Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Obstetric ICU Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Guidelines for ICU Admission, Discharge Diagnosis Model: This model uses specific conditions or diseases to determine appropriateness of ICU admission A Cardiac System Acute myocardial infarction with complications Cardiogenic shock Complex arrhythmias requiring close monitoring and intervention Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support Hypertensive emergencies Unstable angina, particularly with dysrhythmias, hemodynamic instability, or persistent chest pain S/P cardiac arrest Cardiac tamponade or constriction with hemodynamic instability Dissecting aortic aneurysms 10.Complete heart block B Pulmonary System: Acute respiratory failure requiring ventilatory support Pulmonary emboli with hemodynamic instability Patients in an intermediate care unit who are demonstrating respiratory deterioration Need for nursing/respiratory care not available in lesser care areas such as floor or intermediate care unit Massive hemoptysis Respiratory failure with imminent intubation Obstetric I.C.U Anaesthesia, ICU and Pain management Dep C- Neurologic Disorders: Acute stroke with altered mental status Coma: metabolic, toxic, or anoxic Intracranial hemorrhage with potential for herniation Acute subarachnoid hemorrhage Meningitis with compromise altered mental status or respiratory Central nervous system or neuromuscular disorders with deteriorating neurologic or pulmonary function Status epilepticus Brain dead or potentially brain dead patients who are being aggressively managed while determining organ donation status Vasospasm 10 Severe head injured patients D- Drug Ingestion and Drug Overdose: Hemodynamically unstable drug ingestion Drug ingestion with significantly altered mental status with inadequate airway protection Seizures following drug ingestion E- Gastrointestinal Disorders: Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding, or with comorbid conditions Fulminant hepatic failure Severe pancreatitis Esophageal perforation with or without mediastinitis F Endocrine Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Thyroid storm or myxedema coma with hemodynamic instability Hyperosmolar instability state with coma and/or hemodynamic Other endocrine problems such as adrenal crises with hemodynamic instability Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring Hypo or hypernatremia with seizures, altered mental status Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias Hypo or hyperkalemia with dysrhythmias or muscular weakness Hypophosphatemia with muscular weakness G Surgical: Post-operative patients requiring hemodynamic monitoring/ventilatory support or extensive nursing care H Miscellaneous: Septic shock with hemodynamic instability Hemodynamic monitoring Clinical conditions requiring ICU level nursing care Environmental injuries hypo/hyperthermia) (lightning, near drowning, New/experimental therapies with potential for complications Objective Parameters Model: Objective criteria have been requested, expected and reviewed from individual hospitals as part of the Joint Commission on Accreditation of Healthcare Organizations' review process of special care units in the past Vital Signs:  Pulse < 40 or > 150 beats/minute  Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's usual pressure Obstetric I.C.U Anaesthesia, ICU and Pain management Dep  Mean arterial pressure < 60 mm Hg  Diastolic arterial pressure > 120 mm Hg  Respiratory rate > 35 breaths/minute Laboratory Values (newly discovered):        Serum sodium < 110 mEq/L or > 170 mEq/L Serum potassium < 2.0 mEq/L or > 7.0 mEq/L PaO2 < 50 mm Hg pH < 7.1 or > 7.7 Serum glucose > 800 mg/dl Serum calcium > 15 mg/dl Toxic level of drug or other chemical substance in a hemodynamically or neurologically compromised patient Radiography/Ultrasonography/Tomography (newly discovered):  Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs  Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability  Dissecting aortic aneurysm Electrocardiogram  Myocardial infarction with complex arrhythmias, hemodynamic instability or congestive heart failure  Sustained ventricular tachycardia or ventricular fibrillation  Complete heart block with hemodynamic instability Physical Findings (acute onset):         Unequal pupils in an unconscious patient Burns covering > 10% BSA Anuria Airway obstruction Coma Continuous seizures Cyanosis Cardiac tamponade Obstetric I.C.U Anaesthesia, ICU and Pain management Dep DISCHARGE CRITERIA The status of patients admitted to an ICU should be reviewed continuously to identify patients who may no longer need ICU care