产后出血处置课件

产后出血处置过程中不得不注意的5大问题

产后出血处置过程中不得不注意的5大问题讲述内容1背景2靶向治疗思路来源-----来自循征医学3总体原则---------来自个体认识4具体实施方案-----循征+个体5效果评价讲述内容1背讲课内容一背景讲课内容一背景中国孕产妇.围产儿死亡情况2013年：23.2/10万2013年：婴儿死亡率，9.5‰中国孕产妇.围产儿死亡情况2013年：23.2/10万201近年来呈上升趋势，全球范围内1400万发生率，每4分钟1例死亡因素/1000ORaORJObstetGynaecolCan2014;36(1):21–33近年来呈上升趋势，全球范围内1400万发生率，每4分钟1例死妊娠仍然是导致生育年龄妇女死亡主要原因InternationalJournalofWomen’sHealth2014:641–46妊娠仍然是导致生育年龄妇女死亡主要原因Internation可避免死亡原因分类CoastalInlandRemoteCoastalInlandRemote1996-2000PPH84(34.71)317(48.40)364(59.19)7.3725.6271.73PE35(14.46)94(14.35)82(13.33)3.077.6016.16AFE32(13.22)41(6.26)12(1.95)2.813.312.36Cardiacdisorders32(13.22)63(9.62)37(6.02)2.815.097.29Puerperalinfection4(1.65)24(3.66)43(6.99)0.351.948.47Hepaticdiseases13(5.37)17(2.60)12(1.95)1.141.372.362001-2005PPH72(51.80)268(50.85)196(54.14)6.9721.88**40.01**PE18(12.95)70(13.28)50(13.81)1.74***5.72***10.21AFE14(10.07)32(6.07)16(4.42)1.362.613.27Cardiacdisorders6(4.32)54(10.25)31(8.56)0.58***4.416.33Puerperalinfection1(0.72)18(3.42)17(4.70)0.101.473.47***Hepaticdiseases2(1.44)10(1.90)7(1.93)0.190.821.43可避免死亡比例疾病至死可避免死亡原因分类CoastalInlandRemoteCo各级医院业务水平ProblemsCoastalInlandRemoteForindividual/family143(37.54)523(44.24)651(66.70)Knowledge/skill108(28.35)351(29.69)450(46.11)Attitude26(6.83)110(9.30)97(9.94)Resources9(2.36)62(5.25)104(10.66)Formedicalinstitutions237(62.19)635(53.74)305(31.25)Knowledge/skill223(58.52)591(50.01)289(29.61)Village-level21(5.51)197(16.67)100(10.25)Township-level73(19.16)167(14.13)73(7.48)County-level79(20.73)160(13.54)82(8.40)Province-level50(13.12)67(5.67)34(3.48)Forsocialdepartments1(0.27)24(2.02)20(2.05)Knowledge/skill0(0.00)14(1.18)4(0.41)Attitude0(0.00)2(0.17)0(0.00)Management0(0.00)2(0.17)11(1.13)Resources1(0.27)6(0.50)5(0.50)各级医院业务水平ProblemsCoastalInlandR产后出血诊治中存在问题诊断错误或延迟诊断缺乏产后出血共识低估出血速度与出血量缺乏医院内ease-useactionplans缺乏足够的培训（理论+技能）治疗效果差加强子宫收缩药物使用不当输注血液制品延迟（红细胞、凝血制剂）忽略了最基本监测结果治疗决策失误组织系统不完善设备、人员、交通、技术、合作Toolittleisdone“toolate“产后出血诊治中存在问题诊断错误或延迟诊断缺乏产后出血共识低估产后出血定义问题产后出血严重产后出血传统定义：

