Severe Pre Eclampsia and Eclampsia AO4v8 Id 887

Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia
A Clinical Guideline
For Use in:
By:
Obstetrics
All Staff Caring for Pregnant Women
For:
Pregnant Women
Division responsible for document:
Women / Children
Key words:
severe pre-eclampsia (PET), eclampsia
Name of document author:

Job title of document author:
Name of document authors Line
Manager:
Job title of authors Line Manager:
Mrs Daisy Nirmal

Consultant, Obstetrics and Gynaecology
Supported by:
Obstetric Guidelines Committee
Assessed and approved by the:
Obstetric Guidelines Committee
Date of approval:
28/10/2015
Ratified by or reported as approved

to (if applicable):
To be reviewed before:
This document remains current after this
date but will be under review
To be reviewed by:
Reference and / or Trust Docs ID No:
Version No:
Clinical Standards Group and Effectiveness

Sub-Board
Description of changes:
No significant changes
Compliance links: (is there any NICE

related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations of
NICE?If so why?
Alastair McKelvey
Consultant Obstetrician
28/10/2018
Mrs Daisy Nirmal
AO4 id 887
8
(e.g. NICE, CQC)
Author: Mrs Daisy Nirmal

Valid until: 28/10/2018
Document: Management of Severe Pre-eclampsia and Eclampsia
Copy of complete document available from the Trust intranet
Issue: 28/10/ 2015

Guideline Ref No A04 id 887v. 8
Page 1 of 13
Quick reference guideline/s Appendix A: Antihypertensive therapy in severe PET
MAP 125-140 mmHg
MAP > 140 mmHg
Recheck BP every 5 min

If sustained over 15 min
Recheck BP every 15 min

If sustained over 45 min
Labetalol
50 mg IV
Recheck BP
every 15 min
MAP < 125

Recheck MAP
mmHg
After 5 min
(Confirm with manual sphyg)
MAP>125
mmHg
Repeat labetalol
50 mg every 5 min
(max. dose 200mg)
until either
or
MAP 125 mmHg
Consider referral to HDU/ITU

Issue: 28/10/ 2015

Page 2 of 13
Appendix B: Fluid balance in women with severe PET who have a CVP
CVP
reading
<4 mmHg
Voluven 6%
500 mL stat
4-10 mmHg
>10 mmHg
Maintenance Fluids
(85 mL/hr
I.V. Furosemide
40 mg
Hartmanns)
Reassess CVP
Diuresis
reading after 1
CVP
4-10 mmHg
No diuresis
CVP
< 4 mmHg
Maintenance
Referral to
fluids.
HDU/ITU
Maintenance fluids
(85 mL/hr Hartmanns)

Issue: 28/10/ 2015

Page 3 of 13
Objectives & Rationale
Hypertension is the most common medical disorder of pregnancy and both severe
PET and eclampsia are life-threatening conditions, as well as causing significant
morbidity. Although the incidence of eclampsia and its complications in the United
Kingdom appears to have declined since 1992, severe pre-eclampsia/eclampsia
remains the second highest cause of direct maternal deaths. Furthermore, the
importance of adequate treatment of systolic hypertension has been one of the Top
ten recommendations in the last two confidential enquiries into maternal deaths.
Locally, severe PET is the commonest reason for patients to receive Level 2
Intensive Care on the Delivery Suite.
Broad recommendations
The principles of management of severe PET are to stabilise the maternal condition
by controlling blood pressure, prevent seizures, then to deliver the baby by the safest
route.
Measurement of blood pressure
Initially, the blood pressure should be measured using a manual
sphygmomanometer, and recorded to the nearest 2mmHg. The diastolic pressure
should be measured at the disappearance of sounds (Korotkoff phase V) and NOT
as muffling (Korotkoff phase IV), as recommended in the past. A large BP cuff
should be used when the upper arm circumference exceeds 33 cm.
Assessment and diagnosis of severe Pre-eclampsia
Although the diagnosis of severe hypertension is based on the absolute BP, the
subsequent management is largely based on the mean arterial pressure or MAP (the
MAP is usually taken as the diastolic BP plus 1/3 the systolic diastolic difference).
1. Absolute BP 160mmHg systolic or 110mmHg diastolic with proteinuria 2+
(1g./L) or more.
2. Absolute BP >140/90 (or else a rise in systolic BP of 25mmHg and/or a rise
in diastolic BP of 15 mmHg from first trimester values) with proteinuria 2+
(1g./L) or protein creatinine ratio (PCR) >30mg/mmol or more and one of the
following:a. headaches, visual disturbance, dyspnoea, chest or epigastric pain.
b. clonus > 3 beats
c. platelets <100 x 109 /lL or urate >450 umol/lL or ALT >50 u/L
d. creatinine greater than 100 umol/L
3. Eclampsia a seizure occurring in a patient with PET
4. H.E.L.L.P. syndrome
5. Clinical discretion should be used to include any other women who present
with atypical symptoms.
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Page 4 of 13
Immediate action
1. Transfer patient to the Delivery Suite to stay until at least 24 hours after
delivery. The patient needs to be specialled and a high dependence
monitoring chart should be commenced and meticulously up-dated.
2. Insert IV cannula into forearm vein with Hartmann's infusion at 85 mL/hour.
3. Indwelling urinary catheter for hourly urine measurements.
4. Initial maternal investigations:
a. full blood count (including haematocrit) )
Request
b. urea and electrolytes and urate.
Pre-eclampsia
c. liver function tests
screen
d. group and save