This includes: A When a patient's physiologic status has stabilized and the need for ICU monitoring and care is no longer necessary B When a patient's physiological status has deteriorated and / or become irreversible and active interventions are no longer beneficial, withdrawal of therapy should be carried out in the intensive care unit Patient should only be discharged to the ward if bed is required Discharge will be based on the following criteria: Stable hemodynamic parameters Stable respiratory status (patient extubated with stable arterial blood gases) and airway patency Oxygen requirements not more than 60% Intravenous inotropic/ vasopressor support and vasodilators are no longer necessary Patients on low dose inotropic support may be discharged earlier if ICU bed is required Cardiac dysrhythmias are controlled Neurologic stability with control of seizures for 48 hours Patients who require chronic mechanical ventilation (e.g motor neuron disease, cervical spine injuries) with any of the acute critical problems reversed or resolved Patients with tracheostomies who no longer require frequent suctioning Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Acute Pain Management in ICU Definitions Pain An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is always subjective and each individual learns the application of the word through experiences related to injury in early life Acute Pain Pain associated with surgery, trauma, medical emergencies or attacks on top of chronic condition Policy  Doctors as well as nurses should pain assessment Clinical assessment includes the location, severity, radiation, duration, frequency, characteristics, precipitating factors, alleviating and allergy status (use of pain score) Assessment should be done by the ICU nurses upon admission of the patient, in every episode of vital signs check  ICU physician assigned must have at least one rounds per shift for all patients subjected to pain management  Nurses should score for pain with every vital sign episode (fifth vital sign) or more frequent when indicated  Forms for pain, nurses and physician follow up charts are used as appropriate Pain Rating for all conscious adult and finally Behavioral Pain Scale for unconscious, intubated or sedated patient  For pain scores > 4/10 this means inadequate management Revision of plan, monitoring the accuracy of pain management protocol implementation should be done by the pain physician  Any patient admitted for pain treatment will have analgesia and pain management started within 30 minutes  They reassess the effectiveness of a given analgesia within thirty (30) minutes of administration Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Pain Assessment tool Numerical pain Score Behavioral Pain Score To assess pain in ventilated, unconscious and /or sedated patients CATEGORY FACIAL EXPRESSION UPPER LIMBS COMPLIANCE WITH VENTILATION DESCRIPTION SCORE RELAXED PARTIALLY TIGHTENED (eg brow lowering) Fully tightened (eg eyelid closing ) Grimacing No movement Partially bent Fully bent with finger flexion Permanently retracted Tolerating movement Coughing with movement Fighting with ventilator Unable to control ventilation Scoring: = No pain 4-6 = Mild pain 7-9= Moderate pain 10-12= Severe pain Obstetric I.C.U Anaesthesia, ICU and Pain management Dep WONG BAKER PAIN SCALE (non-communicative conscious adults) 10 Point to each face using the words to describe the pain intensity Ask the person to choose the face best describe his/her own pain Pain protocol According to the WHO stepladder approach for acute pain management Step 1(mild pain): Paracetamol  Adult: Paracetamol(perfalgan) IV , 1gm/6hrly NSAIDS if no contraindication  Liomethacine amp IV / 8hrly diluted in 50ml infusion over 30 minutes Once the patient can eat adequately (commonly after 48hrs) ;  Paracetamol tablet orally (Adol) 1000mg/6hrly  Ibuprofen (brufen) orally 400mg /8hrly (after meals) Use one of them or you may combine both according to the severity of pain Step (Moderate pain): (Step + weak opioid)  Nalbuphine 10 mg/70 kg administered IV, IM, every -8 hours as needed Maximum single dose: 20 mg Maximum daily dose: 160 mg  Tramadol (tramal) 50-100mg IM /8hrly p.r.n in the first 48hrs followed by 50 mg oral tablets 8hrly p.r.n Step (Severe pain): (Step + storng opioig) Adult and pediatrics  Pethidine 1mg/kg (50-100mg for an adult) IM/8hrly,p.r.n  Fentanyl mic/ kg  Morphine 0.1 mg/kg  Continuous epidural infusion Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Diabetic Emergencies Diabetic emergencies consist of hyperglycemic conditions such as diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS) HHS diabetic state, and hypoglycemic