Obstetric Hemorrhage Program - PowerPoint Presentation

Slide1

Obstetric Hemorrhage Program

Slide2

Review Committee

Felicia Fitzgerald

,

BSN, RNC-OB, C-EFM, Perinatal Outreach Educator University of Chicago Medicine

Lori Folken

, BSN, RNC-OB, C-EFM, Perinatal Outreach Educator, Carle Foundation Hospital

Paula Melone,

D.O. FACOG, Assistant Professor, Loyola University Health System

Angela Rodriguez,

RNC-OB, BSN,

CCRC, Perinatal Coordinator, Advocate Illinois Masonic Medical Center

Shirley

SCOTT

,

RN-BC, C-EFM, MSN, APN, Perinatal Outreach Educator, University of Illinois at Chicago

Slide3

Obstetric hemorrhage-case #1

28 weeks EGA with complete previa presents with profuse vaginal bleeding

BP 109/70

mmHg

; HR 110 Hct 22% (30% 2 days prior)

Immediate C-section performed under general anesthesia EBL 750 mlFluid replacement of 2500 mlUrine output 200 ml Post extubation HR 120s

Slide4

CASE #1-QUESTION

Patient

s/p uneventful C/S for bleeding – becomes anuric and

is

oozing from

incision site The patient is taken back to the OR for presumed intra-abdominal bleeding Exploratory lap shows no evidence of intraperitoneal hemorrhage

The most appropriate next step in management of this patient is:

Aggressive volume replacement with blood products

Urology consult to assess for concealed GU injury

CT scan of abdomen to look for concealed bleeding

Renal consult to work up her renal disease

Slide5

OBSTETRIC HEMORRHAGE-CASE #1

Delay in diagnosis

Underestimation of blood loss

Prior to hospital admission

Hemorrhage & profound hypovolemia

Delay in treatment

Inadequate initial resuscitation → irreversible hemorrhagic shock, coagulopathy and Acute Tubular Necrosis (ATN)

Time from admission to death was 21 hrs

Slide6

World Maternal Mortality Ratio

(MMR per 100,000 births in women aged 15-49)

Slide7

Slide8

Slide9

Illinois Immediate Cause of Death Hemorrhage by year

Maternal Deaths through

December, 2014

2006

2007

20083-year Total 2009201020113-year Total 

2012

2013

2014

3-year Total

Immediate

Causes of Death Hemorrhage

1

4

6

11

 2226 6208

Initial Program Implementation

Slide10

Etiologies:

Hemorrhage

D

eaths

2001-2006

2007-2013

Ruptured uterus

4

2

Preeclampsia

4

10

Surgery

complication

3

1 Abruption 2 1 Sepsis2 4 Uterine atony1 8 Ectopic pregnancy1 4 Other 3 6 Total reviewed*2036

Case Dispositions 2001-20062007-2013 Not avoidable 214 Undetermined06 Potentially avoidable 1816 Patient factor(s) only 24 Care Factors 1610 Other Factors02

* Does not include traumatic injury

The Illinois Experience MMRC 2001 - 2013

Slide11

No

or

inadequate identification of risk factors

Delayed or wrong diagnosis

Unrecognized abnormal vitals signs (s/s hypovolemia)

Underestimation of blood loss

Delayed and/or inadequate treatment

Under resuscitation

Inadequate/inappropriate referral, consultation,

transfer of care

Inadequate documentation

Chain of communication issues

Potentially Avoidable Factors in Care

Slide12

Program Goal

Recognition and Prevention of

Morbidity & Mortality from Obstetric Hemorrhage

Program Objectives

To improve:

Risk assessment and preparationEarly recognition of obstetric hemorrhageQuantification of

blood loss

Recognition of hypovolemia

Treatment of hemorrhage

and

hypovolemia

To

create and implement

:

Rapid Response Teams for coordinated management

Polic

ies and GuidelinesRapid transfusion protocolActive management of the third stage of labor The Intervention…Education!

Slide13

“Persistent (ongoing) active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage.”

Treat the cause and calculate blood lo

s

s as you

go!

