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Changing Landscape of Obstetrical

Hemorrhage

Jonathan H. Waters, MD
Professor of Anesthesiology and Bioengineering
Chief of Anesthesiology, Magee-Womens Hospital of University of
Pittsburgh Medical Center
Medical Director, UPMC Total Blood Management Program

Blundells Blood Gravitator

http://bloodjournal.hematologylibrary.org/content/112/7/2617/F5.large.jpg

Is obstetrical hemorrhage a
problem worth addressing?

A. Mortality
B. Morbidity

Healthy People, 2010

www.cdc.gov

The Joint Commission Sentinel


Event Alert

Pregnancy-related deaths in the United States in 20062007

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/Pregnancy-relatedMortality.htm

Morbidity of Hemorrhage

Postpartum hemorrhage
associated morbidity
Disseminated intravascular coagulopathy (DIC)
Renal and hepatic failure
Acute respiratory distress syndrome
Sheehans Syndrome

Postpartum hemorrhage
associated morbidity
Iron deficiency
Iron deficiency anemia
Transfusion

Bodnar LM et al. Am J Obstet & Gynecol 2005;193:36-44

Complications of Transfusions
I. Infectious Complications
II. Hemolytic Transfusion
Reactions
III. Immunomodulation

VII. Delayed Transfusion


Reactions
VIII. Nonhemolytic
Transfusion Reactions
IX. Graft-vs-host Disease

IV. Storage Defects

X. Febrile Reactions

V. Cost

XI. Allergic Reactions

VI. Gene Transmission

XII. HLA Sensitization

http://www.cmqcc.org/resources/1484

http://www.cmqcc.org/resources/1484

POSTPARTUM HEMORRHAGE PROTOCOL


Strategy for Managing PPH
Anticipation
Identification of Risk Factors
Prevention / Preparation

Recognition
Assessment
Accurate Estimation of Blood Loss
Identification of Cause

Act
Postpartum Hemorrhage Protocol (PPHP)
Mobilization of Rapid Response Team

Admission Hemorrhage Risk Factors


Low (Type & Screen/Hgb)

Medium (Type & Screen/Hgb)

High (Type & Cross/CBC with


Plt)

No previous uterine incision

Prior Cesarean birth(s) or


uterine surgery (RR = 10.38)

Placenta previa, Low lying


placenta (RR = 3.38)

Singleton Pregnancy (RR =


60.69)

> 5 previous vaginal births

Suspected placenta accreta or


percreta

5 previous vaginal births

Chorioamnionitis (RR = 2.56)

Hgb < 10 and other risk factors

No known bleeding disorder

History of PPH

Active bleeding on admission

No history of PPH

Large uterine fibroids

Known coagulopathy (RR =


2.97)

Hypertensive disorder of
pregnancy (RR = 2.05)

Retained placenta

Overdistended uterus
(macrosomia, polyhydramnios,
etc) (RR = 1.63)

Uterine rupture

Obesity (RR = 1.43)

Hgb < 8

POSTPARTUM HEMORRHAGE PROTOCOL


Strategy for Managing PPH
Anticipation
Identification of Risk Factors
Prevention / Preparation

Recognition
Assessment
Accurate Estimation of Blood Loss
Identification of Cause

Act
Postpartum Hemorrhage Protocol (PPHP)
Mobilization of Rapid Response Team

POSTPARTUM HEMORRHAGE PROTOCOL


Assessment
Ongoing quantitative evaluation of blood loss

Peach pad
250 mL loss

Plaid cloth pad


100 mL loss

Blue Chux pad


150 mL loss

POSTPARTUM HEMORRHAGE PROTOCOL


Strategy for Managing PPH
Anticipation
Identification of Risk Factors
Prevention / Preparation

Recognition
Assessment
Accurate Estimation of Blood Loss
Identification of Cause

Act
Postpartum Hemorrhage Protocol (PPHP)
Mobilization of Rapid Response Team

Obstetric Crisis Patient Safety


Initiative: Magee-Womens Hospital
Medical Emergency Team Paradigm applied to
obstetric care
Condition O
Assemble necessary personnel with single
page
Force interdisciplinary communication
Encourage early crisis recognition
Encourage teamwork

Wiser
Obstetric Crisis Team Training Course
Course Format:
Web-based presentation
Pre-course survey
Pretest
Brief didactic session
3 full scale human simulation scenarios
Video-based debriefing

Post-course survey

C-Section Hemorrhage

Objective: Stop bleeding, maintain


hemodynamic stability, avoid coagulopathy

Staff in room informed of bleeding? Anesthesia aware? Intra-op consults


needed/requested?
Call for help: OR charge (1-2802), Generalist (1-2526), Triage (1-2679), MFM (2862),
Anesthesia (1-4148 ), Gyn Onc (med-trak), Urogyn (Medtrak)
Initial resuscitation: IV access x2? IVF open with pressure bag? Cell saver on the
field? Warming patient?
Source of bleeding?
-Is the uterus atonic?

