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Acute Resuscitation in CatastrophicUncontrolled Obstetric Haemorrhage in
the Peripartum Period
Associate Professor Stephen Gatt, OAM, MOM, KM, KHS, JP; MD, LRCP, DCH, CHE, MASCH, MRACMA, MRCS, AFACHSE, FFARACS, FANZCA, FICANZCA
Director of Anaesthesia, Prince of a!es Hos"ita!,
Hea# of Di$ision, Anaesthesia an# Intensi$e Care, Prince of a!es % Sne& Chi!#ren's Hos"ita!s(
Senior Staff S"ecia!ist )an#, "re$io*s!&, Director of Anaesthesia % Ac*te Care+, Ro&a! Hos"ita! for oen(
Presi#ent, O-stetric Anaesthesia Societ& of Asia an# Oceania )OASAO+(
Kensin.ton % Ran#/ic0, Sne&, A*stra!ia
PIT X Fetomaternal
Batu-Malang, 11thMarch 2009
Agrowisata, Batu
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Order of Battle a LearningObjective
Catastrophic haemorrhage
definitions
action plan
Over!helming transfusion
management
Role of recombinant factor "##a in $assive
Haemorrhage timing
optimised performance
$assive %ransfusion Protocol
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Syllabus Objectives -Syllabus Objectives -
Management of SevereManagement of Severe
HaemorrhageHaemorrhage Immediate volume replacementImmediate volume replacement
rVIIa do not wait too long before usingrVIIa do not wait too long before using
Immediate management training in andImmediate management training in andactivation of the haemorrhage drillactivation of the haemorrhage drill
Pre-preparation of a massive transfusionPre-preparation of a massive transfusion
trolley or box with pressure bags, largetrolley or box with pressure bags, largecannulae, Level blood warmers, bloodcannulae, Level blood warmers, blood
pumps, etc!pumps, etc!
"ctivation of the #assive $ransfusion Protocol"ctivation of the #assive $ransfusion Protocol
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&hat is a 'massive() 'catastrophic()'critical( or 'e*treme( transfusion+
Arbitrar,
%ransfusion of patient(s entire red cell mass!ithin -. hrs
Often /01 units RCC in adults
Perhaps 2management of massive transfusion3should be re4named 2management of criticalbleeding3 )Is-ister J 1223+
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%,pical 2catastrophic bleeding3 profile%,pical 2catastrophic bleeding3 profile
Blood products used in the 24 hrs to infusion (units)Blood products used in the 24 hrs to infusion (units) Packed cellsPacked cells 3030 PlateletsPlatelets 1616 FFPFFP 2020
CryoprecipitateCryoprecipitate 1616 Coagulation prole prior to infusionCoagulation prole prior to infusion
Platelet countPlatelet count !3 " 10!3 " 10##$l$l %&'%&' 1616 P**P** +, secs+, secs
Fi-rinogenFi-rinogen 23 g$l23 g$l .ean dose$kg infused/.ean dose$kg infused/ 113113 gg
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e ho sees thingsfro the -eginning hasthe nest ie of the
ristotle 3!43225 BC
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A55655#78 56"6R#%9A55655#78 56"6R#%9
BPBP
AppearanceAppearance
Heart RateHeart Rate
RespResp
:1140111:1140111 7ormal7ormal Usuall, fastUsuall, fast
;011;011
011140:11011140:11 5AP
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6*treme Haemorrhage %,pe of eliver,
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$assive Haemorrhage Causes
OtherCretainedpla
centaDaton,
andother'mi*ed(c
auses
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hat !o "#P$%an! now &the M%
an! Maternal %eath#n'uiries( teach us
a)out*aemorrhage+
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eading causes of direct deathseading causes of direct deaths
reported to C7.85 200002reported to C7.85 200002
1 : 01 0: -1
%hromboembolism
Haemorrhage
H,pertension
5epsis
6ctopic
Other earl, pregnanc, deaths
Amniotic fluid embolism
Other direct
