File JWaters MD 5-30-12 Presentation

7/26/2019 File JWaters MD 5-30-12 Presentation

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Changing Landscape of Obstetrical

Hemorrhage

Jonathan H. Waters, MD

Professor of Anesthesiology and Bioengineering

Chief of Anesthesiology, Magee-Womens Hospital of University ofPittsburgh Medical Center

Medical Director, UPMC Total Blood Management Program


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http://bloodjournal.hematologylibrary.org/content/112/7/2617/F5.large.jpg

Blundells Blood Gravitator


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Is obstetrical hemorrhage a

problem worth addressing?

A. Mortality

B. Morbidity


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Healthy People, 2010

www.cdc.gov


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The Joint Commission Sentinel

Event Alert


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Pregnancy-related deaths in the United States in 20062007

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/Pregnancy-relatedMortality.htm


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Morbidity of Hemorrhage


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Postpartum hemorrhage

associated morbidity

Disseminated intravascular coagulopathy (DIC)

Renal and hepatic failure

Acute respiratory distress syndrome

Sheehans Syndrome


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Postpartum hemorrhage

associated morbidity

Iron deficiency

Iron deficiency anemia

Transfusion


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Bodnar LM et al. Am J Obstet & Gynecol 2005;193:36-44


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Complications of Transfusions

I. Infectious Complications VII. Delayed TransfusionReactions

II. Hemolytic TransfusionReactions

VIII. NonhemolyticTransfusion Reactions

III. Immunomodulation IX. Graft-vs-host Disease

IV. Storage Defects X. Febrile Reactions

V. Cost XI. Allergic Reactions

VI. Gene Transmission XII. HLA Sensitization


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POSTPARTUM HEMORRHAGE PROTOCOL

Strategy for Managing PPH Anticipation

Identification of Risk Factors

Prevention / Preparation

Recognition Assessment

Accurate Estimation of Blood Loss

Identification of Cause Act

Postpartum Hemorrhage Protocol (PPHP)

Mobilization of Rapid Response Team


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Admission Hemorrhage Risk FactorsLow (Type & Screen/Hgb) Medium (Type & Screen/Hgb) High (Type & Cross/CBC with

Plt)

No previous uterine incision Prior Cesarean birth(s) oruterine surgery (RR = 10.38)

Placenta previa, Low lyingplacenta (RR = 3.38)

Singleton Pregnancy (RR =

60.69)

> 5 previous vaginal births Suspected placenta accreta or

percreta

5 previous vaginal births Chorioamnionitis (RR = 2.56) Hgb < 10 and other risk factors

No known bleeding disorder History of PPH Active bleeding on admission

No history of PPH Large uterine fibroids Known coagulopathy (RR =

2.97)

Hypertensive disorder of

pregnancy (RR = 2.05)

Retained placenta

Overdistended uterus

(macrosomia, polyhydramnios,

etc) (RR = 1.63)

Uterine rupture

Obesity (RR = 1.43) Hgb < 8


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Strategy for Managing PPH

Anticipation Identification of Risk Factors

Prevention / Preparation Recognition

Assessment






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Assessment

Ongoing quantitative evaluation of blood loss

Peach pad Plaid cloth pad Blue Chux pad

250 mL loss 100 mL loss 150 mL loss


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Strategy for Managing PPH

Anticipation Identification of Risk Factors

Prevention / Preparation Recognition

Assessment






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Obstetric Crisis Patient Safety

Initiative: Magee-Womens Hospital

Medical Emergency Team Paradigm applied toobstetric care

Condition O

Assemble necessary personnel with singlepage

Force interdisciplinary communication

Encourage early crisis recognition Encourage teamwork


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Wiser

Obstetric Crisis Team Training Course

Course Format:

Web-based presentation

Pre-course survey

Pretest

Brief didactic session

3 full scale human simulation scenarios

Video-based debriefing

Post-course survey


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Staff in room informed of bleeding? Anesthesia aware? Intra-op consultsneeded/requested?

Call for help: OR charge (1-2802), Generalist (1-2526), Triage (1-2679), MFM (2862),Anesthesia (1-4148 ), Gyn Onc (med-trak), Urogyn (Medtrak)

Initial resuscitation: IV access x2? IVF open with pressure bag? Cell saver on thefield? Warming patient?

