Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In today's episode of the podcast, we will talk about pregnancy, critical care, and COVID-19.
Speaker: Our guest is Dr. Cesar Padilla.
Speaker: Dr. Padilla is an attending physician in the Department of Intensive Care and Resuscitation in the Cleveland Clinic in Ohio.
Speaker: He's a practicing anesthesia critical care physician with additional expertise and training in obstetric anesthesia.
Speaker: He's extremely interested in promoting better care of obstetrical patients requiring critical care and has worked in these areas extensively
Speaker: from the clinical, educational, and research perspectives.
Speaker: Dr. Padilla is also an important medical voice on social media, frequently contributing opinion pieces on his blog and KevinMD.com and can also be reached on Twitter at TheMillennialMD.
Speaker: Cesar, welcome to Critical Matters.
Speaker: Cesar Padilla, thank you for having me.
Speaker: So today I think that we have a very interesting topic.
Speaker: I think something that obviously
Speaker: It touches all critical care practitioners and most listeners of this podcast on one way or the other when they have to deal with a critically ill patient that also is pregnant.
Speaker: But I think it's also a very important part of your practice because you really are a big kind of advance, kind of in the forefront or an innovator in the developing field of pregnancy and critical illness.
Speaker: And really, you kind of occupy
Speaker: a very unique position because you do anesthesia for obstetrical patients, you do critical care for obstetrical patients, and I think you kind of see patients before they get critically ill, when they crash, and when they're critically ill and pregnant and required to be in the ICU.
Speaker: So maybe we can start by just giving us some general thoughts of where pregnancy and critical care is, where you think it's going, your interest in this field in particular, and then we can start with some clinical topics that are more general
Speaker: and relevant to the critically ill-pregnant patient?
Speaker: Absolutely, yeah.
Speaker: So critical care and pregnancy, I like to think of it as a brand new field.
Speaker: And what I mean by it being a brand new field is that the landscape in obstetrics has literally changed underneath our feet in the last 30 years.
Speaker: And to put that into perspective,
Speaker: In the last 25 to 30 years, there has been a near tripling in deaths due to obstetric causes.
Speaker: So maternal mortality has nearly tripled in the last 30 years.
Speaker: And so the next natural question is, well, why are women dying?
Speaker: And the number one cause of death in the United States is cardiovascular disease.
Speaker: So cardiac disease is
Speaker: medical conditions that are being exacerbated by pregnancy are really leading and surging or leading to an increase in maternal mortality.
Speaker: And so this is what I mean by sort of it's a new field that's emerging because the patient population now is just inherently different than what it was 30 years ago.
Speaker: And I think that also another thing that I think I have observed and I would imagine contributes is the fact that
Speaker: the age span of pregnant women keeps getting wider.
Speaker: I think that with all these artificial or assisted reproduction techniques, women are getting pregnant at much later ages as well.
Speaker: So the comorbidities I would imagine are also much higher.
Speaker: Yes, absolutely.
Speaker: So you mentioned something very important and it mentioned the comorbidities because
Speaker: as you said, it's really comorbidities that are also driving a lot of the morbidity, a lot of the ICU level care.
Speaker: You mentioned artificial or in vitro fertilization, I believe that's what you mentioned.
Speaker: And we know now, based off of recent studies, that in vitro fertilization does increase the risk of hemorrhage, for example, at birth.
Speaker: And so these are real risk factors that
Speaker: that sort of are inherent in our patient population that is perhaps of a more advanced maternal age that's using these technologies.
Speaker: And so we also know that advanced maternal age is also associated with a higher risk of ICU-level care.
Speaker: And I think that in terms of ICU care from a perspective as a medical trained patient,
Speaker: an internal medicine-based trained intensivist.
Speaker: I think that working both in medical and surgical ICUs, I have taken care of pregnant patients who either have a pregnancy associated critical illness or have underlying disease such as asthma that now requires critical care, but they're pregnant or sometimes taking care of postpartum complications.
Speaker: And you mentioned hemorrhage being one of the most common.
Speaker: But talking with you before we started recording,
Speaker: it also became apparent that you and your unique dual roles as not only an intensivist, but also an anesthesia with specific expertise in training in obstetrics, you sometimes have to think about the potential for critical illness in patients who are not critically ill yet, but are undergoing a C-section or delivery.
Speaker: Can you comment a little bit about that role?
Speaker: Absolutely, Sergio.
Speaker: That's a
Speaker: that's probably one of the most important aspects of the care that I deliver and what I believe is the future of obstetrics and obstetric critical care.
Speaker: So one of the most important things that I look at is the burden of comorbidities in a patient.
Speaker: So there is an evidence-based tool called the Obstetrical Morbidity Index, also referred to as OCI.
Speaker: And this comorbidity index was developed in 2013
Speaker: by Dr. Bateman, who is currently the Section Head of Obstetric Anesthesia at Brigham and Woman's Hospital in Boston, a Harvard teaching hospital.
Speaker: I did my fellowship there, and I worked under Dr. Bateman, and that's where I was introduced to this screening tool.
Speaker: But what's important is that this is an evidence-based screening tool that's the first of its kind in obstetrics.
Speaker: And it utilizes
Speaker: It utilizes comorbidities and it has an associated weight to it.
Speaker: And the weight is the odds ratio of predicting maternal morbidity or severe maternal morbidity, which is basically the ICD-10 codes that identify end organ dysfunction.
Speaker: And so to give you an idea, if a patient arrives with preeclampsia with severe features, that patient has a score of 5 or an odds ratio of 5 that
Speaker: patient is five times more likely to develop severe maternal morbidity.
Speaker: Now, the rest of the comorbidities are comorbidities that a patient can walk into an office setting with.
Speaker: So, for example, the patient has chronic congestive heart failure, that patient has also a score of 5.
Speaker: A congenital heart disease, a score of 4.
Speaker: Pulmonary hypertension, a score of 4.
Speaker: Chronic ischemic heart disease, sickle cell disease,
Speaker: diabetes on insulin, advanced maternal age is also scored, asthma, gestational hypertension, previous cesarean deliveries.
Speaker: And so we understand now that by adding up these numbers, it has been validated in a prospective setting to predict end-organ dysfunction.
Speaker: And so, for example, if a patient arrives with chronic ischemic heart disease and
Speaker: which gives you a score of three and it is advanced maternal age over the age of 44, that's a score of six already.
Speaker: And let's say that patient has asthma, you're at a score of seven.
Speaker: And what that means in real numbers, based on prospective data, is that that patient has about a 12 to 14% chance of developing severe maternal morbidity.
Speaker: The score has also been shown to be pretty good with hemorrhage.
Speaker: And so when I accept the, or when I'm taking care of a patient who,
Speaker: has this weight of their comorbidities, it's nice to see that distilled into one number because as a provider, it's all about anticipating sort of the deterioration in clinical care.
Speaker: So what I do, for example, if the patient comes in with a score 7 or above, for example, just using that number as an example, I may think about an extra IV.
Speaker: I may want blood two units on hold in the room.
Speaker: I will have a more, perhaps a more detailed discussion with the obstetrician regarding the complexities of the cesarean section if the patient's going to have a cesarean.
Speaker: I may think about also my uterotonics, the medications I can use to control bleeding, such as trinexamic acid, which we now know is useful and based on evidence for decreasing death in the obstetric population due to hemorrhage.
Speaker: So that's how it sort of shaped my care of these patients.
Speaker: And then also the critical care skills.
Speaker: If I have a patient that h as a high score, it may prompt me to do a point-of-care ultrasound, which is very important for determining cardiopulmonary status in a patient, whether it's a volume responsiveness or evaluating for pulmonary edema.
Speaker: as an example.
Speaker: So absolutely, the weight of comorbidities is central towards predicting the ICU-level care, but also for planning what are your routine cases in obstetrics like cesarean section, which can lead to a lot of morbidity if, for example, you don't prepare and you don't have these things lined up at the right time.
Speaker: And this is all important because
Speaker: 60% of maternal deaths are preventable.
Speaker: And this is widely known.
Speaker: The Surgeon General tweeted about this before COVID in December, Dr. Jerome Adams, who was an anesthesiologist.
Speaker: And that's a remarkable number to me because if 60% of maternal deaths are preventable, then this tool or a tool that predicts severe maternal morbidity is
Speaker: absolutely central in our strategy to address maternal morbidity and mortality.
Speaker: Absolutely, Cesar.