Definition of Perinatal Hemorrhage

Illinois Includes Antepartum Blood Loss in Totals

Slide14

A 42 year old G7 P5-0-1-4 at 37 weeks, with a prior IUFD, 3 prior C-sections and known placenta previa, presents for repeat C-section due to worsening hypertension

Pressure range on admission: 186/92-198/98, HR 80

Initial labs: Hgb 14.6,

Hct 43.8, Plts 190

Findings at delivery:

Adhesions- omentum to anterior abdominal wall

& bladder to lower uterine segment

Complete placenta previa

Viable male infant delivered @1743

Intraoperative EBL 700 ml

Intraoperative BP 140/88

OB Hemorrhage - CASE #2

Slide15

This patient’s history of 3 prior cesarean deliveries, and a known placenta previa puts her at increased risk for:

Antepartum hemorrhage

Placenta accreta

Ruptured uterus

All of the above

CASE #2 - Question

Slide16

In addition to her placenta previa, which would be considered a risk factor for perinatal hemorrhage? Choose the best answer.

Chronic hypertension (CHTN)

Grand multiparity

Maternal age

IUFD history

CASE #2 - Question

Slide17

What additional laboratory test(s) should you consider prior to her repeat C-section? Choose the best answer.

Type and screen

24 hour urine collection for protein & Creatinine clearance

Uric acid

Type and cross-match

CASE #2 - Question

Slide18

RISK ASSESSMENT

AND PREPARATION

Slide19

Risk factors associated with hemorrhage

Slide20

1. History of

hemorrhage ________________________

2. Placenta previa/accreta

________________________

3. Grand multiparity

________________________4. Jehovah’s Witness ________________________

5. Other

(e.g. MgSO4,

prolonged

labor,

chorio etc.)

________________________

RISK FACTOR

PLAN

Slide21

Vitals

:

On Admission:

BP 186/92; HR

80

Intra-op: BP 140/88; HR 90 EBL: 700cc

In Recovery Room:

1815

BP 117/69; HR 108

1855

BP 98/61; HR 110

1903

BP 99/56; HR 118

1920

BP 90/50; HR 120

At what point do you first suspect potential hypovolemia?

1815 BP 117/69; HR 108

1855 BP 98/61; HR 110

1903 BP 99/56; HR 118

1920 BP 90/50; HR 120CASE #2 – cont’d

Slide22

RECOGNITION, VISUALZATION AND QUANTIFICATION OF

BLOOD LOSS (QBL)

Slide23

The blood loss at a vaginal delivery is given as

350mL.

To

quantify this

amount correctly, the blood volume in the collection drape would fill a:

Standard soda can Half gallon of milk Pint of milk Quart of milkEBL Recognition

Slide24

1

cup = 250ml

= 5 cm clot (orange)

=

1 unit PRBCs

2 cups = ~ 500 ml

=

10 cm clot

(softball

)

=

2 unit PRBCs12 oz. soda can = 355 mlFloor Spills 23 inches (50 cm): 500 ml 34 inches (75 cm): 1000 ml 45 inches (100 cm

):

1500 mlFamiliar ObjectsIdeal Method = Weighing 1gm of blood = 1 mlEstimating Blood Loss

Slide25

3 hrs postpartum in the

recovery

r

oom

3 orange size clots passed500 ml fluid bolus givenPost infusion BP 108/70; HR 115The first fluid bolus ordered at this time was 500 ml. This amount is:

Adequate

Adequate if vitals checked q 5 minutes & bleeding slows

Adequate if blood replacement is ordered

Inadequate

CASE #2 – Cont’d

Slide26

Less than 2.5 cm (1

inch/hour)

Less than 10 cm (4

inches/hour)

Less than 15 cm (6

inches/hour)

1 pad saturated within 2 hours

Light

Scant

Moderate

Heavy

Visual EBL

Inaccurate

Scant

23-30 ml

Light

Moderate

Heavy

80-100 ml

WeighingMost accurateOB Hemorrhage: RecognitionLowdermilk & Perry (2012)Bose. BJOG 2006

Slide27

A standard 18in x 18in lap that is 75% saturated with blood represents a blood loss of:

25 ml

50 ml

75 ml

100 ml 

EBL Recognition

Slide28

EBL Recognition

Slide29

Hospital Item

Approximate

dry

weight (grams)

“Wet” Weight (grams)