Source of bleeding?

-Is the uterus atonic?-Are all uterotonics in the room (see chart)?

-Recheck uterus for retained tissue?

-Is the uterine incision (including angles) hemostatic? -Apex of extension visualized and hemostatic?

-Is a vaginal/cervical exam warranted?

-Bakri balloon? Compression sutures?

-Is a hysterectomy being considered? Is a hysterectomy tray in the room?

-Any concern for bladder/ureteral injury? Cysto available?

Assessment of hemorrhage:-Stat CBC, platelets, INR, fibrinogen drawn and sent? Are serial labs needed? TEG performed?

-EBL and pt hemodynamics discussed?

-Has the blood bank (4646) been notified? Massive transfusion protocol activated?

Recovery:Does this patient need an ICU bed? Has CCM been notified (1-2790)?

C-Section Hemorrhage

Triggers for

checklist

use:

-EBL

>1000cc

- A bleedingextension

identified

- Surgeon

calls for

uterotonics

Objective: Stop bleeding, maintain

hemodynamic stability, avoid coagulopathy

Call ADM

charge

Picklephone

1-2800

Anesthesia Hemorrhage Checklist


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Call for help if major fluid resuscitation necessary

Reduce volatile agents and nitrous oxide if hypotensive

Maintain normothermia with a fluid warmer and forced air warming blanketConsider rapid transfusion device

Consider blood salvage device (COBE BRAT)

Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if abdomen

open.

Consider aortic cross-clamping.

Consider Vigileo, arterial line and CVP for hemodynamic monitoring

Consider TEE for continued hypotensionMonitor hemoglobin, TEG, electrolytes, ABG at frequent intervals

Remember to normalize any hypocalcemia with supplemental CaCl2at 500-1000 mg doses

Maintain acid base status with volume resuscitation and NaHCO3

Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis

Consider trauma pack or major transfusion protocol.

Consider interosseus drill if IV access problematic

Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes

FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.

Massive Transfusion Protocol (RBC + PLASMA + PLTS)




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open.














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B tl A t t f i S t


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Duncan SE et al. Ann Surg 1974;180:296-304

Bentley Autotransfusion System


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Catling S, Joels L. IJOA 2005;112:131-2


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Organizations recommending blood

salvage during the peripartum period

Confidential Enquiry into Maternal and Child

Health (UK) National Institute for Health and Clinical

Excellence (UK)

Obstetric Anesthetists Association (UK) Assoc. of Anaesthetists of Great Britain and

Ireland (UK)



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Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if

abdomen open.













Interosseus Drill


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Interosseus Drill



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open.














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Vigileo Flo-trac

LiDCO

Non-invasive Cardiac Output Monitors



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Maintain normothermiawith a fluid warmer and forced air warming blanketConsider rapid transfusion device



open.














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Body Temperature ( C)

Effect of Body Temperature on Coagulation

Rohrer MJ, Natale AM. Crit Care Med1992;20:1402-5.


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Meng et al. J. Trauma 2003;55:886


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Probability of Life-Threatening Coagulopathy

increases wi th hypo tension and hypotherm ia

Clinical Status Conditional Probability ofdeveloping coagulopathy

No risk Factor 1%

Severe trauma>25 10%Severe trauma+ISS*Systolic BP


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Point of Care Testing


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Point of Care Testing


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Near Care Testing


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Nuttall GA et al. Anesthesiology 2001;94:773-81

Outcome with Algorithm and Point of care testing


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Nuttall GA et al. Anesthesiology 2001;94:773-81

Outcome with Algorithm and Point of care testing


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Process Measure

Obstetrical and Anesthesia Hemorrhage Checklist

Nominator: Checklist Use

Denominator: Number of OB hemorrhages


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Outcome MeasurePercent of women transfused

The goal would be to reduce the percentage of womentransfused.

Numerator: Women who gave birth >=20 weeks gestation

and received 1 unit or > units of any blood product during

Denominator: All births

Average transfusion exposureThis would measure whether QI has reduced transfusion

exposure. This is important because the complications of

transfusion are dose related.

Numerator: total units transfused

Denominator: women transfused


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Questions?

Jonathan Waters, M.D.

[email protected]

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