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


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)




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.


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


OPPORTUNITY FOR PREVENTION


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)


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


READINESS

Steps

1. Develop Awareness

2. Ensure Access to Equipment & Products

3. Develop Evidence-Based Protocol


READINESS

Awareness

1. Risk Factor Assessment

2. Quantification of Blood Loss (QBL)

3. Vital Sign Triggers

4. Simulated Scenarios to Reinforce

Appropriate “Urgency”


READINESS

Access

1. Hemorrhage Cart

2. Rapid Lab Assessment

3. Rapid Blood Products

4. Massive Transfusion Protocol

5. i-STAT Blood Analyzer


https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjN1O_Lou3ZAhWLnlMKHY5ZCHwQjRwIBg&url=https://www.pointofcare.abbott/int/en/offerings/istat/istat-handheld&psig=AOvVaw2E37sPSGMb-mXnsRU_e4ZR&ust=1521166938278565

READINESS


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


RECOGNITION AND PREVENTION

Admission Risk Assessment & Testing



Ongoing Risk Assessment Each Shift


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.


Ongoing Risk Assessment Each Shift


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


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)


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.


Quantitative Blood Loss Evaluation


BLOOD LOSS AND SIGNS / SYMPTOMS



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


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


RESPONSE: DESIGNATE STAGE


RESPONSE: STAGE 1


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)


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


RESPONSE: TRANEXAMIC ACID


• 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


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


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.)


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.


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.


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


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


RESPONSE: SURGICAL MANAGEMENT


RESPONSE: STAGE 3


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!


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


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


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


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


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


Thank You


CRITICAL CARE OBSTETRICS

#TRIHEALTHCRITICALCAREOB

shock in the obstetric patient...hypersensitivity to drug refrigerate oxytocin (pitocin) 10 units/1...

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