Acute Resuscitation in Massive Haemorrhage in the Peripartum

8/9/2019 Acute Resuscitation in Massive Haemorrhage in the Peripartum

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Acute Resuscitation in CatastrophicUncontrolled Obstetric Haemorrhage in

the Peripartum Period

Associate Professor Stephen Gatt, OAM, MOM, KM, KHS, JP; MD, LRCP, DCH, CHE, MASCH, MRACMA, MRCS, AFACHSE, FFARACS, FANZCA, FICANZCA

Director of Anaesthesia, Prince of a!es Hos"ita!,

Hea# of Di$ision, Anaesthesia an# Intensi$e Care, Prince of a!es % Sne& Chi!#ren's Hos"ita!s(

Senior Staff S"ecia!ist )an#, "re$io*s!&, Director of Anaesthesia % Ac*te Care+, Ro&a! Hos"ita! for oen(

Presi#ent, O-stetric Anaesthesia Societ& of Asia an# Oceania )OASAO+(

Kensin.ton % Ran#/ic0, Sne&, A*stra!ia

PIT X Fetomaternal

Batu-Malang, 11thMarch 2009

Agrowisata, Batu


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Order of Battle a LearningObjective

Catastrophic haemorrhage

definitions

action plan

Over!helming transfusion

management

Role of recombinant factor "##a in $assive

Haemorrhage timing

optimised performance

$assive %ransfusion Protocol


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Syllabus Objectives -Syllabus Objectives -

Management of SevereManagement of Severe

HaemorrhageHaemorrhage Immediate volume replacementImmediate volume replacement

rVIIa do not wait too long before usingrVIIa do not wait too long before using

Immediate management training in andImmediate management training in andactivation of the haemorrhage drillactivation of the haemorrhage drill

Pre-preparation of a massive transfusionPre-preparation of a massive transfusion

trolley or box with pressure bags, largetrolley or box with pressure bags, largecannulae, Level blood warmers, bloodcannulae, Level blood warmers, blood

pumps, etc!pumps, etc!

"ctivation of the #assive $ransfusion Protocol"ctivation of the #assive $ransfusion Protocol


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&hat is a 'massive() 'catastrophic()'critical( or 'e*treme( transfusion+

Arbitrar,

%ransfusion of patient(s entire red cell mass!ithin -. hrs

Often /01 units RCC in adults

Perhaps 2management of massive transfusion3should be re4named 2management of criticalbleeding3 )Is-ister J 1223+


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%,pical 2catastrophic bleeding3 profile%,pical 2catastrophic bleeding3 profile

Blood products used in the 24 hrs to infusion (units)Blood products used in the 24 hrs to infusion (units) Packed cellsPacked cells 3030 PlateletsPlatelets 1616 FFPFFP 2020

CryoprecipitateCryoprecipitate 1616 Coagulation prole prior to infusionCoagulation prole prior to infusion

Platelet countPlatelet count !3 " 10!3 " 10##$l$l %&'%&' 1616 P**P** +, secs+, secs

Fi-rinogenFi-rinogen 23 g$l23 g$l .ean dose$kg infused/.ean dose$kg infused/ 113113 gg


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e ho sees thingsfro the -eginning hasthe nest ie of the

ristotle 3!43225 BC


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A55655#78 56"6R#%9A55655#78 56"6R#%9

BPBP

AppearanceAppearance

Heart RateHeart Rate

RespResp

:1140111:1140111 7ormal7ormal Usuall, fastUsuall, fast

;011;011

011140:11011140:11 5AP


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6*treme Haemorrhage %,pe of eliver,


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$assive Haemorrhage Causes

OtherCretainedpla

centaDaton,

andother'mi*ed(c

auses


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hat !o "#P$%an! now &the M%

an! Maternal %eath#n'uiries( teach us

a)out*aemorrhage+


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eading causes of direct deathseading causes of direct deaths

reported to C7.85 200002reported to C7.85 200002

1 : 01 0: -1

%hromboembolism

Haemorrhage

H,pertension

5epsis

6ctopic

Other earl, pregnanc, deaths

Amniotic fluid embolism

Other direct

Rate per million maternities5ource Confidential enEuiries into maternal deaths) Figure 0G-


