周捷-产后出血的麻醉处理.pptx

周捷-产后出血的麻醉处理.pptx

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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哈佛大学医学院布莱根和妇女医院麻醉科麻醉科周周捷捷JieZhou,MD,MS,MBAJieZhou,MD,MS,MBADepartmentofAnesthesiology,PerioperativeAnesthesiology,PerioperativeandPainMedicineBrighamandWomensHospital,HarvardMedicalSchoolDisclosureBD科学咨询委员会成员TonightontheLaborFloorv30yoG1P0at38weeksvbreechpresentation;inactivelaborv170cm86kg,MallampatiIIvNPOfor11hoursvNoallergiesvNomedicalhistoryIntheOperatingRoomv18gIV,uneventfulspinalanesthesiavHealthybabybornv5minuteslater:

continuousoozinginthefieldvOB:

“Thetoneispoor”vPatient:

“Ifeeldizzy”vVitalsigns:

BP80/49;HR120sSaO2100%vWhatwillyoudo?

ObjectivesvDEFINEPostpartumhemorrhagevIDENTIFYChallengesofmanagementvPREPAREManagementbasedonevidenceMortalityfromPostpartumHemorrhageOnewomaneverysevenminutesPottsMetal.Lancet2010;375:

1762-31995through20041995through2004PPHincreasedby30%PPHincreasedby30%2.9%ofalldeliveries2.9%ofalldeliveriesBloodtransfusion2.4toBloodtransfusion2.4to4.6per1000（90%increase）4.6per1000（90%increase）Uterineatony:

predictableonly40%ofUterineatony:

predictableonly40%ofcases.cases.BatemanBetal.AnesthAnalg2010;110:

1368-73.TheEpidemiologyofPostpartumHemorrhageintheUnitedStatesCardiacArrestDuringHospitalizationForDeliveryintheUnitedStates,1998-2011v4,843casesidentifiedvPostpartumhemorrhage:

v1349patients（27.9%）,55%survivalvAmnioticfluidembolism:

v645patients（13.3%）,52.5%survivalMhyreJetal.,Anesthesiology2014April.UnitedKingdomPostpartumHemorrhageMaternalDeath66%ofcases:

substandardcareObjectivesvDEFINEpostpartumhemorrhagevIDENTIFYchallengesofmanagementvPREPAREformanagementbasedonevidencePostpartumHemorrhageDefinedQuantificationofbloodloss?

v500mLaftervaginaldeliveryv1000mLaftercesareandeliveryvWearebadatestimatingbloodlossCasesthatneedtransfusion?

vRetrospectiveHemodynamicchanges?

vLatesignsinthepregnantpatientACOGPracticeGuideline;ObstetGynecol2006.BosePetal.BJOG2006.ToledoP.Etal.AnesthAnalg2007.MajorPostpartumHemorrhagevEstimatedbloodlossof2500mLormorevTransfusionof5unitsofbloodvTreatmentofcoagulopathyWiseandClarkCurrOpinAnaesthiol2008.ObjectivesvDEFINEpostpartumhemorrhagevIDENTIFYchallengesofmanagementvPREPAREformanagementbasedonevidenceChallengesofPPHRath,WH.ActaObstetriciaetGynecologicaScandinavica2011May;90（5）421-8NORMALABNORMALPPHPROTOCOLCOMMUNICATIONCOMMUNICATIONThe4TsofPPHToneSolomonCetal.BrJAnaesth2012;109（6）:

851-63.TissueTraumaThrombinSliverRMetal;ObstetGynecol2006;107（6）:

1226-3230,132women,cesareandelivery732women:

placentapreviaPlacentaPreviaandPriorCesareanDeliveryPriorCesareanDeliveriesRiskofPlacentaAccreta03%111%240%361%4or67%Anatonicuterusisableedinguterushttp:

/www.nursing-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,Hemabate）UterotonicAgentsforPPHDoseKineticsRedosingAdverseeffectsContra-indicationsOxytocinPitocintitratedIVinfusiont1/21-6minutesn/aNauseavomitingflushinghypotensionallergyMethyl-ergonovinemaleateMethergine200mcgIMororaltabletIM:

2-5minonsetPO:

5-10minonset30-45min（IM）upto5doses（1mg）or6-8h（PO）hypertensionnauseavomitingchestpainarterialspasmMIHypertensionCADCarboprostHemabate250mcgIMPeakplasma30minutes15-90minupto8doses（2mg）bronchospasmnauseavomitingdiarrheafeverhypertensionasthmaMisoprostolCytotec800-1000mcgPRorbuccalFasteronsetafterbuccaldosingnoneDiarrhea,shiveringPyrexia,HeadacheallergyWhenpharmacologictreatmentfailsnnBimanualcompressionnnUterineballoontamponadennUterinecompressionsuturesnnArterialligationnnInterventionalradiologynnHysterectomyObjectivesnDEFINEpostpartumhemorrhagenIDENTIFYchallengesofmanagementnPREPAREformanagementbasedonevidenceHemostasis1.Vasoconstriction2.Plateletplug3.CoagulationcascadefibrinclotformationTheMcGraw-HillCompanies,Inc.LowFibrinogenPredictsWorseOutcomeInPostpartumHemorrhageCharbitetal.JThrombHaemost2007;CortetMetal.BrJAnaesthesia2012.FibrinogenOddsRatio（SeverePPH）200-300mg/dL1.9800mLEBLTXAadministration4g/1hthen1g/hfor6hEBLatT2（30min）,toT4（6h）lowerEBL,shorterduration,lessseverePPHHigh-dosetranexamicacidreducesbloodlossinpostpartumhemorrhageTranexamicAcidfortheTreatmentofPostpartumHaemorrhage:

anInternationalRandomized,DoubleBlind,PlaceboControlledTrialDecember2014/August2015ControlrFVIIaDeath,permanentdisability39%88%Permanentdisabilityinsurvivingpatients19%75%28contols（norVIIa）16treated（rVIIa）LeightonBLetal.Anesthesiology2011;115:

1201-8.UseofRecombinantFactorVIIainsuspectedAmnioticFluidEmbolismIsthereaperfecttransfusionratio?

1:

1:

1PRBC:

FFP:

PlateletsForwhom?

When?

Dose?

Outcomes?

12,226deliveries,2006-20091.1%（142patients）hadseverePPHHigherFFP:

PRBCratiowerelesslikelytohave:

-embolization-arterialligation-hysterectomyPasquierPetal.AnesthAnalg2013FFP:

PRBCRatioinPostpartumHemorrhage:

AnObservationalStudyGoodnoughLTetal.2011Dec.Point-of-CareTesting:

Thromboelastographypractical-;r=timetoinitialclotformationr=timetoinitialclotformationk,a=