Call ADM
charge
Pickle
phone
1-2800

-Are all uterotonics in the room (see chart)?

-Recheck uterus for retained tissue?


-Is the uterine incision (including angles) hemostatic? -Apex of extension visualized and hemostatic?
-Is a vaginal/cervical exam warranted?
-Bakri balloon? Compression sutures?
-Is a hysterectomy being considered? Is a hysterectomy tray in the room?
-Any concern for bladder/ureteral injury? Cysto available?

Assessment of hemorrhage:
-Stat CBC, platelets, INR, fibrinogen drawn and sent? Are serial labs needed? TEG performed?
-EBL and pt hemodynamics discussed?
-Has the blood bank (4646) been notified? Massive transfusion protocol activated?

Recovery: Does this patient need an ICU bed? Has CCM been notified (1-2790)?

Triggers for
checklist
use:
-EBL
>1000cc
- A bleeding
extension
identified
- Surgeon
calls for
uterotonics

Anesthesia Hemorrhage Checklist


Call for help if major fluid resuscitation necessary
Reduce volatile agents and nitrous oxide if hypotensive
Maintain normothermia with a fluid warmer and forced air warming blanket
Consider rapid transfusion device
Consider blood salvage device (COBE BRAT)
Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if abdomen
open.
Consider aortic cross-clamping.
Consider Vigileo, arterial line and CVP for hemodynamic monitoring
Consider TEE for continued hypotension
Monitor hemoglobin, TEG, electrolytes, ABG at frequent intervals
Remember to normalize any hypocalcemia with supplemental CaCl2 at 500-1000 mg doses
Maintain acid base status with volume resuscitation and NaHCO3
Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis
Consider trauma pack or major transfusion protocol.
Consider interosseus drill if IV access problematic
Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes
FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.
Massive Transfusion Protocol (RBC + PLASMA + PLTS)

Anesthesia Hemorrhage Checklist


Call for help if major fluid resuscitation necessary
Reduce volatile agents and nitrous oxide if hypotensive
Maintain normothermia with a fluid warmer and forced air warming blanket
Consider rapid transfusion device
Consider blood salvage device (COBE BRAT)
Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if abdomen
open.
Consider aortic cross-clamping.
Consider Vigileo, arterial line and CVP for hemodynamic monitoring
Consider TEE for continued hypotension
Monitor hemoglobin, TEG, electrolytes, ABG at frequent intervals
Remember to normalize any hypocalcemia with supplemental CaCl2 at 500-1000 mg doses
Maintain acid base status with volume resuscitation and NaHCO3
Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis
Consider trauma pack or major transfusion protocol.
Consider interosseus drill if IV access problematic
Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes
FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.
Massive Transfusion Protocol (RBC + PLASMA + PLTS)

Bentley Autotransfusion System

Duncan SE et al. Ann Surg 1974;180:296-304

Catling S, Joels L. IJOA 2005;112:131-2

Organizations recommending blood


salvage during the peripartum period
Confidential Enquiry into Maternal and Child
Health (UK)
National Institute for Health and Clinical
Excellence (UK)
Obstetric Anesthetists Association (UK)
Assoc. of Anaesthetists of Great Britain and
Ireland (UK)

Anesthesia Hemorrhage Checklist


Call for help if major fluid resuscitation necessary
Reduce volatile agents and nitrous oxide if hypotensive
Maintain normothermia with a fluid warmer and forced air warming blanket
Consider rapid transfusion device
Consider blood salvage device (COBE BRAT)
Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if
abdomen open.
Consider aortic cross-clamping.
Consider Vigileo, arterial line and CVP for hemodynamic monitoring
Consider TEE for continued hypotension
Monitor hemoglobin, TEG, electrolytes, ABG at frequent intervals
Remember to normalize any hypocalcemia with supplemental CaCl2 at 500-1000 mg doses
Maintain acid base status with volume resuscitation and NaHCO3
Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis
Consider trauma pack or major transfusion protocol.
Consider interosseus drill if IV access problematic
Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes
FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.
Massive Transfusion Protocol (RBC + PLASMA + PLTS)

