周捷-产后出血的麻醉处理

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,PerioperativeandPainMedicineBrighamandWomen’sHospital,HarvardMedicalSchoolDisclosureBD科学咨询委员会成员TonightontheLaborFloor…30yoG1P0at38weeksbreechpresentation;inactivelabor170cm86kg,MallampatiIINPOfor11hoursNoallergiesNomedicalhistoryIntheOperatingRoom…18gIV,uneventfulspinalanesthesiaHealthybabyborn5minuteslater:continuousoozinginthefieldOB:“Thetoneispoor”Patient:“Ifeeldizzy”Vitalsigns:BP80/49;HR120sSaO2100%Whatwillyoudo?ObjectivesDEFINEPostpartumhemorrhageIDENTIFYChallengesofmanagementPREPAREManagementbasedonevidenceMortalityfromPostpartumHemorrhageOnewomaneverysevenminutes…PottsMetal.Lancet2010;375:1762-3•1995through2004•PPHincreasedby30%•2.9%ofalldeliveries•Bloodtransfusion2.4to4.6per1000(90%increase)Uterineatony:predictableonly40%ofcases.BatemanBetal.AnesthAnalg2010;110:1368-73.TheEpidemiologyofPostpartumHemorrhageintheUnitedStatesCardiacArrestDuringHospitalizationForDeliveryintheUnitedStates,1998-20114,843casesidentifiedPostpartumhemorrhage:1349patients(27.9%),55%survivalAmnioticfluidembolism:645patients(13.3%),52.5%survivalMhyreJetal.,Anesthesiology2014April.UnitedKingdomPostpartumHemorrhageMaternalDeath66%ofcases:substandardcareObjectivesDEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidencePostpartumHemorrhageDefinedQuantificationofbloodloss?500mLaftervaginaldelivery1000mLaftercesareandeliveryWearebadatestimatingbloodlossCasesthatneedtransfusion?RetrospectiveHemodynamicchanges?LatesignsinthepregnantpatientACOGPracticeGuideline;ObstetGynecol2006.BosePetal.BJOG2006.ToledoP.Etal.AnesthAnalg2007.MajorPostpartumHemorrhageEstimatedbloodlossof2500mLormoreTransfusionof5unitsofbloodTreatmentofcoagulopathyWiseandClarkCurrOpinAnaesthiol2008.ObjectivesDEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidenceChallengesofPPHRath,WH.ActaObstetriciaetGynecologicaScandinavica2011May;90(5)421-8NORMALABNORMALPPHPROTOCOLCOMMUNICATIONThe4T’sofPPHToneSolomonCetal.BrJAnaesth2012;109(6):851-63.TissueTraumaThrombinSliverRMetal;ObstetGynecol2006;107(6):1226-32•30,132women,cesareandelivery•732women:placentapreviaPlacentaPreviaandPriorCesareanDeliveryPriorCesareanDeliveriesRiskofPlacentaAccreta03%111%240%361%4or67%Anatonicuterusisableedinguterus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,PGF2α,Hemabate)UterotonicAgentsforPPHDoseKineticsRedosingAdverseeffectsContra-indicationsOxytocinPitocin®titratedIVinfusiont1/21-6minutesn/aNauseavomitingflushinghypotensionallergyMethyl-ergonovinemaleateMethergine®200mcgIMororaltabletIM:2-5minonsetPO:5-10minonset30-45min(IM)upto5doses(1mg)or6-8h(PO)hypertensionnauseavomitingchestpainarterialspasmMIHypertensionCADCarboprostHemabate®250mcgIMPeakplasma30minutes15-90minupto8doses(2mg)bronchospasmnauseavomitingdiarrheafeverhypertensionasthmaMisoprostolCytotec®800-1000mcgPRorbuccalFasteronsetafterbuccaldosingnoneDiarrhea,shiveringPyrexia,HeadacheallergyWhenpharmacologictreatmentfails…BimanualcompressionUterineballoontamponadeUterinecompressionsuturesArterialligationInterventionalradiologyHysterectomyObjectivesDEFINEpostpartumhemorrhageIDENTIFYchallengesofmanagementPREPAREformanagementbasedonevidenceHemostasis1.Vasoconstriction2.Plateletplug3.Coagulationcascadefibrinclotformation©TheMcGraw-HillCompanies,Inc.LowFibrinogenPredictsWorseOutcomeInPostpartumHemorrhageCharbitetal.JThrombHaemost2007;CortetMetal.BrJAnaesthesia2012.FibrinogenOddsRatio(SeverePPH)200-300mg/dL1.9200mg/dL12®:FibrinogenConcentrateIndications:PPHwithsuspectedorknownDICorfibrinolysis1vial=1gfibrinogen•Add50mLsterilewater•Swirlgently•Infuseover10minutesDucloy-BouthorsASetal.CritCare2011.PPHaftervaginaldelivery:•800mLEBLTXAadministration4g/1hthen1g/hfor6hEBLatT2(30min),toT4(6h)lowerEBL,shorterduration,lessseverePPHHigh-dosetranexamicacidreducesbloodlossinpostpartumhemorrhageTranexamicAcidfortheTreatmentofPostpartumHaemorrhage:anInternationalRandomized,DoubleBlind,PlaceboControlledTrial…December2014/August2015ControlrFVIIaDeath,permanentdisability39%88%Permanentdisabilityinsurvivingpatients19%75%•28contols(norVIIa)•16treated(rVIIa)LeightonBLetal.Anesthesiology2011;115:1201-8.UseofRecombinantFactorVIIainsuspectedAmnioticFluidEmbolismIsthereaperfecttransfusionratio?•1:1:1PRBC:FFP:Platelets–Forwhom?–When?–Dose?–Outcomes?12,226deliveries,2006-20091.1%(142patients)hadseverePPHHigherFFP:PRBCratiowerelesslikelytohave:-embolization-arterialligation-hysterectomyPasquierPetal.AnesthAnalg2013FFP:PRBCRatioinPostpartumHemorrhage:AnObservationalStudyGoodnoughLTetal.2011Dec.Point-of-CareTesting:Thromboelastographypractical-haemostasis.com;haemonetics.comr=timetoinitialclotformationk,a=rateofclotformationMA=clotstrengthLY30,LY60=clotlysisHillJSetal.AnaesthIntCare2012.Developingathromboelastography®-guid