阴道分娩-------------------->500mmltransfusion≥4unitsofblood剖宫产---------------------->1000mml3小内失血超过血容量50%澳大利亚（2008年）20分钟内失血>150ml/(≥50%bloodvolume)出血-------------->500-1000mml伴有低血容量休克外周血血红蛋白浓度降低≥40g/l或失血----------->1000mmlsuddenbloodloss>1500ml(25%ofthebloodvolumeRCOG（2009年）失血-------------500-1000mml不伴有低血容量休克严重出血------->1000mml----轻度------1000-2000mml----重度------->1000mml能反映临床问题吗？产后出血定义问题产后出血严重产后出血传统定义：阴道分娩--产科危急重症患者管理10大不足---我们医院？1缺乏监护设备----以往主要放置在ICU2重症病房设备仅提供生命体征3监护间隔时间过长，未根据患者病情进行调整，且不完整4护士巡视患者间隔时间过长5医师巡视过少，每天1次6非特异性生命体征变化未进行规范化处置7重症患者单一医师处置（经验性处置）8危急重症患者团队组织时间过长9医师.护士人员不足10现代医院管理缺陷产科危急重症患者管理10大不足---我们医院？1缺乏监护设备内容二.开展产后出血治疗----理论基础.实践内容二.开展产后出血治疗----理论基础.实践失血性休克发生严重并发症机制？治疗靶点治疗靶点控制失血容量补充并发症预防Reductioninmaternalmortalityrequiresanin-depthknowledgeofthecausesofdeath失血性休克发生严重并发症机制？治疗靶点治疗靶点控制失血Red失血性休克患者死亡KoreanJAnesthesiol.2011March;60(3):151–160失血性休克患者死亡KoreanJAnesthesiol.内容三.靶向治疗临床实践：控制出血内容三.靶向治疗临床实践：控制出血产后出血治疗---时刻准备.演练16初始治疗难治性产后出血MODs患者死亡快速反应团队三衰治疗小组.ICU产后出血治疗---时刻准备.演练16初始治疗难治性产后出血M具体止血措施---原因处置（产科医师能做到的？）一线治疗方案加强子宫收缩药物子宫按摩排空膀胱软产道损伤缝合残留胎盘处置水囊压迫二线治疗方案子宫缝扎--------------82-100%子宫血管结扎（髂内等）双侧—80-96%

单侧—42-93%子宫动脉栓塞-70-100%-子宫收缩乏力60-83%-胎盘植入三线治疗子宫切除---94-99%

全子宫切除

次全子宫切除A/B/C/D/E|F管理产科医师至少应掌握技术：缩宫素使用、缝扎技术、球囊使用、子宫切除必要时：aorticcross-clamping具体止血措施---原因处置（产科医师能做到的？）一线治疗方案预防与治疗产科出血药物与措施加强子宫收缩预防与治疗性药物，缩宫素.前列腺素.麦角新碱预防与治疗产科出血药物与措施加强子宫收缩预防与治疗性药物，缩注意点1.出血性休克患者止血----早期干预Werecommendthatpatientspresentingwithhaemorrhagicshockandanidentifiedsourceofbleedingundergoanimmediatebleedingcontrolprocedureunlessinitialresuscitationmeasuresaresuccessful(Grade1B)三要------------------止血要迅速.措施要有综合.效果要有效三防------------单独救治.不个体化.没有准备与培训注意点1.出血性休克患者止血----早期干预WerecoTimetohemostasis（药物+栓塞+手术）(Grade1C)Every3minutesofdelayintheresuscita­tionroomleadstoa1%mortalityincreaseinapatientwithhemodynamicinstabilityandbluntabdominaltraumaduringthefirst90minutesoftreatmentataLevelItraumacenter死亡三角：低体温.凝血功能障碍.酸中毒Timetohemostasis（药物+栓塞+手术）(G处置措施、止血速度对患者结局影响较大处置措施、止血速度对患者结局影响较大注意点3.栓塞治疗疗不能解决出血中的所有问题J.Perinat.Med.2014;42(3):359–362注意点3.栓塞治疗疗不能解决出血中的所有问题J.Perin止血时间对患者结局影响止血时间对患者结局影响注意点4.简单有效处置方法—还在培训.使用吗？J.Obstet.Gynaecol.Res.2011,11:1557–1563注意点4.简单有效处置方法—还在培训.使用吗？J.Obst注意点5.产后出血诊断方法不能满足临床需求（容积法、面积法、称重法）2000mml液体快速输注患者变化注意点5.产后出血诊断方法不能满足临床需求（容积法、面积法、（1）腹主动脉阻断.Intheexsanguinatingpatient,aorticcross-clampingmaybeemployedasanadjunct(Grade1C)注意点6.产后出血处理还有进一步措施（2）.损伤控制性手术：deephaemorrhagicshock,signsofongoingbleedingandcoagulopathy.hypothermia,acidosis,inaccessiblemajoranatomicalinjury,aneedfortime-consumingproceduresorconcomitantmajorinjuryoutsidetheabdomen(Grade1C).（3）出血局部用药（1）腹主动脉阻断.Intheexsanguinati注意点7：体温维持earlyapplicationofmeasurestoreduceheatlossandwarmthehypothermicpatientinordertoachieveandmaintainnormothermia(Grade1C)注意点7：体温维持earlyapplicationof体温JTraumaAcuteCareSurg，3,（6）,Supplement5低体温影响体温JTraumaAcuteCareSurg，3,内容四.容量补充何时？怎样？均牵涉失血量估计多少？内容四.容量补充何时？1.出血量估计4个100方案----失血量估计血压<100mmHg，心率>100次/分钟，尿量<100mml/小时出血量>100X10mml广州孕产妇救治中心1.出血量估计4个100方案----失血量估计血压<100m根据出血量及临床表现进行分度1gradeI(bloodloss<15%,withouthemodynamicsignsorsymptoms)2gradeII(bloodvolumelossof20–25%,accompaniedbytachycardia,tachypnea,andhypotension)3gradeIII(bloodvolumelossof30–35%,whenearliersignsaddedcoldextremitiesand/oroliguria)4gradeIV(bloodvolumeloss≥40%andhavingeverythingdescribedbeforeplusalteredsensory.根据出血量及临床表现进行分度1gradeI(blood产后出血量与临床体征关系Conclusion:Wefoundasubstantialvariabilityintherelationshipbetweenbloodlossandclinicalsigns,makingitdifficulttoestablishspecificcut-offpointsforclinicalsignsthatcouldbeusedastriggersforclinicalinterventions.However,theshockindexcanbeanaccurateindicatorofcompensatorychangesinthecardiovascularsystemduetobloodloss.Consideringthatmostoftheevidenceincludedinthissystematicreviewisderivedfromstudiesinnon-obstetricpopulations,furtherresearchontheuseoftheshockindexinobstetricpopulationsisneeded休克指数=心率/收缩压0.5----------------正常=1-----------------轻度休克，失血20%－30%>1-----------------休克>1.5---------------严重休克，失血30%－50%>2-----------------重度休克，失血>50%产后出血量与临床体征关系Conclusion:丢失血容量计算

