Microsoft word - cmace

1. Regarding the most recent (2006-2008) triennial report of UK
maternal deaths from the Centre for Maternal and Child
Enquiries (CMACE)

1. Sepsis was the second most common cause of direct maternal death after thromboembolic disease 2. Deaths from β-haemolytic streptococcus Group B infection 3. The use of early warning scoring charts to monitor obstetric 4. Substandard care did not occur in any of the sepsis related 2. Maternal sepsis and infection
1. Often presents early due to the physiological changes of 2. May present with hypothermia 3. Is most commonly due to bacterial pathogens 4. May warrant hysterectomy as part of its management 3. Regarding the management of sepsis and septic shock
1. Antibiotic therapy should always be delayed until all 2. A target haemaglobin over 10g/dl should be maintained 3. Steroids are not recommended in the management of septic 4. A central venous oxygen saturation ≥ 65% is a goal of
Table 1. The following antibiotic recommendations are taken
from the CMACE report 2006- 2008

Where the organism is unknown and the woman is not critically ill.

co-amoxiclav 1.2g 8hrly + metronidazole 500mg 8hrly
or
cefuroxime 1.5g 8hrly + metronidazole 500mg 8hrly
or
cefotaxime 1-2g 6 to 12hrly + metronidazole 500mg 8hrly

In cases of penicillin and cephalosporin allergy

clarithromycin 500mg 12hrly + gentamicin
or
clindamycin 600mg to 1.2g 6-8hrly + gentamicin
In severe sepsis or septic shock
piperacillin-tazobactam 4.5g 8hrly + gentamicin 3-5mg/kg daily
or
ciprofloxacin 600mg 12hrly + gentamicin 3-5mg/kg daily
a carbopenem such as meropenem 500mg - 1g 8hrly may be added
metronidazole 500mg 8hrly may be considered to provide anaerobic
cover

If Group A streptococcal infection is suspected
clindamycin (600mg to 1.2mg 6-8hrly) is more effective than penicillin
as it inhibits exotoxin production
If there are risks for MRSA
add teicoplanin 10mg/kg 12hrly for 3 doses then 10mg/kg daily or
linezolid 600mg 12hrly
Table 1
Definitions related to sepsis
SIRS
Two of the following:
- Temperature >38 oC or <36 oC
- Heart rate >90 beats/min
- Respiratory rate >20 breaths/min or PaCO2
<32 mmHg (4.3 kPa)
- White cell count: >12 000 cells/microl
or <4000 cells/microl or 10% immature/band forms
Sepsis
SIRS with infection
Severe sepsis
Sepsis associated with organ dysfunction,
hypoperfusion or hypotension. Hypoperfusion and perfusion
abnormalities may include, but are not limited to, lactic acidosis, oliguria
or an acute alteration in mental status
Septic shock
Sepsis associated with hypotension, despite adequate fluid resuscitation
along with the presence of perfusion abnormalities as listed for severe
sepsis. Patients who are on inotropic or vasopressor agents may not be
hypotensive at the time that perfusion abnormalities are measured


Table 2
Diagnostic criteria for sepsis (infectiona, documented or suspected and
some of the followingb)
General variables
Fever (core temperature >38.3 oC)
Hypothermia (core temperature <36 oC)
Heart rate >90 beats/min or >2 SD above the normal value for age
Tachypnea
Altered mental status
Significant oedema or positive fluid balance (>20 ml/kg over 24 h)
Hyperglycaemia (plasma glucose >120 mg/dl or 7.7 mmol/l) in the
absence of diabetes
Inflammatory variables
Leukocytosis (WBC count >12 000/microl)
Leukopenia (WBC count <4000/microl)
Normal WBC count with >10% immature forms Plasma C-reactive protein >2 SD above the normal value Plasma procalcitonin >2 SD above the normal value Haemodynamic variablesc
Arterial hypotension (SBP <90 mmHg, MAP <70 mmHg, or an SBP
decrease >40 mmHg in adults or <2 SD below normal for age)
SvO2 >70%
Cardiac index >3.5 l/min/m2
Organ dysfunction variables
Arterial hypoxemia (PaO2/FiO2 <300)
Acute oliguria (urine output <0.5 ml/kg/h or 45 mmol/l for at least 2 h)
Creatinine increase >0.5 mg/dl
Coagulation abnormalities (INR >1.5 or aPTT >60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count <100 000/microl)
Hyperbilirubinaemia (plasma total bilirubin >4 mg/dl or 70 mmol/l)
Tissue perflusion variables
Hyperlactataemia (>1 mmol/l)
Decreased capillary refill or mottling
aPTT, activated partial thromboplastin time; INR, international normalized ratio; MAP, mean arterial blood pressure; SBP, systolic blood pressure; SvO2, mixed venous oxygen saturation; WBC, white blood cell. a Infecti on defined as a pathologic process induced by a microorganism. b Diagnostic criteria for sepsis in the paediatric population are signs and symptoms of inflammation plus infection with hyperthermia or hypother- mia (rectal temperature >38.5 or <35 oC), tachycardia (may be absent in hypothermic patients) and at least one of the following indications of altered organ function: altered mental status, hypoxaemia, increased serum lactate level or bounding pulses. c SvO2 sat >70% is normal in children (normally 75–80%) and cardiac index 3.5 – 5.5 l/min/m2 is normal in children; therefore, neither should be used as signs of sepsis in newborns or children.

Source: http://kssdeanery.org/sites/kssdeanery/files/CMACE.pdf