Looks like we got ourselves a Bleeder

 

The Post-Partum Hemorrhage: Notes from Anesthesiology Core Review Part Two Advanced Exam

most common cause of blood loss in OB practice
leading cause of fetal and maternal M&M globally
definition: bleeding w/in 6wks of delivery
->500ml for vaginal, >1000ml for c/s
-decrease of 10% in hct from admission
-often underestimated!
Uterine blood flow = 700ml/min
-get good access fast
Uterine Atony
2-5% of all deliversies
cause of >90% of pp hemorrhage
results from failure of uterus to contract
risk factors:
-multiparity
-macrosomia
-polyhydramnios
-long labor (+oxytocin)
-chorioamnionitis
-placenta: retained, accreta, increta, percreta
-poor perfused myometrium
-drugs: inhalationals, oxytocin, tocolytics
Management of Atony
Oxytocin to contract uterus
-rapid: hypotension, decrease svr, tachy (rare card collapse), chest pain, ischemia, anaphylaxis
-ECG changes resolve spontaneously
-similar to ADH, so watch for water intox. so never give with hypotonic solution!
Ergot Alkaloids
-0.4mg – methylergonovine IM only
-10 minutes to action, lasts 3-6hrs
-vasoconstrictive -> HTN, avoid with pre-eclempsia.eclampsia
-if given IV -> intense vasoconstric -> siezures, CVA, retinal detach – MI
-Common ade: nausea vomiting
-2 dose then move on
Prostaglandins
-increase calcium -> myosin kinase

-carboprost = 15-methyl prostaglandin f2alpha given 260ucg IM
-increase force/interval of contraction
-also don’t give IV
-side effects: diarrhea, HTN, fever, flush, tachy
-bronchospasm, pulmonary vasoconstriction – so careful with asthmatics
-Misoprostol (prostaglandin E1) oral, rectal intrauterine also effective, side effect hypothermia
Retained Placenta

1-3 in 100 deliveries

result: uterus unable to fully contract –> bleeding

Need for uterine relaxation to explore and fix

GA -> 1MAC+ Inhalational

IV or sublingual Nitorglycerin
-100 ug works in 30-45seconds
-60-90 seconds return to baseline, may need redosing
-tx hypotension with phenylephrine

The Abnormal Placenta

Normal interface between placenta and uterus : Decidua basalis
When that’s missing -> uteri gets implanted
Placenta Accreta = ON myometrium
Placenta Increta = IN myometrium
Placenta Perceta = through and to other organs!
Bleeding serious complication and common
1:2000 births have accreta
-prior c/s
-placenta previa
-more c/s higher risk

If known beforehand, discuss plan about possible hysterectomy
-this can incur massive blood loss
-cell saver, think general anesthesia, secure airway, arterial line
-also consider prophylactic internal iliac balloon catheters in IR preop

Genital Trauma

lacerations of cervix, vagina, perinuem most common injuries of childbirth
if continued hypotension: think retriperitoneal hematoma!
-CT or MRI, tx with ex lap

help along repair with IV meds, neuraxial continuation, or nitrous oxide, think low dose ketamine too

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Insulin Pumps and Infusions

Insulin Action Review!
Insulin Action Review!

 

Nice quick reference from the Joslin Diabetes Center and Clinic on management of perioperative blood glucose in patients undergoing surgery, a few things to note:

  • Insulin pumps can be maintained at basal rate throughout surgery
  • Maintenance IVF need NOT have dextrose
  • If starting insulin infusion, give fluids with a substrate, e.g. D5W at 40 ml/hr or D10W at 20 ml/hr
  • if MAJOR surgery start infusion and track throughout case (a line)
  • i/o generally check BG every 2hrs
  • 24hr glucose if on infusion should be 50g
  • Protocols vary by institution for bolus/infusion rates, generally follow local guides (this sheet has one)

See: http://www.joslin.org/Inpatient_Guideline_10-02-09.pdf for more details!

 

Sufenta TIVA!

http://www.ncbi.nlm.nih.gov/pubmed/16750467

Clin Ther. 2006 Apr;28(4):560-8.

Anesthesia was induced with propofol and either remifentanil 1 microg/kg or sufentanil 0.25 microg/kg. Propofol was continued using a target-controlled infusion (TCI) system. Maintenance infusion rates for remifentanil and sufentanil were 0.25 and 0.0025 microg.kg-1.min-1 [or 0.15mcg/kg/hr for sufenta] respectively.