emergencies DKA is an acute medical emergency associated with fetal loss rates in excess of 50% Maternal mortality rates are generally less than 1% DKA in pregnancy most commonly occurs in women with pregestational, insulin dependent diabetes who are poorly controlled or in women newly diagnosed with insulin dependent diabetes DKA may be provoked by an exposure to a stress such as infection, surgery, or labor DKA and HHS Transfer to the ICU may be required if Severe ketoacidosis (pH < 7.0) Altered consciousness More intensive monitoring anticipated (e.g intercurrent illness) Step 1: Start initial resuscitation  Urgently insert two wide-bore intravenous peripheral catheters for volume infusion  A central line is needed in presence of hypotension, lack of peripheral access, multiple infusions, severe acidosis, and impaired cardiorespiratory or renal parameters  Airway should be maintained as HHS patients could be obtunded on presentation  Hyperventilation is prominent with acidosis and may require assisted breathing Step 2: Take focused history and perform physical examination  History of insulin omission in a diabetic patient is common and often points toward a diagnosis of DKA Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Hematologic management  Corticosteroids—may improve the platelet count and other laboratory parameters more quickly, but have not been shown to improve long-term maternal or fetal outcomes  Supportive care with blood products—there is no contraindication to platelet transfusion  Therapeutic plasma exchange—if thrombocytopenia, hemolysis or renal failure continues to worsen 48-72 hours postpartum Thrombotic Thrombocytopenia Purpura (TTP)/Atypical Hemolytic Uremic Syndrome (aHUS)  Differentiating between severe preeclampsia, HELLP, AFLP, or evolving  TTP/aHUS precipitated by pregnancy may be difficult (see Table 6)  While the use of eculizumab has been described in paroxysmal nocturnal  Hemoglobinuria during pregnancy, as yet no reports exist on eculizumab in aHUS during pregnancy  Since therapeutic plasma exchange has been shown to improve the outcome of all of these conditions, when plasma exchange is otherwise indicated, diagnostic certainty is not required - Plasmapheresis is the first-line therapy Plasmapheresis removes platelet-aggregating substances causing TTP and HUS Treatment is 90% successful with TTP but is less successful with HUS - Steroids have been used, often in conjunction with plasmapheresis However, steroids are less effective than plasmapheresis (25% response rate) - Platelet transfusions should be avoided when possible because they can cause a clinical deterioration Use platelet transfusions only for uncontrolled bleeding or intracranial hemorrhage Obstetric I.C.U Anaesthesia, ICU and Pain management Dep - Other therapies include immunosuppressive agents (vincristine, azathioprine,cyclosporine), splenectomy for TTP, and hemodialysis for HUS Premature termination of pregnancy has been associated with relapse Delivery should be considered only when no response to other therapies occurs Immune Thrombocytopenic Purpura Women with no bleeding manifestations and platelet counts ≥ 30 x 109/L not require any treatment until 36 weeks gestation (or sooner if delivery is imminent)  If platelet counts are < 30 x 109/L or clinically relevant bleeding is present, first line therapy is oral corticosteroids or intravenous immunoglobulin (IVIg)  The recommended starting dose of IVIg is g/kg  In pregnancy, the oral corticosteroids prednisone and prednisolone are preferred to dexamethasone, which crosses the placenta more readily  While “The American Society of Hematology 2011 Evidence-Based Practice  Guideline for Immune Thrombocytopenia” recommends a starting dose of prednisone of 1mg/kg daily, there is no evidence that a higher starting dose is better than a lower dose Therefore, other experts recommend a starting dose of 0.25 to 0.5 mg/kg daily  Medications are adjusted to maintain a safe platelet count Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Therapeutic options for management of ITP during pregnancy Plasma exchange:  PEX should be started with 1·5 PV exchanges, using S/D plasma in all age groups and reassessed daily  The volume of exchange can be reduced to 1·0 PV when the clinical condition and laboratory test results are stabilizing  Intensification in frequency and or volume of PEX procedures should be considered in life-threatening cases  Daily PEX should continue for a minimum of d after platelet count has been >150 000 and then stopped Steroids (methyle prednisone)  Start immediately after PEX  Give steroids; either IV methylprednisolone (1 g/day for days) or oral