血液稀释法，抽出的血容量（V）或最佳初期血细胞比容（Hct）可由以下公式算出：V=EBV(HctiHctf)/Hctav

（EBV是估计血容量、Hctf是最低血细胞比容、Hctav是平均血细胞比容

[(HctiHctf)/2]）丢失血容量计算血液稀释法，抽出的血容量（V）或最佳初注意点：HCT受诸多因素影响WedonotrecommendtheuseofsingleHctmeasurementsasanisolatedlaboratorymarkerforbleeding(Grade1B）注意点：HCT受诸多因素影响Wedonotrecomm2.补充血容量.Abouttime1.definitionofhaemorrhagicshock,(SBP≤90mmHgandBE≤-6mmol/l),2.expectedandongoingbleeding(notmeetinghaemorrhagicshockcriteria,butwitheitherprehospitalbloodlossand/orexpectedfurtherbloodlossintraoperativelyduetotheneedformultipleprocedures)3.droppingHb(Hbdroptobelow80g/lorbelow100g/land30g/ldropwithin2h4.lowSBP(persistenthypotensiononserialmeasurements<90mmHgforatleast30mindespitefluidreplacement)5.tachycardia(persistentelevatedHRonserialmeasurements>110beats/minforatleast30mindespitefluidreplacement)2.补充血容量.Abouttime1.definit注意点.so-called‘permissivehypotensiontargetsystolicbloodpressureof80to100mmHguntilmajorbleedinghasbeenstoppedintheinitialphasefollowingtrauma(Grade1C)Coagulopathywasobservedinmorethan40%ofpatientswithmorethan2000ml,inmorethan50%withmorethan3000ml,andinmorethan70%withmorethan4000mladministeredSeveralexperimentalstudieshaveshownthatmaintaininganSBPofapproximately90mmHgandanMAParound60mmHg,untildefinitivesurgicalhemostasiswasachieved,resultedinincreasedoxygendelivery,decreasedbloodloss,andreducedmortality