The median extubation time was similar in the remifentanil and sufentanil groups (10 minutes [interquartile range, 5-19 minutes] and 16 minutes [interquartile range, 10-30 minutes], respectively). Remifentanil was associated with the need for significantly fewer adjustments to maintain hemodynamic stability compared with sufentanil (0.8 vs 2.1; P=0.037), greater use of postoperative morphine (44.8% vs 22.6% of patients, P=0.01; mean IV morphine dose per patient: 4 vs 1.3 mg, P=0.016), and higher intraoperative opioid costs per patient euro vs euro P<0.001). The incidence of PONV did not differ significantly between groups.

Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. – PubMed – NCBI

http://www.ncbi.nlm.nih.gov/pubmed/9972747

From the original article on TEG for  Cardiac Surgery…

The hypothesis:

Our hypothesis was that using TEG as a point-of-care test of the hemostatic system would result in prompt identification of hemostasis disorders and a reduction in transfusion requirements compared with laboratory-based testing. This would help to reduce the costs and risks associated with allogeneic transfusions. In a prospective, randomized trial, we compared bleeding and transfusion requirements in cardiac surgical patients at moderate to high risk of microvascular bleeding using a TEG-guided algorithm or standard laboratory coagulation testing.

The algorithm:

image

The key results:

image

Who is Brugada?

 

There is not just one Brugada, but a family of them!

It all began in 1987 when Professor Brugada was running the electrophysiology laboratory at the University of Maastricht in the Netherlands and a Polish man brought his son to see him. The boy was 3 years old and had a history of repeated episodes of fainting and cardiac arrest; his father had resuscitated him several times. His sister had suffered similar symptoms and had died at the age of 3 in spite of treatment with a pacemaker and amiodarone.
“The electrocardiogram of that boy was never seen before and something you could not find in any publication,” Professor Brugada remembers. “I was very fortunate that the father was able to return to Poland and bring the electrocardiograms of the sister, which turned out to be exactly the same as those of the brother. Remember, it was 1987; the Berlin Wall was still there, so everything that this guy was doing was illegal.”
It took 4 years for the Brugadas to find 2 more patients with similar ECGs – one from the Netherlands and the other from Belgium. They presented the 4 cases as an abstract to an American Heart Association conference, and several doctors who had come across similar cases contacted them. A year later, they published details of 8 patients [in JACC: http://www.sciencedirect.com/science/article/pii/073510979290253J%5D.

AICD Indications

Secondary Prevention of death due to VF/VT in settings of:

1. prior VT/VF req’ing resuscitation, or unstable VT with unknown cause
-includes idiopathic vf/vt and congenital long qt
-excludes vt/vf w/in 48hrs of MI

2. spontaneous sustained VT in presence of heart disease (valvular, ischemic, hypertrophic, dilated, infiltrative cardiomyopathy or channelopathies)

Primary Prevention

For the primary prevention of VT/VF in patients at risk of sudden cardiac death due to vf/vt, who are optimized under medical management, such as:

1. Prior MI (40+ days ago) and LVEF <= 30%

2. Cardiomyopathy, NYHA class 2-3 + LVEF <=35% ( if nonischemic this means 3 months of med tx)

The others:

Syncope + documented VT/VF

Underlying disorders:
-congenital long qt
-hypertrophic cardiomyopathy
-Brugada Syndrome
-arrhythmogenic RV cardiomyopathy

Who is Brugada?

Two terms: syndrome and pattern
One EKG: pseudo-right bbb and persistent ST elevations V1-V2

Pattern = ECG findings + ASYMPTOMATIC

Syndrome = ECG findings + at least one episode of sudden cardiac death or sustained VT

Anesthetic implications (See http://bja.oxfordjournals.org/content/89/5/788.full)

-likely has AICD, so disable it
-avoid alpha agonists
-avoid neostigmine
-Contraindicated / MUST avoid class 1 antiarythmics ( see: https://en.wikipedia.org/wiki/Antiarrhythmic_agent#Class_I_agents)
so NO LIDOCAINE OR PHENYTOIN!
-caution with iso? (http://www.jcvaonline.com/article/S1053-0770%2801%2907405-5/abstract)