Wet - Dry = Totalfluid/blood

Blue Chux Bed Pad

115g

205g

205g-115g=90g=90ml

Large Peripad

45g

75g

75g-45g=30g=30ml

Small Peripad

17g

35g

35g-17g=18g=18mlMesh Underwear

17g

35g35g-17g=18g=18mlWash/Face Cloth28g40g40g-28g=12g=12mlLonger Hand/Body Towel185g225g225g-185g=40g=40mlFitted Bottom Sheet500g550g550g-500g=50g=50ml(1 mL or 1 cc = 1 gram)Quantification Examples

Slide30

Quantification of blood loss has been shown to decrease the incidence of errors in blood loss estimation.

Blood loss estimation can lead to:

Overestimation

leads to unnecessary treatments

Underestimation

leads to delays in treatmentMethods such as a calibrated drapes

had

an error rate of less than

15%

Quantification of Blood Loss (QBL)

Toledo

, McCarthy &

Wong

(2007);

Patel, Goudar, Geller, Kodkany, Edlavitch, Wagh, Patted, Naik, Moss, Derman (2006);

Al Kadrik, H., Al Anazi,B., Tamim, H. (2010)

Slide31

Slide32

Est

. Blood Loss

(

EBL)

~900 ml

~1200-1500 ml

~1800-2100 ml

>2400 ml

Pulse

<100 bpm

>100

bpm

>120

bpm

>

140 bpm

Respirations

14-20 bpm

20-30 bpm

30-40 bpm>35 bpm Blood PressureNormalOrthostatic changesOvert hypotensionOvert hypotension Mental Status Alert, mild thirst +Anxious and RestlessAgitated or confusedDrowsy, confused and lethargic Urine Output>30 cc/hr20-30 cc/hr5-15 cc/hrAnuria

Cap RefillNormal>2 seconds>2 secondsCold & clammy >2 secondsCold & clammy Fluid Replacement (3:1 Rule)CrystalloidsCrystalloidsCrystalloids& blood Crystalloids& bloodBlood Loss Quantification and Replacement

Slide33

Recognition and Management of Hemorrhage

ANTEPARTUM INTRAPARTUM POSTPARTUM

Concealed

signs and symptoms

of hypovolemia

Overt

objective measurement

of blood loss

Blood Loss Recognized

Slide34

Question

Choose the

earliest

sign of compensatory change that occurs with hypovolemia? Tachycardia Hypotension Hyperventilation

Pallor

Slide35

Signs and Symptoms of Hemorrhage

Look for

t

rends in vital

s

igns and patient status

Pulse

Respirations

Pallor

Change in Mental Status

Urinary Output

Capillary Refill

Blood Pressure

Slide36

Question

In cases of severe hemorrhage, the minimum rate of urine output per hour needed to prevent renal tubular necrosis is

A. 10 ml/hr

B. 30 ml/hr

C. 100 ml/hr

D. 300 ml/hr

Slide37

Delayed Recognition of Hypovolemia

Maternal Physiology

Pregnancy - Hypervolemic State

Nearly 50% increase in blood volume

Up to

30% loss

of volume

(1500 to 2000ml) to alter vitals

(vasoconstriction/SVR)

Need earlier replacement of higher volumes for adequate resuscitation!

Gordon,

2013. Obstetrics: Normal and Problem Pregnancies, 6

th

ed. Page 52.

Slide38

Francois. (2013). Obstetrics Normal and Problem Pregnancies 6d.ed. p. 416

BP

Late Finding

BP remains stable until 25 – 30%

(1500 – 2000 ml) of volume is lost

Slide39

Urine output 20 ml/hr

1 liter D5LR given over 2 hours

HGB ordered – Result of 5.9 mg/dL reported back

4 hrs postpartum

12 hrs postpartum

1

st

unit PRBC’s started

BP 90/50, P128

Patient combative

Blood oozing from IV site

Pelvic exam: two 5cm clots

An additional estimated blood loss of 1600 ml

Patient coded five minutes after pelvic exam

CASE #2 - Outcome

Slide40

No/inadequate identification

of risk factors

4

th

C/S →

Previa →

High Parity

Delayed/Wrong Diagnosis

Unrecognized abnormal vitals (s/s hypovolemia)

Inadequate assessment of vitals and physical findings

Underestimation of blood

loss in OR and postpartum

Pre-op Hgb 14.6

Post-op Hgb 5.9

Delayed/Inadequate Treatment

Inadequate volume replacement

1st unit of PRBCs started 14 hours post-cesarean

CASE #2 Summary of Issues

Risk of accreta

Slide41

Lack of documentation has been identified

as a major problem!