)
on ICE
A clotting screen is also required if the platelet count is < 100 x 109/L
1. Give prophylactic antacid (ranitidine 150 mg 6-hourly, by mouth)
2. Notify the Delivery Suite coordinator and the duty consultant obstetrician and
obstetric anaesthetist. It may also be appropriate to alert NICU of the patients
admission (see below).
Lines of communication
Clear lines of communication between the consultant obstetrician, consultant
anaesthetist, neonatologist and Delivery Suite co-ordinator are essential to recognise
rapid deterioration and plan appropriate management.
1.
The woman will have one-to-one care with a qualified midwife who will provide
the continuity of care and report to the co-ordinating midwife.
2.
Care for women with severe pre-eclampsia or eclampsia on Delivery Suite will
be coordinated by the consultant obstetrician, consultant anaesthetist and the
senior midwife coordinator on duty/call.
3.
The named obstetric consultant will take the overall lead in the management of
care.
4.
The woman will be reviewed by the multi-professional team at each ward

round or more frequently depending on the clinical findings to provide an
opportunity for clear lines of communication.
5.
Following each review a plan of care will be clearly documented in the

maternal notes.
6.
Any deterioration in the womans condition must be immediately

communicated to the consultant obstetrician, consultant anaesthetist and coordinator of midwives for DS in order to ensure appropriate care is given.
7.
The neonatologist and Neonatal Intensive care unit (NICU) will be made aware
of the womans condition, gestation, fetal wellbeing and any plans to induce
labour/deliver the baby

Issue: 28/10/ 2015

Page 5 of 13
8.
Liaison will be made with consultant haematologist where there is concern

regarding abnormal blood parameters.
9.
The multi-professional team will ensure that the woman and her family are
given the information required to make informed choices/give informed
consent in relation to her care and that they are included in the decision
making regarding the management of labour and delivery.
Maternal Monitoring
1.
After initial measurement of blood pressure with a manual

sphygmomanometer, subsequent measurements may be made more easily
with an automated device, such as a Datascope or Dinamap machine.
Although these machines will tend to underestimate the BP, this is rarely of
clinical significance.
2.
Record MAP and pulse every 15 minutes for a minimum of four hours until
stabilized, and then half hourly. Treatment should be based on the trends in
blood pressure. The anaesthetist may consider it appropriate to site an
invasive arterial line if the MAPs are persistently greater than 140.
3.
Oxygen saturation should be measured continuously and recorded hourly. If

saturation falls below 95% on room air, administer oxygen and consult
anaesthetist promptly consider interstitial pulmonary oedema (fluid overload)
or excess respiratory depressants.
4.
Indwelling catheter and hourly measurement of urine output and proteinuria.
5.
Fluid balance should be monitored very carefully. Detailed Input and Output
recordings should be added to the megachart.
6.
Temperature should be assessed four hourly.
7.
Routine PET blood samples should be taken every 12-24 hours or more
frequently at the discretion of the consultant.
8.
(CVP only necessary if oliguric or bleeding - see below. Most patients can be
managed safely without CVP monitoring)
Blood pressure control and anti-hypertensive treatment (see Appendix A)

