for the Management of Cardiac Arrest in Pregnancy: Consensus Recommendations on Implementation Strategies Dini Hui, MD, FRCSC, 1 Laurie J. Morrison, MD, MSc, FRCPC, 2,3 Rory Windrim, MD, FRCSC, 4
Andrea Y. Lausman, MD, FRCSC, 5 Laura Hawryluck, MSc (Bioethics), MD, FRCPC, 6
Paul Dorian, MD, FRCPC, 7 Stephen E. Lapinsky, MB BCh, MSc, FRCPC, 8
Stephen H. Halpern, MD, MSc, FRCPC, 9 Douglas M. Campbell, MD, FRCPC, 10
Paul Hawkins, MD, MCFP(EM), FACEP, 11 Randy S. Wax, MD, MEd, FRCPC, FCCM, 12
Jose C.A. Carvalho, MD, PhD, FANZCA, FRCPC, 13 Katie N. Dainty, PhD, 2
Cynthia Maxwell, MD, FRCSC, 4 Farida M. Jeejeebhoy, MD, FRCPC, FACC 14 11 Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON 12 Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michaels Hospital, University of Toronto, Toronto ON 13 Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto ON 14 Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto ON 15 Department of Obstetrics and Gynaecology, St Michaels Hospital, University of Toronto, Toronto ON 16 Critical Care, Toronto General Hospital, University of Toronto, Toronto ON 17 Department of Medicine, Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto ON 18 Interdepartmental Division of Critical Care, University of Toronto, Intensive Care Unit, Mount Sinai Hospital, Toronto ON 19 Obstetrics and Gynaecology, Anaesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON 10 Department of Paediatrics, Li Ka Shing Knowledge Institute, St Michaels Hospital, University of Toronto, Toronto ON 11 Department of Emergency Services, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON 12 Departments of Emergency Medicine and Critical Care, Lakeridge Health Corporation and Interdepartmental Division of Critical Care, University of Toronto, Oshawa ON 13 Departments of Anaesthesia and Pain Management and Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON 14 Division of Cardiology, William Osler Health Centre, Department of Medicine, University of Toronto, Toronto ON COMMENTARY Key Words: Cardiac arrest, pregnancy, resuscitation, multidisciplinary care, implementation strategy, management Competing Interests: None declared Received on January 27, 2011 Accepted on April 1, 2011 J Obstet Gynaecol Can 2011;33(8):858863 INTRODuCTION C ardiac deaths during pregnancy have increased steadily over the past two decades. 1 According to the recently published 20062008 Confdential Enquiries into Maternal Deaths in the United Kingdom, the largest population-based data set for this target population, cardiac disease in the United Kingdom represented the most common cause of maternal death overall, exceeding the rates of thromboembolism, sepsis, and hemorrhage. 1 The most common causes of maternal death from cardiac disease were sudden adult death AUGUST JOGC AOT 2011 l 859 The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy syndrome, myocardial infarction (mainly related to ischemic heart disease), aortic dissection, and cardiomyopathy (mainly peripartum cardiomyopathy). 1 All the women who died of ischemic heart disease had identifable risk factors such as older age, obesity, smoking, diabetes, and hypertension. 1 The incidence of cardiac arrest during pregnancy also increased, from 1:30 000 in the 20002002 Confdential Enquiries report 2 to 1:20 000 in the 20032005 report. 3 Management of cardiac arrest in pregnant women is more complicated than in non-pregnant patients. 4 Maternal physiologic adaptations to pregnancy present special challenges, and the resuscitation team must consider the needs of both the mother and the fetus. In comparison, cardiac arrest in young athletes is much less common than in pregnant women, with an incidence of 1:200 000. 5
However, there have been many position statements addressing prevention and prediction of sudden death in the young athlete. 6 There is a need for heightened awareness of and education about the management of cardiac arrest during pregnancy, as illustrated in two publications assessing knowledge regarding management of maternal cardiac arrest among health care providers. 7,8
