产后出血的麻醉处理

1、 产后出血的麻醉处理产后出血的麻醉处理 Disclosure Tonight on the Labor Floor v30 yo G1P0 at 38 weeks vbreech presentation; in active labor v170 cm 86 kg, Mallampati II vNPO for 11 hours vNo allergies vNo medical history In the Operating Room v18g IV, uneventful spinal anesthesia vHealthy baby born v5 minutes later: co

2、ntinuous oozing in the field vOB: “The tone is poor” vPatient: “I feel dizzy” vVital signs: BP 80/49; HR 120s SaO2100% v What will you do? Objectives Mortality from Postpartum Hemorrhage Potts M et al. Lancet 2010; 375: 1762-3 Bateman B et al. Anesth Analg 2010; 110: 1368-73. The Epidemiology of Pos

3、tpartum Hemorrhage in the United States Cardiac Arrest During Hospitalization For Delivery in the United States, 1998-2011 v4,843 cases identified vPostpartum hemorrhage: v1349 patients (27.9%), 55% survival vAmniotic fluid embolism: v645 patients (13.3%), 52.5% survivalMhyre J et al., Anesthesiolog

4、y 2014 April. United Kingdom Postpartum Hemorrhage Maternal Death 66% of cases: substandard care Objectives v 500 mL after vaginal delivery v 1000 mL after cesarean delivery v We are bad at estimating blood loss v Retrospective v Late signs in the pregnant patient ACOG Practice Guideline; Obstet Gyn

5、ecol 2006. Bose P et al. BJOG 2006. Toledo P. Et al. Anesth Analg 2007. Wise and Clark Curr Opin Anaesthiol 2008. Objectives Rath, WH. Acta Obstetricia et Gynecologica Scandinavica 2011 May; 90(5)421-8 NORMAL ABNORMAL PPH PROTOCOL Solomon C et al. Br J Anaesth 2012; 109(6): 851-63. Sliver RM et al;

6、Obstet Gynecol 2006; 107(6): 1226-32 30,132 women, cesarean delivery 732 women: placenta previa Placenta Previa and Prior Cesarean Delivery http:/www.nursing- v 二线子宫收缩药物 v 甲基麦角新硷 (Methergine) v 前列腺素 v 米索前列醇(Misoprostol, PGE1, Cytotec) v 地诺前列酮(Dinoprostone, PGE2, Cervidil) v 卡波前列素(Carboprost, PGF2, H

7、emabate) Uterotonic Agents for PPH DoseKineticsRedosingAdverse effectsContra- indications Oxytocin Pitocin titrated IV infusion t1/2 1-6 minutesn/aNausea vomiting flushing hypotension allergy Methyl- ergonovine maleate Methergine 200 mcg IM or oral tablet IM: 2-5min onset PO: 5-10 min onset 30-45 mi

8、n (IM) up to 5 doses (1mg) or 6-8h (PO) hypertension nausea vomiting chest pain arterial spasm MI Hypertension CAD Carboprost Hemabate 250 mcg IMPeak plasma 30 minutes 15-90 min up to 8 doses (2mg) bronchospasm nausea vomiting diarrhea fever hypertension asthma Misoprostol Cytotec 800-1000 mcg PR or

9、 buccal Faster onset after buccal dosing noneDiarrhea, shivering Pyrexia, Headache allergy When pharmacologic treatment fails Objectives 1. Vasoconstriction2. Platelet plug 3. Coagulation cascade fibrin clot formation The McGraw-Hill Companies, Inc. Charbit et al. J Thromb Haemost 2007 ; Cortet M et

10、 al. Br J Anaesthesia 2012. www.R Ducloy-Bouthors AS et al. Crit Care 2011. High-dose tranexamic acid reduces blood loss in postpartum hemorrhage Tranexamic Acid for the Treatment of Postpartum Haemorrhage: an International Randomized, Double Blind, Placebo Controlled Trial December 2014/August 2015

11、 Leighton BL et al. Anesthesiology 2011; 115: 1201-8. Use of Recombinant Factor VIIa in suspected Amniotic Fluid Embolism Pasquier P et al. Anesth Analg 2013 FFP: PRBC Ratio in Postpartum Hemorrhage: An Observational Study Goodnough LT et al. 2011 Dec. practical-; Hill JS et al. Anaesth Int Care 201

12、2. Developing a thromboelastography- guided transfusion algorithm for postpartum hemorrhage Electronic Resources for Management of Postpartum Hemorrhage Just another day at the L HR 120s SaO2100% What will you do? Summary v- Simulation drills v- Sophisticated produc

13、t transfusion 周周 捷捷 Jie Zhou, MD, MS, MBA In the Operating Room v18g IV, uneventful spinal anesthesia vHealthy baby born v5 minutes later: continuous oozing in the field vOB: “The tone is poor” vPatient: “I feel dizzy” vVital signs: BP 80/49; HR 120s SaO2100% v What will

14、you do? Bateman B et al. Anesth Analg 2010; 110: 1368-73. The Epidemiology of Postpartum Hemorrhage in the United States Cardiac Arrest During Hospitalization For Delivery in the United States, 1998-2011 v4,843 cases identified vPostpartum hemorrhage: v1349 patients (27.9%), 55% survival vAmniotic fluid embolism: v645 patients (13.3%), 52.5% survivalMhyre J et al., Anesthesiology 2014 April. Sliver RM et al; Obstet Gynecol 2006; 107(6): 1226-32 30,132 women, cesarean delivery 732 women: placenta previa Placenta Previa and Prior Cesarean Delivery Ducl