Speaker: I think that this is something worth diving in a little bit further into because I suspect that for the majority of our listeners who are bedside intensivists working in communities and trainees and people taking care of patients, unless they're doing anesthesia as well and specifically focusing on obstetric anesthesia like you do,
Speaker: I think that they missed this concept.
Speaker: And I think it's a big paradigm shift because historically, I think we've only been reactive to women who become critically ill during delivery, right?
Speaker: So, and a lot of times we react late and that obviously is a time sensitive intervention.
Speaker: And here I think with an objective way of assessing an individual
Speaker: a population that's getting sicker on average, although the vast majority of women who are pregnant are very healthy, but on average it's getting sicker for all the things you mentioned, this OCI gives you a very objective way of pre-establishing a higher risk and like you said, being much more proactive in terms of what are the things that you might need, what are the things that you can implement during delivery or pre-delivery to minimize that risk.
Speaker: But I think it's also very useful
Speaker: for clinicians who are on the receiving end in the ICU to understand maybe what this OCI is, because I'm sure that if they work in places where they have obstetric anesthesia as developed as with your practice, that might be part of the conversation.
Speaker: Or on the other hand, if they work in a place that needs to refer these very complicated patients, being able to share that information would also, I think, help people speak the same language and understand what we're talking about in terms of risk.
Speaker: Absolutely.
Speaker: And what you just mentioned, Sergio, this sort of the value of intensivist knowing what the score may be is actually somewhat mandated in the American College of Obstetrician and Gynecologist ACOG levels of maternal care.
Speaker: So I want to just mention what this levels of maternal care
Speaker: sort of mandate is.
Speaker: So ACOG and the Society of Maternal and Funeral Medicine, SMFM, have developed these definitions sort of like trauma hospitals.
Speaker: So we know very well as providers what a level one trauma hospital is.
Speaker: We drive down the freeway and sometimes we see signs for what a level one is or a level two.
Speaker: We know the level one is the highest, sort of provides the highest level of care.
Speaker: Well, similarly,
Speaker: And so, a few years ago, ACOG and SMFM, along with our anesthesia societies, which sponsor the definition, SMFM and ACOG developed their own definitions of the top-level hospital, which is a level four, and then your basic sort of level one center.
Speaker: And if you look closely at the definitions for the top levels, which is a level four and a level three,
Speaker: there is actually very clear language which states that you need to have medical and surgical ICUs that are available for cross-collaboration with obstetric providers at all times.
Speaker: And so what you have essentially is in the definition of the level of care that have now been released by the leading obstetric societies, you have language that is
Speaker: sort of asking of our ICU providers for this cross-collaboration.
Speaker: And so the way I see a tool like this is I see a tool like this as sort of, you know, it's promoting this natural marriage which needs to happen between an intensive care unit and obstetrics.
Speaker: So, for example, it would be useful if in a large hospital, let's say it's a level three hospital or a level four hospital, it would be useful if when a patient arrives
Speaker: and it's flagged as a high risk based off the comorbidity index, for example, perhaps that intensivist or the group, whether it's the SICU or the MICU based off these specific conditions, perhaps they should be aware or the ICU should be aware preemptively of that patient because I think we've all had those situations when you have a patient just arriving, you know nothing about the patient and you're sort of scrambling to get your things together.
Speaker: But this sort of allows for that preemptive sort of strategy to prepare, to have a multidisciplinary discussion.
Speaker: And importantly, that this is sort of mandated in the levels of maternal care.
Speaker: So this is something that is not going away.
Speaker: It's coming towards us.
Speaker: And the next step after these definitions have been released, the next step is to designate hospitals.
Speaker: based off the, you know, which hospitals are going to be B-level four, which hospitals are going to be level three.
Speaker: That is going to be rolled out.
Speaker: But to give you an example of how serious states are taking these mandates, you know, Texas is sort of leading the country with mandating these levels of maternal care into legislation.
Speaker: And so Texas has a very centralized sort of approach towards
Speaker: the delivery of maternal care.
Speaker: And they have served as sort of an example for what the rest of the country can do.
Speaker: So this is definitely something that's coming.
Speaker: And as I like to say, it's coming to an ICU near you and whether it's up to us to prepare and sort of spread this knowledge.
Speaker: Absolutely.
Speaker: And I think that also to mention, I mean, you mentioned Texas, obviously I'm based in Texas and Houston.
Speaker: One of the things that's also always been very interesting to me
Speaker: is that the maternal mortality in Texas is very high compared to the rest of the country.
Speaker: So obviously something that's much needed and I'm happy to hear that at a state level, they are implementing systems to try to improve the care of these obstetric and especially the critically ill obstetric patients.
Speaker: So that's always welcome news.
Speaker: So this obviously is very helpful.
Speaker: I mean, as you're planning and for patients who are either usually in labor and delivery,
Speaker: But what about what I think a lot of us also experience is patients coming to the ICU either after or just because they're pregnant with other conditions.
Speaker: What are the most common reasons that patients come to the ICU when they're pregnant, Cesar?
Speaker: Absolutely.
Speaker: That's a great question.
Speaker: So, yeah, you're always going to have those patients that arrive that have no comorbidities, right?
Speaker: And so the most common reason
Speaker: cause for admission is hemorrhage.
Speaker: That's going to be your bread and butter admission to an ICU.
Speaker: Now, there's a higher likelihood that they're going to have comorbidities, but sometimes they arrive because there may have been a surgical complexity or just the patient is bleeding due to uterine apnea.
Speaker: And so when a patient arrives to the ICU, the way my perspective is
Speaker: on a bleeding patient, and I'll just focus on bleeding because of the incidence of sort of the ICU admission, I sort of think about a trauma patient.
Speaker: So what I mean by that is I sort of, you know, I see sort of the world of balance for facilitation.
Speaker: So let's stick to what we know in the literature and let's give balance, you know, blood products.
Speaker: You know, let's do a one-to-one
Speaker: to one transfusion.
Speaker: Let's check coagulation factors.
Speaker: An important lab parameter is a fibrinogen level.
Speaker: So we know that fibrinogen goes up in pregnancy.
Speaker: And so certainly if you have levels that are decreasing or levels that are below normal,
Speaker: Those are predictive of hemorrhage at birth.
Speaker: Of course, your COAG, your standard INR, PT, PTT.
Speaker: And then also having the intensivist, just be aware of what are the common euteronics that are available for you to give the patient.
Speaker: So can we give metherogen?
Speaker: Can we give hemabate, also known as carboprost?
Speaker: or prostaglandin F2-alpha.
Speaker: That medication has like three different names.
Speaker: Tranexamic acid is another one, another medication.
Speaker: And, you know, I think that's sort of the, you know, my mind sort of goes to a trauma patient, you know, and it's all about the basics.
Speaker: You know, don't forget about, you know, giving your FFP because you can certainly dilute clotting factors that will just sort of, it becomes a sink where just things can quickly go down the drain for your patient.
Speaker: if you're not thinking about balance resuscitation.
Speaker: And then in terms of leading causes of death, so this is a separate subject right now because if we're talking about leading causes of admission, which is most likely hemorrhage and or hypertensive disorders of pregnancy like preeclampsia, well, we have to separate that from sort of causes of death, which is cardiac related.
Speaker: So I'm happy to talk about that, but that's sort of a different
Speaker: sort of on a different subject and a different scale, just because that is much, much less likely, of course, just naturally.
Speaker: But that does entail sort of a different approach and a different strategy.
Speaker: And Cesar, let me ask you, in terms of outcomes of pregnant, critically ill patients, especially when they have non-pregnancy-related diseases, how does it compare to non-pregnant women with the same disease, like let's say sepsis or ARDS, pregnant versus non-pregnant?
Speaker: Yeah, that's a great question.
Speaker: Yes, absolutely.
Speaker: So in general, women are at higher risk of morbidity and mortality because of pregnancy.
Speaker: So you brought up sepsis.
Speaker: So inherently, there's a higher risk of death because pregnancy is an immune-compromised state.
Speaker: And so we know that
Speaker: that sepsis is a leading cause of maternal death.
Speaker: And if you look at the CDC data of cost-specific mortality for the last 25 years, sepsis has remained the leading cause of death.
Speaker: It's not the leading cause of death.
Speaker: It's one of the leading causes of death.
Speaker: But there has been no increase, really, or no significant decrease.
Speaker: It just always has been there.
Speaker: We're not very good at capturing and sort of timely
Speaker: treatment of septic patients.
Speaker: Because as I mentioned earlier, 60% of maternal deaths are preventable.
Speaker: And so sepsis has always remained the problem.