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$assive Bleeding reEuiring r"##aCases b, Presentation 4 overall

%otal cases -1-=

Position Ma 200.$)stetric /

In!o uiah

131,000,000,000,000


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Patients reEuiring r"##a Obstetricmaes up @4:I


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&ill !e see more bleeding+JI of deliveries in 75& for each categor, in 75& in -11.K


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$assive Haemorrhage

$assive haemorrhage continues to be a an*iet, producingchallenge for medical staff especiall, junior doctors

&ill !e see it more often+

$anagement involves A7%#C#PA%#O7) #A87O5#5)$A7A86$67%

iagnosis reEuires vigilance and a!areness of confounders

$anagement is through team4!or and goodcommunication !ith obstetricians) $Os) surgeons)mid!ives) haematologists and radiologistsG


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Principles Underpinning $assiveObstetric Haemorrhage

8ravid uterus receives up to 0:I of maternal CO Jfrom-IK

;>11mlMmin Placental haemorrhage represents ;0 unit blood lossMmin

Lo! resistance placental circulation lacs autoregulation

Uterine m,ometrial contraction primaril, responsible forcessation of bleeding


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Improved OutcomesImproved Outcomes

Lower mortalityLower mortalityLess morbidityLess morbidity

%ewer complications%ewer complications

&enal failure&enal failure

'heehan(s syndrome'heehan(s syndrome

&etained reproductive function&etained reproductive function'maller reliance on radiological'maller reliance on radiological

embolisation proceduresembolisation procedures


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$aing a diagnosisN$aing a diagnosisN

Placenta complete/incompletePlacenta complete/incomplete

Vaginal bleedingVaginal bleeding

Uterus soft or contractedUterus soft or contractedUterus palpation and uterine positionUterus palpation and uterine position

Abdominal pain or shoulder tip painAbdominal pain or shoulder tip pain

Additional bleeding from otherAdditional bleeding from other

wound siteswound sites


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56"6R6 HA86 R6CO87#56

CALL FOR H6LP

567#OR$#"65

OB5%6%R#C#A75 A7A65%H6%#5% HA6$A%OLO8#5%

BLOO BA7A7A65%H6%#CR68#5%RAR5

POR%6R5 897A6 O7COLO8#5%#CU


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/ 4te Plan 5or Managing PP*

I6 I!enti5 4ource o5 Blee!ing7 8ie :terotonics

II6 Al Pressure to :terus7 Trans5use

III6 "ontrol Bloo! 4ul to :terus, 8ie Bloo!Pro!ucts

I;6 Place :terine "omression 4utures

;6 Per5orm *sterectom


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Uterine Bleeding

%rug %ose 4i!e e55ects

5,ntocinon 4:U slo! #" bolus

[email protected] in 0L titrated

4H,potension

4Refle* tach,cardiaMarrh,thmias

4!ea AH lie effect

6rgometrine 4-:1ug #$ or

40-:ug slo!l, #"

4nMv JcommonK

4H% Jcan be severeK

4coronar, spasmM ischaemic pain

Carboprost

P8 F-

41G-:mgintram,ometriall, or#$ repeated to ma*

-mg

4nMvMdiarrhoea4severe bronchospasm

4h,po*ia Jalter pulm shunt fractionK


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Alldied

from

MODS

/MOF


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"rstalloi! < "olloi! < Pac=e!"ells as er MassieTrans5usion Protocol

Pac=e! "ells < Platelets ation7 Trans5use-sta ahea!

;I6 Procee! withAGGRESSIVE SURGICAL MANEUVERSGAPA$T$MHaC Gigate )lee!ers)C :terine Arter Gigation $(Gear 4uturescC B-Gnch or Mo!i5ie! B-Gnch 4utures!C *sterectomeC Pac= Pelis

5C Mast 4uit as nee!e!