Both studies concluded that knowledge of important basic concepts of cardiac arrest in pregnancy among anaesthesiologists, obstetricians, midwives, and emergency medicine specialists was inadequate. In October 2010, the American Heart Association (AHA) published new guidelines for cardiopulmonary resuscitation and emergency cardiovascular care for maternal cardiac arrest 9 based on the 2010 consensus on science and treatment recommendations for maternal cardiac arrest, published by the International Liaison Council on Resuscitation. 1012 As these guidelines represent a signifcant change in practice, it will be important for knowledge translation programs to disseminate the information, to educate and train caregivers, and to develop strategies that will enable caregivers to adhere to the guidelines at the point of care. The management of maternal cardiac arrest requires a multidisciplinary team and it is important to bring the specialties involved together to ensure that such teams are coordinated and ready to respond. Several publications have outlined potential strategies to prepare for maternal cardiac arrest in accordance with older guidelines. 1316 The 2010 guidelines, however, are transformative, and their implementation will require training, preparation, ongoing feedback, and support to ensure that all maternal cardiac arrest victims are treated optimally and consistently. 9 In order to address this objective, a group of physicians from six different hospitals within the Greater Toronto Area representing obstetrics, cardiology, emergency medicine, anaesthesia, critical care, and neonatology, met with a knowledge translation expert to develop an implementation strategy to be used by hospitals, resuscitation teams, and related units for the management of maternal cardiac arrest. The group considered available evidence leading to the new maternal cardiac arrest guidelines. 912 We present this strategy, providing a framework for emergency preparedness and management of these devastating events, as a tool for others to consult, adapt, and review to ensure that their institution and their staff are prepared. IMPLEMENTATION RECOMMENDATIONS 01. There should be a specifc manner in which to activate the maternal cardiac arrest team. If a hospital does not have a system in place, consider Code Blue Obstetrics as the universal call to action. 02. Suggested composition for the maternal cardiac arrest team: (a) Adult resuscitation team (b) Obstetrics: one obstetrical nurse, one obstetrician (c) Anaesthesia: obstetrical anaesthesiologist if available, or staff anaesthesiologist; anaesthesia assistant if available (d) Neonatology team: one nurse, one physician, one neonatal respiratory therapist (e) In centres without obstetrics/neonatology services, we suggest that the Code Blue committee and hospital emergency services discuss contingency plans in the event of maternal cardiac arrest. 03. The AHA ACLS (Advanced Cardiac Life Support) maternal cardiac arrest algorithm should be used as a template for management of cardiac arrest in pregnancy (Figure). 9 A laminated card of the algorithm should be available throughout hospitals and outpatient settings in which the potential for maternal cardiac arrest exists. The AHA ACLS maternal cardiac arrest algorithm should be posted in prominent locations as well as on code carts. 9
Dissemination of information in this algorithm should be part of the education program for all obstetrics and anaesthesia residents, obstetric nurses, physicians and nurses working in a critical care setting, and those who deliver care through the Code Blue teams. 9 There should be specifc initiatives in education regarding the potential etiologies of maternal arrest. The acronym 860 l AUGUST JOGC AOT 2011 COMMENTARY 2010 American Heart Association Search for and treat possible contributing factors (BEAU-CHOPS) Bleeding/DIC Embolism: coronary/pulmonary/amniotic fuid embolism Anesthetic complications Uterine atony Cardiac disease (MI/ischemia/aortic dissection/cardiomyopathy) Hypertension/preeclampsia/eclampsia Other: differential diagnosis of standard ACLS guidelines Placenta abruptio/previa Sepsis Subsequent responders Maternal interventions Treat per BLS and ACLS algorithms Do not delay defbrillation Give typical ACLS drugs and doses Ventilate with 100% oxygen Monitor waveform capnography and CPR quality Provide postcardiac arrest care as appropriate Maternal modications Start IV above the diaphragm Assess for hypovolemia and give fuid bolus when required Anticipate diffcult airway; experienced provider preferred for advanced airway placement If patient receiving IV/IO magnesium prearrest, stop magnesium and give IV/IO calcium chloride 10 mL in 10% solution, or calcium gluconate 30 mL in 10% solution Continue all maternal resuscitative interventions (CPR, positioning, defbrillation, drugs, and fuids) during and after cesarean section Obstetric interventions for patient with an obviously gravid uterus* Perform manual left uterine displacement (LUD) displace uterus to the patients left to relieve aortocaval compression Remove both internal and external fetal monitors if present Obstetric and neonatal teams should immediately prepare for possible emergency cesarean section If no ROSC by 4 minutes of resuscitative efforts, consider performing immediate emergency cesarean section Aim for delivery within 5 minutes of onset of resuscitative efforts *An obviously gravid uterus is a uterus that is deemed clinically to be suffciently large to cause aortocaval compression First responder Activate maternal cardiac arrest team Document time of onset of maternal cardiac arrest Place the patient supine Start chest compressions as per BLS algorithm; place hands slightly higher on sternum than usual Maternal cardiac arrest algorithm 9