prednisolone (e.g mg/kg/day) with an oral proton pump inhibitor  Give oral folic acid mg OD Obstetric I.C.U Anaesthesia, ICU and Pain management Dep  Response time is 3-7 days; maximum effect occurs by 2-3 weeks  Approximately 70% of patients will respond, and 25% will enter complete remission  Risks include hyperglycemia, fluid retention, and bone calcium loss Intravenous immune globulin (IVIG)  IVIG is ideal when time is inadequate for steroids to take effect (prior to surgery or low platelet counts with bleeding)  Response time is 6-72 hours  Approximately 70% of patients will return to pretreatment levels within 30 days  This treatment is very expensive Anti-D immunoglobulin  In Rh-positive, non splenectomized women, the following is noted:  It is not useful in Rh-negative or splenectomized women  Response time of anti-D immunoglobulin is 1-2 days, peak effect in 7–14 days, average duration 30 days Splenectomy  In non-pregnant women, splenectomy is used for patients who are unresponsive to IVIG  Splenectomy usually is avoided during pregnancy for technical reasons, although it remains an option in the first and second trimesters when ITP is severe (counts < 10,000/μL) and the patient does not respond to steroids or IVIG  Complete remission occurs in two thirds of cases  Splenectomy does not have an impact on circulating antibodies that may still cross the placenta and cause neonatal thrombocytopenia Platelet transfusion  This is a temporary measure, which should be administered for life-threatening hemorrhage and should be available prior to surgery for patients with severe thrombocytopenia  Six to 10 units of platelets are usually administered at one time Obstetric I.C.U Anaesthesia, ICU and Pain management Dep  Platelet counts normally rise by 10,000/μL for each unit of platelets transfused, but in ITP the rise is less pronounced due to destruction of donor platelets Prevent thrombosis When platelet count >50 000, start low molecular weight heparin thromboprophylaxis and aspirin 75 mg OD Refractory  There is a subgroup of patients who present with TTP who subsequently show a slow or incomplete response to PEX ± corticosteroids Refractory disease was previously arbitrarily defined as persistent thrombocytopenia or LDH elevation after a total of seven daily PEX procedures LDH is not however, a reliable marker of disease activity We have therefore redefined refractory disease as progression of clinical symptoms or persistent thrombocytopenia despite PEX  Intensification of PEX with the introduction of 12-hourly or double PV exchanges and the addition of further steroids have provided some benefit addition of rituximab can be considered in refractory TTP References: Kadir RA, McLintock C Thrombocytopenia and disorders of platelet function in pregnancy Semin Thromb Hemost 2011 Sep 37(6):640-52 Reference: Gernsheimer T, James AH, Stasi R, How I treat thrombocytopenia in pregnancy Blood 2013; 121(1):38-47 Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy Cochrane Database Syst Rev 2010(9) Practice Bulletin No 166: Thrombocytopenia in Pregnancy Obstet Gynecol 2016 Sep 128 (3):e43-53 Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Renal Disease with pregnancy Urinary Tract Infection  Asymptomatic bacteriuria  Acute cystitis  Acute pyelonephritis Asymptomatic Bacteriuria Diagnosis  Most women with asymptomatic bacteriuria are found to be infected during early pregnancy and very few subsequently acquire asymptomatic bacteriuria  Bacteriuria is only considered significant if the colony count exceeds 100,000/ml on a MSU Management  The choice of antibiotic depends on culture/sensitivity  Ampicillin, amoxicillin, Augmentin and the cephalosporin are safe and appropriate antibiotics in pregnancy Treatment should be continued for weeks in the first instance and regular urinary culture required Acute Cystitis Clinical features Urinary frequency, dysuria, haemeturia and suprapubic pain Diagnosis Significant bacteriuria on MSU Management  Same as asymptomatic bacteriuria Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Several non-pharmacological maneuvers may help to prevent recurrent infection in women with recurrent urinary-tract infections in pregnancy These include increase fluid intake Acute Pyelonephritis Clinical Features  Fever  Loin and abdominal pain  Vomiting  Rigors  Proteinuria  Hematuria Risk increases in women  On steroid therapy  With polycystic kidneys  Congenital abnormalities of renal tract  Urinary-tract calculi  Diabetes Diagnosis  Significant bacteriuria on MSU specimen Management,  Should be after hospitalization  I/V Antibiotic Penicillin and cephalosporin are the 1st choice Pregnancy with Chronic Renal