产后出血的麻醉处理

产后出血的麻醉处理第1页/共42页Disclosure

BD科学咨询委员会成员

第2页/共42页TonightontheLaborFloor…30yoG1P0at38weeksbreechpresentation;inactivelabor170cm86kg,MallampatiIINPOfor11hoursNoallergiesNomedicalhistory第3页/共42页IntheOperatingRoom…18gIV,uneventfulspinalanesthesiaHealthybabyborn5minuteslater:continuousoozinginthefieldOB:“Thetoneispoor”Patient:“Ifeeldizzy”Vitalsigns:BP80/49;HR120sSaO2100%

Whatwillyoudo?第4页/共42页ObjectivesDEFINEPostpartumhemorrhageIDENTIFYChallengesofmanagementPREPAREManagementbasedonevidence第5页/共42页MortalityfromPostpartumHemorrhageOnewomaneverysevenminutes…PottsMetal.Lancet2010;375:1762-3第6页/共42页1995through2004PPHincreasedby30%2.9%ofalldeliveriesBloodtransfusion2.4to4.6per1000(90%increase)Uterineatony:predictableonly40%ofcases.BatemanBetal.AnesthAnalg2010;110:1368-73.TheEpidemiologyofPostpartumHemorrhageintheUnitedStates第7页/共42页CardiacArrestDuringHospitalizationForDeliveryintheUnitedStates,1998-20114,843casesidentifiedPostpartumhemorrhage:1349patients(27.9%),55%survivalAmnioticfluidembolism:645patients(13.3%),52.5%survivalMhyreJetal.,Anesthesiology2014April.第8页/共42页UnitedKingdomPostpartumHemorrhageMaternalDeath66%ofcases:substandardcare第9页/共42页ObjectivesDEFINE postpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence第10页/共42页PostpartumHemorrhageDefinedQuantificationofbloodloss?>500mLaftervaginaldelivery>1000mLaftercesareandeliveryWearebadatestimatingbloodlossCasesthatneedtransfusion?RetrospectiveHemodynamicchanges?LatesignsinthepregnantpatientACOGPracticeGuideline;ObstetGynecol2006.BosePetal.BJOG2006.ToledoP.Etal.AnesthAnalg2007.第11页/共42页MajorPostpartumHemorrhageEstimatedbloodlossof2500mLormoreTransfusionof>5unitsofbloodTreatmentofcoagulopathyWiseandClarkCurrOpinAnaesthiol2008.第12页/共42页ObjectivesDEFINE postpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence第13页/共42页ChallengesofPPHRath,WH.ActaObstetriciaetGynecologicaScandinavica2011May;90(5)421-8第14页/共42页NORMAL ABNORMALPPHPROTOCOLCOMMUNICATION第15页/共42页The4T’sofPPHToneSolomonCetal.BrJAnaesth2012;109(6):851-63.TissueTraumaThrombin第16页/共42页SliverRMetal;ObstetGynecol2006;107(6):1226-3230,132women,cesareandelivery732women:placentapreviaPlacentaPreviaandPriorCesareanDeliveryPriorCesareanDeliveriesRiskofPlacentaAccreta03%111%240%361%4or>67%第17页/共42页Anatonicuterusisableedinguterus/2011/03/post-partum-hemorrhage.html第18页/共42页