Rate per million maternities5ource Confidential enEuiries into maternal deaths) Figure 0G-
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$assive Bleeding reEuiring r"##aCases b, Presentation 4 overall
%otal cases -1-=
Position Ma 200.$)stetric /
In!o uiah
131,000,000,000,000
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Patients reEuiring r"##a Obstetricmaes up @4:I
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&ill !e see more bleeding+JI of deliveries in 75& for each categor, in 75& in -11.K
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$assive Haemorrhage
$assive haemorrhage continues to be a an*iet, producingchallenge for medical staff especiall, junior doctors
&ill !e see it more often+
$anagement involves A7%#C#PA%#O7) #A87O5#5)$A7A86$67%
iagnosis reEuires vigilance and a!areness of confounders
$anagement is through team4!or and goodcommunication !ith obstetricians) $Os) surgeons)mid!ives) haematologists and radiologistsG
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Principles Underpinning $assiveObstetric Haemorrhage
8ravid uterus receives up to 0:I of maternal CO Jfrom-IK
;>11mlMmin Placental haemorrhage represents ;0 unit blood lossMmin
Lo! resistance placental circulation lacs autoregulation
Uterine m,ometrial contraction primaril, responsible forcessation of bleeding
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Improved OutcomesImproved Outcomes
Lower mortalityLower mortalityLess morbidityLess morbidity
%ewer complications%ewer complications
&enal failure&enal failure
'heehan(s syndrome'heehan(s syndrome
&etained reproductive function&etained reproductive function'maller reliance on radiological'maller reliance on radiological
embolisation proceduresembolisation procedures
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$aing a diagnosisN$aing a diagnosisN
Placenta complete/incompletePlacenta complete/incomplete
Vaginal bleedingVaginal bleeding
Uterus soft or contractedUterus soft or contractedUterus palpation and uterine positionUterus palpation and uterine position
Abdominal pain or shoulder tip painAbdominal pain or shoulder tip pain
Additional bleeding from otherAdditional bleeding from other
wound siteswound sites
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56"6R6 HA86 R6CO87#56
CALL FOR H6LP
567#OR$#"65
OB5%6%R#C#A75 A7A65%H6%#5% HA6$A%OLO8#5%
BLOO BA7A7A65%H6%#CR68#5%RAR5
POR%6R5 897A6 O7COLO8#5%#CU
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/ 4te Plan 5or Managing PP*
I6 I!enti5 4ource o5 Blee!ing7 8ie :terotonics
II6 Al Pressure to :terus7 Trans5use
III6 "ontrol Bloo! 4ul to :terus, 8ie Bloo!Pro!ucts
I;6 Place :terine "omression 4utures
;6 Per5orm *sterectom
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Uterine Bleeding
%rug %ose 4i!e e55ects
5,ntocinon 4:U slo! #" bolus
[email protected] in 0L titrated
4H,potension
4Refle* tach,cardiaMarrh,thmias
4!ea AH lie effect
6rgometrine 4-:1ug #$ or
40-:ug slo!l, #"
4nMv JcommonK
4H% Jcan be severeK
4coronar, spasmM ischaemic pain
Carboprost
P8 F-
41G-:mgintram,ometriall, or#$ repeated to ma*
-mg
4nMvMdiarrhoea4severe bronchospasm
4h,po*ia Jalter pulm shunt fractionK
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Alldied
from
MODS
/MOF
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"rstalloi! < "olloi! < Pac=e!"ells as er MassieTrans5usion Protocol
Pac=e! "ells < Platelets ation7 Trans5use-sta ahea!
;I6 Procee! withAGGRESSIVE SURGICAL MANEUVERSGAPA$T$MHaC Gigate )lee!ers)C :terine Arter Gigation $(Gear 4uturescC B-Gnch or Mo!i5ie! B-Gnch 4utures!C *sterectomeC Pac= Pelis
5C Mast 4uit as nee!e!
?*emorrhageAlert@
Potential for PPH
Inform patient/family of
potential for pp hemorrhage
Notify NIC & Unit
Coordinator about
Hemorrhage Alert --
potential for PPH.