Documentation must include:

Date/time, name of provider for each

person who provides care during the eventOngoing vital signsSigns of hypovolemiaActual blood loss amount*

Interventions

Patient response

Above information reported to

…?

Discussion with family member(s)

CASE #2 Summary of Issues Continued

IDPH recommends the quantification of actual Blood Loss for All deliveries

Slide42

Treatment

&

Product Replacement

Slide43

Recognition and Management of Hemorrhage

ANTEPARTUM INTRAPARTUM POSTPARTUM

Concealed

signs and symptoms

of hypovolemia

Overt

objective measurement

of blood loss

Blood Loss Recognized

Stop the hemorrhage

treat the cause

Homeostasis

correct hypovolemia

Slide44

ACTIVATE RAPID RESPONSE TEAM

Identify Source of Bleeding & Abate

Intervention

Simultaneous actions

Slide45

O

xygenate

Assist with airway protection

Apply pulse oximeter

Start Oxygen by mask 10L/min

Restore circulation

Deliver if indicated

Ensure IV access with two (2) large bore catheters

(LR/NS infusing)

Accurately assess blood loss

Draw Labs: CBC, Coagulation Panel, Chemistry Panel

Give volume expanders (crystalloid & blood as indicated)

D

rug therapy

Oxytocin (Pitocin)

Methylergonovine (Methergine)

Carboprost Tromethamine (Hemabate) Prostaglandin F2 AlphaMisoprostol (Cytotec)Evaluate statusTrend Vital SignsMonitor lab results, urine output, bleeding and IV fluidsObserve Mental Status

R

emedyReplace and ResuscitateIdentify and treat the underlying cause and/or prepare for intraoperative managementACOG Technical Bulletin 235, April 1997Remember “ORDER” for Action

Slide46

After a normal spontaneous vaginal delivery (NSVD), bright red bleeding continues in the presence of a firmly contracted uterus.

This is likely the result of:

Uterine rupture

Retained placenta

Vaginal laceration

Thrombocytopenia

Question

Slide47

Objective

:

To

compare the effectiveness of active versus expectant management of thethird stage of laborDefinitions:

Recommendations

:

Active management of third stage

was associated with reduced

Maternal blood

loss

Reduced postpartum anemia, and decreased need for blood transfusion

Risk of prolonged third stage labor

Use of additional therapeutic uterotonic drugs

Women should be given information on the benefits and harms to support informed choice

Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical to look at the individual components of third stage management

Active Management

Prophylactic uterotonicEarly cord clamping Controlled cord traction to deliver the placentaExpectant Management Signs of placental separation are awaited Placenta is delivered spontaneously Active versus Expectant Management for Women in the Third Stage of Labor (Review)Begley, Gyte, Devane, McGuire, Weeks (2011)

Slide48

Administration of uterotonic drugs

Controlled cord traction

Uterine massage

Active Management of the Third Stage of Labor (AMTSL)

Slide49

Can be vulvar, vaginal or pelvic

Complaints of pressure and pain

Pain may be verbalized as excruciating

Discolored skin that is tight, full feeling, and painful to the touch

Possible tachycardia or decrease in BP

Decrease or absence of lochia flow if the vagina is impeded Management depends on size http://gynaeonline.com/vulvar_hematoma.htm

http://ogscience.org/search.php?where=aview&id=10.5468/ogs.2014.57.2.168&code=3021OGS&vmode=PUBREADER

Hematomas

Slide50

Non-Surgical Techniques for

Acute Blood Loss

fundal massage

bimanual compression

uterotonics

tamponade devices

uterine packing

Recombinant Activated Factor VII

Slide51

Other Options

Acute Normovolemic Hemodilution (ANH)*

Pre-op Autologous Blood Donation*

Cell Saver*

Tranexamic Acid (TXA)

