Uma Munnur

Baylor College of Medicine, Houston, TX, United States

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Publications (10)27.73 Total impact

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    ABSTRACT: The goals in management of critically ill obstetric patients involve intensive monitoring and physiologic support for patients with life-threatening but potentially reversible conditions. Management principles of the mother should also take the fetus and gestational age into consideration. The most common reasons for intensive care admissions (ICU) in the United States and United Kingdom are hypertensive disorders, sepsis, and hemorrhage. The critically ill obstetric patient poses several challenges to the clinicians involved in her care, because of the anatomic and physiologic changes that take place during pregnancy.
    Clinics in chest medicine 03/2011; 32(1):53-60, viii. · 2.51 Impact Factor
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    ABSTRACT: Cardiopulmonary arrest occurs in 1: 30 000 pregnancies. Although rare, optimal outcomes are dependent on the cause of the arrest, the rapid response team's understanding of the physiological effects of pregnancy on the resuscitative efforts and application of the latest principles of advanced cardiac life support (ACLS). Anaesthesia-related complications, secondary to difficult or failed intubation, and inability to oxygenate and ventilate can result in adverse outcomes for mother and baby. Experience in advanced airway management has been shown to decrease the incidence of brain death and maternal mortality. Awareness of lipid resuscitation of local anaesthetic toxicity is important. The effects of lipid resuscitation and its interference with ACLS medications are also important. Peri-mortem caesarean delivery of the foetus greater than 24 weeks' gestational age must be considered. Caesarean delivery should be performed no later than 4min after initial maternal cardiac arrest. A foetus delivered within 5min has the best chance of survival. Delivery of the baby helps in the maternal resuscitation efforts and recovery of circulation. Finally, the 2003 International Liaison Committee on Resuscitation (ILCOR) and the 2005 American Heart Association (AHA) advocate the provision of mild therapeutic hypothermia to the survivors of cardiac arrest. This will improve the neurological outcomes by decreasing cerebral oxygen consumption, suppression of the radical reactions and reduction of intracellular acidosis and inhibition of excitatory neurotransmitters.
    Best practice & research. Clinical obstetrics & gynaecology 04/2010; 24(3):383-400. · 1.87 Impact Factor
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    ABSTRACT: Anesthesia-related maternal mortality rates have improved in the United States, but it still remains a prominent cause of maternal mortality. Anesthesia is the seventh leading cause of maternal mortality in the United States with the top six causes being embolism, hypertensive disorders, hemorrhage, infection, cardiomyopathy, and cerebrovascular accident (1). General anesthesia is more likely to be associated with maternal mortality than regional anesthesia in the obstetric patient for the following reasons: (1) airway management tends to be more difficult in pregnant patients due to altered anatomy and physiology; (2) general anesthesia is chosen in emergency surgeries when there is no time for adequate preoperative evaluation and aspiration prophylaxis; (3) conversion of regional anesthetic to general anesthesia for inadequate block, hemorrhage, etc., with the patient not in the optimal position for intubation; and (4) increased usage of regional anesthesia in obstetrics with minimal exposure of trainees to general anesthesia for cesarean sections, resulting in decreased airway management skills for training and maintenance in the obstetric patient. KeywordsPregnancy–airway–cesarean section–difficult intubation–mechanical ventilation–maternal mortality–airway devices
    12/2008: pages 385-403;
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    ABSTRACT: To provide a current review of the literature regarding airway problems in pregnancy and management. Obstetrical anesthesia is considered to be a high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Failure to appropriately manage a difficult or failed intubation increases the risk of hypoxemic cardiopulmonary arrest and/or pulmonary aspiration, resulting in a high probability of maternal morbidity and mortality. Anesthesia is the seventh leading cause of maternal mortality in the United States. Anatomic and physiologic changes during pregnancy place the parturient at increased risk for airway management problems. It is essential to perform a thorough preanesthetic evaluation and identify the factors predictive of difficult intubation. Airway devices such as the laryngeal mask airway, ProSeal, intubating laryngeal mask airway, Combitube, and laryngeal tube are described and have been used during failed intubation in pregnant patients. Teamwork between an anesthesiologist and an obstetrician is absolutely essential for the safety of both the mother and baby. Most of us tend to agree that airway emergencies have a way of occurring at the worst possible times. It is essential that all anesthesia care practitioners must have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.
    Critical Care Medicine 11/2005; 33(10 Suppl):S259-68. · 6.12 Impact Factor
