally
impaired because not adjusted

Piperacillin/tazobactam I.V.=
4.5 g q 6hrs for 7-14 days +(
Gentamicin 7 mg/kg /day or
Ciprofloxacin I.V.400mg q 8
hrs

Ampicillin -sulbactam 1.5 IV q
Pyelonephritis in pregnancy
Intravenous antibiotics are continued 6hrs
until the patient has been afebrile for
48 hours. Oral antibiotics are then
used for 10-14 days
I.V., Oral: clindamycin 600 mg q8
Cellulitis
hrs
Treatment duration 7-14 days
If cellulitis with purulent drainage:
Vancomycin 15mg/kg LV. q 12 hrs
for 1-3 days than transition to oral
medications if patient is improving
Pelvic inflammatory disease
Clindamycin 900mg IV q 8hrs +
Parentra! therapy can be discontinued Gentamicin 2mg/kg loading dose
24 hrs and oral therapy initiated for then 1.5 mg/kg q8hrs or once daily
14 days
therapy 3-5 mg/kg
Dosing


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Sepsis
Origin

Antibiotic therapy

Sepsis of unknown
origin

Piperacillin/tazobactam 3.375g IV q6hrs for 7-10
days + vancomycin 30-60 mg/kg/day IV divided
q8-12 hrs

Urosepsis

Ciprofloxacin 500mg PO bd or if vomiting IV
400mg bd, Plus if severe sepsis or the blood
pressure fails to
respond to initial fluid bolus: Gentamicin IV 5
mg/kg (if normal renal function)
as a single dose (max 500mg)
Fluconazole
Loading dose 800mg (12 mg/kg) on day 1 then
400 mg daily (6mg/kg/day) for 14 days after first
negative blood culture and resolution of signs
and symptoms
Vancomycin:15-20mg/kg every8-12 hrs for 26weeks
Linezolid: Oral, IV. 600mg/12hrs forl4-28
days

Fungal Infections
Candidemia

MRSA
VRSA


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Anaesthesia, ICU and Pain management Dep.

Meningitis
Ceftriaxone IV 2g ql2hrs +
Treatment duration 7-14 days Vancomycin 500 mg every 6 hrs
depending on severity

Intra-abdominal infections

Imipinem —cilastatin
Mild infection: 250-500 q 6hrs
Severe infection:500 mg q 6hrs or 1 g
q8 hrs
Mild - moderate: Metronidazole 500
mg q 8hrs for 10-14 days

Clostridium difficile
infection

Initial severe: Vancomycin 125 mg by
mouth q 6hars

If the patient is admitted form the ward and already has started an
antibiotic, the ICU protocol will continue on the same medication
unless there is a suspected other source of infection as listed in the
previous table.


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Hyperemesis Gravidarum
Severe nausea and vomiting in
pregnancy
Hyperemesis Gravidarum is an extreme form of nausea and
vomiting which affects 1.5% of women. It is associated with the triad of
weight loss greater than 5% of pre-pregnancy weight, large ketonuria and
electrolyte imbalance and dehydration. Up to 60% of women continue to
have symptoms until the end of their pregnancy.
Complications
 Acidosis
 DVT
 Hyponatremia
 Wernicke`s Encephalopathy
 Depression and social isolation
 Pressure damage to skin tissue
 Retinal hemorrhage
 Esophageal rupture or Mallory-Weiss tears
 Small for Gestational Age (SGA) in women with low pregnancy
weight gain

Initial Assessment
History
 Onset, duration and frequency of nausea and vomiting
 Whether food and drink are being tolerated
 History to exclude other causes:
- abdominal pain (more than mild epigastric tenderness after
retching)
- urinary symptoms
- infection
- drug history
- chronic Helicobacter pylori infection
- Headache


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Anaesthesia, ICU and Pain management Dep.