Speaker: So the reason, as I mentioned, is because it's immune compromised state.
Speaker: Now, if we were to break that down, and I do want to focus on sepsis a little bit, why is it that pregnant women are at higher risk of sepsis?
Speaker: And specifically, which type of bacteria are they more susceptible to?
Speaker: We know based off animal models that patients are at a higher risk of glycopolysaccharide-induced infections, which come from your gram-negative bacteria like E. coli.
Speaker: So E. coli is a very common organism.
Speaker: So when you're treating a patient with sepsis, you want to think about your gram-negative coverage or anaerobic coverage.
Speaker: That's very important.
Speaker: You're going to start off with your broad spectrum sort of coverage, but absolutely keeping in mind that gram-negative lipopolysaccharide infections are common.
Speaker: And I think that's one of the most important kind of disease states to talk about that sort of highlights the higher morbidity in these patients.
Speaker: ARDS, you brought up ARDS as well.
Speaker: there is, you know, put that in the same category as sepsis infection.
Speaker: A lot of data for ARDS and pregnancy came from the H1N1 outbreak, the influenza outbreak where a pregnant woman were at higher risk of developing morbidity and certainly dying.
Speaker: And that is certainly true when compared to their not-pregnant counterparts.
Speaker: Things are a bit different with COVID.
Speaker: It's not following the blueprint of H1N1, but H1N1 and that outbreak and associated disease like ARDS helped us understand a significant amount of critical illness in pregnancy.
Speaker: An example is the following.
Speaker: There was a lot of patients that were cannulated with ECMO during the H1N1 pandemic, and
Speaker: to our surprise, perhaps, certainly to my surprise, fetal and maternal survivability was high.
Speaker: It was, in some studies, above 70%.
Speaker: So imagine you h ave a patient that could be cannulated on BV ECMO for ARDS, and maternal and fetal survivability was certainly high in this demographic.
Speaker: So that gave
Speaker: certainly gives us a lot of hope when treating these critically ill patients that these sort of invasive methods that we use in the ICU are certainly helpful for this vulnerable patient population.
Speaker: Absolutely.
Speaker: And I think that as we move forward, one of the things that has always been important for me and I wanted to get some of your thoughts on are the unique challenges that a critically ill pregnant patient presents
Speaker: I think that there's no question that for a lot of people who obviously are not in the obstetrical world, the challenge of dealing with more than one life is always very stressful and making sure that we don't do things that ultimately harm the fetus.
Speaker: Also, the timing of delivery, obviously, which is something that obviously our obstetric colleagues, I mean, decide.
Speaker: But also, that always puts a lot of pressure, I think, in the ICUs when we have these pregnant patients who are critically ill.
Speaker: But one of the things that also I think is very unique and I wanted to dive in a little bit is that pregnancy as a state has physiological changes that are associated with it that I think have important implications in terms of critical care support, in terms of recognition of illness, in terms of targets for care.
Speaker: And I think it's always something good to review because most intensivists
Speaker: are not seeing pregnant patients on a daily basis, like somebody in your venue of work that you're very embedded in this niche.
Speaker: So maybe we can dive into a little bit of the physiology of pregnancy and how it impacts illness and critical care or practice of medicine in the ICU.
Speaker: Absolutely.
Speaker: It's such a central topic and such an important topic to really dive into.
Speaker: So I sort of have, in my mind, the highlights of pregnancy-induced changes in physiology.
Speaker: You know, if we start with – let's start with the brain.
Speaker: So as an intensivist, I think of systems-based.
Speaker: So when I have my residents present to me, I have them present in a systems-based fashion.
Speaker: So I'll just present to you in a systems-based fashion.
Speaker: So we'll start with the brain.
Speaker: So inherently, there is – patients are more sensitive to sedatives.
Speaker: And we use the MAC level, the minimum alveolar concentration level in anesthesia, which is sort of predictive of the amount of anesthetic that a patient needs to be essentially sedated.
Speaker: It's about 40% reduced from non-pregnant patients.
Speaker: If I have a patient who requires a benzodiazepine in the operating room, one milligram is certainly going to have a profound effect, perhaps the same as about two milligrams in a nonpregnant patient.
Speaker: In general, patients are just more sensitive to sedatives.
Speaker: Progesterone, which is a hormone that does go up in pregnancy, obviously has been implicated as causing that decrease in sort of the threshold for sedation.
Speaker: So that's key.
Speaker: I think that's very important for all of us to remember.
Speaker: And then there are new alternatives and sedatives that have been found to be certainly useful in pregnancy.
Speaker: For example, dexmedetomidine, Prestidex.
Speaker: There's been a lot of case reports and a lot of evidence showing that it has the potential of at least showing
Speaker: safety in the pregnant population is very lycophilic, stays in the placenta, it doesn't cross over to the baby.
Speaker: And it's important to highlight sort of these alternatives, especially in the world of COVID, right?
Speaker: We have these shortages in propofol, potential shortages in other incentives.
Speaker: So a medication like dexbetetamidine can prove to be helpful.
Speaker: And then other organ systems that were just moving down, let's think of the lungs.
Speaker: So if we look at the lungs and your oxygenation sort of capabilities, patients who are pregnant at term, and I'll use the phrase at term, patients who are ready to deliver, they certainly have a decrease in their functional residual capacity, which basically is going to alter your respiratory physiology because these patients are going to have an
Speaker: aponectomy to desaturation time that is much quicker than a non-pregnant patient.
Speaker: So imagine a patient like this who you induce with no pre-oxygenation.
Speaker: That patient is going to be desaturating very quickly.
Speaker: So as an intensivist, it is extremely important for me to plan an effective intubation.
Speaker: So because the patient is pregnant, I understand they're going to have less of a
Speaker: reserve in terms of their oxygenation as as i mentioned to their frc that's decreased i will pre-oxygenate that patient i will denitrogenate that patient and that will lead you know that will prolong my apnec to desaturation time what's important as well is because of the after 20 weeks of gestation because of the pressure of the of the uterus and the and the baby on the grain vessels you have
Speaker: potential for compression of the great vessels.
Speaker: And so you need to tilt your patients to the left at least 15 degrees.
Speaker: What helps really is to put a wedge underneath, you know, on the right side so you're tilting them to the left.
Speaker: That, you know, alleviating that compression is really useful.
Speaker: And to give you an idea, there's some really good evidence suggesting and showing that the measured cardiac output patients were tilted.
Speaker: and those will remain flat.
Speaker: And even though patients may remain asymptomatic, if they're flat, they still have a less, the cardiac output is less.
Speaker: And also during a cesarean section, they require more vasopressors.
Speaker: So they'll require more phenylephrine, for example, which is a very common pressure that we use.
Speaker: So that's a very simple fix as an intensivist that everyone needs to do.
Speaker: So the other day, you know, I was
Speaker: I'm just thinking of a scenario in my mind where it's taking care of a patient.
Speaker: The first thing you want to do is just tilt them.
Speaker: Just tilt them to the left.
Speaker: Easy.
Speaker: It's going to help you.
Speaker: The heart, you have an increase in stroke volume.
Speaker: You have an increase in your plasma volume, so your cardiac output is going to increase steadily.
Speaker: That is maximized after delivery.
Speaker: You have auto transfusion, so all the blood that was going through the baby.
Speaker: going to the placenta staff, going back to the system.
Speaker: And so you have an increase in cardiac output that's maximized after delivery.
Speaker: And then perhaps another system that's important to mention as well is hypercoagulability, so your hematological state.
Speaker: So patients are at a higher risk of clotting.
Speaker: And certainly you have patients at a higher risk for clotting.
Speaker: like pulmonary embolism, DVTs, disease states from that standpoint.
Speaker: But those are sort of the highlights.
Speaker: Neurological, cardiac, respiratory, and keeping in mind your simple things like tilting a patient, and then hyperprogulable disorders.
Speaker: And I already mentioned before, sort of your immune depressed state, the immune suppressed state that happens in pregnancy.
Speaker: But those are sort of some of the highlights that allow me to really think about
Speaker: the unique implications in pregnancy, especially as an intensivist.
Speaker: Absolutely.
Speaker: And I think that as we talk a little bit more about some of the therapies within COVID that are supportive care, we can reemphasize and dive into some of these a little bit more.
Speaker: Now, as intensivists, I think that we all believe that we are pretty good at determining who's critically ill and who's not.
Speaker: But sometimes that can be very challenging.
Speaker: And I think that in pregnancy,
Speaker: It can even be more so.