Alert other a needed.
Actie Management o5 Dr!4tage o5 Ga)or
8ive uterotonics beforeplacenta deliversQ notetimeplacenta delivers
Uterus contracts!ithout problem
Call Off PPH alert
Postpartum Hemorrhage Process .ap
Announce minutes 5rom T0
Announce 4urgical ;ariance-4tage I, then 4tage II
4urgical ;ariance 4tage III
time subtotal = X min
time subtotal = X min
time subtotal = X min
Grand Total Time = X min
Announce minutes 5rom T0
ee trac= o5 time emem)er ?Fole, I E $(s@
emem)er :terotonics
If
pa
tient
sympto
matic
%ocumentE
Tal= withFamil
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B* "GB $)stetric 4urgical ;arianceUnexpected, Emergent
Peripartum Event
Vaginal Delivery C-Section Deviation from Exect
"atient Sta#le"atient Sta#le
Remain in CL$ roomRemain in CL$ room
rimary %# Care &eamrimary %# Care &eam
Manage' EventManage' Event"age $eeer ())
a' nee!e!
"atient"atient
Un'ta#leUn'ta#le
"atient"atient
Un'ta#leUn'ta#le
Anno*nce S*rgicalAnno*nce S*rgical
VarianceVariance
"age t+e NIC"age t+e NIC
danced ;urgicaldanced ;urgicalProcedure(s)Procedure(s)
"all 5or *el"all 5or *el ,$eeer
()),
Move to %RMove to %R
STAGE I S.V.
STAGE II AHODResources w/in Labor & Deliver
A!!itional 4urgical Proce!ureJsCA!!itional 4urgical Proce!ureJsC
+ *sterectom+ *sterectom
STAGE III
Resources ou!si"e o# L & D
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Intro!*ction of an o#'tetric-Intro!*ction of an o#'tetric-
'eci.c me!ical emergency'eci.c me!ical emergency
team for o#'tetric cri'e'/team for o#'tetric cri'e'/imlementation an!imlementation an!
exerienceexerience
Ga#riella G0 Go'man MD1 Marie R0Ga#riella G0 Go'man MD1 Marie R0
$al!i''eri MD1 2aren L0 Stein RN$al!i''eri MD1 2aren L0 Stein RN
MSED1 &ri'+ A0 Nel'on RN M3RM1MSED1 &ri'+ A0 Nel'on RN M3RM1
S*'an 30 "e!aline MS $SN1 4onat+an 30S*'an 30 "e!aline MS $SN1 4onat+an 30
5ater' MD1 3yagriv N0 Sim+an MD5ater' MD1 3yagriv N0 Sim+an MD
MSCRMSCR$agee4&omens Hospital) Pittsburgh) PA) -11SG
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PO&45CH4RH&4PO&PH
PAC6
i Bl d P d t U
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rop in Blood Product Usage
PROUC%
I Reduction
in Use5tate!ide
I Reduction
in Use Area4!ide
I Reduction
in Use atRand!icCampus
Red cells >G- =G0 =G-
Platelets 0-G1 G11current usage $ar (1
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rF"##a boosts thrombin generation on activated platelets
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Number of Cases of rVIIa by Population
P
er011)1
11
heado
fpopulation Australia 20,3D3,1KL
:4A 299,D9L,3.3
In!onesia 2.0,123,L3L
X 1/
6ffect on
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Outcome at-< a,s
6ffect onBleeding
n -S
*aemostasis egistr r;IIa First 2K P$4"* an 200K
$utcome E #55ect on Blee!ing
Rand!ic Campus vs %otal Registr,
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Rand!ic Campus vsG %otal Registr,
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ose
7umber of patients -1-=
%otal number of doses @11@
$edian dose SG- mg J#TR .GK
$edian dose =1G> gMg J#TR S0G:401-G:K
um)er o5 %oses
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6ffect on Bleeding vs Outcome
Bum)ero
5cases
-- @0
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6ffect on Bleeding vs Outcome
$)stetrics
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Causes of r"##a failureCauses of r"##a failure
Fibrinogen ?1G
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%A:M A%, BAT:-MAGA8, 2009
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%emp and 6ffect on Bleeding
-0. ..) p ? 1G110
%otal cases 0G@1S
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pH and 6ffect on Bleeding
-0> 0==) p ? 1G110
%otal cases 0)0
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pH and
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pH and%emperature
n 0)0>=
!ecreasing
*
!ecreasing
tem
H % t 6ff t Bl di
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pH) %emperature 6ffect on Bleeding
n 0)1@.