Astrategythatacceptsacertaindegreeofhypotensioninordertobalancetheprimaryofgoaloforganperfusionagainsttherisksofrebleedingthatmaydevelopwithresuscitationtoanormotensivestate注意点.so-called‘permissivehypo注意点.FluidtherapyCrystalloids（晶体液）beappliedinitiallytotreatthebleedingtraumapatient(Grade1B)hypertonicsolutionsalsobeconsideredduringinitialtreatment(Grade2B).theadditionofcolloidsbeconsideredwithintheprescribedlimitsforeachsolutioninhaemodynamicallyunstablepatients(Grade2C)注意点.FluidtherapyCrystalloids（注意点.液体量---反思与争议1.初期：来自动物实验结果，3:1液体补充疗法，越战期间：未控制性出血的限制性补液2.

demonstratedthata2Lcrystalloidbolusadministeredbeforeintrinsichemostasiswasachieved,increasedbloodlossfrom4%to29%，Furthermore,thatsame2Lcrystalloidbolusadministeredatahighrate(0.2L/min)didnoteventransientlycorrecttheexistinghypotensioninapatientthathaslostbloodatarateof1.5Lin15minutesandstillhasongoingbleeding.Further,thishighvolumeandrateofcrystalloidscarriedahighprobabilityoftriggeringrebleedingifadministeredtoapatientduringtheperiodwhentheinitialthrombuswasforming(usuallywithinthefirst30minofinjury).3.Acutehemorrhage(30%totalestimatedbloodvolume)causedarapidandmoderatedropinmeanHctto17%belowbaselinewithin15minutesposthemorrhage.Large-volumefluidresuscitation(3:1)resultedinafurtherHctdropto50%belowbaseline,whereassmall-volumeresuscitation(1:1)resultedinadecreaseinHcttoonly24%belowbaseline.Inaddition,large-volumeresuscitationresultedinamoresignificantprolongationoftheprothrombintimeanddecreaseinplateletcountascomparedtosmall-volumeresuscitation.Interestingly,althoughlarge-volumeresuscitationresultedinasupranormalelevationofcardiacoutputinitially,thiseffectwasonlytransient(approximately30min)andoveralltherewasnosustainedadvantageinsystemichemodynamicsorend-organperfusionbetweenthetworesuscitativeapproaches他山之石，可以攻玉注意点.液体量---反思与争议1.初期：来自动物实验结果，3.输注血液成分与凝血功能异常管理RBC:血浆：血小板.输注血液成分与凝血功能异常管理RBC:血浆：血小板atargethaemoglobin(Hb)of7to9g/dl(Grade1C)Arestrictivetransfusionregimen(Hbtransfusiontrigger<7.0g/dl)resultedinfewertransfusionsascomparedwiththeliberaltransfusionregimen(Hbtransfusiontrigger<10g/dl)andappearedtobesafe注意点.红细胞可以改善凝血功能atargethaemoglobin(Hb)of注意点.Coagulationsupport（1）.Monitoringandmeasurestosupportcoagulationbeinitiatedasearlyaspossible(Grade1C)（2）.calciumlevelsabove0.9mmol/l，ionisedcalciumlevelsbemonitoredduringmassivetransfusion(Grade1C).ifionisedcalciumlevelsareloworelectrocardiographicchangessuggesthypocalcaemia(Grade2C)（3）.Freshfrozenplasma：earlytreatment(Grade1B).Theinitialrecommendeddoseis10to15ml/kg.Furtherdoseswilldependoncoagulationmonitoringandtheamountofotherbloodproductsadministered(Grade1C)（PTAPTT>1.5倍）注意点.Coagulationsupport（1）.Mo血小板plateletsbeadministeredtomaintainaplateletcountabove50×109/l

(Grade1C).maintenanceofaplateletcountabove100×109/linpatientswithmultipletraumawhoareseverelybleeding(Grade2C).aninitialdoseoffourtoeightplateletconcentratesoroneaphaeresispack(Grade2C)aunitofwholebloodcontains7.5×1010plateletsonaverageandshouldincreasetheplateletcountby5to10×109/lina70kgrecipient.Aphaeresisplateletconcentratesgenerallycontainapproximately3to6×1011platelets,dependingonlocalcollectionpractice,andphysiciansshouldbecognisantofthedosesprovidedlocally.Apooloffourtoeightplateletconcentratesorasingle-donoraphaeresisunitisusuallysufficienttoprovidehaemostasisinathrombocytopaenic,bleedingpatient.注意点：Coagulationsupport血小板plateletsbeadministeredtoFibrinogenandcryoprecipitate

适应症functionalfibrinogendeficitoraplasmafibrinogenleveloflessthan1.5to2.0g/l(Grade1C).

aninitialfibrinogenconcentratedoseof3to4gor50mg/kgofcryoprecipitate,whichisapproximatelyequivalentto15to20unitsina70kgadult.

