hemorragia obstetrica masiva y c
TRANSCRIPT
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HEMORRAGIA OBSTETRICA MASIVA Y C.I.D.ADALBERTO PACHECO PACHECO
RESIDENTE NIVEL III
ANESTESIOLOGIA Y REANIMACION
UDC
2013
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ANATOMIA
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GLOSARIO Y ESTADISTICAS
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CHESTNUT'S OBSTETRIC ANESTHESIA 4 EDT
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CHESTNUT'S OBSTETRIC ANESTHESIA 4 EDT
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SEGUNDA CAUSA DE MORTALIDAD
66% DE MUERTES POR HEMORRAGIA SON ATRIBUIBLES A CUIDADOS SUB STANDARD
ATONIA UTERINA
PLACENTA ACRETA
VIGILANCIA POST PARTO INADECUADA
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MOTIVACION
ALTERA ADECUADA PERFUSION Y OXIGENACION
PARALISIS CEREBRAL,
ENCEFALOPATIA HIPOXICO ISQUEMICA
MUERTE INTRA UTERINA
FOM
PERDIDA DE FERTILIDAD (S
SHEEHAM, HISTERECTOMIA
ANEMIA, COAGULOPATIA (NECESIDAD DE
TRANSFUSIONES)
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DEFINICIONES
PERDIDA SANGUINEA
SIGNIFICATIVA
PERDIDA SANGUINEA
MAYOR
HEMORRAGIA OBSTETRICA
MASIVA
HEMORRAGIA ANTEPARTO
HEMORRAGIA POST PARTO
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SIEMPRE RECUERDE LAS 4T’s !!!
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TONO• SOBRE DISTENSION UTERINA
• PARTO PROLONGADO
• INDUCCION OXITOCICA
• ABRUPTIO
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TEJIDO• RETENCION DE TEJIDOS
• ABRUPTIO
• PLACENTA ACRETA
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TRAUMA• PARTO PRECIPITADO
• PARTO INSTRUMENTADO
• CERCLAJE
• RUPTURA UTERINA
• EPISIOTOMIA, DESGARROS
• INTRAOPERATORIO
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TROMBINA• ANORMALIDADES LA COAGULACION
• COAGULOPATIAS ADQUIRIDAS ( PRECLAMSIA, HELLP, ABRUPTIO, SEPSIS, EMBOLISMO DE LIQUIDO AMNIOTICO, DILUCIONAL)
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HEMORRAGIA ANTEPARTO
• PLACENTA PREVIA
• ABRUPTIO DE PLACENTA
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PLACENTA PREVIA
CHESNUT OBSTETRIC ANESTHESIA
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INCIDENCIA Y FACTORES DE RIESGO
• 3.6 X 1000 EMBARAZOS.
• ASOCIADO A CICATRIZ UTERINA PREVIA.
• MULTIPARIDAD
• CESAREA PREVIA
• EDAD MATERNA AVANZADA
• PLACENTA PREVIA EN EMBARAZO ANTERIOR• CHESNUT OBSTETRIC ANESTHESIA
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ABRUPTIO DE PLACENTA
CHESNUT OBSTETRIC ANESTHESIA
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•
• CHESNUT OBSTETRIC ANESTHESIA
• HIPERTENSION / PRECLAMSIA
• EDAD MATERNA AVANZADA• TABAQUISMO• USO DE SUSTANCIA
PSICOACTIVAS• TRAUMA • CORIOAMNIONITIS• SANGRADO EN EMBARAZO
TEMPRANO• ABRUPTIO PREVIO• EFERMEDAD PULMONAR
MATERNA
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HEMORRAGIA POST PARTO
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MANEJO
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• .
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ESTRICTA ADHERENCIA PROTOCOLOS Y CUIDADOS STANDARIZADOS
• “DEBIDO A QUE INVARIABLEMENTE LAS PERDIDAS SANGUINEAS SON SUB ESTIMADAS, TODO SANGRADO MAYOR DE 1000 ML DEBE SER CAUSA DE MOVILIZACION DE TODOS LOS RECURSOS DISPONIBLES.”
• Wise A & Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol 2010
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“HEMOSTASIS”• "HELP• ESTABLISH ETIOLOGY• MASSAGE THE UTERUS• OXYTOCIN INFUSION AND PROSTAGLANDINS• SHIFT TO OPERATING THEATER• TAMPONADE TEST; APPLY COMPRESSION SUTURES• SYSTEMATIC PELVIC DEVASCULARIZATION• INTERVENTIONAL RADIOLOGY• SUBTOTAL/TOTAL ABDOMINAL HYSTERECTOMY “
• Int J Gynaecol Obstet. 2011 Outcome of the management of massive postpartum hemorrhage using The algorithm"HEMOSTASIS"
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EVALUE LA PERDIDA SANGUINEA!!
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PIDA AYUDA!!
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RESUCITACION - OBJETIVOS
• RESTAURAR VOLUMEN INTRAVASCULAR
• MAXIMIZAR ENTREGA DE OXIGENO
• PREVENIR / REVERTIR COAGULOPATIA.