Disease Effects of Pregnancy The risks include:  Accelerated decline in renal function  Rising hypertension  Worsening proteinuria Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Effects of chronic renal disease on pregnancy The risks includes:  Miscarriage  Pre-eclampsia  Intrauterine growth retardation  Preterm delivery  Fetal death Management  Women with chronic renal disease should be managed jointly by obstetricians and physicians  Preconceptual assessment of renal functions and blood pressure should be made  In view of the increased risk of pre-eclampsia, treatment with low dose aspirin should be considered especially in those with hypertension, renal impairment or a previous poor obstetric history  Careful monitoring and control of blood pressure both prepregnancy and antenatally is important Acute Renal Failure Clinical Features  Anuria/oliguria  urea, creatinine rises  Decreased GFR Causes Infection  Septic abortion  Puerperal sepsis  Rarely acute pyelonephritis Blood Loss  Postpartum hemorrhage  Abruption Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Volume Contraction  Pre-eclampsia  Eclampsia (6%)  Hyperemesis Gravidarum Post-renal Failure  Ureteric damage or obstruction Pre-eclampsia HELLP Syndrome  7% have actual renal failure  Thrombotic thrombocytopenic purura/hemolytic uraemic syndrome (TTP/HUS) Management  This will depend on underlying cause Dialysis should be initiated when the serum creatinine level is 3.5-5.0 mg/dL or the glomerular filtration rate (GFR) is below 20 ml/min Fetal outcome is improved with longer, more frequent hemodialysis sessions, which usually involves 20 hours of dialysis per week Daily dialysis is more likely to prevent hypotension and significant metabolic shifts Dialysis should aim to keep blood urea nitrogen levels below 50 mg/dL, because controlling uremia may avoid polyhydramnios, control hypertension, and improve the mother's nutritional status Peritoneal dialysis with smaller volumes and frequent exchanges can also be done to achieve these same goals Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Sepsis with pregnancy Risk factors: Investigations: Blood cultures are the key investigation and should be obtained prior to antibiotic administration; however, antibiotic treatment should be started without waiting for microbiology results Serum lactate should be measured within six hours of the suspicion of severe sepsis in order to guide management Serum lactate ≥4 mmol/l is indicative of tissue hypoperfusion Any relevant imaging studies should be performed promptly in an attempt to confirm the source of infection Obstetric I.C.U Anaesthesia, ICU and Pain management Dep What empirical and specific antimicrobial therapy should be used to treat the woman? Administration of intravenous broad spectrum antibiotics is recommended within one hour of suspicion of severe sepsis, with or without septic shock If genital tract sepsis is suspected, prompt early treatment with a combination of high-dose broad spectrum intravenous antibiotics may be lifesaving Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Venous thrombo-embolism Diagnosis of acute Venous Thrombo Embolism Any woman with symptoms and/or signs suggestive of VTE should have objective testing performed expeditiously and treatment with lowmolecular-weight heparin (LMWH) given until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated What investigations are needed for the diagnosis of an acute DVT Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT If ultrasound is negative and there is a low level of clinical suspicion, anticoagulant treatment can be discontinued If ultrasound is negative and a high level of clinical suspicion exists, anticoagulant treatment should be discontinued but the ultrasound should be repeated on days and Compression duplex ultrasound is the primary diagnostic test for DVT What investigations are needed for the diagnosis of an acute PE Women presenting with symptoms and signs of an acute PE should have an electrocardiogram (ECG) and a chest X-ray (CXR) performed In women with suspected PE who also have symptoms and signs of DVT, compression duplex ultrasound should be performed If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue In women with suspected PE without symptoms and signs of DVT, a ventilation/perfusion (V/Q) lung scan or a computerized tomography pulmonary angiogram (CTPA) should be performed When the chest Xray is abnormal and there is a clinical suspicion of PE, CTPA should be performed in preference to a V/Q scan Alternative or repeat testing should be carried out where V/Q scan or CTPA is normal but the clinical suspicion of PE remains Anticoagulant treatment