Speaker: And how do we recognize as a critically ill pregnant patient?
Speaker: I mean, sometimes it's very obvious, but I think there's a lot of times that there's clues in front of us that if we don't pay attention, we might miss.
Speaker: Could you comment on that a little bit?
Speaker: Absolutely.
Speaker: It's a fantastic question.
Speaker: And it's a question that is actually, or the answer is evolving as we speak.
Speaker: So,
Speaker: How do we recognize a particularly ill patient?
Speaker: My central tool is ECHO.
Speaker: So we know now that patients with preeclampsia with severe features, which is highly, highly, highly predictive of ICU-level care of severe maternal morbidity when compared to patients who don't have preeclampsia with severe features.
Speaker: Significant approach
Speaker: About 20% of these patients, based off a recent study from the chemist Stanford looking at point-of-care ultrasound in these patients, showed that they have evidence of interstitial syndrome, basically B-lines or evidence of acute pulmonary edema on ultrasonography.
Speaker: So point-of-care ultrasound, I'd go to that first, because if a patient does have shortness of breath and the patient has evidence of interstitial syndrome, has pulmonary edema, B-lines,
Speaker: that patient has evidence of endoorgan dysfunction.
Speaker: Essentially, that patient is going to require close monitoring, which is the same as an ICU-level patient because either that patient is going to have impending respiratory compromise if they're not delivered, or you need to have a plan for that patient whether you're going to diurese or how are you going to treat that patient.
Speaker: So I think that point-of-care ultrasound has really helped from that standpoint.
Speaker: We understand that also a significant – that diastolic dysfunction is also very prevalent in pre-consular features.
Speaker: And then the one – you know, other things just sticking to our standard definitions in the ICU world is looking, for example, at the Berlin criteria for ARDS.
Speaker: I think that an arterial blood gas and looking at the P-A2, the F-L-O-2 ratio is
Speaker: It's a very useful tool because it's standardized.
Speaker: You can go to any hospital here, Germany, and we all know, you know, we can all cross-reference PF ratios, and I think that utilizing those ratios in pregnancy is extremely important.
Speaker: One of my mentors always said, you know, if pregnant, a patient who is,
Speaker: pregnant and delivering on oxygen is not normal.
Speaker: And it's certainly true because there's really no reason for a patient to be on oxygen other than that patient is sick.
Speaker: You know, something else is going on.
Speaker: But a lot of times, really, the physiology that's driving someone who perhaps is more robust and perhaps younger, it can easily sort of introduce a bias.
Speaker: into your perception, oh, the patient's okay.
Speaker: They're just on three, four liters of oxygen.
Speaker: But we really need to have our ICU hats on and think about, no, well, why is that patient on three or four liters of oxygen?
Speaker: It's not normal for a 35-year-old, just throwing a number out, 35-year-old to be on three to four liters of oxygen.
Speaker: That is, you know, let's do a point-of-care ultrasound.
Speaker: Let's perhaps check a PF ratio.
Speaker: And, you know, those have certainly become very standard tools.
Speaker: that I have certainly used.
Speaker: And then another one that is absolutely central is your lactate level.
Speaker: So I mentioned earlier, substance is the leading cause of maternal death.
Speaker: Getting a lactate level, which is just showing your level of inadequate perfusion, is absolutely central in guiding your resuscitation and really stratifying the risk of your patients.
Speaker: And these are all things that are very routine in ICU level settings, right?
Speaker: So we have a patient that's admitted with sepsis.
Speaker: We do get a lactate.
Speaker: If we're worried about their, you know, if they have an arterial line or their risk for respiratory compromise, we get a PF ratio.
Speaker: We certainly, you know, the world of ultrasonography is really revolutionized the way we deliver care in the ICU.
Speaker: And these are things that apply to pregnant patients as well.
Speaker: It's the culture of bringing the ICU to labor and delivery.
Speaker: So as an intensivist, we have our eyeglasses on, which are our lenses, our ICU lenses that we have, so we see the world through end-organ dysfunction.
Speaker: And sometimes on labor and delivery, we want to put the other lenses on, which are the lenses of everyone's young and healthy.
Speaker: But what our landscape, what our demographics have proven is that, as I mentioned earlier, there's a change in demographics, it's getting sicker, higher ICU level care, mortality is increasing.
Speaker: So how do we take the lenses, how do we put those glasses on, those ICU glasses on labor and delivery?
Speaker: And that's really, to me, that's the fun part about the future of obstetrics is that this is all opportunity for us to help create these changes.
Speaker: And, you know, as you mentioned earlier, you know, treating a patient as if they're, you know, as if they're not pregnant is also just important.
Speaker: You just need to approach a patient with the same sort of lenses that we all have on in the ICU.
Speaker: But those are some of the highlights that I think about when sort of trying to identify critical illness and obstetrics.
Speaker: Excellent.
Speaker: I think that it's a very important point that I want to reemphasize is that we get used to seeing people on oxygen.
Speaker: And when somebody is on a couple of liters of nasal cannula, it almost looks like normal to a critical care intensive, especially in these days with COVID.
Speaker: and we feel very comfortable sending those patients out of the unit or not thinking that they require critical care.
Speaker: But like you said, in a pregnant young female, the need for oxygen should be a red alarm for us that something's not right.
Speaker: And I think that investigating a little bit more, I think is the way to go.
Speaker: And I think that's an important problem that we not only have with pregnancy, but I think in general, sometimes we have with younger patients, which is not what we usually see in the ICU.
Speaker: So we normalize
Speaker: so many things that in some particular populations is quite abnormal that we have to be very careful there.
Speaker: Absolutely.
Speaker: So I would like to talk, obviously we're in the midst of a pandemic.
Speaker: I mean, I think I recognize that we've been seeing millions of cases of COVID-19 in the United States for the last several weeks.
Speaker: And in some places such as where I am in Texas, the numbers are rising again very quickly, suggesting second waves.
Speaker: And there's been a lot of talk about COVID and pregnancy, recognizing, Cesar, that we obviously don't have a lot of clinical trials that are specific for COVID and yet even less specific for pregnancy.
Speaker: But I do think that there's things that we've learned, things that we're doing in these patients on a regular basis within respiratory support, drug therapy, and anticoagulation, for example, that I think have applications if we were to have a pregnant patient.
Speaker: And what I really wanted to do is just
Speaker: tap into your expertise as an obstetrical expert in critical care and kind of maybe talk about what we know, what we don't know, but also kind of, I mean, what are some of the underlying basic concepts that we can apply to the bedside if we were to have a patient who now is pregnant and has COVID.
Speaker: And you did mention earlier H1N1, which obviously was a previous pandemic that a lot of us dealt with, I mean, much smaller numbers.
Speaker: But also, I mean, I recall very vividly some of these cases with young pregnant women who were extremely ill.
Speaker: I mean, I remember, like you said, I mean, at that point we were using a lot of oscillators, ECMO, and prolonged, prolonged courses of mechanical ventilation support.
Speaker: But like you said, with remarkable positive outcomes, both of the fetus and the mother.
Speaker: So obviously,
Speaker: When COVID started, a lot of people were very concerned about pregnancy.
Speaker: But right now, based on what we know, do pregnant women have a particularly higher risk of contracting COVID?
Speaker: Do we know that right now, Cesar?
Speaker: Fantastic question.
Speaker: Because, you know, whenever a pandemic arises, we always think about the previous one, right, to compare, which is natural.
Speaker: So we think about, like, the Middle Eastern respiratory disease.
Speaker: syndrome h1n1 so right now you know if you look at the um the acog and the smfm sort of statements with regard to covid19 there's really limited data but it what they with those societies which are the leading obstetric societies state is that um
Speaker: that right now the data that's available does not indicate that pregnant individuals are at an increased risk of infection or severe morbidity, which basically is your need for an ICU level of care or mortality when compared to non-pregnant individuals.
Speaker: So that's fascinating because that sort of signals something different from sort of like H1N1, for example.
Speaker: understanding that, you know, we have to keep our physiology sort of intact knowing that these patients are also have a decrease in their immunological sort of response as they're pregnant.
Speaker: But also looking at the same sort of statements from ACOG and SMFM, what they also recommend is that you assess the
Speaker: clinical risk of a patient.
Speaker: So they understand, you know, what they're stating is that you have to look at the patient's comorbidities like hypertension, diabetes, asthma, chronic heart disease, a lot of the same ones that are sort of outlined in the screening tool that I mentioned earlier in the OCI, because that will sort of place your patient in a different category.
Speaker: And we know that.