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    ABSTRACT: To compare case-mix, health care practices, and outcome in obstetric ICU admissions in inner-city teaching hospitals in economically developed and developing countries. Retrospective study. Ben Taub General Hospital (BTGH), Houston, Texas, and King Edward Memorial Hospital (KEMH), Mumbai, India. Women admitted during pregnancy or 6 weeks postpartum between 1992 and 2001. Patients from BTGH (n=174) and KEMH (n=754) had comparable age, number of organs affected, incidence of medical disorders (30%), liver dysfunction, and thrombocytopenia. Fewer KEMH patients received prenatal care (27 vs 86%) and came to hospital within 24 h of onset of symptoms (60 vs 90%). They had higher APACHE II scores (median 16 vs 10), greater incidence of neurological (63 vs 36%), renal (50 vs 37%), and cardiovascular dysfunction (39 vs 29%). Severe malaria, viral hepatitis, cerebral venous thrombosis, and poisoning were common medical disorders. The BTGH group had higher incidence of respiratory dysfunction (59 vs 46%) and disseminated intravascular coagulation (40 vs 23%), placental anomalies, HELLP syndrome, chorioamnionitis, peripartum cardiomyopathy, puerperal sepsis, urinary infection, bacteremia, substance abuse, and asthma. More BTGH patients required mechanical ventilation and blood component therapy, whereas more KEMH patients needed dialysis. Of BTGH patients, 78.2% were delivered by cesarean section (vs 15.4%). Maternal (2.3 vs 25%) and fetal (13 vs 51%) mortality were lower in BTGH patients. There were marked differences in medical diseases, organ failure, and intensive care needs. Higher mortality in the Indian ICU may be due to difference in case mix, inadequate prenatal care, delay in reaching hospital, and greater severity of illness.
    Intensive Care Medicine 09/2005; 31(8):1087-94. · 5.26 Impact Factor
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    ABSTRACT: Acute respiratory failure can be the result of a variety of clinical conditions, such as congestive heart failure, pneumonia, pulmonary embolism, exacerbation of obstructive lung diseases, and acute respiratory distress syndrome (ARDS). This article focuses on developments related to acute lung injury and ARDS and reviews epidemiology, pathogenesis and therapeutic advances with an emphasis on the obstetric population. A brief discussion of tocolytic-induced pulmonary edema, preeclampsia, venous air embolism, and aspiration-related ARDS is included. Management of pregnant women with ARDS is outlined.
    Critical Care Clinics 11/2004; 20(4):577-607. · 1.95 Impact Factor
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    Uma Munnur, Maya S Suresh
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    ABSTRACT: Obstetric anesthesia is considered to be a difficult, high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of parturient patients is a challenge, as it involves simultaneous care of two lives. The anesthesia practitioner has a duty to provide safe anesthetic care, including effective airway management when providing regional or general anesthesia. The potential need to manipulate the airway is perhaps the leading cause of concern among obstetric anesthesiologists.
    Critical Care Clinics 11/2004; 20(4):617-42. · 1.95 Impact Factor
  • Critical Care Medicine 07/2004; 32(6):1418-9. · 6.12 Impact Factor
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    Uma Munnur, Maya S Suresh
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    ABSTRACT: Back pain, chemical backache, PDPH, and neurologic deficit all may be reported after regional anesthesia for childbirth. Back pain is common during pregnancy, but epidural analgesia during labor does not increase the incidence of long-term back pain. Chemical backache caused by 2-chloroprocaine is probably a result of hypocalcemic tetany of paraspinous muscles. The mechanism is presumed to be chelation of calcium by sodium bisulfite, an antioxidant present in nesacaine-MPF. PDPH after dural puncture is caused by leakage of CSF, which causes cerebral hypotension. Cerebral hypotension leads to traction on pain-sensitive intracranial structures and cerebral vasodilation. Initial therapy includes hydration, caffeine, and sumatriptan. EBP is the most effective treatment in severe PDPH. If the first EBP fails, a second blood patch can be performed. Neurologic deficits after regional anesthesia are rare. Meticulous technique and vigilance are the keystones in avoiding major neurologic complications of regional anesthesia. Rapid diagnosis and appropriate treatment are essential to optimize a successful outcome if complications do develop.
    Anesthesiology Clinics of North America 04/2003; 21(1):71-86.
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    ABSTRACT: The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patient's family, and the patient's primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. Equipment for managing a difficult airway should be available. Alternate methods of managing the airway (e.g., the laryngeal mask airway, fiberoptic scopes, and the WU Scope) (Achi Corporation, Fremont, CA) are of great help in dealing with airway problems. The potential for cervical spine instability exists in patients with rheumatologic disorders. Intubating with care and avoiding spinal movement both seem to be more important than any particular mode of intubation in preserving neurologic function. One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.
    Critical Care Clinics 11/2002; 18(4):749-65. · 1.95 Impact Factor