Case Presentation

Case Summary

Madam S,41 years old,malay lady,G5P3+1 @ 20weeks 4 days POA,ASA II, with antenatal hx of:

1.Mild anemia

Hb 10.7g/dL @ 12wk

2.Hx of abortion in 2009

Missed abortion, D+C done at HSIJB under hold mask-uncomplicated.

She referred from HKT to O&G team in view of incomplete abortion TRO septic abortion. She had hx of inevitable abortion at 16 weeks on 26.1.2011 and came to HKT with leaking liquor and treated with T.augmentin 625mg BD for 1 week.She was soon discharged well from HKT. Later on she developed another episode of per vaginal bleeding for 3 days prior to admission.

Upon assessment in PAC,she was comfortable,not pale,not septic looking and temp was 37.5C with HR of 109 and BP 129/79mmHg. Per abdomen examination revealed palpable uterus at 20 weeks but soft,non tender.Per vaginal and speculum examination showed blood clots at os and removed with sponge forceps.The doctor noted minimal oozing from opened os with cervical erosion seen.No POC detected. Abdominal US revealed Placenta seen in Uterus sized of 10x 4 cm.After discussion with consultant she was posted for suction and curettage with antibiotics commencement(ampicillin 1 g stat and 500mg QID).Impression at that time was incomplete abortion.She was admitted in the morning and kept NBM since then and was called to OT at ~ 10pm on the same day.

On arrival to OT,she was comfortable,not pale and not toxic looking with vital sign of BP 144/75,HR 77 and SpO2>98%.

She was counseled for op under GA in view of anticipation of bleeding.She understood and agreed.

She was induced with IV Fentanyl 50mcg and IV Sodium thiopentone 250mg and subsequently given IV suxamethonium 100mg.

She was intubated with ETT size 7 and anchored at 19cm.

The procedure commenced and findings as followed:Uterus 20 weeks with os open cevix 2cm and POC felt.However,the procedure was complicated with massive blood loss;initial blood loss was 1L within 3 minutes and surgeon was called in.Later,the blood loss increased to 2 L as POC was difficult to be removed and suspected placenta accreta. Subsequently, total hysterectomy with bilateral internal iliac arteries ligation done due to bleeding from raw area. Total blood loss was 3.5L( 2 L during d&c and 1.5 L during hysterectomy )There was difficulty to contact husband prior to hysterectomy but surgeon proceeded in view of persistent bleeding.The diagnosis given was retained placenta post abortion with ?placenta accreta complicated with massive blood loss.

Intra operatively,she was transfused with 4 pint whole blood and 1 cycle of DIVC regime(6 cryoprecipitate,4 FFP,and 2 platelets).Her BP was labile throughout operation with episodes of hypotension down to 80/50mmHg and tachycardia(up to 120bpm).Her Hb dropped from 10.3 to 6.8g/dl and planned to transfused 3 more whole blood postoperatively.She was also started on IVI dopamine 5mcg/kg/hr in view of labile BP despite fluid resuscitation given up to ~ 4 L of fluids.

List of medications given intra-operatively:

IV Fentanyl 50mcg

IV Sodium Thiopentone 250mg

IV Suxamethonium 100mg

IV Atracurium 95mg

IM Hemabate 250mcg

IV Tranxenemic Acid 1gm

IV Ephedrine 6mg

IV Morphine 8mg

IV Flagyl 500mg

IV Pitocin 80 unit - infusion, stopped post hysterectomy

IM Syntometrin 1 ampule

IVI Dopamine 5mcg/kg/h

•Fluids•4 whole blood •1 cycle of DIVC ( 2 platelet, 4 FFP, 6 cryoprecipitate )•Gelafundin 1000ml•Normal Saline 0.9% 1000ml•Tetraspane 500ml•Voluven 500ml•Hartmanns 1000ml

•Urine output:500ml(reddish)

•Blood Gp:A+ve

Post operatively,she was sent to ICU for weaning and post op stabilization.

There she was not sedated and was transfused with another 3 pints whole blood in ICU(total 7 pints).

Her Hb picked up to 10.8 and dopamine was able to wean off as BP stabilized.

She was extubated ~ 15 hours post op without complication and transferred back to HDU labour room for continuation of care.

Throughout admission,no blood transfusion adverse reaction such as rashes,urticaria,itchiness,or anaphylactic reaction happened to her.

Discussion

Massive blood loss

1. Loss of one blood volume within a 24 hrs period,or;

2. 50% blood volume loss within 3 hrs,or;

3. Rate of loss of 150ml/min

Normal blood volume can be calculated as:

1.Approximately 7% of ideal body weight in adults and 8-9% in children,or;

2.70mls/kg in adult and 80-90mls/kg in children

In this case her weight ~ 60kg and her blood volume ~4200mls(60 x 70mls/kg).In the operation, she lost ~ 3.5L of blood and it was ~ 80% of her total blood volume.