Speaker: There was a study recently from the United Kingdom
Speaker: that looked at 400 patients who were, you know, they followed 400 patients who were COVID positive, and they looked at the ICU level care for those patients, which I believe is 10% in that study.
Speaker: And advanced maternal age and obesity was increased in that group of requiring ICU level care.
Speaker: And those are comorbidities that are clearly well-recognized.
Speaker: And I believe that 40% also of that population had comorbidities.
Speaker: And so those are things that are identifiable and that are quantifiable.
Speaker: Advanced maternal age, obesity, BMI is certainly one of the scoring indexes that we use, and your comorbidities.
Speaker: So that paper from the UK sort of mirrors the...
Speaker: sort of assessment of clinical risk that ACOG and SMFM have.
Speaker: So even though they're not saying the exact same thing, they're acknowledging that a patient with comorbidities may, in fact, have an inherently higher risk of clinical deterioration.
Speaker: And so that's sort of, you know, the way that I would approach a patient is that, you know, this is perhaps a virus that's different from the previous, you know, pandemic that we've had.
Speaker: Nonetheless, it stands that if you have a higher comorbidity burden, that patient may become sicker.
Speaker: That patient may deteriorate based off at least some of the limited evidence that we have and based off the ACOG and SMSM statement.
Speaker: Absolutely.
Speaker: And I think that that's interesting because with H1N1, I recall that one of the pregnancy by itself was a risk factor, not only for infection, but for severe disease.
Speaker: And we saw a lot of young women who were pregnant, who became very ill, who had no real comorbidities in addition to their pregnant state.
Speaker: But what about, is there anything right now, Cesar, about, there's been a lot of talk about healthcare workers and their risk, obviously, and understanding PPE, the challenges of PPE.
Speaker: I mean, that's been like a very unique situation with this pandemic.
Speaker: Obviously, we have a lot of colleagues who might be pregnant, a lot of healthcare workers who are pregnant.
Speaker: I think it all depends what's going on in each hospital, places where they were able to accommodate and maybe decrease the risk of exposure.
Speaker: People have done that.
Speaker: But is there anything official on the risk of a healthcare worker?
Speaker: Obviously, they would take the same precautions that anybody else would.
Speaker: But is there anything official from ACOG or from anybody else, CDC, that you know of?
Speaker: No, not that anything.
Speaker: Nothing comes to mind, but there has been a hot topic recently that ACOG and SMFM has talked about, which is, you know, this has been on this, you know, recently on, you know, the risk of vertical transmission has been certainly, you know, highlighted.
Speaker: And, you know, some papers are showing that perhaps there is a risk.
Speaker: ACOG and SMFM states that there is no conclusive evidence of vertical transmission of COVID-19.
Speaker: Although we understand that that is obviously sort of evolving, and this is from a statement from late April that they published.
Speaker: But in terms of the risk that a health worker has in terms of contracting the
Speaker: the virus, I think that the last few months have sort of shown us, right, and just looking at epidemiological data, that the risk of asymptomatic transmission is perhaps more important than what we previously thought.
Speaker: So we sort of understood that in late March, April, and certainly wearing masks and, you know, utilizing the mask to reduce the aerosolization,
Speaker: has definitely helped.
Speaker: And I think that we've arrived to that conclusion as professionals in the medical studies that say that, yes, masks do in fact help prevent transmission and your standard hand washing and all that, of course.
Speaker: But I know that unfortunately, the whole issue of mask wearing has sort of taken on, for whatever reason, it's taken on sort of this divisive sort of
Speaker: you know, the tone in the, in the, you know, when we're talking about sort of the, our approach to COVID, but, you know, that's been, you know, at least what I've seen in the literature is that, you know, wearing a mask definitely helps and it definitely decreases the risk of not only new transmitting, you know, potentially the virus, but of also receiving it as well.
Speaker: Absolutely.
Speaker: And I think that at this point, um,
Speaker: there's a very a good data there's a nice meta-analysis from from Lancet looking at the use of mask social distancing which is in terms of distance right one meter is better than closer than one meter and two meters better than one meter and the use of face shields but also we know the using the using of frequent and deliberate hand washing are all things that definitely mitigate the risk and for me one of the big the big turning points in terms of transmission from what i've observed at least a
Speaker: in many hospitals around the United States that work within our group is when hospitals went to universal masking, the rate of colleagues being exposed drops significantly, right?
Speaker: Because it's not that you get exposed in the patient you know is COVID positive, is you probably get exposed in the patient that nobody's suspecting COVID positive, like you mentioned with asymptomatic or some other issue, which is also interesting because I think in New York at one point,
Speaker: they did publish a paper that looked at a whole bunch of women in labor and delivery, and very similar to what happens outside of the pregnancy world, there was a large number or significant large number of people who were COVID positive who had no symptoms or very mild symptoms.
Speaker: So I think that that seems to parallel what's happening in the community as well.
Speaker: Yes.
Speaker: Yeah, that paper from, I believe that paper was from Columbia,
Speaker: that showed the vast majority of these patients were asymptomatic.
Speaker: And I think that really was, that paper was sort of, you know, it sort of took the obstetric world from surprise.
Speaker: And I believe the title of the, was like, it was like nine in 10 pregnant patients with COVID-19 were asymptomatic, at least based off this study.
Speaker: But absolutely, that's,
Speaker: that's very important to know sort of the potential risk of asymptomatic transmission.
Speaker: So it seems that what we've learned, and obviously this is a very evolving and fluid situation and body of knowledge, but pregnancy per se does not convey a higher risk of infection or a worse outcome.
Speaker: Comorbidities associated with pregnancy play the same role.
Speaker: They play not only in maternal morbidity, but also in
Speaker: COVID-associated morbidity.
Speaker: And I think that's something important to recognize.
Speaker: And what we know is that the vast majority of pregnant women who get COVID, like the vast majority of people who get COVID, will have very mild to symptomatic disease.
Speaker: But there's a subset of patients who will develop symptoms that are severe enough that they were required to come to the hospital.
Speaker: And there's a subset of those who might get critically ill and end up in our ICUs.
Speaker: And what we're seeing, obviously, is that when the numbers are so big,
Speaker: that small subset of 5% coming to an ICU can be enough to overrun ICUs.
Speaker: But so clearly there's been COVID positive patients who have developed symptoms severe enough to go to the hospital, be hospitalized in the ICU.
Speaker: And among those we could have pregnant and there have been some pregnant patients, even though it's not necessarily a disproportionate number of those patients being pregnant.
Speaker: But let's talk about three areas
Speaker: Cesar, and I want your thoughts on these topics.
Speaker: Obviously, I think that right now, infection prevention and control has always been, I think, a cornerstone of what we're doing with COVID.
Speaker: But right now, in terms of treatment, when I think of the ICU, you really have, I mean, kind of like three big buckets, which is supportive care, which is mostly going to be centered around respiratory support, a little bit of hemodynamics, but mostly respiratory.
Speaker: Drug therapy, which obviously everybody
Speaker: has been hoping for some miracle cure.
Speaker: We don't have one, but we have learned that some things work and some things don't work.
Speaker: So I think that's positive.
Speaker: And then finally, there's been a lot of talk about supportive or adjunctive drug therapy or care such as antipyrelation within COVID, which also I think plays an important role in pregnancy in general.
Speaker: So maybe we could just talk about those.
Speaker: And I know making the caveat that there's not a lot of
Speaker: specific trials for pregnant patients with COVID, just understanding what we know about pregnancy, what we know about COVID, and how, I mean, you look at these from a clinical perspective if you were taking care of these patients.
Speaker: So I would like to start with respiratory support and start with oxygen targets.
Speaker: You did mention a decrease in functional residual capacity, and I think that's an important starting point because perhaps we need to have a little bit of a higher target with pregnancy.
Speaker: Could you talk a little bit about that?
Speaker: Yeah, absolutely.
Speaker: So in general, it's, you know, just using, as you mentioned, using the caveat that there's not a lot of information just based off of these critically ill pregnant patients.
Speaker: There's really nothing out that shows, you know, outcomes in intubated patients and what was the oxygen sort of target, et cetera.
Speaker: But I think that there's a lot of value in looking at the Society of Critical Care Medicine, sort of a resource center for COVID-19.
Speaker: So SCCM has a fantastic sort of outline on treatment algorithms for respiratory failure and COVID-19, which, in my opinion, are transferable to, you know, can be used in the obstetric setting as well.
Speaker: So when we're talking about oxygen therapy, you certainly want to maintain the highest level that you can.