?*emorrhageAlert@

Potential for PPH

Inform patient/family of

potential for pp hemorrhage

Notify NIC & Unit

Coordinator about

Hemorrhage Alert --

potential for PPH.

Alert other a needed.

Actie Management o5 Dr!4tage o5 Ga)or

8ive uterotonics beforeplacenta deliversQ notetimeplacenta delivers

Uterus contracts!ithout problem

Call Off PPH alert

Postpartum Hemorrhage Process .ap

Announce minutes 5rom T0

Announce 4urgical ;ariance-4tage I, then 4tage II

4urgical ;ariance 4tage III

time subtotal = X min



Grand Total Time = X min

Announce minutes 5rom T0

ee trac= o5 time emem)er ?Fole, I E $(s@

emem)er :terotonics

If

pa

tient

sympto

matic

%ocumentE

Tal= withFamil


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B* "GB $)stetric 4urgical ;arianceUnexpected, Emergent

Peripartum Event

Vaginal Delivery C-Section Deviation from Exect

"atient Sta#le"atient Sta#le

Remain in CL$ roomRemain in CL$ room

rimary %# Care &eamrimary %# Care &eam

Manage' EventManage' Event"age $eeer ())

a' nee!e!

"atient"atient

Un'ta#leUn'ta#le

"atient"atient

Un'ta#leUn'ta#le

Anno*nce S*rgicalAnno*nce S*rgical

VarianceVariance

"age t+e NIC"age t+e NIC

danced ;urgicaldanced ;urgicalProcedure(s)Procedure(s)

"all 5or *el"all 5or *el ,$eeer

()),

Move to %RMove to %R

STAGE I S.V.

STAGE II AHODResources w/in Labor & Deliver

A!!itional 4urgical Proce!ureJsCA!!itional 4urgical Proce!ureJsC

+ *sterectom+ *sterectom

STAGE III

Resources ou!si"e o# L & D


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Intro!*ction of an o#'tetric-Intro!*ction of an o#'tetric-

'eci.c me!ical emergency'eci.c me!ical emergency

team for o#'tetric cri'e'/team for o#'tetric cri'e'/imlementation an!imlementation an!

exerienceexerience

Ga#riella G0 Go'man MD1 Marie R0Ga#riella G0 Go'man MD1 Marie R0

$al!i''eri MD1 2aren L0 Stein RN$al!i''eri MD1 2aren L0 Stein RN

MSED1 &ri'+ A0 Nel'on RN M3RM1MSED1 &ri'+ A0 Nel'on RN M3RM1

S*'an 30 "e!aline MS $SN1 4onat+an 30S*'an 30 "e!aline MS $SN1 4onat+an 30

5ater' MD1 3yagriv N0 Sim+an MD5ater' MD1 3yagriv N0 Sim+an MD

MSCRMSCR$agee4&omens Hospital) Pittsburgh) PA) -11SG


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PO&45CH4RH&4PO&PH

PAC6

i Bl d P d t U


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rop in Blood Product Usage

PROUC%

I Reduction

in Use5tate!ide

I Reduction

in Use Area4!ide

I Reduction

in Use atRand!icCampus

Red cells >G- =G0 =G-

Platelets 0-G1 G11current usage $ar (1


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rF"##a boosts thrombin generation on activated platelets


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Number of Cases of rVIIa by Population

P

er011)1

11

heado

fpopulation Australia 20,3D3,1KL

:4A 299,D9L,3.3

In!onesia 2.0,123,L3L

X 1/

6ffect on


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Outcome at-< a,s

6ffect onBleeding

n -S

*aemostasis egistr r;IIa First 2K P$4"* an 200K

$utcome E #55ect on Blee!ing

Rand!ic Campus vs %otal Registr,


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Rand!ic Campus vsG %otal Registr,


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ose

7umber of patients -1-=

%otal number of doses @11@

$edian dose SG- mg J#TR .GK

$edian dose =1G> gMg J#TR S0G:401-G:K

um)er o5 %oses


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6ffect on Bleeding vs Outcome

Bum)ero

5cases

-- @0


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6ffect on Bleeding vs Outcome