Reduction of severe hypertension (MAP > 125 and/or systolic BP of 150-160mmHg)
is mandatory to reduce the risk of cerebrovascular accident. In eclampsia, antihypertensive treatment may also reduce the risk of further seizures. The aim of the
anti-hypertensive treatment is to keep the diastolic blood pressure between 90 100
mmHg and the systolic blood pressure between 140 150 mmHg.
In the acute situation, the treatment alternatives include intravenous, labetolol and
intravenous hydralazine and there appears little to choose between these drugs in
terms of efficacy. However, recent national guidance recommends labetolol, with
hydralazine as a second line therapy for those who may less responsive to labetolol,
such as women of Afro-Caribbean origin, or when it is contraindicated, such as in
women with asthma.
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Page 6 of 13
Labetolol regimen:
NB Contraindications to labetolol: asthma and cardiac failure
Principles:
1. Aim for MAP 125 and for systolic BP of less than 150-160mmHg.
2. For undelivered women with MAP over 140 the labetolol should be given
immediately.
3. If the woman can tolerate oral therapy an initial 200mg oral dose can be given.
This can be done immediately before venous access and so can achieve as
quick a result as an initial intravenous dose. This should lead to a reduction in
blood pressure in about half an hour. A second 200mg oral dose can be given
if needed in 30 minutes.
4. If there is no initial response to oral therapy or if it cannot be tolerated control
should be by repeated bolus of labetalol followed, if necessary, by a labetalol
infusion.
5. Bolus infusion is 50mg (= 10mL of labetalol 5mg/mL) given over at least 1
minute. This should have an effect by 5 minutes and should be repeated if
diastolic blood pressure has not been reduced. This can be repeated to a
maximum dose of 200mg (four bolus doses). The pulse rate should remain
over 60 beats per minute.
Labetalol is located in the red eclampsia box on the emergency trolley
6. Following this a maintenance infusion of labetalol should be commenced, if
required an infusion of (neat) labetalol 5mg/mL at a rate of 4mL/hour via a
syringe pump should be started. The infusion rate should be doubled every
half-hour to a maximum of 32mL (160mg)/ hour until the blood pressure has
dropped and then stabilized at an acceptable level. This level will vary
between women.
7. Oral antihypertensive treatment should be considered when intravenous
treatment has been discontinued.
Hydralazine regime
Principles:
1. Aim for MAP 125 and for systolic BP of less than 150-160mmHg.
2. Hydralazine may induce placental hypoperfusion in undelivered women, so
before it is administered to lower blood pressure in the acute phase of
treatment, volume expansion using a bolus dose of 500 mL Voluven 6% is
essential. For undelivered women with MAP 125-140 administer the Voluven
6% over 20 minutes, then recheck the blood pressure before administering
hydralazine, if necessary. For undelivered women with MAP over 140 the
hydralazine should be given immediately after starting the Voluven. No prior
volume expansion with Voluven is necessary before hydralazine
administration if the patient is delivered.