Speaker: And the reason is you have a steep drop off in your hemoglobin concentration or your hemoglobin attachment to oxygen when you're talking about the transferability of oxygen to your baby or to the baby.
Speaker: So you really want to maintain a normal level of oxygen.
Speaker: SCCM recommends, you know, supplemental oxygen when you're less than 90%.
Speaker: You certainly want to keep it higher than that during pregnancy.
Speaker: But what really has happened in the last few months, which has been fascinating, has been the role of high-flow nasal cannula in COVID-19 and respiratory failure.
Speaker: And, you know, I think just thinking about the, you know,
Speaker: the role of sort of noninvasive or just high-flow nasal cannula, the ability to provide humidified oxygen that does give you a little – that gives you some supplemental PEEP is an important strategy.
Speaker: Understand that there's really limited data of this in pregnancy.
Speaker: But, you know, SCCM recommends the use of high-flow nasal cannula with hypoxia, and it's recommended over noninvasive ventilation.
Speaker: And I think this is a valuable sort of tool that we have at our disposal.
Speaker: And I think in the beginning of the pandemic, it was sort of like, well, early intubation is just the only way to go.
Speaker: But I think that recently that sort of approach has been somewhat challenged.
Speaker: There's a lot of consequences with intubating someone.
Speaker: I mean, you have to use a lot of heavy sedatives.
Speaker: Some of you're using sedatives, you know, you have the
Speaker: You know, you have metabolites that are building up in the blood and you have patients that could be, you know, they're at higher risk for delirium.
Speaker: And then, I mean, there's a whole cascade that certainly comes from that.
Speaker: Yeah, I was going to ask you, I think there's been a lot of debate back and forth.
Speaker: And I think that ultimately the way I look at it is we should always intubate as early as possible somebody who needs to be intubated.
Speaker: But the question is sometimes...
Speaker: we found that with COVID, it seems that some people can be supported with high flow oxygen or other modalities and eventually don't need to be intubated.
Speaker: So that's, I think, the challenge to try to find that, which requires us to just pay attention at the bedside and look for certain signs.
Speaker: Now, there's been also a lot of debate, Cesar, about for non-mechanical ventilation, and then we'll go into mechanical ventilation.
Speaker: So the timing, obviously, like I think some people, like you said at the beginning, were early, they were intubating everybody who required more than
Speaker: more than six liters or being very aggressive.
Speaker: And then we kind of figured out, well, maybe some people don't need to be intubated and we can get them through without intubation.
Speaker: But I do think that the message still should be that if you think clinically they need to be intubated, you should intubate, but that you can assess whether there's other ways to support them.
Speaker: Now, there's been also a lot of discussion versus high flow nasal cannula versus non-invasive positive pressure ventilation like BiPAP.
Speaker: In ARDS in general, I think high flow nasal cannula
Speaker: probably has more support just because there's more studies that have shown that it might help.
Speaker: Is there anything inherent about pregnancy that would make you worry about one versus the other?
Speaker: Like I know when I think of BiPAP sometimes with a decreased lower esophageal spinter tone, precision for aspiration, that sometimes worries me in pregnant patients, but that has anything to do with COVID.
Speaker: I'm just curious from a purely obstetrical standpoint, do you see one being
Speaker: more appropriate or that's not really an issue?
Speaker: That's a really good question.
Speaker: I don't know if I can necessarily make that distinction.
Speaker: I'll just give you my bias.
Speaker: If I had a patient who needed hyponasal cannula or was a candidate and was pregnant or that needed a supplement of oxygen, I would choose hyponasal cannula.
Speaker: But it's more because of the patient comfort.
Speaker: I mean, you're using these nasal prongs.
Speaker: You do get some peep.
Speaker: It's humidified.
Speaker: It's titratable.
Speaker: And you should always assume a pregnant patient has a full stomach.
Speaker: The risk of aspiration is high.
Speaker: So, yeah, I think that's also a very valid point where you were mentioning that you were mentioning is that you're sort of having this lower esophageal stincter tone that happens because of compression from the uterus.
Speaker: And you have this relaxation of that, which does make a patient at higher risk for aspiration.
Speaker: So I think that risk is certainly, could be potentially a real one.
Speaker: But other than that, I am not aware of any sort of,
Speaker: So, it has been pinning one versus the other.
Speaker: But I would say from a patient comfort level, tetradability, humidified, and the level of PEEP, I would say hyphalomasocanid would probably have, in my opinion, it's probably more advantageous.
Speaker: Okay.
Speaker: And for those patients who eventually, let's say, we support with this, we should definitely, I mean, I think, put the appropriate infection control,
Speaker: prevention as we would with somebody who's not pregnant and very close monitoring.
Speaker: If they're not progressing well, deteriorating, I think that then we make that decision to proceed to intubation.
Speaker: Let's talk, before we go to mechanical ventilation, are there any additional precautions?
Speaker: I think that we already have learned a lot in terms of intubation obviously is a high risk procedure for aerosolized droplets.
Speaker: So in terms of protecting ourselves, minimizing people in the room,
Speaker: making sure that if we can, we use video assisted, if you're fast out with that, to improve first pass, being as ready as possible.
Speaker: Anything you would add to all this in terms of just intubating a pregnant patient that might be more difficult, Cesar?
Speaker: Yes, absolutely.
Speaker: So when intubating a pregnant patient, engorgement of tissues can make an airway difficult.
Speaker: And so, in general, you want to use a smaller endotracheal tube.
Speaker: That's very critical.
Speaker: And you want to, of course, have your – this sort of depends on every hospital setting, right?
Speaker: Every hospital has their own recommendations.
Speaker: But in general, you want to use video endoscopy.
Speaker: Preoxygenation is extremely vital, as I mentioned earlier, because of the physiological changes in
Speaker: in your respiratory mechanics.
Speaker: And if you add on top of that a respiratory illness, that certainly makes it even more important to pre-oxygenate.
Speaker: And, you know, earlier we were talking about sort of high-flow mesocannula versus other forms of ventilation.
Speaker: Well, you can intubate someone on high-flow meso... And this is not for a COVID-19 patient, but when I have a patient that's
Speaker: risk for a hypothyroid.
Speaker: I've intubated before, certainly having my hyphalonidocanaly running.
Speaker: Again, that's in a patient where there's no risk of aerosolization of any infected particles or whatnot.
Speaker: But yeah, I mean, those are very, very good questions.
Speaker: I think just recognizing that your airway is going to be engorged.
Speaker: Some studies have put the risk of difficult intubation seven times higher.
Speaker: So seven times higher risk of it being difficult compared to a non-pregnant patient.
Speaker: And that the tissues can be friable if you have, you know, a traumatic airway, the patient's going to be at higher risk of bleeding when you have much more plasma volume.
Speaker: And, you know, just imagine sort of the vascular engorgement that you have that can place you at a higher risk for bleeding.
Speaker: which is certainly going to put you in a different category.
Speaker: But I think that's probably one of the most important things to remember is your risk of aspiration.
Speaker: You want to do rapid sequence intubation.
Speaker: That's also important to mention.
Speaker: And the risk of an engorged sort of edematous airway that's certainly part of the physiological changes of pregnancy.
Speaker: Excellent.
Speaker: And in terms of intubation, I think that one of the things that's been a lot of discussion about is this ARDS.
Speaker: I think most people believe that severe COVID eventually behaves like ARDS and we should stick to obviously what we know works, which is lung protective ventilation, using the least amount of people we need as needed for helping oxygenation and recruitment, using small tidal volumes.
Speaker: A lot of people have used
Speaker: to permissive hypercapnia in these patients to reduce the airway pressures.
Speaker: Are there any specific points you want to make about treating mechanically ventilated patients with a pregnant patients with ARDS or with ARDS due to COVID?
Speaker: So again, a lot of that data is limited, but if we look back on previous, so I'm sort of using the, you know, extrapolating from previous data, right?
Speaker: So if we look previously,
Speaker: it's really your standard care, your lung protective ventilation, your small tidal volumes, you know, in a range of 4 to 6 cc, anywhere from 5 to 8 cc per kilo of your tidal volume.
Speaker: Permissive hypercapnia, of course, is also important.
Speaker: Then also one thing that is critical to mention here is that
Speaker: in pregnancy, you are going to have less of a buffer base.
Speaker: So you have what is essentially a normal physiologic state at term pregnancy is respiratory alkalosis with compensation.
Speaker: So you will have inherently a slightly higher pH with a bicarb that's going to be a bit lower.