The priorities for treatment are:

1.restoration of blood volume to maintain tissue perfusion and oxygenation

2.achieving haemostasis by:treating any surgical source of bleeding

correcting coagulopathy by the judicious use of blood component therapy

GuidelineGoal Procedure Comments

1.Restore circulating volume

•Insert wide-bore peripheral cannulae•Give adequate volumes of warmed crystalloids,colloid,blood•Aim to maintain normal blood pressure and urine output>30ml/hr

•14G or larger•monitor CVP•Blood loss is often underestimated•Refer to ACLS guidelines•Keep pt warm

2.Contact key personnel •Clinician in charge•Duty anaesthetist•Blood bank•Duty haematologist

•Nominated coordinator should take responsibility for communication and documentation

3.Arrest bleeding •Early surgical or obstetric intervention•Interventional radiology

4.Request lab ix •FBC,PT,APTT,fibrinogen,blood-bank sample,biochemical profile,blood gases or pulse oximetry•Ensure correct sample identity•Rpt FBC,PT,APTT,fibrinogen every 4hrs or after 1/3rd blood volume replacement•Rpt after blood component infusion

•Take sample at earliest opportunity as results may be affected by colloid infusion•Misidentification is commonest tx risk•May need to give components before results available

5.Request suitable red cells • Un-crossmatched gp O Rh negative1. In extreme emergency2. No more than 2 units• Un-crossmatched ABO gp-specific1. When blood gp known• Fully cross-matched1. If irregular Ab present2. When time permits3. Use blood warmer and/or rapid

infusion device4. Employ blood salvage if available

and appropriate

•Rh +ve is acceptable if pt male or postmenopausal female•Lab will complete cross-match after issue•Further cross-match not required after replacement of 1 blood volume(8-10units)•Blood warmer indicated if flow rate >50ml/kg/hr in adult•Salvage contraindicated if wound heavily contaminated

6.Request platelet •Allow for delivery time from blood centre•Anticipate plt <50 after 2x blood volume replacement

•Target plt:•>100 for multiple/CNS trauma or if plt function abnormal•>50 for other situation

7.Request FFP(12-15ml/kg body weight=1L or 4 units

for an adult)

•Aim for PT and APTT <1.5x control mean•Allow for 30 min thawing time

•PT and APTT>1.5x control mean correlates with increased surgical bleeding

8.Request cryoprecipitate(1-

1.5packs/kg body weight)

•Replace fibrinogen and factor VII•Aim for fibrinogen >1.0g/L•Allow for delivery time +30min thawing time

•Fibrinogen<0.5 strongly associated with microvascular bleeding•Fibrinogen deficiency develops early when plasma-poor red blood cells used for replacement

9.Suspect DIC •Treat underlying cause if possible •Shock,hypothermia,acidosis leading to risk of DIC•Mortality from DIC is high

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Complications of massive blood transfusion

Acidosis- is more likely to be the result of inadequate treatment of hypovolaemia than the effects of transfusion.HyperkalemiaCitrate toxicity and hypocalcemia

Citrate toxicity is rare, except in large volume, rapid transfusion of whole blood.Citrate binding of ionized calcium can lead to a clinically significant fall in the plasma free calcium concentration. Hypocalcaemia particularly in combination with hypothermia and acidosis can cause a reduction in cardiac output, bradycardia and other arrhythmias

Depletion of fibrinogen and coagulation factors.Depletion of plateletsDisseminated intravascular coagulation (DIC) may develop during massive blood transfusion although its cause is less likely to be due to the transfusion than to the underlying reason for transfusion, such as hypovolaemia, trauma or obstetric complications.

COMPLICATIONS OF CITRATE INFUSIONLarge amounts of citrate are given with massive blood transfusion, since blood is anticoagulated with sodium citrate and citric acidMetabolic alkalosis and a decline in the plasma free calcium concentration are the two potential complications of citrate infusion and accumulation.

Metabolic alkalosis The pH then falls 0.1 pH unit/week due to the production of lactic and pyruvic acids by the red cells. Acidosis does not develop in a massively bleeding patient even if "acidic" blood is infused as long as tissue perfusion is restored and maintained. In this setting, the metabolism of each mmol of citrate generates three meq of bicarbonate (for a total of 23 meq of bicarbonate in each unit of blood). As a result, metabolic alkalosis can occur if the renal ischemia or underlying renal disease prevents the excess bicarbonate from being excreted in the urine. This may be accompanied by hypokalemia as potassium moves into cells in exchange for hydrogen ions that move out of the cells to minimize the degree of extracellular alkalosis

Free hypocalcemia Citrate binding of ionized calcium can lead to a clinically significant fall in the plasma free calcium concentration. This change can lead to paresthesias and/or cardiac arrhythmias in some patients