鲍红光-产科出血的麻醉与处理.ppt

So I was called in at 01.30…. Previous Caesarian Section Fully dilated - prolonged second stage Placenta stuck in vagina and therefore traction applied Uterus inverted into vagina Patient started to go into shock There is a lot of blood around… Rushed to theatre and given a GA Uterus reverted to normal manually and with pressure Ergometrin given and syntocinon infusion started However: Bleeding continues And there is no sign of it stopping Managed with continuous uterine massage and manual compression The night draws on…… Coagulopathy 0230: Still compressing Everything reasonably stable but needing continued resuscitation 0330: Still compressing Everything still OK but awaiting results and feeling a bit concerned 0400: 9 units blood, 4 units FFP, + Cryo given Hb 5.7 Platelets 43,000 PT 40 APTT 100 Probably needs a central line…… Experienced operator if platelets 50,000 Just what you need at 0430 Central line inserted first pass Sewing it in uneventful But now I can’t find the wire…… It must be on the tray It must be on the floor Has it been put in the sinbin? Have I lost it down the line? Nurse suggests clamping the catheter Call for the image intensifier….. Always keep hold of the guidewire Losing the guidewire Overtired staff Inattention 当心！ Be carefol ！ 请勿疲劳工作！ 感谢楼主给以这么好的交流机会 这一行真的不易。。。 * * * 医疗团队：胎盘植入患者需要多学科与个性化的医疗服务，包括产科医生、妇科医生（盆腔外科医生）、麻醉科医生、介入治疗医生、新生儿科医生、血液科医生、检验科医生及护理团队，多科会诊，制定详细的手术方案，以减少术中失血、术后出血。 科医师充分备血，常规配红细胞悬液6～10U，并通知血库准备新鲜冰冻血浆（fresh frozen plasma,FFP）800～1000ml，保证第一时间提供配合性血液成分； （2）产科医生尽早通知检验科工作人员作相应的血液检测并实时监测，包括术前、术中血常规，凝血功能，血液生化等，及时了解凝血功能情况，结合临床情况对拟输注的血液成分及血液制品作相应调整。 * * * 输血治疗在抢救凶险型前置胎盘的产后出血中至关重要 凶险型前置胎盘患者平均出血量约为3000-5000ml。40%患者输血超过10U红细胞悬液。 大量输血后凝血功能障碍、酸中毒以及低体温等并发症的发生，造成接受大量输血患者的死亡率亦较高。因此，合理、及时和充足的大量输血，对降低凶险型前置胎盘患者的死亡率具有重要意义。 DO2：氧输送； SaO2 ：动脉血氧含量； CO：心输出量? 影响氧输送（DO2） 的因素主要是心输出量CO）和血红蛋白浓度（ Hb ），而CO减少对病人的威胁要大于Hb 浓度的降低。? 对于急性失血病人的首要目标是维持心输出量（CO），其次才是纠正贫血。要维持CO，输血就不是有效途径，Hb可能通过增加肺血管阻力指数阻碍右心室射血。 因此，在低血容量病人的早期扩容阶段，选择液体复苏。 我国