Issue: 28/10/ 2015

Page 7 of 13
3. Initial dose of hydralazine 5 mg. IV slowly every 10 min. until BP controlled
(maximum dose 20 mg). The BP response to the administered hydralazine
needs to be monitored by automated BP measurement, and confirmed by one
or two measurements using a manual sphygmomanometer.
4. Maintenance IV infusion of hydralazine 50 mg. in 50 mL. saline via syringe
pump starting at 5mlL/hour and titrating with MAP.
5. Reduce the dose if there are significant side effects or the maternal pulse >
120 bpm
6. Caution should be used in patients with renal disease.
7. Oral antihypertensive treatment should be considered when intravenous
treatment has been discontinued.
Prevention of seizures - prophylactic anti-convulsant treatment
One in 200 cases of severe PET progress to eclampsia, prophylactic anti-convulsant
therapy is aimed at reducing the risk of this progression.
1. Loading dose of magnesium sulphate 4 g. (20 mL. of 20% solution) given
slowly IV (over 10 min) via a syringe driver, only once the BP has been
stabilised.
2. Maintenance infusion of magnesium sulphate at a set dose of 1 g./hour (5
mL/hour of 20% solution via syringe driver). This rate continued unless knee
jerks abolished urine output less than 100 mL in 4 hours, or respiratory rate
under 12 per min. when the infusion should be stopped.
3. Test reflexes and monitor respiratory rate hourly. The knee jerks are usually
the easiest reflexes to test, but these will be affected by regional anaesthesia
and the biceps reflexes are more appropriately tested under these
circumstances.
Control of an eclamptic seizure
Eclampsia is defined as generalised convulsions in any woman with signs and
symptoms of pre-eclampsia, or in any woman who then presents with hypertension in
pregnancy.
The overall incidence of eclampsia is only 2.7/10,000 maternities in the UK but the
associated maternal mortality rate is 3.1%. Eclampsia rarely occurs without
premonitory symptoms (e.g. severe headache, visual disturbance, epigastric pain),
and these symptoms should always be taken seriously.
Eclampsia is an absolute indication for delivery - but not until the condition of the
mother has been stabilised.
Remember, over 40% of fits occur after delivery, so post-natal vigilance is essential
although the disease will resolve spontaneously in all but a few cases.
Principles of management of eclamptic fits:
1. Place patient in the left lateral position and secure the airway.
2. Administer oxygen at 10 L/min.
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Page 8 of 13
3. Administer magnesium sulphate - give 4 g. magnesium sulphate as per
instructions for loading dose above. Recurrent seizures should be treated by a
further bolus dose of 2 - 4g. depending on the patients weight; 2g. if less than
70 kg and 4g, if over 70Kg.
4. Mg SO4 is located in the red eclampsia box on the emergency trolley
5. Contact anaesthetist.
Magnesium sulphate
Dispensed as vials of 50 mL. of 20% magnesium sulphate (1g. in 5mL.)
Care should be taken to avoid overdose particularly in renal failure. Signs and
symptoms include loss of tendon reflexes, respiratory depression, confusion and
cardiac arrest. If toxicity is suspected, the infusion should be stopped immediately
and consideration given to measuring levels. Therapeutic levels are 2-4 mmol/L,
adverse effects are seen at levels over 5mmol/L and levels over 6mmol/L may be
lethal.
Antidote to magnesium sulphate is 500 mg. calcium chloride (5 mL. of 10% solution)
given IV over 5 min. This is available in pre-filled syringes kept on Delivery Suite.
Fluid balance (see Appendix B)
It is important to strike a balance between overzealous administration of intravenous
fluid (increasing the risk of pulmonary oedema) and under infusion, predisposing to
oliguria and renal complications. The objective is to maintain a minimum urine output
of 100 mL/4 hours.
The principles of fluid management:
1. Accurate recording of fluid balance (including delivery and post partum)
2. Maintenance crystalloid infusion of Hartmanns 85 mL/hour (minus the volume
of any infused drugs)
For women who require the post partum syntocinon regimen, this can
be safely administered by diluting 20 units of syntocinon in 50mL of
0.9% normal saline and delivering this through a syringe driver set at
25mL/hour.
Avoid potential Nephrotoxics especially Diclofenac or other

NSAIDs
3. Selective monitoring of CVP
haemorrhage
oliguria
significant fall in platelet count
liver tenderness
4. Selective colloid expansion-
oliguria and low CVP

prior to antenatal vasodilatation:epidural
labetolol/hydralazine
5. Diuretics in pulmonary oedema (discuss with anaesthetist)