Speaker: So a bicarb at 20 can be certainly normal in pregnancy.
Speaker: And that's going to have implications for a patient who's potentially at risk of an infection because that buffer base is going to be lower and potentially put higher risk of a metabolic state, for example.
Speaker: But keeping in mind that sort of physiology is also important when you're treating a patient with mechanical ventilation.
Speaker: But I would say just approaching it definitely sort of based on the previous knowledge that we know from other, from our previous sort of studies of ARDS in pregnancy.
Speaker: And it's just sort of unfortunate there's not that much data out right now with COVID-19.
Speaker: Yeah, absolutely.
Speaker: And I think another thing I was going to ask you, and we talked a little bit about H1N1, but clearly with COVID-19, a prone positioning has been proposed for severe moderate ARDS.
Speaker: A lot of patients
Speaker: with COVID-19 on mechanical inhalation are being ventilated in the prone position.
Speaker: And even a lot of people have pushed for prone position in non-intubated patients.
Speaker: There's no studies I know in prone position in pregnancy, but anecdotally, historically, I know that people have proned pregnant patients.
Speaker: Any comments from your perspective?
Speaker: Are there any things that we should be cautious with?
Speaker: What are your thoughts?
Speaker: Oh, no, that's a fantastic question.
Speaker: So in general, again, sort of just treating patients like, you know, when you're a portrait critical care patient, you know, the first, you have your caveat, your physiological caveat, but at the same time, you want to, you know, just do what's safest for the patient.
Speaker: So if you look at updates from sort of the leading OB societies in pregnancy and what's the language of
Speaker: What do they say about proning?
Speaker: Proning can be done during pregnancy and the postpartum period as well.
Speaker: There's also this mention of passive proning, which is basically when a patient is not intubated, which we know that there are sort of anecdotal cases of proning patients who are not intubated.
Speaker: That could certainly increase your ventilation-perfusion ratios.
Speaker: But in terms of, you know, specific recommendations of when to do it or guidelines, no, I'm not aware.
Speaker: And I don't think there's certainly anything out.
Speaker: But I would say, yeah, absolutely.
Speaker: Pro-nearing during pregnancy is absolutely, you know, a strategy that is certainly acceptable.
Speaker: Understanding that you should
Speaker: have sort of the appropriate resources you should be at a hospital where you are in active engagement with maternal fetal medicine, with your obstetric professionals and all of that.
Speaker: So really you would treat it the same way you would treat, I mean obviously depending on how pregnant in terms of what trimester you would get, you always have more involvement or less involvement in maternal fetal medicine, but in terms of treating ARDS
Speaker: without or with COVID in a pregnant patient, we really would kind of focus on the similar things that we would do for somebody who's not pregnant.
Speaker: And that includes proning.
Speaker: Yeah.
Speaker: Yeah.
Speaker: And I know that, you know, I know that there have been cases of prone patients who are pregnant.
Speaker: And I mean, absolutely.
Speaker: And it comes down, and I think this comes out, it's, you know, our approach,
Speaker: I think a lot of our approach in the ICU can become so individualized because there's just so many factors that play into each case, into each patient.
Speaker: But absolutely, I think it's still an essential strategy that should be standard of care when other modalities fell to improve oxygenation.
Speaker: You should always consider pounding.
Speaker: Absolutely.
Speaker: And I think it's important because sometimes, I mean, intensivists feel that because the patient's pregnant, they're going to be treated differently.
Speaker: But I think that in this case, especially as we get more and more cases in some places, the treatment, as long as our supportive therapy would be very similar, taking into consideration some of the physiologic issues that we discussed.
Speaker: I would like to, and you did mention, I think that we could just say that in terms of other salvage therapies, ECMO,
Speaker: inhaled nitric oxide, you would treat it very similarly.
Speaker: If you think that the patient needs that to survive, whether they're pregnant or not, you would offer it to the patient if they're appropriate patients, correct?
Speaker: Yeah, absolutely.
Speaker: I mean, what you want to do is just really utilize, you know, what tools you have at your disposal to really just, you know, get your patient through the critical period.
Speaker: But I think understanding that the utility of ECMO has really changed in the last – our perception and our understanding of it has really changed in the last 10 years towards that of being more sort of showing higher survivability with ECMO.
Speaker: So I think that the evidence that's coming out for VV and VA ECMO is certainly proving to show
Speaker: that sort of treatment option as a modality for these patients.
Speaker: And I think this is going to be important as the levels of maternal care are rolled out, you have these sort of regional, you have these level four centers that are going to be your referral centers.
Speaker: It may be that this is where these patients that are the highest risk for decompensation are going to go.
Speaker: And it
Speaker: these may be the centers where there is going to be a cluster of sort of these ECMO patients.
Speaker: But yeah, I think that's very, you know, there's a very good point sort of mentioning those two treatment modalities.
Speaker: Absolutely.
Speaker: So I would like to just talk about, I mean, drug therapy, obviously very extensive.
Speaker: There's a lot of things that have been thrown out and are being studied for COVID.
Speaker: But I wanted to talk with you about like three things that I think have emerged that we're using more and more based on the available,
Speaker: evidence or sometimes more robust than others.
Speaker: And just maybe get your quick thoughts.
Speaker: And I know that there's no trials for pregnant patients, but just if there's any considerations that you're aware of for pregnancy.
Speaker: So in terms of, obviously, of antivirals, remdesivir is a drug that's being utilized in the United States, at least, and that showed some improvement in terms of time to symptom improvement in one study by the NIH.
Speaker: And there's more studies going on.
Speaker: Is that something that pregnant women, if they qualify based on their levels of support for respiratory failure, would get?
Speaker: Do you know of anything about remdesivir in pregnancy, Cesar?
Speaker: Yeah, so remdesivir was actually studied in pregnant patients during the Ebola outbreak, and it was actually approved for pregnant patients.
Speaker: So even though the number of patients that was treated at that time was relatively small, nonetheless, it did show sort of a safety profile for Ebola.
Speaker: So remdesivir is a repurposed antiviral that was originally used for Ebola.
Speaker: And so a lot of our data comes from that profile.
Speaker: So clearly considered, yeah.
Speaker: So consider a safe option.
Speaker: So I think it shouldn't be a contraindication.
Speaker: I think it's important for people to know that.
Speaker: The other thing that I think has been talked a lot about lately is obviously the use of steroids for ARDS.
Speaker: I mean, steroids are utilized for fetal maturation in pregnancy and other situations, pre-partum.
Speaker: But in terms of now, there seems to be emergent data from the recovery trial on the use of dexamethasone for patients requiring oxygen or mechanical ventilation.
Speaker: is that something that you foresee as being problematic or not an issue for pregnant patients?
Speaker: That's a very good question because, you know, if we look historically at the role of steroids and they are in viral, you know, sort of in viral respiratory illness, it's certainly, you know, the staying away from steroids has always kind of been, or at least steroids were associated with worse outcomes.
Speaker: This is sort of a,
Speaker: has been somewhat of a surprise.
Speaker: So, you know, I think that certainly more data is needed in the – at least in the pregnant population.
Speaker: But – and that's sort of the challenge that we have as intensive is sort of treating, you know, patients in an evolving sort of clinical scenario.
Speaker: What I've learned is, you know, do I see –
Speaker: potential in it, you know, I definitely see potential in it, but as we learned from hydroxychloroquine, you know, sometimes you have to really take a step back and really let the data sort of come in and analyze things because, you know, a lot of patients were exposed to, you know, hydroxychloroquine and that sort of definitely, you know, we know now these sort of adverse effects for that medication.
Speaker: So,
Speaker: To my knowledge, that one study is showing the role of dexamethasone, but I think we certainly need sort of more data, especially for or in pregnancy, to really make an accurate judgment on that.
Speaker: Excellent.
Speaker: And the other topics that I think as we wrap up that are relevant is obviously a lot of people are exploring under registries or clinical trials the use of convalescent plasma.
Speaker: That would be more on the category of transfusions.
Speaker: So I presume that that would not be something that would be – pregnant patients would be excluded if they're done within the auspices of a trial or a registry.
Speaker: Is that correct?
Speaker: So as far as I know, pregnant women are being enrolled in studies.
Speaker: I believe the University of Pennsylvania has a study where they're enrolling pregnant patients, but I'm not aware of any published data on this yet.
Speaker: Okay, so we'll wait for that.
Speaker: Anticoagulation, the risk of thrombomboic complications is obviously higher with pregnancy.
Speaker: It's also been reported to be higher with COVID.