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• www.jpnnjournal.com
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NUNCA OLVIDE LO BASICO !!• VIA AEREA
• RESPIRACION
• CIRCULACION
• HEMODERIVADOS Y ESTADO HEMOSTATICO
• GASTO URINARIO
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TENGA SIEMPRE EN MENTE…LA REGLA DE LOS 30´s!!
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INDICE DE SHOCK MAYOR DE 0.9 SE RELACIONA CON POBRE DESENLANCE Y NECESIDAD DE UCI
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DETENGA EL SANGARDO
• INTERVENCIONES MEDICAS (15%)
• UTERO TONICOS• MASAJE UTERINO• EVACUE VEJIGA
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MANEJO MEDICO• MANEJO ACTIVO DE TERCERA ETAPA
• SYNTOCINON 5 UDS (INFUSION 10 UDS/ HORA)
• ERGOMETRINA 0.25 MGS IV O IM
• PF2ALFA 0.25 MGS IM CADA 15 “
• MISOPROSTOL (rr 0.57; 95% ci 0.34 to 0.96).
• CARBETOCINA??
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INTERVENCIONES QUIRUGICAS
• B-LYNCH (91%)
• BALON HIDROSTATICO (84%)
• EMBOLIZACION DE UTERINAS (90.7)
• LIGADURA A UTERINAS O ILIACAS INT (84.6%)
• EXAMEN BAJO ANESTESIA• HISTERECTOMIA
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CORRECION DE SANGRADO• UMBRALES
• 1. Hb < 8 MGS/dL.
• 2.PLAQUETAS >75000/mL CON SANGRADO ACTIVO.
• 3.PT Y PTT RATIO > 1.5.
• 4.FIBRINOGENO < 1 Gmo/L
FIBRINOGENO < DE 200 Mgs/dL (INDICADOR DE
SEVERIDAD)
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• “EN SITUACIONES DE SANGRADO INTRAOPERATORIO RARA VEZ SE NECESITA TRANSFUSIONES CON HEMOGLOBINA MAYOR DE 10 Y CASI SIEMPRE ES NECESARIA CON HEMOGLOBINA MENOR DE 6 G/DL”
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OBTENCION DE HEMOCOMPONENTES
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GLOBULOS ROJOS EMPACADOS• DISPONIBILIDAD INMEDIATA
• TRANSFUNDIR CON CRITERIOS CLINICOS DE ESTIMACION DEL SANGRADO
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PLASMA FRESCO CONGELADO• TRANSFUNDIR PLASMA :• TODA PACIENTE QUE REQUIERA > 4 UDS GRE.
• TIEMPOS DE COAGULACION > 1.5
• TRANSFUNDIR 1:2 VS 1:1.
• 1 UD DE FFP AUMENTA FIBRINOGENO 7-10 mGS/Dl
• OTROS FACTORES 5% A 7%.
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• Todos los partos en 4 años (2006-2009) • Inclusion: necesidad de hemoderivados y prostaglandina
E2.• Necesidad de intervenciones quirúrgicas objetivo primario• 12 226 ptes -141 HPPS – 63% control con sulprostone• 37% Requirieron intervenciones• 41ptes fueron transfundidas con ffp y gre• Relación de transfusión 1:1.8 y 1:1.1• Relación 1:1.1 se relaciono con menor necesidad de
procedimientos intervensivos
• www.anesthesia-analgesia.org January 2013 • Volume 116 • Number 1
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• RELACION ALTA 1:1 SE ASOCIO CON MENOR RIESGO DE NECESIDAD DE PROCEDIMIENTOS INTERVENSIVOS
• (OR [95% Cl], 1.25 [1.07–1.47]; P = 0.008).
• NO MUERTES O DISFUNCION ORGANICA EN NINGUNA DE LAS PACIENTES DEL ESTUDIO
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• Current Opinion in Critical Care 2010, 16:309–316
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CRIOPRECIPITADO• ES LA PARTE INSOLUBLE EN FRIO DEL PLASMA QUE
RESULTA DE LA DESCONGELACIÓN ENTRE 1 Y 6º C DEL PFC.
• CONTIENE UN 50% DEL FACTOR VIII, UN 20-40% DEL FIBRINÓGENO Y UN 30% DEL FACTOR XIII
• CONTIENE TANTO FACTOR VIII:C COMO FACTOR DE VON WILLEBRAND.
• CADA UNIDAD CONTIENE FIBRINÓGENO 100-350 MG.
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FIBRINOGENO
• DISMINUYE REQUERIMINETOS DE GRE, PLASMA Y PLAQUETAS
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• Br J Anaesth. 2008 Dec. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, Ingerslev J, Sørensen B
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PLAQUETAS
• INDICACION:
• PLAQUETAS MENOR DE 50000 ( 80000 SI INTERVENCION QUIRURGICA)
• COAGULOPATIA MARCADA Y CONTEO BAJO
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ACIDO TRANEXAMICO
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FACTOR VII RECOMBIANTE• USO FUERA DE INDICACIONES FORMALES
• 90 UGMS EN 3- 5 MINUTOS ( SEGUNDA DOSIS 20 MIN DESPUES SI NECESARIO)
• ALTAMENTE COSTOSO Y POCO DISPONIBLE.
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CELL SALVAGE
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• DOCUMENTACION.
• ENTREVISTAS
• PROGRAMAS DE ENTRENAMIENTO
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GRACIAS.