While not an expert, and my realm of experience is generally not in the
Maternal-Child realm, I can offer the following thoughts...The key thing is her
lactate. If her lactate is normalizing that indicates that oxygenation demands
are being met on a cellular level, and even though the extraction is elevated,
supply is meeting current demand with anaerobic metabolism resolved (creating
and delivering another human being, healing and dealing with sepsis is hard
work!!).
The arguably empiric administration of PRBCs with normalizing lactate and
clinical improvement carries risk that may outweigh the benefits. The big
picture should be examined for patient specific factors that would tilt one in
favor of transfusion - is she currently on supplemental 02? What is her
activity level? Is she on bed rest or ambulating? Is she able to tolerate the
increased activity required for discharge and to prevent other complications
such as VTE? Is she currently on Iron supplementation and stool softener?
Why is her hgb 8.2? What was her CBC baseline - both count and morphology? I
did not see mention of whether there was significant bleeding during the C
section that accounts for this level, but can it be adequately explained? Any
splenomegaly? I see that you mention that she did have thrombocytopenia but it
is resolving. I am sure you have considered iatrogenic causes such as HIT or
common pharmacologic culprits in the differential. You don't mention
morphology so I am guessing there is no issue there.
Erin Sparling Broccolo MSN-Ed RN CCRN
Critical Care Clinical Nurse Educator
Arrowhead Regional Medical Center
Colton, CA
[email protected]<mailto:[email protected]>
909-580-2556
.
From: Houston, Katrina ARMC-Performance Improvement
Sent: Wednesday, December 19, 2012 8:08 AM
To: Fletcher, Annabelle ARMC-Performance Improvement; Sparling-Broccolo, Erin
ARMC-SICU
Subject: FW: [Sepsis Groups] Maternal sepsis with low scvo2
Hmmm! Wish we could help...
From:
[email protected]<mailto:[email protected]>
[mailto:[email protected]] On Behalf Of Dr.Sunil T
Pandya
Sent: Tuesday, December 18, 2012 6:55 PM
To:
[email protected]<mailto:[email protected]>
Subject: [Sepsis Groups] Maternal sepsis with low scvo2
Hi friends,
We have a young lady who had premature rupture of membranes (PROM), had an
emergency Cesarean section after 48Hrs, was already on prophylactic antibiotics
(IV. Cephazolin) as per the protocol.
Intraoperatively developed refractory hypotension / full blown SIRS
(Unexplained by low dose spinal), and chorio amnionitis - severe sepsis was
suspected / and confirmed (High vag swab at admission revealed Klebsiella
growth) considering 48 hrs of PROM. Sepsis profile / CVP line inserted for
fluid administration and vasopressors support. Lactate was 4 and SCVO2 was 48%.
(Hb-10g).
Change of antibiotics as per the cultures and fluids and nor adr / organ
supports etc. have helped her and is stabilizing.
Her lactate improved and is within normal limits. SCVO2 is still @ 55% and her
Hb is 8.2g%. CLinically she is doing good and on soft diet. Blood culture also
was positive for klebsiella
My question to the the expert is:
My fellows were debating whether to give her couple of units of Packed cell
transfusion in view of low ScVO2.....I seek you opinion as well - Does she need
blood transfusion?
She has come out of all organ dysfunctions (Renal / ALI / Low plt) and is
asymptomatic and white cell counts are 10800/cumm, Polymorphs - 72%, Bands - 4%!
Thanking you in advance!
Regards,
Sunil
------------
Dr.Sunil T Pandya
Hon. Secretary, Association of Obstetric Anaesthesiologists, India
(www.aoaindia.com<http://www.aoaindia.com>)
Hon. Secretary, Society of Obstetric Medicine, India
Head, Dept. of Anaesthesia, Pain and Critical Care,
Fernandez Hospital (Health care for Women and the Newborn),
www.fernandezhospital.com<http://www.fernandezhospital.com>
Director, Prerna Anaesthesia and Critical Care Services Pvt Ltd
(www.prernaanaesthesia.com<http://www.prernaanaesthesia.com>)
Hyderabad, India.
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