Shock in the Obstetric Patient...Hypersensitivity to drug Refrigerate Oxytocin (PITOCIN) 10 units/1...
Transcript of Shock in the Obstetric Patient...Hypersensitivity to drug Refrigerate Oxytocin (PITOCIN) 10 units/1...
OBSTETRIC
HEMORRHAGE
CRITICAL CARE OBSTETRICS
#TRIHEALTHCRITICALCAREOB
Critical Care OBstetrics
OBSTETRIC HEMORRHAGE
Learning Objectives
• Understand the scope of the problem
• Readiness
• Recognition and Prevention
• Response
• Reporting
Critical Care OBstetrics
OB HEMORRHAGE: SCOPE OF THE PROBLEM
Critical Care OBstetrics
OB HEMORRHAGE: SCOPE OF THE PROBLEM
Critical Care OBstetrics
OB HEMORRHAGE: SCOPE OF THE PROBLEM
MMR (Maternal Mortality Ratio) = # Maternal
Deaths / 100,000 live births (per year)
– Worldwide – MMR dropped 2.3% annually from 1990-
2015 (216/100,000 L.B’s.)
– U.S. – 1.7% annual increase (17.2/100,000 L.B’s.)
– TriHealth – equates to potentially 1-2 per year
Attributable Factors
– Increased: Maternal Age, BMI, Co-Morbidities
– Race (Non-Hispanic Black Women)
Critical Care OBstetrics
OB HEMORRHAGE: SCOPE OF THE PROBLEM
Critical Care OBstetrics
27.1
14
10.7
7.9
3.2
0 5 10 15 20 25 30
HEMORRHAGE
HYPERTENSIVE DISORDERS
SEPSIS
ABORTION
EMBOLISM
Percentage
Causes of Maternal Death
Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a
WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323.
OB HEMORRHAGE: SCOPE OF THE PROBLEM
Critical Care OBstetrics
OB HEMORRHAGE: SCOPE OF THE PROBLEM
Maternal Hemorrhage: cumulative blood loss > 1
liter or blood loss accompanied by signs/symptoms of
hypovolemia within 24 hrs of the birth process
• Leading cause of maternal mortality worldwide
• Leading cause of severe maternal morbidity in
the U.S.
– ARDS, shock, DIC, acute renal failure, infertility, &
pituitary necrosis
• Rates increasing by 26% over past 30 yrs
Critical Care OBstetrics
OPPORTUNITY FOR PREVENTION
Critical Care OBstetrics
Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths:
results of a state-wide review. Obstet. Gynecol. Dec 2005;106(6):1228-1234.
THE SAFETY BUNDLE
Obstetric Hemorrhage Safety Bundle
Readiness: (every unit)
• Hemorrhage Cart / with Procedural Instructions (balloons, compression
stiches)
• Rapid access to hemorrhage medications (kit or equivalent)
• Establish a response team: multiple partnerships // unit education, drills,
debriefs
• Establish MTP and 0-neg/uncrossmatched transfusion protocols
Recognition: (every patient)
• Assessment of hemorrhage risk (prenatal, on admission, ongoing in labor &
PP)
• Measurement of CUMMULATIVE blood loss
• Active Management of 3rd Stage (oxytocin after birth)
Critical Care OBstetrics
THE SAFETY BUNDLE
Obstetric Hemorrhage Safety Bundle
Response: (every hemorrhage)
• Unit-standard, stage-based OB Hemorrhage Emergency Management Plan
with checklist
• Support program for patients, families and staff
Reporting / Systems Learning: (every unit)
• Establish a culture of Huddles for high-risk patients and post-event
debriefings
• Review all stage 3 hemorrhages for systems issues
• Monitor outcome and process metrics in perinatal QI committee
Critical Care OBstetrics
READINESS
Steps
1. Develop Awareness
2. Ensure Access to Equipment & Products
3. Develop Evidence-Based Protocol
Critical Care OBstetrics
READINESS
Awareness
1. Risk Factor Assessment
2. Quantification of Blood Loss (QBL)
3. Vital Sign Triggers
4. Simulated Scenarios to Reinforce
Appropriate “Urgency”
Critical Care OBstetrics
READINESS
Access
1. Hemorrhage Cart
2. Rapid Lab Assessment
3. Rapid Blood Products
4. Massive Transfusion Protocol
5. i-STAT Blood Analyzer
Critical Care OBstetrics
READINESS
Critical Care OBstetrics
TRIHEALTH OBSTETRIC HEMORRHAGE MANAGEMENT PLAN Assessments/Actions Meds/Interventions Blood Bank
STAGE 1 - Blood loss >500 ml (Vaginal) or >1000 ml (Cesarean) OR vital sign (VS) changes >15% OR HR ≥110, BP ≤85/45, O2 sat <95% OR Increased bleeding during recovery or postpartum STAGE 1 □ EPIC post-partum hemorrhage flowsheet □ Notify Charge Nurse □ Notify Senior resident if attending not present □ Call for Hemorrhage cart □ US to bedside □ VS, including O2 sats every 5 min (maintain O2 sats > 95%) □ Weigh, calculate, announce and record cumulative blood loss every 10 min