Interosseus Drill

Anesthesia Hemorrhage Checklist


Call for help if major fluid resuscitation necessary
Reduce volatile agents and nitrous oxide if hypotensive
Maintain normothermia with a fluid warmer and forced air warming blanket
Consider rapid transfusion device
Consider blood salvage device (COBE BRAT)
Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if abdomen
open.
Consider aortic cross-clamping.
Consider Vigileo, arterial line and CVP for hemodynamic monitoring
Consider TEE for continued hypotension
Monitor hemoglobin, TEG, electrolytes, ABG at frequent intervals
Remember to normalize any hypocalcemia with supplemental CaCl2 at 500-1000 mg doses
Maintain acid base status with volume resuscitation and NaHCO3
Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis
Consider trauma pack or major transfusion protocol.
Consider interosseus drill if IV access problematic
Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes
FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.
Massive Transfusion Protocol (RBC + PLASMA + PLTS)

Non-invasive Cardiac Output Monitors


Vigileo Flo-trac

LiDCO

Anesthesia Hemorrhage Checklist


Call for help if major fluid resuscitation necessary
Reduce volatile agents and nitrous oxide if hypotensive
Maintain normothermia with a fluid warmer and forced air warming blanket
Consider rapid transfusion device
Consider blood salvage device (COBE BRAT)
Ensure adequate IV access, consider CVP, surgical cannulation of abdominal vein if abdomen
open.
Consider aortic cross-clamping.
Consider Vigileo, arterial line and CVP for hemodynamic monitoring
Consider TEE for continued hypotension
Monitor hemoglobin, TEG, electrolytes, ABG at frequent intervals
Remember to normalize any hypocalcemia with supplemental CaCl2 at 500-1000 mg doses
Maintain acid base status with volume resuscitation and NaHCO3
Consider Tranexamic Acid, 1 gm IV for continued bleeding and suspected fibrinolysis
Consider trauma pack or major transfusion protocol.
Consider interosseus drill if IV access problematic
Trauma Pack = 10 units of RBCs (uncross-matched Group O) available in 5 minutes
FFP is NOT included but the Transfusion Service Staff will ask if FFP is needed.
Massive Transfusion Protocol (RBC + PLASMA + PLTS)

Effect of Body Temperature on Coagulation

Body Temperature ( C)
Rohrer MJ, Natale AM. Crit Care Med 1992;20:1402-5.

Meng et al. J. Trauma 2003;55:886

Probability of Life-Threatening Coagulopathy


increases with hypotension and hypothermia
Clinical Status

Conditional Probability of
developing coagulopathy

No risk Factor
Severe trauma>25
Severe trauma+ISS*Systolic BP<70mm Hg
Severe trauma+pH<7.1
Severe trauma+Temp<34C
Severe trauma+Systolic BP<70mm Hg+Temp<34C
Severe trauma+BP<70mm Hg+Temp<34C+pH<7.1

1%
10%
39%
58%
49%
85%
98%

Using FFP in these dire clinical situations is likely to fail to achieve


hemostasis, unless the other problems are successfully addressed

*Injury Severity Score

Cosgriff et al. J Trauma 1997;42:857-61.

Point of Care Testing

Near Care Testing

Outcome with Algorithm and Point of care testing

Nuttall GA et al. Anesthesiology 2001;94:773-81

Outcome with Algorithm and Point of care testing

Nuttall GA et al. Anesthesiology 2001;94:773-81

Process Measure
Obstetrical and Anesthesia Hemorrhage Checklist
Nominator: Checklist Use
Denominator: Number of OB hemorrhages

Outcome Measure
Percent of women transfused
The goal would be to reduce the percentage of women
transfused.
Numerator: Women who gave birth >=20 weeks gestation
and received 1 unit or > units of any blood product during
Denominator: All births

Average transfusion exposure


This would measure whether QI has reduced transfusion
exposure. This is important because the complications of
transfusion are dose related.
Numerator: total units transfused
Denominator: women transfused

Questions?
Jonathan Waters, M.D.
watejh@upmc.edu