Rotem

http://www.nordicphotos.is/details/4721109

Slide52

Oxytocin

(Pitocin

)

10-40 units/liter NS/LR IV rapid infusion

Other rapid infusion routes: IM & IU

Hemabate

(PGF2

α

;

Carboprost tromethamine

)

250 mcg IM q 15-90 minutes (max 8 doses)

Other rapid infusion routes: IU

Methergine (Methylergonovine Malaeate;

Ergonovine Maleate

)

0.2 mg IM q 2-4hrs

(max 5 doses)Misoprostol (Cytotec)400-1000 mcg PR

Uteroto

nicsHTNASTHMA

Slide53

Method of testing the efficiency of blood

coagulation

:

Clotting time CT (sec)

Speed of fibrin formation; influenced by clotting factors, anticoagulantsClot Formation Time CFT (sec)Kinetics of clot formationMaximum Clot Firmness, MCFPercentage of clot firmness loss during measurement Rotational Thromboelastography (TEG)

Slide54

Multidisciplinary treatment approach

Formulate a plan of care for avoiding/controlling blood loss

Consult promptly

Promptly investigate and treat anemia

Decisive intervention, including surgery

Be prepared to modify routine practice when appropriate

Restrict blood draws

Decrease or avoid the use of anticoagulants and antiplatelet agents

Stimulate erythropoiesis

Transfer a stabilized patient, if necessary, to a major center before the patient’s condition deteriorates

General Principles of Bloodless Medicine Management

Care During Pregnancy

Prenatal Care

Comprehensive discussion

Aggressively prevent anemia (Iron, Folate, B12, Erythropoeitin)

Consultants (consider MFM, Hematology, Anesthesiology, Neonatology)

Early Third Trimester: Reassessment of hemorrhage risk and discussion of options

Labor and Delivery

Early Anesthesia & Neonatology Consultations

Reassessment of hemorrhage risk and discussion of optionsReview specific techniques Review PlanPostpartumMaintain volume with crystalloids and allowed blood substitutesAggressively treat anemiaWomen Who May Decline Blood and Blood Products Gyamfi & Berkowitz (2008)

Slide55

WatchtowerJW.org

Hughes, Ullery & Barie, (2008)

Slide56

Question

Which of the following techniques may be attempted to stop uterine bleeding from the implantation site of a placenta previa during cesarean delivery?

Bilateral internal iliac artery embolization

Bilateral uterine artery ligation

Intraoperative uterine packing

All of the above

Slide57

Surgical Interventions for Uterine Atony

uterine

curettage

uterine

artery ligation (O’Leary)

b-lynch suture?

hypogastric artery

ligation

selective arterial

embolization

hysterectomy

Slide58

Classification of topical and internal

hemostatic agents

Mechanical Hemostats

Gelatin sponge

Collagen

CellulosePolysaccharide spheres

Flowable Hemostats

Gelatin

Gelatin + Thrombin matrix

Fibrin Sealants

Fibrinogen + Thrombin

Active Hemostats

Thrombin products

Slide59

144 women (72 in each

group)

EBL: TXA

group (173 mL)

<

control group (221 mL), P=0.041TXA group: Bleeding duration shorter Progression to severe PPH and pRBC transfusion less frequent

Conclusion

:

High-dose TXA can reduce EBL and maternal morbidity in PPH

Slide60

High Dose TXA Protocol

Slide61

Treatment and Product Replacement

Call for backup

Surgery, Gyn-Onc, IR, ICU, Hematology

Stop the bleeding

Non-surgical options

Medical options

Surgical options

Accurately quantify and document blood loss

IV access

2 large bore IVs with LR/NS

Draw labs

CBC, Coag. Panel, Chem. Panel

Prepare for transfusion/ blood bank notification

Crystalloid, blood, other products

Rapid Response Team

Slide62

Remember

“ORDER” for Action

O

xygenate

Assist with airway protection

Apply pulse oximeterStart Oxygen by mask 10L/min (O

2

stats >95%)

R

estore circulation

Ensure IV access with two (2) large bore catheters

(LR/NS infusing)

Consider arterial line

Accurately assess blood loss

Draw Labs: CBC, Coagulation Panel, Chemistry Panel

Give volume expanders (crystalloid (2-3 L) & blood as indicated)

Drug therapyOxytocin (Pitocin)Methylergonovine (Methergine)Carboprost Tromethamine (Hemabate) Prostaglandin F2 AlphaMisoprostol (Cytotec)E

valuate Status

Trend Vital SignsMonitor lab results, urine output, bleeding and IV fluidsObserve Mental StatusAvoid hypovolemiaRemedyIdentify and treat the underlying cause and/or prepare for intraoperative management

Slide63

Preparedness - Need to know

Availability of & time to get

Type and Cross

Lab results – CBC, coags

Blood products – PRBCs, plts, FFP, cryo etc.