□ Place IV with16 or 18 gauge (if no IV in place) □ Increase IV fluids - LR with oxytocin (replace blood loss at 2:1) □ Empty bladder - straight cath or foley □ Vigorous fundal massage □ Bimanual pelvic exam and uterine massage per provider □ Keep patient warm □ Determine and treat etiology (4 T’s – Tone, Trauma, Tissue & Thrombin). □ Give uterotonic medication
□ Methergine 0.2 mg IM (contraindication: hypertension); give once. If no response, move to Cytotec. □ Cytotec (Misoprostol) 800 mcg sublingual (SL) or per rectum
□ Consider Fentanyl 25 mcg IV for one dose if needed for pain management
□ Type & Crossmatch for 2 - 4 units PRBC STAT
STAGE 2 - If continued bleeding or VS instability and < 1500 ml cumulative blood loss, complete Stage 1 items and PROCEED TO STAGE 2. If cumulative blood loss > 1500 ml or vital signs remain unstable or suspicion of DIC, PROCEED TO STAGE 3.
STAGE 2 □ Call Red Alert □ Notify private attending □ Hemorrhage Cart in room □ Huddle; appoint leader, recorder and nursing roles □ Identify hemorrhage stage, document blood loss & interventions □ Consider moving to OR or L&D □ Assign family support person □ CBC without differential and OB
Coag panel STAT (Consider ISTAT)
□ Anesthesia to consider further pain management □ TWO IV lines with 16 or 18 gauge □ Additional uterotonics medications:
□ Methergine 0.2 mg IM x1 dose(Contraindication: Hypertension) □ Cytotec (Misoprostol) 800 mcg sublingual (SL) or per rectum □ Hemabate 250 mcg IM q 15 min(Contraindication: reactive airway disease, e.g. asthma) (max dose 2 mg/8 doses).
□ Bimanual uterine massage per provider □ Apply warming blanket □ Vaginal Birth consider the following:
□ Move to OR □ Evaluate/repair any tears □ Use US and/or D&C to rule out retained placenta □ Place intrauterine balloon □ Selective Embolization by Interventional Radiology
□ Cesarean Birth : □ Inspect broad ligament, posterior uterus, adnexal structures and retained placenta □ Place intrauterine balloon □ B-lynch suture
□ Set up blood administration tubing and blood warmer (consider rapid infuser) □ Release 2-4 units PRBCs □ Transfuse based on clinical signs/symptoms; do not wait for lab results □ Notify Blood Bank (BNH 51592 or GSH 22222) of OB hemorrhage; order 2 units FFP □ Transfuse O neg blood if cross matched blood is unavailable □ If using more than 4 units PRBC consider Massive Transfusion Protocol (MTP)
STAGE 3 - If cumulative blood loss >1500 ml, > 2 uPRBCs given, VS remain unstable or suspicion for DIC, complete items in Stage 1 and 2 and PROCEED TO STAGE 3.
STAGE 3 □ Consider Moving to OR □ Consider Gyn Onc and Interventional Radiology □ Repeat labs as ordered
□ Apply sequential compression device □ Continue blood products as ordered □ If using 4 more units of PRBC, activate MTP □ Aggressively transfuse based on VS and blood loss □ If coagulopathic, add cryoprecipitate
POST HEMORRHAGE MANAGEMENT FOR ALL PATIENTS □ Return unused blood products to Blood Bank ASAP □ Clinical consideration (including appropriate level of care for patient) □ Continue modified postpartum management with increased surveillance □ Discuss with patient/family members □ Debrief and document after team debrief (Complete IRIS Report) □ Restock Hemorrhage cart
Adapted from California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care Version 2.0
TriHealth
Specific Protocols
READINESS
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Admission Risk Assessment & Testing
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Admission Risk Assessment & Testing
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Ongoing Risk Assessment Each Shift
Critical Care OBstetrics
Intrapartum PostpartumProlonged Second Stage (> 2 hrs) Vacuum- or Forceps-assisted birth
Prolonged Oxytocin Use (> 12 hrs) Cesarean delivery (urgent/emergent)
Active bleeding Retained placenta
Chorioamnionitis / Fever
Magnesium Sulfate Treatment
Modified from CMQCC Obstetric Hemorrhage Safety Bundle ANDNyfløt LT, Stray-Pedersen B, ForseÂn L,Vangen S (2017) Duration of labor and the risk ofsevere postpartum hemorrhage: A case-control study. PLoS ONE 12(4): e0175306.