二线子宫收缩药物甲基麦角新硷(Methergine)前列腺素米索前列醇(Misoprostol,PGE1,Cytotec)地诺前列酮(Dinoprostone,PGE2,Cervidil)卡波前列素(Carboprost,PGF2α,Hemabate)第19页/共42页第20页/共42页UterotonicAgentsforPPHDoseKineticsRedosingAdverseeffectsContra-indicationsOxytocinPitocin®titratedIVinfusiont1/21-6minutesn/aNauseavomitingflushinghypotensionallergyMethyl-ergonovinemaleateMethergine®200mcgIMororaltabletIM:2-5minonsetPO:5-10minonset30-45min(IM)upto5doses(1mg)or6-8h(PO)hypertensionnauseavomitingchestpainarterialspasmMIHypertensionCADCarboprostHemabate®250mcgIMPeakplasma30minutes15-90minupto8doses(2mg)bronchospasmnauseavomitingdiarrheafeverhypertensionasthmaMisoprostolCytotec®800-1000mcgPRorbuccalFasteronsetafterbuccaldosingnoneDiarrhea,shiveringPyrexia,Headacheallergy第21页/共42页Whenpharmacologictreatmentfails…BimanualcompressionUterineballoontamponadeUterinecompressionsuturesArterialligationInterventionalradiologyHysterectomy第22页/共42页Objectives

DEFINE postpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence

第23页/共42页Hemostasis1.Vasoconstriction2.Plateletplug3.Coagulationcascade

fibrinclotformation©TheMcGraw-HillCompanies,Inc.第24页/共42页LowFibrinogenPredictsWorseOutcomeInPostpartumHemorrhageCharbitetal.JThrombHaemost2007;CortetMetal.BrJAnaesthesia2012.FibrinogenOddsRatio(SeverePPH)200-300mg/dL1.9<200mg/dL12第25页/共42页www.RRiaSTAP®:FibrinogenConcentrateIndications:PPHwithsuspectedorknownDICorfibrinolysis1vial=1gfibrinogenAdd50mLsterilewaterSwirlgentlyInfuseover10minutes

第26页/共42页Ducloy-BouthorsASetal.CritCare2011.PPHaftervaginaldelivery:>800mLEBLTXAadministration4g/1hthen1g/hfor6hEBLatT2(30min),toT4(6h)lowerEBL,shorterduration,lessseverePPHHigh-dosetranexamicacidreducesbloodlossinpostpartumhemorrhage第27页/共42页TranexamicAcidfortheTreatmentofPostpartumHaemorrhage:anInternationalRandomized,DoubleBlind,PlaceboControlledTrial…December2014/August2015第28页/共42页ControlrFVIIaDeath,permanentdisability39%88%Permanentdisabilityinsurvivingpatients19%75%28contols(norVIIa)16treated(rVIIa)LeightonBLetal.Anesthesiology2011;115:1201-8.UseofRecombinantFactorVIIainsuspectedAmnioticFluidEmbolism第29页/共42页Isthereaperfecttransfusionratio?1:1:1PRBC:FFP:PlateletsForwhom?When?Dose?Outcomes?第30页/共42页12,226deliveries,2006-20091.1%(142patients)hadseverePPHHigherFFP:PRBCratio

werelesslikelytohave: -embolization -arterialligation -hysterectomyPasquierPetal.AnesthAnalg2013FFP:PRBCRatioinPostpartumHemorrhage:AnObservationalStudy第31页/共42页GoodnoughLTetal.2011Dec.第32页/共42页Point-of-CareTesting:Thromboelastography;r=timetoinitialclotformationk,a=rateofclotformationMA=clotstrengthLY30,LY60=clotlysis第33页/共42页HillJSetal.AnaesthIntCare2012.Developingathromboelastography®-guidedtransfusionalgorithmforpostpartumhemorrhage第34页/共42页ElectronicResourcesforManagementofPostpartumHemorrhage第35页/共42页第36页/共42页JustanotherdayattheL&Dsimulator…-Yourlaboringpatientgetsalaborepidural-Thepatientfalls,breakingherfemur!-TotheORforC/S.-Epiduraldoseduptotalspinal!-Difficultairway!-Bradycardia,hypoxiccardiopulmonaryarrest!MinehartRetal.SimHealthcare2012SpeakingAcrosstheDrapes:

CommunicationStrategiesofAnesthesiologistsandObstetriciansDuringaSimulatedMaternalCrisis第37页/共42页WordsMatter!AdvocacyInquiryJointPlanAnesthesiolo