Repeatdosesmaybeguidedbythrombelastometricmonitoringandlaboratoryassessmentoffibrinogenlevels(Grade2C).Fibrinogenandcryoprecipitate1:1:1(pRBC/plasma/platelets）靶向目标：组织灌注，血压？1:1:1(pRBC/plasma/platelets）靶产后出血血液制品治疗趋势与效果收缩压<90mmHg，PH<7.1体温<34°CINR>2.0，血小板<50,000/mm³红细胞新鲜冰冻血浆血小板冷沉淀Round16units6units6units10unitsRound26units6units20unitsRound3活化7因子产后出血血液制品治疗趋势与效果收缩压<90mmHg，PH<7注意点：其他药物选择AntifibrinolyticagentsAntifibrinolyticagentsbeconsideredinthebleedingtraumapatient(Grade2C).Fibrinolysisinallpatientsandadministrationofantifibrinolyticagentsinpatientswithestablishedhyperfibrinolysis(Grade1B)氨甲环酸：10to15mg/kgfollowedbyaninfusionof1to5mg/kgperhourrFVIIamajorbleedinginblunttraumapersistsdespitestandardattemptstocontrolbleedingandbestpracticeuseofbloodcomponents(Grade2C).RBCs,platelets,FFPandcryoprecipitate/fibrinogenresultinginHctabove24%,plateletsabove50,000×109/landfibrinogenabove1.5to2.0g/l注意点：其他药物选择Antifibrinolyticage内容五降低严重并发症内容五降低严重并发症氧输送DO2能量供应内环境血糖6~9mmol/L循环、血液、呼吸水、电解质、酸碱Na、K、pH7.35-7.45

满足标准；理论基础氧输送能量内环境血糖6~9mmol/L循环、血液、呼吸水、电广州孕产妇救治中心—产后出血患者救治AAirwaymaintenance，--------------------（气道与通道维持）BBreathingandventilation，---------------（呼吸与通气）CCirculationwithhemorrhagecontrol-----（循环与控制出血）DDrug--------------------------------------------（药物）EExposurewithenvironmentalcontrol&evaluation(环境与评价）FFetus---------------------------------------------（胎儿处理）陈敦金，等。中国实用妇科与产科杂志，2012,6:45-48Minimisebloodloss,restoretissueperfusionandachievehaemodynamicstability广州孕产妇救治中心—产后出血患者救治AAirwaymaiAandB(呼吸维持）----团队人员组织要求-------呼吸通道A-------静脉通道-------人员组织B-------呼吸维持Availabilityofappropriateemergencysuppliesinaresuscitationcart(crashcart)orkitDevelopmentofarapidresponseteamDevelopmentofprotocolsthatincludeclinicaltriggersUseofstandardizedcommunicationtoolsforhuddlesandbriefs(eg,SBAR)ImplementationofemergencydrillsandsimulationsAandB(呼吸维持）----团队人员组织要求-----保证患者：DO2=1.38×Hb×SaO2×CO×10CaO2一定时，DO2由心排量(CO)决定CO则又取决于每搏输出量(SV)和心率(HR)，CO＝SV×HRSV取决于心肌收缩力和心室前、后负荷前、后负荷则又分别与血容量及外周血管阻力有关保证患者：DO2=1.38×Hb×SaO2×CO×10保证患者组织灌注.升压药物选择：目标：MAP60-65mmHg去甲肾上腺素from0.01to3.3mg/kg/min多巴胺lessthan5mg/kg/minute,dopaminergicreceptorsareactivated,肾、肠系膜血管扩张

5to10mg/kg/minute,b1-adrenergiceffectspredominate,increasingcardiaccontractilityandheartrateabove10mg/kg/minute,a1-adrenergiceffectspredominate,leadingtoarterialvasoconstrictionandanincreaseinbloodpressure.肾上腺素保证患者组织灌注.升压药物选择：目标：MAP60-65mmH根据检测结果判断：乳酸水平与碱缺失（监测）乳酸inwhomlactatelevelsreturnedtothenormalrange(≤2mmol/l)within24hourssurvived.Survivaldecreasedto77.8%ifnormalisationoccurredwithin48hoursandto13.6%inthosepatientsinwhomlactatelevelswereelevatedabove2mmol/lformorethan48hours碱缺失

theextentofbasedeficiti