周捷产后出血麻醉处理.pptVIP

产后出血的麻醉处理 哈佛大学医学院布莱根和妇女医院 麻醉科 周 捷 Jie Zhou, MD, MS, MBA Department of Anesthesiology,Perioperative and Pain Medicine Brigham and Women’s Hospital, Harvard Medical School Disclosure BD 科学咨询委员会成员 Tonight on the Labor Floor… 30 yo G1P0 at 38 weeks breech presentation; in active labor 170 cm 86 kg, Mallampati II NPO for 11 hours No allergies No medical history In the Operating Room… 18g IV, uneventful spinal anesthesia Healthy baby born 5 minutes later: continuous oozing in the field OB: “The tone is poor” Patient: “I feel dizzy” Vital signs: BP 80/49; HR 120s SaO2100% What will you do? Objectives DEFINE Postpartum hemorrhage IDENTIFY Challenges of management PREPARE Management based on evidence Mortality from Postpartum Hemorrhage One woman every seven minutes… Potts M et al. Lancet 2010; 375: 1762-3 1995 through 2004 PPH increased by 30% 2.9 % of all deliveries Blood transfusion 2.4 to 4.6 per 1000 (90% increase) Uterine atony: predictable only 40% of cases. Bateman B et al. Anesth Analg 2010; 110: 1368-73. The Epidemiology of Postpartum Hemorrhage in the United States Cardiac Arrest During Hospitalization For Delivery in the United States, 1998-2011 4,843 cases identified Postpartum hemorrhage: 1349 patients (27.9%), 55% survival Amniotic fluid embolism: 645 patients (13.3%), 52.5% survival Mhyre J et al., Anesthesiology 2014 April. United Kingdom Postpartum Hemorrhage Maternal Death 66% of cases: substandard care Objectives DEFINE postpartum hemorrhage IDENTIFY challenges of management PREPARE for management based on evidence Postpartum Hemorrhage Defined Quantification of blood loss? 500 mL after vaginal delivery 1000 mL after cesarean delivery  We are bad at estimating blood loss Cases that need transfusion?  Retrospective Hemodynamic changes?  Late signs in the pregnant patient ACOG Practice Guideline; Obstet Gynecol 2006. Bose P et al. BJOG 2006. Toledo P. Et al. Anesth Analg 2007. Major Postpartum Hemorrhage E