$)stetrics


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Causes of r"##a failureCauses of r"##a failure

Fibrinogen ?1G


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%A:M A%, BAT:-MAGA8, 2009


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%emp and 6ffect on Bleeding

-0. ..) p ? 1G110

%otal cases 0G@1S


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pH and 6ffect on Bleeding

-0> 0==) p ? 1G110

%otal cases 0)0


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pH and


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pH and%emperature

n 0)0>=

!ecreasing

*

!ecreasing

tem

H % t 6ff t Bl di


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pH) %emperature 6ffect on Bleeding

n 0)1@.


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#n haemorrhage)r"##a is

97A$#%6

Jbut do not !aste itK

f f 5 OF lfil t f 5 ll b Obj ti i th


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Fulfilment of 5,llabus Objectives in theFulfilment of 5,llabus Objectives in the

$anagement of Catastrophic$anagement of Catastrophic

HaemorrhageHaemorrhage "olume replacement"olume replacement r"##a the Haemostasis Registr, r"##a the Haemostasis Registr,

Australia 7e! WealandAustralia 7e! Wealand Haemorrhage 'fire( drills Asia perspectiveHaemorrhage 'fire( drills Asia perspective $assive transfusion bo*$assive transfusion bo* $assive %ransfusion Protocol Australian$assive %ransfusion Protocol Australian

perspectiveperspective

oint OA5AO 5OAP $eeting


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So muchmore to

haemorrhage

Stephen Gatt, MD

Terima asih Atas

Perhatian An!a


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Adverse 6vents 4 %rauma

efinitel, Lined 1Probabl, Lined 1

Possibl, Lined 0

4u) Total 1 N 262

Unliel, to be Lined .

7ot Lined =

Unable to Assess 0Causalit,

:0,GoG male !ith previous histor, ofchronic alcoholic liver disease sufferedblunt assault including liver lacerationsG

A6 #C) ?> hours post rF"##aadministrationG

eceased a, 0-Cause of eath 4 unno!n Ja!aitingcoroner(s reportK

@


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-11)111

.11)111

>11)111

Aug 1S

Februar, -11>

August -11S

D: ,ears

Y0)1@0)111

Y0)>1-)111

Rand!ic Campus CumulativeRand!ic Campus Cumulative

6*penditure6*penditure


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Econo$ic As%ec!sEcono$ic As%ec!s

Cost of drug?

Survival?

Intensive care unitcost?

Days in hospital?


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Obstetrics rF"##a

Units of Paced Cells Before rF"##a After ose0 After ose- After ose@

1 . S - 0;1 ?: - 0@ 0 1> 4 01 - 0 0 100 4 0: < 1 1 10: 4 -1 - 1 1 1-0 4 -: 1 1 0 1-> 4 @1 0 0 1 1

; @1 @ 1 1 1 %otals -- -- : 0

n--n--Position on -.GviiG1> B %* before after "##aPosition on -.GviiG1> B %* before after "##a


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''6conomic( Considerations6conomic( Considerations

&hat is the cost of a life+&hat is the cost of a life+

&hat is the cost of a fatherless or&hat is the cost of a fatherless ormotherless famil,+motherless famil,+

&hat is the cost of saved blood blood&hat is the cost of saved blood blood

products+products+&hat is the cost of #CU sta,+ Of return to&hat is the cost of #CU sta,+ Of return to

OMR+OMR+


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G#:"$%#PG#TI$ TA8#T4


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Leucodepletion %argets

100 uniersal leuco!eletion ) 1st6$cto)er 200. to "ouncil o5 #uroe8ui!elines

"ost etra O100unit

+ 4econ! B" )e!si!e 5ilter Jto re!uce5urther log B"C

G#:"$%#PG#TI$ TA8#T4


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elivering Blood from Blood Ban

Pneumatic %ube5,stem J5CUK

0- units broenJ0G0G1


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BG %* "##a 4 CostsBG %* "##a 4 Costs

Acute Resuscitation in Massive Haemorrhage in the Peripartum

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