RECOGNITION AND PREVENTION
Ongoing Risk Assessment Each Shift
Critical Care OBstetrics
Intrapartum PostpartumProlonged Second Stage (> 2 hrs) Vacuum- or Forceps-assisted birth
Prolonged Oxytocin Use (> 12 hrs) Cesarean delivery (urgent/emergent)
Active bleeding Retained placenta
Chorioamnionitis / Fever
Magnesium Sulfate Treatment
Modified from CMQCC Obstetric Hemorrhage Safety Bundle ANDNyfløt LT, Stray-Pedersen B, ForseÂn L,Vangen S (2017) Duration of labor and the risk ofsevere postpartum hemorrhage: A case-control study. PLoS ONE 12(4): e0175306.
Best Practice AdvisoryThis patient has been identified as HIGH RISK for an
obstetric hemorrhage. Please consider ordering a Blood Type & Crossmatch for 2 units of packed red blood cells.
Click here to order 2 units PRBCs
RECOGNITION AND PREVENTION
Triggers Reflecting Excessive Blood Loss
• Direct Blood Loss Measurement (QBL >
500 ml after vaginal birth, >1000 ml c/s)
• Heart Rate Increase of > 10%
• Systolic BP Decrease of > 10%
• Shock Index Increase of > 10%
– HR / SBP (>0.85 considered CONCERNING)
Critical Care OBstetrics
Pacagnella RC, Souza JP, Durocher J, et al. A systematic
review of the relationship between blood loss and clinical
signs. Hawkins SM, ed. PLoS One. 2013;8(3):e57594.
RECOGNITION AND PREVENTION
Quantitative Blood Loss Evaluation
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Critical Care OBstetrics
BLOOD LOSS AND SIGNS / SYMPTOMS
Critical Care OBstetrics
RECOGNITION AND PREVENTION
Steps For Preventing Obstetric Hemorrhage
• Oxytocin prophylactically – 20 units/1 L crystalloid IV @ 10 ml/min for first hour
– May increase to 40 units or 80 units/1 L
– May initiate following delayed cord clamping
• Uterine Massage
• Umbilical Cord Traction
• Tranexamic acid for very high risk women at
time of incision during cesarean delivery
Critical Care OBstetrics
RESPONSE: FIRST STEPS
RECOGNITION Call for assistance (Red Alert)
Designate
Team leader
Checklist reader/recorder
Primary RN
Announce
Cumulative blood loss
Vital signs
Determine stage
Critical Care OBstetrics
RESPONSE: DESIGNATE STAGE
Critical Care OBstetrics
RESPONSE: STAGE 1
Critical Care OBstetrics
RESPONSE: STAGE 1
INITIAL STEPS
Ensure 16G or 18G IV access
Increase IV fluid (crystalloid without oxytocin)
Insert indwelling urinary catheter
Fundal massage
MEDICATIONS
Increase oxytocin, additional uterotonics
BLOOD BANK
Type & crossmatch 2 units RBCs
ACTIONDetermine etiology & treat
Prepare OR, if clinically indicated
(optimize visualization/examination)
Critical Care OBstetrics
RESPONSE: MEDICATIONS
Drug Dose Route Frequency Side Effects Contraindications Storage
Albumin 5% 250 ml IV bolus Fever, chills, rash, nausea, vomiting, rapid
HR, headache, itching, flushing
Heart failure Room Temp
Carboprost (HEMABATE)
And
Diphenoxylate-atropine
(LOMOTIL)
250 mcg IM Every 15 min (not to exceed 8
doses/24 hrs)
-if no response after several
doses, it is unlikely that
additional doses will be
effective
Nausea, vomiting, diarrhea, fever
(transient), headache, chills, shivering,
hypertension
bronchospasm
Caution in women with
hepatic disease, asthma,
hypertension, active cardiac
or pulmonary disease
Refrigerate
fentanyl (SUBLIMAZE) 25 mcg
(100
mcg/2ml
amp)
IV
over 1-2
min
May be repeated as ordered Respiratory depression, bradycardia,
drowsiness, hypotension, nausea
Allergy or hypersensitivity to
drug
Room Temp
Lidocaine 1% Smallest
effective
dose
SQ Once to achieve local
anesthetic effect
Hypersensitivity to drug Room Temp
Oxytocin (PITOCIN) 10 units/LR
500 ml
(already
mixed)
IV 10 ml/min Nausea, vomiting, hyponatremia (“water
intoxication”) with prolonged IV admin.
