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1 Allen Clark M.D..  I have no financial disclosures 2.

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1 1 Allen Clark M.D.

2  I have no financial disclosures 2

3  25y/o G2P1001 undergoing primary cesarean section for breech  Starting Hgb 9.0  Intraoperative EBL suspected at 1000ml, still having difficulty obtaining control of bleeding  Vitals: 110/60, P95, rr18, T36.6  Surgeon requests to start transfusing 2 units pRBC  Anesthesia disagrees and wants to not give the transfusion 3

4  34y/o G4P3003 at 39 and 0 undergoing her 4 th cesarean section  Starting Hgb 11.0  Anterior placenta, no signs of accreta on ultrasound  h/o uterine atony in prior cesarean section 4

5  Define and classify hemorrhage  Review different types of fluid resuscitation available  Discuss the different products used in resuscitation  Review massive transfusion protocols  Preview newer resuscitation strategies 5

6  In 2005, hemorrhage was the third leading cause of maternal death  Per the WHO, leading cause of death worldwide  Highly preventable, with aggressive therapy and appropriate management  Mortality has been improving with the development and implementation of massive transfusion protocols 6

7  Pregnancy is a protected state  40-50% volume expansion  Increase in RBC mass by 20-30%  Elevated Cardiac Output, 30-50%  Decreased systemic vascular resistance  Increase in fibrinogen, coagulation factors I, VII, VIII, IX, X 7

8 8

9 9 Hemorrhage Class Acute Blood Loss % LostPhysiologic Response 1900ml15Asymptomatic 21,200-1, Tachycardia and tachypnea, Narrowed pulse pressure, Orthostatic Hypotension, Delayed hypothenar refilling 31,800-2,100ml30-35Worsening tachycardia and tachypnea, Hypotension, Cool extremities 4>2,400ml40Shock, Oliguria, Anuria Total blood volume = 6,000ml, Average for 60kg pregnant woman

10 10 Hemorrhage Class Acute Blood Loss % LostPhysiologic Response 1900ml15Asymptomatic 21,200-1, Tachycardia and tachypnea, Narrowed pulse pressure, Orthostatic Hypotension, Delayed hypothenar refilling 31,800-2,100ml30-35Worsening tachycardia and tachypnea, Hypotension, Cool extremities 4>2,400ml40Shock, Oliguria, Anuria Total blood volume = 6,000ml, Average for 60kg pregnant woman

11 11 Class 1Class 2Class 3Class 4 Blood Loss<750ml ml ml>2000ml Blood volume<15%15-30%30-40%>40% Pulse(beats/min)<100>100>120>140 Blood PressureNormal/IncreaseOrthostaticDecreased Pulse PressureNormalDecreased Capillary RefillNormalMay be delayedUsually DelayedAlways Delayed RespirationsNormal, > Near Respiratory Collapse >35 Urinary Output>30ml/hr20-30ml/hr5-15ml/hrEssentially anuric Mental statusNormalAnxiousConfusedObtunded

12 12 Class 1Class 2Class 3Class 4 Blood Loss<750ml ml ml>2000ml Blood volume<15%15-30%30-40%>40% Pulse(beats/min)<100>100>120>140 Blood PressureNormal/IncreaseOrthostaticDecreased Pulse PressureNormalDecreased Capillary RefillNormalMay be delayedUsually DelayedAlways Delayed RespirationsNormal, > Near Respiratory Collapse >35 Urinary Output>30ml/hr20-30ml/hr5-15ml/hrEssentially anuric Mental statusNormalAnxiousConfusedObtunded

13  Class 1- Minimal physiologic changes  Class 2- Tachycardia, narrowing pulse pressure  Typically compensatory mechanism such as renin- angiotensin compensate  Class 3- Compensatory mechanisms begin to fail  Class 4- Life threatening  If this reaches ischemic injury in the heart or brain, death typically results 13

14  IV access  On the basis of speed of fluid infusion, what is preferred, a 16 gauge peripheral IV catheter or a 16 gauge central venous catheter?? 14