Used with permission, American Heart Association AUGUST JOGC AOT 2011 l 861 The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy BEAU-CHOPS may be a helpful mnemonic (Figure). 9 04. Ensure there is a process for a sterile emergency Caesarean section tray to be immediately available in the event of a maternal cardiac arrest. This can be accomplished by having all code carts in high- risk areas for maternal cardiac arrest equipped with a sterile emergency Caesarean section tray; this tray should be included in routine Code Blue cart check lists (Table 1). Alternatively, this may be brought to the code site by a member of the Code Blue Obstetrics team. In nonhigh-risk areas, a regular procedural tray and scalpel may be used for the emergency Caesarean section in the event of maternal cardiac arrest. Neonatal expertise in the resuscitation, stabilization, and treatment of the preterm and term neonate is essential. Resuscitation equipment for the preterm and term neonate should be readily available in high-risk areas (Table 1). We suggest that neonatal caregivers be trained in neonatal resuscitation, including the 2010 AHA Neonatal Resuscitation Program guidelines. 17,18 05. The areas that should be considered high risk for maternal cardiac arrest include (a) Obstetrical units, including antepartum areas (b) Emergency departments (c) Intensive care units; the equipment described should be routinely placed outside the room of a critically ill pregnant patient, in anticipation of sudden cardiac arrest. 06. All resuscitation staff should be familiar with the 2010 AHA ACLS guidelines for the management of maternal cardiac arrest, with special attention to the following 9 : (a) Because superfuous personnel can contribute to challenges in crisis management or crowd control, the Code Blue Obstetrics team should include only the necessary complement of health care staff members to bring the required competencies to the scene. (b) Correct use of one- or two-hand manual left and upward uterine displacement, as opposed to leftward tilt, should be used to relieve aortocaval compression. (c) Team training should emphasize rapid decision- making and excellent communication strategies, especially in advance airway management and emergency Caesarean section. (d) Advanced airway placement should be performed by the most experienced provider available. Ensuring optimal positioning and expert assistance are necessary parts of managing the maternal airway. 07. In the patient with an obviously gravid uterus who has not had a return of spontaneous circulation, the team leader should pay particular attention to the time interval between onset of cardiac arrest and decision to initiate an emergency Caesarean section. Regular announcements of time elapsed since collapse by the person recording details of the resuscitation may help the entire team focus on avoiding inappropriate delays in delivery. When time elapsed has reached four minutes from confrmed maternal cardiac arrest, the decision to perform a Caesarean section must be made in order to meet the fve-minute limit for time to delivery of the neonate. 08. Post-arrest care after a successful resuscitation for cardiac arrest in pregnancy requires the coordinated effort of all services involved to provide comprehensive care, prevent premature withdrawal of life-sustaining therapy, and optimize survival to discharge. Particular issues that may need to be addressed include the use of therapeutic hypothermia during pregnancy (which is a relative contraindication, but one case report suggests beneft 19 ) and the management of a post-arrest, unstable patient post- Caesarean section who may be conscious and aware. 09. We recommend development of an initial and ongoing training program for maternal ACLS, which should include regular and random drills to maintain team competence. 