Examination
 Temperature (Fever suggest an alternative diagnosis)
 Pulse
 Blood pressure
 Oxygen saturations
 Respiratory rate
 Abdominal examination
 Weight
 Signs of dehydration (Dry mucus membranes, tachycardia, weight
loss, concentrated urine)
 Signs of muscle wasting
 abnormal neurological examination (suggest an alternative
diagnosis)
 Goitre (suggest an alternative diagnosis)
Investigation
 Urine analysis. if glycosuria as well as ketones consider diabetes
 Complete blood count (CBC)
- Haematocrit is usually raised
 Urea and electrolytes daily
- usually reveals hyponatremia, hypokalaemia and high serum urea
 Check magnesium if hyperemesis severe , or if potassium, 3.0
mmol/l
 LFTS`s
- Abnormal in 25-40%
- Usual mild elevations in serum transaminases and total
bilirubin
- Exclude other liver disease such as hepatitis or gallstones
 Thyroid function tests not required (abnormal in two-thirds of
patients)
 Amylase: exclude pancreatitis
 ABG: exclude metabolic disturbances to monitor severity
 Ultrasound scan to confirm gestation and exclude multiple or molar
pregnancy
 Oesophageal gastroduodenoscopy
 H. pylori antibodies


Obstetric I.C.U

Anaesthesia, ICU and Pain management Dep.

Differential Diagnosis for conditions causing nausea and vomiting in
pregnancy:
 Genito-urinary conditions
– UTI, uraemia, pyelonephritis, ovarian torsion
 Metabolic disorders and endocrine conditions
– Hypercalcaemia, thyrotoxicosis, diabetic ketoacidosis,
Addison`s disease
 Gastrointestinal conditions
–Gastritis, peptic ulcer, pancreatitis, bowel obstruction, hepatitis,
appendicitis, cholecystitis
 ENT conditions e.g. labyrinthitis
 Neurological disorders
– Vestibular disease, migraine
 Other pregnancy-related conditions
– Acute fatty liver of pregnancy, pre-eclampsia (consider preeclampsia if the onset is of NVP is in second half of pregnancy).
 Drug induced vomiting
– e.g. iron or opioids
 Psychological disorders
– e.g. eating disorders

Management
Anti-emetic Therapy
 Withhold non-essential medications associated with NVP e.g.
oral iron
 Give first dose IM/ IV on admission
 Continued regular prescription of anti-emetics is essential. IV
/IM until patient is eating without vomiting
 A combination of medications may be required
 Prescribe at times which give maximum effect at meal times
First line Cyclizine 50 mg PO, IM or IV 8 hourly
Prochlorperazine 5–10 mg 6–8 hourly PO; 12.5 mg 8 hourly
IM/IV; 25 mg PR daily
Promethazine 12.5–25 mg 4–8 hourly PO, IM, IV or PR
Chlorpromazine 10–25 mg 4–6 hourly PO, IV or IM; or 50–
100 mg 6–8 hourly PR


Obstetric I.C.U

Second
line

Third
line

Anaesthesia, ICU and Pain management Dep.

Metoclopramide 5–10 mg 8 hourly PO, IV or IM (maximum
5 days’ duration) Domperidone 10 mg 8 hourly PO; 30–60
mg 8 hourly PR
Ondansetron 4–8 mg 6–8 hourly PO; 4-8 mg over 15
minutes 12 hourly IV
Corticosteroids: hydrocortisone 100 mg twice daily IV and
once clinical improvement occurs, convert to prednisolone
40–50 mg daily PO, with the dose gradually tapered until the
lowest maintenance dose that controls the symptoms is
reached

 Drug-induced extrapyramidal symptoms and oculogyric crises can
occur with the use of phenothiazines and metoclopramide. If this
occurs, there should be prompt cessation of the medications.
Fluid and Electrolyte Replacement
Most women admitted to the ICU with HG are hyponatremic,
hypochloremic, hypokalemic and ketotic.
 Avoid dextrose infusions unless the serum sodium levels are
normal and thiamine has been administered. – Dextrose-containing
solutions may precipitate Wernicke`s Encephalopathy
 2000ml normal saline given over 4 hours
 Additional fluid and electrolyte requirements should be adapted
based on urinalysis and Urea and electrolytes
Potassium is almost always required with subsequent IV fluids
Nutrition
 Encourage oral fluids when they can be tolerated
 Record fluid balance
 Encourage frequent snacks of “safe foods” when able to eat
 Enteral and parenteral nutrition should be considered when all
other medical therapies have failed
Thiamine
Thiamine 50mg x 3 daily should be routinely given to all women
admitted to hospital with severe prolonged vomiting until eating
normally. Oral Thiamine may need to be continued after discharge.


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