should be continued until PE is definitively excluded Obstetric I.C.U Anaesthesia, ICU and Pain management Dep D-dimer testing should not be performed in the investigation of acute VTE in pregnancy What baseline blood investigations…a full blood coagulation screen, urea and electrolytes, and liver function tests count, Therapeutic dose of LMWH in pregnancy Twice-daily dosage regimen for enoxaparin and dalteparin in the treatment of VTE in pregnancy (enoxaparin 1mg/kg) twice daily How massive life-threatening PE in pregnancy and the puerperium should be managed Women should be managed on an individual basis regarding: intravenous unfractionated heparin, thrombolytic therapy or thoracotomy and surgical embolectomy Intravenous unfractionated heparin is the preferred, initial treatment in massive PE with cardiovascular compromise regimen for the administration of intravenous unfractionated heparin is loading dose of 80 units/kg, followed by a continuous intravenous infusion of 18 units/kg/hour l if a patient has received thrombolysis (see below), the loading dose of heparin should be omitted and an infusion started at 18 units/kg/hour It is mandatory to measure activated partial thromboplastin time (APTT) level 4–6 hours after the loading dose, hours after any dose change and then at least daily when in the therapeutic range The therapeutic target APTT ratio is usually 1.5–2.5 times the average laboratory control value In the initial management of DVT, the leg should be elevated and a graduated elastic compression stocking applied to reduce edema Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Mobilization with graduated elastic compression stockings should be encouraged Consideration should be given to the use of a temporary inferior vena cava filter in the peripartum period for patients with iliac vein VTE to reduce the risk of PE or in patients with proven DVT and who have recurrent PE despite adequate anticoagulation Placement of a temporary inferior vena cava (IVC) filter in obstetric practice What is the maintenance treatment of DVT or PE Treatment with therapeutic doses of subcutaneous LMWH should be employed during the remainder of the pregnancy and for at least weeks postnatally and until at least months of treatment has been given in total Anticoagulant therapy during labor and delivery Should anticoagulant therapy be altered during labor and delivery When VTE occurs at term, consideration should be given to the use of intravenous unfractionated heparin which is more easily manipulated The woman on LMWH for maintenance therapy should be advised that once she is in established labor or thinks that she is in labor, she should not inject any further heparin Where delivery is planned, either by elective cesarean section or induction of labor, LMWH maintenance therapy should be discontinued 24 hours prior to planned delivery Regional anesthetic or analgesic techniques should not be undertaken until at least 24 hours after the last dose of therapeutic LMWH LMWH should not be given for hours after the use of spinal anesthesia or after the epidural catheter has been removed, and the epidural catheter should not be removed within 12 hours of the most recent injection Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Postnatal anticoagulation How anticoagulation should be managed postnatally Therapeutic anticoagulant therapy should be continued for the duration of the pregnancy and for at least weeks postnatally and until at least months of treatment has been given in total Before discontinuing treatment, the continuing risk of thrombosis should be assessed Women should be offered a choice of LMWH or oral anticoagulant for postnatal therapy after discussion about the need for regular blood tests for monitoring of warfarin, particularly during the first 10 days of treatment Postpartum warfarin should be avoided until at least the fifth day and for longer in women at increased risk of postpartum hemorrhage Women should be advised that neither heparin (unfractionated or LMWH) nor warfarin is contraindicated in breastfeeding ... control ventilation Scoring: = No pain 4-6 = Mild pain 7-9= Moderate pain 10-12= Severe pain Obstetric I.C.U Anaesthesia, ICU and Pain management Dep WONG BAKER PAIN SCALE (non-communicative conscious... administration Obstetric I.C.U Anaesthesia, ICU and Pain management Dep Pain Assessment tool Numerical pain Score Behavioral Pain Score To assess pain in ventilated, unconscious and /or sedated... describe the pain intensity Ask the person to choose the face best describe his/her own pain Pain protocol According to the WHO stepladder approach for acute pain management Step 1(mild pain): Paracetamol