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Page 9 of 13
Management
1. Initial fluid therapy of Hartmanns 85 mL/hour.
2. If initial haematocrit < 35% (< 0.35) continue Hartmanns 85 mL/hour.
3. If initial haematocrit > 35% (ie. haemoconcentrated) give 500mL colloid
4. Hartmanns 85 mL/hour.
5. The volume of infused drugs should be subtracted from the Hartmanns 85
mL/hour.
6. Any oral intake should be also subtracted from the Hartmanns 85 mL/hour.
7. Prior to epidural analgesia, consider a pre-load of 500 mL Voluven 6%, and
then continue the Hartmanns at 85 mL/hour.
Oliguria and CVP (see Appendix B)
Oliguria is relatively common in labouring pre-eclamptic patients and may represent a
normal response to short-lived pre-renal causes.
Principles:
Oliguria is defined as <100 mL/4 hours.
1. The anaesthetist will set up and supervise the CVP.
2. Subclavian line insertion is relatively contraindicated if the patient has a
coagulopathy.
3. All readings to be taken at the mid axillary line angle with patient lying flat.
Ensure left lateral tilt is maintained to avoid aorto-caval compression.
Fetal assessment and delivery planning
In all cases of severe pre-eclampsia/eclampsia, concerns about stabilising the
maternal condition should take priority over any assessment of the fetus. However,
once the mother is stable, fetal wellbeing may be assessed in the initial stages by
continuous CTG. Consideration should be given to assessing the fetus with a growth
scan, liquor assessment and umbilical artery Doppler flow.
The mode of delivery to be decided with the consultant obstetrician and will depend
on the history, presentation, Bishop score, coagulation defect etc. The precise
timing of the delivery may also be determined by factors such as cot availability on
NICU and will be arranged following consultation with the consultant obstetrician,
Delivery Suite coordinator, anaesthetist and NICU (where appropriate).
Anaesthesia
1. If platelet count is 80 - 100 x 109 /L, and the clotting screen is normal, regional
anaesthesia is usually acceptable. In all other circumstances, please liaise
closely with the obstetric anaesthetist.
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Page 10 of 13
2. A pre-load of 500 mL. of Voluven 6% should be considered prior to siting an
epidural.
3. Consider the administration of alfentanil 1.0 2.0 mg intravenously as part of
the rapid sequence technique for laryngoscopy in an attempt to obtund the
hypertensive response. A bolus dose of magnesium (40 mg/kg) can also be
used for this purpose; this should be reduced to 30 mg/kg if the patient is
already receiving magnesium. In cases of severe PET, magnesium and
alfentanil can be used together.
4. Do not give NSAIDs this may worsen renal failure
Continuing care
1. Patient should remain in the Delivery Suite and be fully monitored (including
laboratory investigations) for at least 24 hours after delivery. Fluids should
continue at 85mL/hour, if there is no evidence of pulmonary oedema.
2. Magnesium sulphate infusion should be continued for 24 hours after delivery.
3. Labetalol infusion should be continued as necessary to control BP. The
decision for continuing anti-hypertensive treatment with oral therapy should be
made by the patients consultant - who should also be responsible for the
choice and dose of the agent used.
4. Consider the need for thromboprophylaxis. Apply anti-embolism stockings and
commence dalteparin, provided platelet count > 100.
5. If there are concerns about the patients blood pressure or fluid management,
or if her condition deteriorates, consider early referral to HDU/ITU.
Postnatal follow-up and final diagnosis
1. An assessment of BP and proteinuria by the GP at the 6 weeks postnatal
check should be performed. If there were any biochemical abnormalities peripartum, then a repeat PET screen should be performed, too. If any
abnormalities persist, the patient should be referred for further investigations.
2. Women whose pregnancies have been complicated by severe PET or
eclampsia should be offered a formal postnatal review to discuss the events of
the pregnancy with their obstetrician. This should afford an opportunity to
discuss preconception counselling, identification of modifiable risk factors and
any preventative therapies.
3. All cases of eclampsia and severe pre-eclampsia should be the subject of
multidisciplinary case review, and, where appropriate, action plans approved.
Clinical audit standards
The Maternity Services are committed to the philosophy of clinical audit, as part of its
Clinical Governance programme. This standards contained in this clinical guideline
will be subject to continuous audit, with multidisciplinary review of the audit results at
one of the monthly departmental Clinical Governance meetings. The results will also
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Page 11 of 13
be summarised and a list of recommendations formed into an action plan, with a
commitment to re-audit within three years, resources permitting.
1. Rate of documented involvement of consultant obstetrician and anaesthetist in
acute management (target 100%, exceptions none)
2. Proportion of women with a full complement of appropriate investigations
(target 100%, exceptions none)
3. Proportion of women in whom fluid has been restricted to 85 mL/hour (target
100%, unless otherwise determined by a consultant obstetrician)
4. Proportion of women receiving appropriate magnesium sulphate prophylaxis
(target 100%, unless otherwise determined by a consultant obstetrician)
5. Proportion of women with eclampsia treated with magnesium sulphate (target
100%, exception - none)
6. Proportion of women with eclampsia and severe PET attending for postnatal
review and/or preconception counselling (target 100%, exceptions patient
declines or is unable to eg. patients transferred for delivery from elsewhere).
Summary of development and consultation process undertaken before
registration and dissemination
The author listed above drafted this guideline on behalf of the Obstetric Guidleines
Committee who have agreed the final content. During its development it was has
been circulated for comment to: all members of the obstetric guideline committee.
This version has been endorsed by the Obstetric Guidelines Committee.
Distribution list/ dissemination method
Electronic Mail