Speaker: There's still a lot of discussion on what's the ideal
Speaker: a therapeutic approach, but I think that most people agree that a COVID-19 patient should be on prophylaxis chemically.
Speaker: Are there any drugs that you would recommend as preferential for pregnant patients in terms of DVT and thrombotic prophylaxis?
Speaker: Yeah.
Speaker: So as you mentioned, pregnancy is a hyperponglable state.
Speaker: You're at a higher risk of clotting.
Speaker: There's not
Speaker: to my knowledge, is not in the information right now with COVID-19 and pregnancy and specifically with the burden of clotting.
Speaker: But if we just look at, you know, let's take a step away from COVID-19 and just look in general, like what modalities, treatment options are out there, what works in pregnancy.
Speaker: We know that low molecular weight heparin definitely produces a more predictable sort of response than ultrafiltrate heparin.
Speaker: It doesn't require routine monitoring.
Speaker: And then in terms of just knowing things about your choice of anticoagulant for pregnancy, heparin, it's the most commonly used anticoagulant during pregnancy.
Speaker: It does not cross the placenta.
Speaker: It's not teratogenic.
Speaker: So it doesn't result in fetal anticoagulation.
Speaker: So I think those are some of the
Speaker: sort of important aspects of sort of anticoagulation when we're thinking about anticoagulation and pregnancy.
Speaker: Excellent.
Speaker: And I think that, like we said, Cesar, there's still a lot, obviously, that we don't know about pregnancy and critical care in general, and even less about what we know about pregnancy and COVID-induced critical illness.
Speaker: But I think that discussing some of these topics is of great relevance to what's going on right now.
Speaker: I really appreciate, I mean, your time and expertise.
Speaker: And I think that definitely we'll keep a, we'll all be posted in terms of new data coming down, down the line and things evolving.
Speaker: But to close the podcast, we like to talk about some questions that are not related to the clinical topic.
Speaker: Would that be okay?
Speaker: Oh yeah, absolutely.
Speaker: So the first question relates to books and I was just curious if you could give us some books that have influenced you the most or that you have gifted most often to others.
Speaker: So you're,
Speaker: One book that I picked up was actually a gift for me from my wife.
Speaker: It's called 12 Rules of Life and An Antidote to Chaos.
Speaker: So it's written by Dr. Jordan Peterson, who's a professor, I believe, of psychology in Canada.
Speaker: I forgot which university he is.
Speaker: He may be at the University of Toronto.
Speaker: But it's just a fantastic way to, you know,
Speaker: it's a great approach to sort of structuring your life and just taking a biological kind of perspective into psychology, which is fascinating.
Speaker: But that's definitely a book that I would recommend to, you know, my friends, colleagues, anyone out there who's listening, 12 Rules of Life by Dr. Jordan Peterson.
Speaker: So we'll definitely link that up on the show notes.
Speaker: I've read it, I think, a lot of
Speaker: very powerful insights into human behavior and I think things that you can apply, like you said, to your life to make things a little bit better, which I think are especially important in times that are difficult like the ones we have now, but also just in terms of living a more deliberate as opposed to a life by default.
Speaker: I think that's a great recommendation.
Speaker: The second question relates to something that you believe to be true in medicine or in life that many other people don't believe.
Speaker: That's a fantastic question.
Speaker: Something that I believe to be true in the clinical setting you mentioned, Sergio?
Speaker: It can be clinical or outside of clinical.
Speaker: I mean, whatever you want, but then other people don't believe or don't behave like they believe.
Speaker: You know, this answer may take on a philosophical tone, but I'll give it a shot.
Speaker: I think that subscribing to evidence is
Speaker: something that's easier said than done.
Speaker: And what I mean by that is, when we really sit down and make decisions, are we really looking objectively at the data?
Speaker: Are we really doing things that are based off best practices?
Speaker: Because we should, right?
Speaker: That should be the standard, which should be driving our decision-making.
Speaker: It should always be evidence-based medicine.
Speaker: And I think that one of the challenges is just, again, being, you know, human psychology, being in a clinical setting, which is also a work setting, is the introduction of bias.
Speaker: So I think, you know, implicit bias, which has taken on a whole new reality now, you know, in this inner world, we understand it very well, that it's a problem.
Speaker: There's a lot of forms of biases.
Speaker: One that I mentioned earlier was just treating young patients and assuming they're always, pregnant patients are always healthy.
Speaker: But are we always using evidence in the right way or are we introducing sort of political or maybe other external factors into our decision making?
Speaker: Because I think that that's something that maybe we can all be a little better at in all settings, whether it's in business, in medicine.
Speaker: but especially in medicine.
Speaker: We should always adhere to evidence.
Speaker: We should always adhere to best practices that are based on scientific data.
Speaker: And really, there should be no introduction of sort of this political, if you will, sort of connotations that can or political tones that can influence our decision-making.
Speaker: I think that's one of our challenges in medicine that really, you know, it's a
Speaker: it's a challenge going from the, it can be a challenge going from the trainee to the, you know, to the advanced kind of role once you graduate, but you should always adhere to evidence.
Speaker: Yeah.
Speaker: And I think that when you talk about bias, I think that you're right.
Speaker: There's so many types of bias, but one thing that I think a lot I see, and we all have biases that we just have to be able to recognize them, right.
Speaker: And use tools like evidence to try to overcome them, but the confirmation bias, right.
Speaker: So,
Speaker: I criticize somebody for doing something because I don't believe in that and there's no evidence.
Speaker: But yet I do something without evidence that I do believe in.
Speaker: I justify whatever I have around me to confirm to that bias.
Speaker: I think that bias is definitely present, ever present.
Speaker: And I think like you mentioned right now, in a time of a lot of polarization within our society, but also a lot of stress through the pandemic, that has become even more evident and I think more dangerous.
Speaker: So I think it's a great comment.
Speaker: I think something to think about.
Speaker: And the last question, Cesar, is there anything that you would want every intensivist listening to us today to know?
Speaker: Could be a quote or fact or just a thought.
Speaker: Yes, I think the other day I gave a little talk to our residents, a little farewell on their graduation.
Speaker: And everything is virtual now because of COVID.
Speaker: And I think
Speaker: you know, thinking about like a role as doctors and what does it mean to be a physician for now in 2020.
Speaker: And I live in Ohio and I guess naturally if you live in Ohio, one of the first people that comes to mind is LeBron James, right?
Speaker: So LeBron James is a superstar, probably the best athlete coming out of Ohio ever.
Speaker: And he coined the term more than an athlete.
Speaker: And,
Speaker: I think that was powerful because if you think about the role of an athlete, like look at historically, let's look at like Muhammad Ali.
Speaker: Muhammad Ali was certainly just an advocate for his community and was an advocate for just issues that come from a kind of social justice route.
Speaker: And
Speaker: LeBron James has sort of kind of done the same thing.
Speaker: And he's like, you know, we're more, you know, my image means more than just me being a basketball player.
Speaker: You know, I sort of am a role model for other people as well.
Speaker: And he understands that responsibility.
Speaker: And I told the residents, I'm like, just like LeBron says, more than an athlete, you should strive to be more than a doctor.
Speaker: And I really, you know, thought about that because I think it's true.
Speaker: I think that we are more than a doctor.
Speaker: And let's think about our role in society.
Speaker: And let's think about our role in promoting change.
Speaker: Let's think about our role in providing best practices and in influencing our legislators.
Speaker: Are we, you know, are we really doctors if we're not influencing the people that write the laws?
Speaker: You know, I don't think so.
Speaker: I think that to be the full extent of a physician, you need to influence
Speaker: the people that are shaping this world because we are the experts in healthcare.
Speaker: And so we need to be influencing the people that are shaping our legislation, our, you know, writing our laws.
Speaker: So that's where that term more than a doctor comes in.
Speaker: You are more than an employee.
Speaker: You are more than just being confined to the walls of your hospital.
Speaker: You're sort of, we're part of this network of physicians.
Speaker: across the world, even not just the country in the U S, but across the world where our responsibility stretches beyond our own, our own hospital.
Speaker: So I would say I would leave everyone with the, the thought of, you know, be strive to be more than a doctor.
Speaker: And I think that will lead us down a better path for our future.
Speaker: I think that's a beautiful place to stop.
Speaker: I really appreciate your expertise, your time,
Speaker: and look forward to talking with you again soon on the podcast.
Speaker: Thank you, Tethi.
Speaker: I really appreciate your time.
Speaker: Thanks for having me on.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
