Dear all, New year greetings. Thank you each one of you for your input....sorry couldn't get back to you earlier as I was on Vacation! This lady was a case of severe chorioamnionitis with severe systemic gram negative sepsis. All the parameters (Ventilatory, Echo, SVV - CO, PF ratio, DVT-VTE, WBC counts, Band forms etc) recovered well with aggressive implementation of sepsis bundles. The intriguing thing was ScVO2 didn't improve despite all Cardio-resp parameters returning to baseline. She recovered but ScVO2 when central line was removed, was still 43 (after one unit of Pcked cell transfusion, Hb 9.2g%). Clinically she is asymptomatic / cardio-resp parameters and vitals stable and doing well....have just seen her in Post ICU Discharge follow-up clinic. No complaints, Repeat Hb / Hct is 9.5G%, 28%. Thank you all again, Regards, Sunil *------------* ** *Dr.Sunil T Pandya* * * *Hon. Secretary, Association of Obstetric Anaesthesiologists, India ( www.aoaindia.com)* *Hon. Secretary, Society of Obstetric Medicine, India* * * *Head, **Dept. of Anaesthesia, Critical care and Pain medicine,* *Fernandez Hospital (Health care for Women and the Newborn), ** www.fernandezhospital.com* * * *Director, Prerna Anaesthesia and Critical Care Services Pvt Ltd ( www.prernaanaesthesia.com)* *Hyderabad, India.* * *
On Thu, Jan 3, 2013 at 12:18 AM, Angela Craig <[email protected]> wrote: > ** ** ** ** ** ** > > > When I have a patient with a low SCVO2 – I Look at a variety of items. > I like to start with first the oxygen consumption side – What are her > demands that I can help with – basic things like – fever, anxiety, pain, > shivering and muscle activity – I try to take care of this and treat this > first.**** > > ** ** > > Secondly I look at oxygenation – is that adequate? Do we need to increase > her Fi02 – is she ventilating appropriately? Then I look at her HGB Is she > bleeding – is she anemic? Do we need to transfuse??**** > > ** ** > > Third, I look at Cardiac output – whats the HR and do I need to treat ? > Then what is my pre-load, afterload and contractility status to make sure > I am giving the appropriate product to the patient whether that be a > positive inotrope, vasopressor or fluids. **** > > ** ** > > Just my way of looking at all the items that affect SCVO2. Hope this is > helpful!!**** > > ** ** > > Angela Craig APN,MS,CCNS**** > > Clinical Nurse Specialist**** > > Intensive Care Unit**** > > ****Cookeville** **Regional** **Medical** **Center******** > > 931-783-5035**** > ------------------------------ > > *From:* [email protected] [mailto: > [email protected]] *On Behalf Of *Sparling-Broccolo, > Erin ARMC-SICU > *Sent:* Wednesday, December 19, 2012 11:16 AM > *To:* [email protected] > *Cc:* Houston, Katrina ARMC-Performance Improvement > *Subject:* Re: [Sepsis Groups] Maternal sepsis with low scvo2**** > > ** ** > > 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]**** > > 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]<[email protected]>] > *On Behalf Of *Dr.Sunil T Pandya > *Sent:* Tuesday, December 18, 2012 6:55 PM > *To:* [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)***** > > *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***** > > ** ** > > *Director, Prerna Anaesthesia and Critical Care Services Pvt Ltd ( > www.prernaanaesthesia.com)***** > > *****Hyderabad****, India****.***** > > * ***** > > ** ** > > > Confidentiality Notice: This e-mail message, including any attachments, is > for the sole use of the intended recipient(s) and may contain confidential > and privileged information. Any unauthorized review, use, disclosure or > distribution is prohibited. If you are not the intended recipient, please > contact the sender by reply e-mail and destroy all copies of the original > message. > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > >
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