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References/ source documents
1. The management of severe pre-eclampsia/eclampsia. RCOG Green top
Guideline number 10(A). March 2006. RCOG Press: London.
2. Saving Mothers Lives: reviewing maternal deaths to make motherhood safer
2006-2008. The eighth report of the Confidential Enquiries into Maternal
Deaths in the United Kingdom. 2011; 66 76. RCOG Press: London.
3. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and
their babies, benefit from magnesium sulphate? The Magpie Trial: a
randomised placebo-controlled trial. Lancet 2002;359:1877-1890.
4. Duley L, Glmezoglu AM, Henderson-Smart DJ, Chou D. Magnesium sulphate
and other anti-convulsants for women with pre-eclampsia. Cochrane Database
of Systematic Reviews 2010, Issue 11.
5. Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database of Systematic Reviews
2006, Issue 3.
6. Knight M on behalf of UKOSS. Eclampsia in the United Kingdom 2005. BJOG
2007;114:1072-1078.
7. National Institute for Health and Clinical Excellence. Hypertension in
pregnancy. The management of hypertensive disorders during pregnancy.
NICE clinical guideline 107. August 2010.
8. von Dadelszen P et al. Prediction of adverse maternal outcomes in preeclampsia: development and validation of the fullPIERS model. Lancet
2011;377:219-227.

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Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia

Division responsible for document:

severe pre-eclampsia (PET), eclampsia

Name of document author:

Mrs Daisy Nirmal

Obstetric Guidelines Committee

Assessed and approved by the:

Obstetric Guidelines Committee

Ratified by or reported as approved

Clinical Standards Group and Effectiveness

Compliance links: (is there any NICE

(e.g. NICE, CQC)

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

MAP > 140 mmHg

Recheck BP every 5 min

Recheck BP every 15 min

MAP < 125

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Issue: 28/10/ 2015

b. urea and electrolytes and urate.

c. liver function tests

d. group and save

The woman will be reviewed by the multi-professional team at each ward

Following each review a plan of care will be clearly documented in the

Any deterioration in the womans condition must be immediately

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Liaison will be made with consultant haematologist where there is concern

After initial measurement of blood pressure with a manual

Oxygen saturation should be measured continuously and recorded hourly. If

Indwelling catheter and hourly measurement of urine output and proteinuria.

Temperature should be assessed four hourly.

Blood pressure control and anti-hypertensive treatment (see Appendix A)

Issue: 28/10/ 2015

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Issue: 28/10/ 2015

Avoid potential Nephrotoxics especially Diclofenac or other

3. Selective monitoring of CVP

4. Selective colloid expansion-

oliguria and low CVP

5. Diuretics in pulmonary oedema (discuss with anaesthetist)

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Issue: 28/10/ 2015

Issue: 28/10/ 2015

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

Author: Mrs Daisy Nirmal

Issue: 28/10/ 2015

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