Good discussion for clinical practise

1. OBSTETRIC ICU MANAGEMENT PROTOCOLS GIMS.
1-Comprehensive Management Guidelines for Peripartum Cardiomyopathy (PPCM).
Signs and Symptoms:
Early Identification:
Vigilantly monitor pregnant or recently postpartum mother’s for symptoms such as fatigue,
dyspnea, palpitations, and edema.
Respiratory Distress and Hypoxia:
If the patient becomes breathless or experiences a drop in oxygen saturation, conduct a
prompt clinical assessment.
Auscultation Findings:
Auscultation may reveal bilateral crepitations indicative of pulmonary edema.
Point-of-Care Ultrasound (USG):
Perform point-of-care ultrasound to assess for B-lines, supporting the diagnosis of
pulmonary edema.
Intervention for Pulmonary Edema:
Non-Invasive Ventilation (NIV):
Initiate NIV support promptly to alleviate respiratory distress and reduce pulmonary edema.
Criteria to start NIV Support:
1-Respiratory rate:
Typically, a respiratory rate above 25-30 breaths per minute, indicating increased work of
breathing.
2-Oxygen saturation:
Persistent oxygen saturation below 90% despite supplemental oxygen therapy, indicating
severe hypoxemia.
3-Clinical signs of respiratory distress:
Such as the use of accessory muscles, paradoxical breathing, or nasal flaring.
Lasix (Furosemide) Infusion:
Administer Lasix infusion based on IVC diameter and clinical response to manage fluid
overload.
1-Assessment of IVC diameter:
Using bedside ultrasound, the diameter and collapsibility of the IVC can be measured. A
dilated IVC of more than 1.6cm2 with reduced collapsibility (>50% collapse with inspiration)
suggests elevated CVP and fluid overload.
2-Clinical evaluation:

2. The decision to initiate a Lasix infusion should also consider the patient's clinical
presentation, including symptoms such as dyspnea, orthopnea, and peripheral edema, as
well as vital signs, electrolyte levels, and renal function.
3-Selection of infusion rate:
Based on the severity of symptoms and the degree of fluid overload, the initial infusion rate
of furosemide can be determined.
Typical starting doses range from 5 to 10 mg/hour.
4-Monitoring and titration:
The patient's response to the Lasix infusion should be closely monitored, including urine
output, vital signs, and clinical symptoms. Serial assessments of IVC diameter can also guide
the titration of the infusion rate. A reduction in IVC diameter along with improvement in
symptoms and signs of fluid overload indicates a positive response to diuresis.
5-Adjustment of infusion rate:
The infusion rate of furosemide can be adjusted based on the patient's urine output,
electrolyte levels (particularly potassium and if possible magnesium), and hemodynamic
status. Titration may involve increasing the infusion rate if there is inadequate diuresis or
reducing it if there are signs of excessive diuresis or electrolyte abnormalities. Electrolytes,
including potassium, should be monitored at least once every 12 hours when a Lasix infusion
is initiated.
Fluid Intake:
1-IV fluids:
IV fluids should generally be minimized to avoid exacerbating volume overload. IV fluids may
be necessary to maintain hydration in patients with poor oral intake or those who are unable
to tolerate oral fluids. However, the volume and rate of IV fluid administration should be
carefully monitored and adjusted based on urine output and clinical response.
2-Oral fluids:
Encouraging oral fluid intake is often preferable in patients with PPCM and pulmonary
edema who are hemodynamically stable and able to tolerate oral intake. Oral fluids help
maintain hydration and can facilitate diuresis. Patients should be encouraged to drink fluids
as tolerated, with particular emphasis on non-sodium-containing fluids such as water.
Medication Regimen in PPCM:
1- Bromocriptine 2.5mg bd
Exert its effects by modulating the activity of dopamine receptors, which may help improve
myocardial function and reduce cardiac remodeling. Additionally, bromocriptine has anti-
inflammatory and anti-fibrotic properties.
2- Pentoxifylline 400mg TID
As an anti-inflammatory, immunomodulatory, and vasodilatory effects.

