周捷-产后出血的麻醉处理PPT课件

产后出血的麻醉处理,哈佛大学医学院布莱根和妇女医院麻醉科周捷JieZhou,MD,MS,MBADepartmentofAnesthesiology,PerioperativeandPainMedicineBrighamandWomensHospital,HarvardMedicalSchool,1,.,Disclosure,BD科学咨询委员会成员,2,.,TonightontheLaborFloor,30yoG1P0at38weeksbreechpresentation;inactivelabor170cm86kg,MallampatiIINPOfor11hoursNoallergiesNomedicalhistory,3,.,IntheOperatingRoom,18gIV,uneventfulspinalanesthesiaHealthybabyborn5minuteslater:continuousoozinginthefieldOB:“Thetoneispoor”Patient:“Ifeeldizzy”Vitalsigns:BP80/49;HR120sSaO2100%Whatwillyoudo?,4,.,Objectives,DEFINEPostpartumhemorrhageIDENTIFYChallengesofmanagementPREPAREManagementbasedonevidence,5,.,MortalityfromPostpartumHemorrhage,Onewomaneverysevenminutes,PottsMetal.Lancet2010;375:1762-3,6,.,1995through2004PPHincreasedby30%2.9%ofalldeliveriesBloodtransfusion2.4to4.6per1000(90%increase)Uterineatony:predictableonly40%ofcases.,BatemanBetal.AnesthAnalg2010;110:1368-73.,TheEpidemiologyofPostpartumHemorrhageintheUnitedStates,7,.,CardiacArrestDuringHospitalizationForDeliveryintheUnitedStates,1998-2011,4,843casesidentifiedPostpartumhemorrhage:1349patients(27.9%),55%survivalAmnioticfluidembolism:645patients(13.3%),52.5%survival,MhyreJetal.,Anesthesiology2014April.,8,.,UnitedKingdom,PostpartumHemorrhageMaternalDeath66%ofcases:substandardcare,9,.,Objectives,DEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence,10,.,PostpartumHemorrhageDefined,Quantificationofbloodloss?500mLaftervaginaldelivery1000mLaftercesareandeliveryWearebadatestimatingbloodlossCasesthatneedtransfusion?RetrospectiveHemodynamicchanges?Latesignsinthepregnantpatient,ACOGPracticeGuideline;ObstetGynecol2006.BosePetal.BJOG2006.ToledoP.Etal.AnesthAnalg2007.,11,.,MajorPostpartumHemorrhage,Estimatedbloodlossof2500mLormoreTransfusionof5unitsofbloodTreatmentofcoagulopathy,WiseandClarkCurrOpinAnaesthiol2008.,12,.,Objectives,DEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence,13,.,ChallengesofPPH,Rath,WH.ActaObstetriciaetGynecologicaScandinavica2011May;90(5)421-8,14,.,NORMALABNORMAL,PPHPROTOCOL,COMMUNICATION,15,.,The4TsofPPH,Tone,SolomonCetal.BrJAnaesth2012;109(6):851-63.,Tissue,Trauma,Thrombin,16,.,SliverRMetal;ObstetGynecol2006;107(6):1226-32,30,132women,cesareandelivery732women:placentaprevia,PlacentaPreviaandPriorCesareanDelivery,17,.,Anatonicuterusisableedinguterus,http:/www.nursing-,18,.,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,PGF2,Hemabate),19,.,20,.,UterotonicAgentsforPPH,21,.,Whenpharmacologictreatmentfails,BimanualcompressionUterineballoontamponadeUterinecompressionsuturesArterialligationInterventionalradiologyHysterectomy,22,.,Objectives,DEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidence,23,.,Hemostasis,1.Vasoconstriction,2.Plateletplug,3.Coagulationcascadefibrinclotformation,TheMcGraw-HillCompanies,Inc.,24,.,LowFibrinogenPredictsWorseOutcomeInPostpartumHemorrhage,Charbitetal.JThrombHaemost2007;CortetMetal.BrJAnaesthesia2012.,25,.,www.R,RiaSTAP:FibrinogenConcentrate,Indications:PPHwithsuspectedorknownDICorfibrinolysis1vial=1gfibrinogenAdd50mLsterilewaterSwirlgentlyInfuseover10minutes,26,.,Ducloy-BouthorsASetal.CritCare2011.,PPHaftervaginaldelivery:800mLEBLTXAadministration4g/1hthen1g/hfor6hEBLatT2(30min),toT4(6h)lowerEBL,shorterduration,lessseverePPH,High-dosetranexamicacidreducesbloodlossinpostpartumhemorrhage,27,.,TranexamicAcidfortheTreatmentofPostpartumHaemorrhage:anInternationalRandomized,DoubleBlind,PlaceboControlledTrial,December2014/August2015,28,.,28contols(norVIIa)16treated(rVIIa),LeightonBLetal.Anesthesiology2011;115:1201-8.,UseofRecombinantFactorVIIainsuspectedAmnioticFluidEmbolism,29,.,Isthereaperfecttransfusionratio?,1:1:1PRBC:FFP:PlateletsForwhom?When?Dose?Outcomes?,30,.,12,226deliveries,2006-20091.1%(142patients)hadseverePPHHigherFFP:PRBCratiowerelesslikelytohave:-embolization-arterialligation-hysterectomy,PasquierPetal.AnesthAnalg2013,FFP:PRBCRatioinPostpartumHemorrhage:AnObservationalStudy,31,.,GoodnoughLTetal.2011Dec.,32,.,Point-of-CareTesting:Thromboelastography,practical-;,r=timetoinitialclotformationk,a=rateofclotformationMA=clotstrengthLY30,LY60=clotlysis,33,.,HillJSetal.AnaesthIntCare2012.,Developingathromboelastography-guidedtransfusionalgorithmforpostpartumhemorrhage,34,.,ElectronicResourcesforManagementofPostpartumHemorrhage,,35,.,,36,.,JustanotherdayattheLHR120sSaO2100%Whatwillyoudo?,39,.,Summary,PostpartumhemorrhageisontheriseintheU.S.Uterineatonyisthelead