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#n haemorrhage)r"##a is
97A$#%6
Jbut do not !aste itK
f f 5 OF lfil t f 5 ll b Obj ti i th
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Fulfilment of 5,llabus Objectives in theFulfilment of 5,llabus Objectives in the
$anagement of Catastrophic$anagement of Catastrophic
HaemorrhageHaemorrhage "olume replacement"olume replacement r"##a the Haemostasis Registr, r"##a the Haemostasis Registr,
Australia 7e! WealandAustralia 7e! Wealand Haemorrhage 'fire( drills Asia perspectiveHaemorrhage 'fire( drills Asia perspective $assive transfusion bo*$assive transfusion bo* $assive %ransfusion Protocol Australian$assive %ransfusion Protocol Australian
perspectiveperspective
oint OA5AO 5OAP $eeting
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So muchmore to
haemorrhage
Stephen Gatt, MD
Terima asih Atas
Perhatian An!a
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Adverse 6vents 4 %rauma
efinitel, Lined 1Probabl, Lined 1
Possibl, Lined 0
4u) Total 1 N 262
Unliel, to be Lined .
7ot Lined =
Unable to Assess 0Causalit,
:0,GoG male !ith previous histor, ofchronic alcoholic liver disease sufferedblunt assault including liver lacerationsG
A6 #C) ?> hours post rF"##aadministrationG
eceased a, 0-Cause of eath 4 unno!n Ja!aitingcoroner(s reportK
@
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-11)111
.11)111
>11)111
Aug 1S
Februar, -11>
August -11S
D: ,ears
Y0)1@0)111
Y0)>1-)111
Rand!ic Campus CumulativeRand!ic Campus Cumulative
6*penditure6*penditure
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Econo$ic As%ec!sEcono$ic As%ec!s
Cost of drug?
Survival?
Intensive care unitcost?
Days in hospital?
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Obstetrics rF"##a
Units of Paced Cells Before rF"##a After ose0 After ose- After ose@
1 . S - 0;1 ?: - 0@ 0 1> 4 01 - 0 0 100 4 0: < 1 1 10: 4 -1 - 1 1 1-0 4 -: 1 1 0 1-> 4 @1 0 0 1 1
; @1 @ 1 1 1 %otals -- -- : 0
n--n--Position on -.GviiG1> B %* before after "##aPosition on -.GviiG1> B %* before after "##a
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''6conomic( Considerations6conomic( Considerations
&hat is the cost of a life+&hat is the cost of a life+
&hat is the cost of a fatherless or&hat is the cost of a fatherless ormotherless famil,+motherless famil,+
&hat is the cost of saved blood blood&hat is the cost of saved blood blood
products+products+&hat is the cost of #CU sta,+ Of return to&hat is the cost of #CU sta,+ Of return to
OMR+OMR+
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G#:"$%#PG#TI$ TA8#T4
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Leucodepletion %argets
100 uniersal leuco!eletion ) 1st6$cto)er 200. to "ouncil o5 #uroe8ui!elines
"ost etra O100unit
+ 4econ! B" )e!si!e 5ilter Jto re!uce5urther log B"C
G#:"$%#PG#TI$ TA8#T4
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elivering Blood from Blood Ban
Pneumatic %ube5,stem J5CUK
0- units broenJ0G0G1
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BG %* "##a 4 CostsBG %* "##a 4 Costs