3. 3- Spironolactone 25mg OD
To manage fluid balance and inhibit aldosterone effects.
4- Dapagliflozin 10mg OD
As an SGLT2 inhibitor to improve heart failure outcomes.
5- Dosage of Ivabradine
Starting dose: 5 mg twice daily
Maximum dose: 7.5 mg twice daily
Target Heart Rate:
The target heart rate for PPCM is often less than 100 beats per minute (bpm), and in some
cases, less than 90 bpm may be desired.
Heart Rate Response:
The heart rate response to Ivabradine can vary among individuals based on factors such as
baseline heart rate, severity of symptoms, and overall cardiovascular health.
Generally, a starting dose of 5 mg twice daily may aim to reduce the heart rate to below 100
bpm.
If a lower target heart rate is desired, or if the patient experiences bradycardia or other
adverse effects, the dosage of Ivabradine may be adjusted downward to 2.5 mg twice daily.
Hemodynamic Support:
Dobutamine Infusion:
Initiate dobutamine infusion to enhance cardiac contractility and improve cardiac output.
Screening echo showing LV dysfunction:
1-Reduced LV contractility evident on echocardiography.
2-Global hypokinesis or regional wall motion abnormalities observed.
3-Decreased LV systolic function indicated by impaired myocardial wall motion.
Ultrasonography (USG) lung findings:
1-Presence of pulmonary edema evident on lung ultrasound.
B-lines, consolidations, and pleural effusions may be observed.
2-Signs of interstitial and alveolar edema indicative of fluid overload
Hypotension (BP less than 90/60):
Systolic blood pressure (SBP) <90 mmHg and/or diastolic blood pressure (DBP) <60 mmHg.
Dosage:
Initiate dobutamine infusion at a low dose (e.g., 2.5 to 5 mcg/kg/min) and titrate upwards
based on clinical response and hemodynamic parameters for first 24 to 48 hours.
Higher doses may be required in patients with more severe symptoms or hemodynamic
instability.

4. Noradrenaline Infusion:
Blood Pressure (BP):
1-The goal BP in patients with PPCM is typically to maintain a mean arterial pressure (MAP)
above 65 mmHg to ensure adequate organ perfusion.
2-Initiation of noradrenaline infusion may be considered if the systolic blood pressure (SBP)
is persistently below 90 mmHg or the MAP is below 65 mmHg despite fluid resuscitation and
other measures.
Hourly Urine Output:
1-Adequate urine output is essential to assess renal perfusion and function.
2-Target hourly urine output is generally 0.5 to 1 mL/kg/hr in patients with PPCM.
3-Initiation of noradrenaline infusion may be warranted if urine output is persistently below
these targets despite fluid resuscitation.
Dosage Titration:
1-The initial infusion rate of noradrenaline is typically 0.05 to 0.1 mcg/kg/min.
2-Titrate the infusion rate based on hemodynamic response, aiming to achieve and maintain
the target BP and urine output.
3-The dosage may be increased gradually by increments of 0.05 to 0.1 mcg/kg/min every 5
to 10 minutes until the desired hemodynamic endpoints are achieved.
Minimum and Maximum BP:
1-The minimum BP to be maintained with noradrenaline infusion is typically a MAP above 65
mmHg to ensure adequate organ perfusion.
2-The maximum BP to be tolerated with noradrenaline infusion may vary depending on the
clinical scenario, but vigilance for hypertension and end-organ damage is essential.
3-In PPCM, the focus is on maintaining a hemodynamically stable BP rather than aggressively
targeting higher BP levels.
Deep vein thrombosis (DVT) prophylaxis
1-LMWH: Enoxaparin dosage is 40 mg subcutaneously once daily.
2-UFH: For patients unable to receive LMWH, UFH may be administered subcutaneously or
intravenously according to weight-based dosing protocols.
3-Initiate pharmacological prophylaxis as soon as feasible, preferably within 24 to 48 hours
of hospital admission or diagnosis of PPCM.