Medications – Pitocin, Methergine, Hemabate, Misoprostol, etc.

Availability of Cell Saver

Specialist availability

Anesthesia, Gen surgeon, Gyn-Onc

,

radiology, MFM, etc.

Are these processes in place?

Rapid Response Team

ICU/Critical Care Team

Critical Data Manager

Labs

Vital signs

I & OMedications Massive transfusion policyChain of Communication

Consult/Transport

Slide64

Rapid Response Protocols

Facility resources:

Optimal medical skills

Optimal surgical skills

Optimal administrative skills

Blood bank stores

Lab response times

Ancillary resources

Knowledge of these resources etc.

Who’s going to do what?

Slide65

Treatment Algorithms

Slide66

Slide67

Slide68

Hemorrhage Contacts

Overhead page to room:

Charge nurse #_________________

Anesthesia #_________________

Resident #_________________

Provider #_________________Blood Bank contact #_________________Pharmacy #_________________ICU contact #_________________

Gyn-Onc;

Gen Surg #_________________

Slide69

Est. Blood Loss (EBL)

~900 ml

(Stage 1)

~1200-1500 ml

(Stage 2)

~1800-2100 ml

(Stage 3)

>2400 ml

Pulse

<100 bpm

> 100 bpm

> 120 bpm

>140 bpm

Respirations

14-20 bpm

20-30 bpm

30-40 bpm

> 35 bpm

Blood Pressure

NormalOrthostatic changesOvert hypotensionOvert hypotensionMental Status +Anxious+AnxiousAnxious and ConfusedConfused and Lethargic

Urine Output>30 cc/hr.20-30 cc/hr5-15 cc/hrAnuriaFluid Replacement (3:1 Rule)CrystalloidsCrystalloidsCrystalloids + bloodCrystalloids + bloodLabsCBC; PT/PTT; Fibrinogen; T&S versus T&C; FDP; Plts; D-dimerProduct ReplacementCrystalloids →Transfuse PRBCs →Transfuse other (FFP, Cryo, Plts)Bleeding AbatementMassage →Uterotonics →Packing/Tamponade/Embolization

→ Surgery

Management Algorithm

Slide70

Blood Product Administration Chart

Type

Indication

Administration Techniques

Special Consideration

Packed Red Blood Cells (PRBCs)

Improves oxygen carrying capacity of blood

Straight line or Y-set with filter

Microaggregate recipient set

First choice in blood replacement

Contains little plasma

Increases Hct 3-4% per

unit

1 unit = 200 ml volume

May take several hours or days to cross-match if antibodies are present

Fresh Frozen Plasma (FFP)

Increases clotting factors

Contains all clotting factors

Corrects

prolonged PT > 18 sec; PTT > 55 sec; INR > 2.0Rapid infusion, straight line set with filter3-9 units usually neededMaximal benefit within 2-4 hoursHighly desired if > 2 units of PRBC are given0.9% NS not needed for Y-set because the component contains no RBCs1 unit - 180 ml volume; increase fibrinogen 10%-15%/unitCryoprecipitateFactor VIIIReplace fibrinogen or Factor XIII Initial dose 2 u/12 kg body weight then;1u/12 kg body weightRapid infusion, component drip set onlySource of fibrinogenGive if fibrinogen level <801 dose = 10 unit pack raises fibrinogen 80-100 mg/dl3000-4000 ml total is needed to restore maternal fibrinogen to > 150 mg/dLPlateletsTo control clotting or prevent bleedingAs rapidly as possibleUse a non-wettable blood filterShort lasting effect

Given when count < 50,000 mm31 pack = 6 units of platelet concentrates of single donor raises count by 5000-8000 mm3Least hazardous if given fresh5% AlbuminPrevent hemoconcentrationMaintain appropriate electrolyte balanceTreat hypoproteinemiaAs rapidly as possible, undiluted or dilute with saline or D5WGiven as a volume expander in place of RBCs while patient is being cross matched

Slide71

American Association of Blood Banks (AABB)

Restrictive Transfusion Strategy Statement

“...Transfusion should be given for symptoms of anemia and should not be based on hemoglobin concentration alone

.”