10. All maternal cardiac arrest cases should be reviewed by quality improvement teams within the hospital to derive beneft from experience. This review must be done expeditiously and the knowledge gained disseminated widely as soon after the event as possible. Creating a standardized system for managing maternal cardiac arrest is only the frst step in an active knowledge translation (KT) strategy. This includes multi-disciplinary involvement and a variety of ongoing dissemination approaches, and it is crucial to ensure adoption of and adherence to the evidence and the guidelines. Common KT strategies for change include interdisciplinary education, embedding the algorithm in routine care processes, reminder systems, and audit and feedback. Specifc examples are 862 l AUGUST JOGC AOT 2011 COMMENTARY Table 1. Recommended equipment in high risk areas Equipment contents of the emergency Caesarean section tray Equipment for neonatal resuscitation and stabilization Scalpel with no 10 blade Over-bed warmer Lower end of Balfour retractor Neonatal airway supplies Pack of sponges Umbilical access 2 Kelly clamps Medications (eg, epinephrine 1:10 000) Needle driver Russian forceps Sutures and suture scissors Table 2. Knowledge-to-action model applied to implementation of the maternal cardiac arrest algorithm Knowledge-to-action steps Specifc strategies Assess barriers to knowledge use Prior to implementation, work with staff from all relevant units (eg, using focus groups) to understand current local process for managing maternal cardiac arrest and any shortcomings to be sure improvements are addressed properly when the algorithm is implementated This step is often missed but is crucial to ensuring uptake Adapt knowledge to local use Compare the algorithm recommendations with current local process and adapt or innovate as needed to encourage acceptance and meet existing local requirements Ensure all relevant disciplines are included so that there are no gaps and full consensus is reached on all decisions Implement with tailored strategies Use implementation/dissemination strategies that are known to work well in the local context For example, if laminated pocket cards are used regularly by staff, have one made for the algorithm; if not, perhaps one copy on the crash cart is enough Because of the uncommon and urgent nature of maternal cardiac arrest, posters, emails, and printed educational material may be less useful than evidence-based instructions at the point of care Monitor knowledge use Establish measures of performance associated with steps in the algorithm and provide timely feedback on performance to the team involved; build in case debrief sessions with the team to understand what went well, what didnt, and why, and how to prepare proactively for future cases Evaluate outcomes Using the performance data described above, compare relevant patient outcomes (eg, survival) with performance longitudinally over time to evaluate the impact of the new algorithm, and be prepared to adjust the implementation strategy accordingly Sustain knowledge use A plan for regular annual updating of the evidence and communication of changes to the implementation strategy should be agreed upon prior to launching Ensure that information about decision-making processes and algorithm steps remain accessible to all staff in various mediums (eg, electronic, hardcopy, posters) and that input on upgrades is sought from all relevant disciplines If maternal cardiac arrests are not frequent in any given setting, incorporating a random mock code system to keep staff competence high may be useful 21 AUGUST JOGC AOT 2011 l 863 The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy included in the above recommendations (steps 1 to 10 above) and in Table 2, which uses the knowledge-to-action framework of Graham et al. to outline a tailored KT plan. 20
Information and guidelines must be kept up to date with the evidence and must be accessible to all staff, or guidelines will very likely fall out of use. CONCLuSION Maternal cardiac arrest requires an organized and coordinated effort on the part of various specialties. We hope that this framework will help hospitals and emergency personnel organize and prepare for the management of this rare but critical event. ACKNOWLEDGEMENTS Dr Morrison is the Robert and Dorothy Pitts Chair in Acute Care and Emergency Medicine, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michaels Hospital, Past Chair of the Advance Cardiac Life Support Committee of the American Heart Association and the Co Chair of the Advance Life Support Task Force of the International Liaison Committee on Resuscitation for Consensus 2010. REFERENCES 1. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers lives: reviewing maternal deaths to make motherhood safer: 20062008. 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