Hypersensitivity to drug Refrigerate
Oxytocin (PITOCIN) 10 units/1 ml
vial
IV-add to
fluids
Continuous or bolus as ordered Nausea, vomiting, hyponatremia (“water
intoxication”) with prolonged IV admin.
Hypersensitivity to drug Room temp
Methylergonovine
(METHERGINE)
0.2 mg IM One dose Nausea, vomiting, hypertension Hypertension, pre-eclampsia Refrigerate
Misoprostol (CYTOTEC) 800 mcg Rectal or
SL
Once Nausea, vomiting, diarrhea, shivering,
fever (transient) headache
Allergy to prostaglandin Room temp
Tranexamic acid (TXA) 1 g (100
mg/ml)
IV 1 ml/min, may repeat after 30
min
Headache, muscle cramps,
back/abdominal/muscle pain
None Room temp
Critical Care OBstetrics
RESPONSE: TRANEXAMIC ACID
Critical Care OBstetrics
• Anti-fibrinolytic agent = stops clot break-
down
• WOMAN Trial (Lancet, May 2017)
– Double blind RCT of women with PPH
– 1 gm TXA vs placebo over 20 min
– Repeated once after 30 min if cont. bleeding
– Death due to bleeding significantly reduced
(1.5% vs 1.9%, RR 0.81; CI 0.65-1.0) – esp
when given within 3 hours of delivery
RESPONSE: STAGE 2
Critical Care OBstetrics
RESPONSE: STAGE 2
INITIAL STEPS
Mobilize additional help
Place 2nd IV (16-18G)
Draw STAT labs (CBC, coags, fibrinogen, ionized Ca, electrolytes)
Prepare OR
MEDICATIONS
Continue Stage 1 medications
Administer 1 gm Tranexamic Acid (100mg/ml) IV @ 1ml/min
BLOOD BANK
Obtain 2-4 units PRBCs (DO NOT wait for labs. Transfuse per
clinical signs/symptoms)
Thaw 2-4 units FFP
ACTION
Escalate therapy with goal of hemostasis
Critical Care OBstetrics
RESPONSE: STAGE 2
Ionized Calcium Evaluation:
• Decreasing serum ionized calcium
concentrations correlate with risk of death
• 1.65 RR for each decrement of 1.8 mg/dl
(normal 4.6 – 5.3 mg/dL)
• Sensitivity, specificity, & accuracy rates of
ionized calcium and other indicators in predicting
mortality
Critical Care OBstetrics Choi YC, Hwang SY. The Value of Initial Ionized Calcium as a Predictor of
Mortality and Triage Tool in Adult Trauma Patients. Journal of Korean Medical
Science. 2008;23(4):700-705. doi:10.3346/jkms.2008.23.4.700.
RESPONSE: PRIOR TO ACTIVATING MTP
• Initial Transfusion Approach: – 4 units of PRBCs
– If ongoing bleeding: transfuse 4 units of FFP
– If ongoing bleeding: alternate packed red cells and FFP until 8 units of
PRBCs + 6 pack of platelets + 5 packs of cryoprecipitate are given
– If ongoing bleeding: activate MTP
• Massive Transfusion Protocol (MTP):– Order when the transfusion requirement expected to be >10 units of red
cells in 24 hrs or 5 units in 3 hrs
– Reasons to avoid pre-emptive activation:
• Wastage
• Pulmonary toxicity associated with plasma exposure (TACO/ARDS)
(Collins P. J of Thromb Hemost:14, 205, 2015.)
Critical Care OBstetrics
RESPONSE: MTP GUIDELINES
• The decision to call the MTP is made by the lead treating
physician
• The clinical team must designate a single team member to
communicate with the blood bank
• An order is entered into EPIC and the blood bank is called.
