Page 757 - ACCCN's Critical Care Nursing

734 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

medications is often a balance between the benefit of
BOX 26.10 Maternal cardiac arrest algorithm administering the drug to the pregnant woman compared
with the risk of not administering the drug.
First responder:
l Activate cardiac arrest team e.g. Code Blue and note time There are a number of anatomical, physiological, cellular
l Place the woman supine and molecular changes in pregnancy that affect the
l Commence chest compressions as per standard BLS algori- pharmacokinetic and pharmacodynamic mechanisms of
189
thm. Place hands slightly higher on the sternum than usual drugs administered during pregnancy. These include
due to raised diaphragm reduced serum protein levels (reduced protein binding
capacity), increased circulating volume (potential for
Subsequent responders: dilution), delayed gut motility (potential for increased
l Apply standard BLS and ALS algorithms gut absorption), increased glomerular filtration rate
l Commence documentation of cardiac arrest management (potential for increased excretion) and changes to mater-
e.g. time of onset nal drug-metabolising enzymes (difficult to predict
l Do not delay defibrillation metabolism pattern of regular drugs). Medication may
190
l Give standard ALS drugs and doses be classified according to the likelihood for teratogenesis,
l Use 100% oxygen however there may be little understanding about efficacy
l Monitor effectiveness of ventilation and CPR quality in pregnancy; standard adult doses may be inadequate or
l Provide the standard post-arrest care toxic during pregnancy due to the adapted physiology of
pregnancy. 189
Maternal modifications:
l Start IV above the diaphragm
l Assess for hypovolaemia and treat appropriately but Potential for Teratogenesis
cautiously A teratogen is any agent that increases the incidence of
191
l Anticipate a difficult airway a congenital anomaly. The major organs are developed
l If the woman is on a magnesium infusion, cease and by 10 weeks’ gestation, however, the recommendation
consider administration of calcium chloride 10 mL in 10% is to avoid any teratogenic drug throughout the first
solution or calcium gluconate 30mL in 10% solution to treat trimester (14 weeks). 192 Some medications exert an
hypermagnesaemia adverse effect in the second or third trimesters of preg-
l Continue all elements of resuscitation effort during and nancy, such as ACE inhibitors (fetal anuria and stillbirth),
after caesarean section indomethacin (potential premature closure of the ductus
arteriosus) and selective serotonin uptake inhibitors
Women with an obviously gravid uterus e.g. >20 weeks’ 192
gestation: (neonatal withdrawal syndrome). Medical staff pre-
l To relieve aorto-caval compression and enable more effec- scribing drugs and nursing staff administering them
tive CPR, manually displace the uterus towards the left should each check the potential impact of the medica-
l Alternatively, use a wedge to position the woman in a tion in pregnancy, and consult a pharmacist when
left lateral tilt possible.
l Remove any internal or external fetal monitors if present
l Prepare for a potential emergency caesarean section Immediately Prior to Delivery
l Call for immediate obstetrician attendance when the Besides effects on the structural development of the fetus
arrest is activated in the first trimester, the other key time for consideration
l Aim for delivery within 5 minutes of onset of resusci- of drug administration is immediately prior to delivery.
tative efforts Common sedative agents like midazolam, morphine,
fentanyl and propofol cross the placenta readily and exert
Consider and treat any possible contributing factors: an action on the fetus. 193-195 Consequently, even mature
l Haemorrhage with or without DIC term babies may be born sedated and require assistance
l Assess for placent abruption/praevia and uterine atony with breathing. Planning for delivery of a pregnant
if woman is postpartum woman in ICU should include the involvement of a
l Embolism, e.g. pulmonary, amniotic fluid paediatrician/neonatologist or the local newborn emer-
l Anaesthetic complications, e.g. high spinal block gency transport service (NETS) if no paediatricians are
l Cardiac disease, e.g. preexisting or new on site.
l Preeclampsia
l Sepsis
Therapeutic Routine Drug Therapy
Adapted from (187). in Pregnancy
For women admitted to ICU for prolonged periods of
time, for example those with Guillain–Barré syndrome,
consideration may be given to routine therapeutic
of drug therapy is paramount: during the first trimester medication in pregnancy. For example, folic acid (400 µg
when embryo/fetal malformations may occur, and daily) is recommended pre-conception and throughout
immediately prior to delivery as the newborn baby may the first trimester to prevent neural tube defects. 192
be adversely affected, e.g. sedated and unable to sponta- Similarly, iron and Vitamin D supplementation
neously breathe. The decision to administer various may be indicated dependent on blood levels. Vitamin