Sepsis and Pregnancy

Pregnant graffiti in Lebanon (Wikimedia)

According to an excerpt from Randi Hutter Epstein’s book Get Me Out: A History of Childbirth From the Garden of Eden to the Sperm Bank, five hundred years ago a folk healer advised Catherine de Medici, then the queen of France, to drink mare’s urine and bathe in cow manure to increase her chances of getting pregnant. And she did it. Fortunately, you won’t need mare’s urine to treat pregnant patients with sepsis. But you will need to listen to the March EM:RAP podcast or read the PDF called Sepsis and Infections in Pregnancy by Stewart Swadron MD, Gillian Schmitz MD, Rachel Bridwell MD and Brandon Carius PA.

What are the most common infections seen in pregnancy in your region? Are vital signs good indicators during maternal and fetal resuscitation? If you don’t have much time there are five quick Take Home Points for a 30-second read.

Wikimedia photo.

Who Knew? Some of the earliest women’s health books were written by monks…although they would not be my first or even seventh guess as authors. One of the most popular monk guides, Women’s Secrets, or De Secretis Mulierum, has been translated from the original text into modern language by Helen Rodnite Lemay, a medieval scholar.

PreHospital Air Medical Plasma Trial (PAMPer)

Fresh frozen plasma (Wikimedia)

Fluid resuscitation, including type and amount, has been scrutinized for prehospital care of trauma patients. This recent multi-center study demonstrated remarkable results. The abstract is reproduced from the NEJM website:

The New England Journal of Medicine

Abstract

BACKGROUND

After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.

METHODS

To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days.

RESULTS

A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, −9.8 percentage points; 95% confidence interval, −18.6 to −1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan–Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients’ arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

CONCLUSIONS

In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427.)

Who Knew?

Two vampires walked into a bar.

The bartender said, “what will it be?”

The first vampire said, “I’ll have a blood.”

The second vampire said, “I’ll have a plasma.”

“Right”, the bartender replied, “one blood and one blood lite.”