“Optimal use should… maximize clinical outcomes while avoiding...potential...risks

”Carson, et. al., .2012;157:49-58.

Slide72

Massive Transfusion

Definition

Replacement of a blood volume equivalent within 24hrs

>10 RBC units within 24hrs

>4 RBC units within 1hr

Replacement of 50% of blood volume in 3hrs

A rate of blood loss >150ml/hr

Consider Activation When

Patient actively bleeding and any of the following:

Systolic BP <90 mmHg

pH <7.1

Base deficit >6 mEq/L

Temperature below 34°C

INR >2.0

Platelet count <50,000/mm³

Pacheco

, Saade,

Gei

,

& Hankins, 2011

Slide73

Fluid Replacement Strategy

Crystalloid &

colloid

s

olutions

replace loss of intravascular volumeRed blood cells restore oxygen carrying

capacity

Clotting factors and platelets restore physiologic hemostasis

Massive Transfusion

Slide74

Massive Transfusion – protocol example

Early administration of FFP, Platelets, PRBCs in ratio 1:1:1 before Coags

Pacheco, L., Saade, L., Gei, A., Hankins, G. (2011). AJOG

Slide75

Summary

Slide76

Preparation and Risk Assessment

Recognition

Treatment

Communication

Quality Reporting

Summary of Hemorrhage Steps

Slide77

Risk Assessment

Screen every patient for hemorrhage risk

Risk factor may include:

Medical:

cardiac, HTN, Obesity

Pregnancy: Multiple gestation, known placenta previa, induction, prolonged 2nd stage

Preparation

Hemorrhage Cart

Rapid access to hemorrhage medications

Multidisciplinary rapid response

Simulation

Documentation

STEP 1:

Preparation and Risk Assessment

Slide78

STEP 2: Recognition of Hemorrhage

ANTEPARTUM INTRAPARTUM POSTPARTUM

Blood Loss Recognized

Concealed

signs and symptoms

of hypovolemia

Overt

objective measurement

of blood loss

Slide79

STEP 3: Treatment of Hemorrhage

ANTEPARTUM INTRAPARTUM POSTPARTUM

Blood Loss Recognized

Concealed

signs and symptoms

of hypovolemia

Overt

objective measurement

of blood loss

Stop the hemorrhage

stop the cause

Homeostasis

correct hypovolemia

Treat the cause and calculate blood loss as you go!

Slide80

STEP 4:

Communication Strategies

Clinical considerations

Disposition of patient

Resources for clinicians after severe morbidity

Debrief

Document after team debrief

Discuss with patient/family members

Slide81

STEP 4: Communication Strategies

SITUATION

Briefly describe the current

situation.

Give clear, succinct

overview of pertinent issues.

BACKGROUND

Briefly state pertinent

history.

What got us to

this point?

ASSESSMENT

Summarize the facts and give your best

assessment.

What is going on?

Use

your judgment. RECOMMENDATIONS What actions are you asking for?What do you want to happen

next?

SBAR

Slide82

Key steps for reducing maternal mortality and morbidity due to hemorrhage

Training of all healthcare providers in early diagnosis, prevention and treatment options

Promote and reinforce the value and effectiveness of

Active Management of the Third Stage of Labor

as standard

Develop and use treatment protocols

Monitor the incidence of hemorrhage and ensure quality assurance

Slide83

STEP 5: Quality Reporting & Systems Learning

Establish a culture of huddles for high-risk patients and post-event debriefs

Conduct a multidisciplinary review of serious hemorrhages for systems issues

Monitor outcomes and processes metrics

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STEP 5: Quality Reporting & Systems Learning

Recommended process for obstetric hemorrhage

Quality Reporting

Debrief

SMMI

Outcome

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