• The blood bank will designate a single tech to receive
communications from the MTP team
• Send a type and screen stat if one is not already in the blood
bank.
• The blood bank will send a pack containing one dose of
platelets, 6 units of red cells and 6 units of FFP.
• The FFP may arrive later than the platelets and red cells as it
may need time to thaw.
Critical Care OBstetrics
RESPONSE: MTP GUIDELINES
• Transfuse the platelets first then transfuse a unit of red cells
alternating with a unit of FFP.
• If the FFP has not arrived, transfuse the red cells until the
FFP arrives then transfuse the units of FFP to catch up to the
red cells, then alternate.
• Red cells and plasma are kept in the cooler and platelets are
kept at room temperature.
• Transfuse units at the rate that is clinically indicated by the
patient’s status.
• The communicator must keep the blood bank informed of
when further MTP packs are needed.
• Stop the MTP promptly when hemostasis achieved, notify the
blood bank, and return unused units to the blood bank.
Critical Care OBstetrics
RESPONSE: BAKRI BALLOON TAMPONADE
• Insert under ultrasound guidance
• Inflate to 500 ml with sterile water or NaCl
• Use vaginal packing (iodoform or antibiotic
soaked gauze) to maintain correct
placement and maximize tamponade
• Gentle traction
– secure to patient’s leg
– or attach weight < 500 gm
Critical Care OBstetrics
RESPONSE: BAKRI BALLOON TAMPONADE
• Transabdominal placement (via incision)
– Place into incision and feed tubing out vagina
– Consider placing B-Lynch suture
– Close incision and then inflate balloon and tie-down B-Lynch suture
• Connect to fluid collection bag to monitor hemostasis
• Continuous monitoring of vital signs & signs of increased
bleeding
• May need to flush clots with sterile isotonic saline
• Maximum time to remain in place is 24 hours
• To deflate:
– Remove tension from shaft
– Remove packing
– Aspirate fluid
– Remove catheters gently
Critical Care OBstetrics
RESPONSE: SURGICAL MANAGEMENT
Critical Care OBstetrics
RESPONSE: STAGE 3
Critical Care OBstetrics
RESPONSE: THE LETHAL TRIAD
Lethal Coagulopathy Triad:
• Dilution– Transfusion of crystalloid and packed cells devoid of clotting factors
– A problem once 1 – 1 ½ total blood volume replaced
• Hypothermia– Significantly decreases platelet function: even if counts are adequate
– Keep patient warm (Bair Hugger®, fluid warmer)
• Acidemia– Occurs with massive hemorrhage due peripheral tissue hypoxia
– As hydrogen ion concentration increases, enzyme functions involved in
coagulation pathway stop functioning
– VERY DIFFICULT TO REVERSE!
Critical Care OBstetrics
RESPONSE: CARDIOVASCULAR COLLAPSE
INITIAL STEPS
Mobilize additional resources
MEDICATIONS
ACLS
BLOOD BANK
Simultaneous aggressive massive transfusion
ACTION
Immediate surgical intervention to ensure
hemostasis (hysterectomy)
Central line placement & Transfer to the ICU
Critical Care OBstetrics
RESPONSE: POST-HEMORRHAGE PROCESSES
Determine disposition of patient (whether
ICU required)
Debrief with the whole obstetric care team
Debrief with patient and family
Document = IRIS report
Critical Care OBstetrics
REPORTING / SYSTEMS LEARNING
• Establish a culture of huddles for high-risk
patients and post-event debriefs
• Conduct a multidisciplinary review of
serious hemorrhages for systems issues
• Monitor outcomes and processes metrics
Critical Care OBstetrics
REPORTING: TAKE-AWAY POINTS
• Most maternal mortalities and near misses due
to hemorrhage are preventable
• 1/3 of patients will have no risk factors prior to
labor
– Must be prepared for every patient
– QBL every delivery so can respond early
• Requires reliance not on individuals but on team
approach
Critical Care OBstetrics
REPORTING: TAKE-AWAY POINTS
• Blood products are VERY expensive
• Hemabate is ALSO VERY expensive
• R-Factor VIIa and Uterine Artery
Embolization are VERY VERY expensive
• Math: more early interventions
=fewer hemorrhages that reach “massive”
=fewer high level (expensive) interventions
Critical Care OBstetrics
Thank You
Critical Care OBstetrics
CRITICAL CARE OBSTETRICS
#TRIHEALTHCRITICALCAREOB