15  Mateer JR Thompson BM, Aprahamian C, et al. Rapid fluid resuscitation with central venous catheters. Ann Emerg Med 1983; 12:

16  Crystalloids, Colloids, Blood?  Surgical specialties tend to use lactated ringers, emergency rooms use normal saline, trauma surgeons are starting to use blood products  Why do we use lactated ringers?  Should we? 16

17  Electrolyte solutions with small molecules that freely diffuse throughout extracellular space  Mostly Na and Cl  Sodium- abundant in extracellular fluid, 75% in interstitial fluids  For IV administered Na, 75% will therefore end up in interstitial fluids  Therefore, the predominant effect of crystalloids is to expand INTERSTITIAL volume, not plasma volume 17

18  Therefore, how much of 1 L of normal saline stays in the plasma?  A – 1000 ml  B – 700 ml  C – 500 ml  D – 275 ml  E – 0 ml 18

19  275ml of a liter of normal saline stays in plasma, 825ml in interstitial volume  But wait Allen, =  Prepare to have your mind blown 19

20 20

21  Slightly higher Na concentration then plasma 154 vs 140 mEq/L  Much higher Cl Concentration 154 vs 103mEq/L  Lower pH 5.7 vs 7.4  Slightly higher osmolality 308 vs 290 mOsm/L  This causes a shift of approximately 100ml of fluid from intracellular to extracellular upon administration, causing total volume expansion to be 1100ml...BOOM! 21

22  Large volumes of isotonic saline will produce a metabolic acidosis  Hyperchloremic acidosis produced by the high levels of Cl in isotonic saline  Though this is typically without clinical consequence, it has potential negative consequences if it delays identification of lactic acidosis or is combined with another type of acidosis (ie respiratory from anesthesia) Scheingraber S, Rehm, M, et al. Rapid saline infusion produces hyperchloremic acidosis in patient undergoing gynecologic surgery. Anesthesiology. 1999, 90:

23  Contains Potassium and Calcium in approximately the same ionized concentrations in plasma  This causes a lower sodium concentration  LR also contains lactate, which allows reduction of the chloride concentration  With a chloride concentration closer to that of plasma, there is no risk of hyperchloremic metabolic acidosis with large infusions 23

24  It can’t be infused with some meds, because the calcium can bind to some drugs  Examples include aminocaproic acid, amphotericin, ampicillin, thiopental  Can bind citrated anticoagulant of blood products and cause clotting  If volume of LR does not exceed 50% of pRBC volume, this does not occur 24

25  In 2009, 20 pigs underwent liver injuries, hemorrhaged for 30 min, and then in a blinded fashion given LR or NS for resuscitation  Given IV fluid to maintain preinjury MAP  Monitored oxygenation and pulmonary edema, total fluid volume given, pH, and blood loss  Little impact on oxygenation  LR has favorable effects on pH, coagulation and hemodynamics Phillips CR, Vinecore K, et al. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on exygenation, extravascular lung water and hamodynamics. Crit Care, 2009; 13: R30 25

26  In 2007, 20 pigs underwent liver injuries, hemorrhaged for 30 minutes, then underwent NS or LR resuscitation to maintain the preinjury MAP for 90 minutes  Results: it took 256ml/kg of NS vs 125ml/kg of LR to maintain MAP, urine output for NS was 46.6ml/kg vs LR 18ml/kg,  NS animals developed dilutional coagulopathy, had lower fibrinogen, lower platelet count, and lower PT  NS animals developed hyperchloremic metabolic acidosis and coagulopathy  LR animals developed lacticemia not associated with acidosis Todd SR, Malinoski D, et al. Lactated ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. Trauma March; 62,

27  In 2006, 20 pigs underwent liver injuries, hemorrhaged for 30 minutes, and then given either NS or LR to maintain MAP at baseline for 90 minutes  Baseline and Q30 min Lactate, ABG, chemistry, PTT, PT and fibrinogen were taken, and thrombelastography (TEG) was performed Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. Trauma: 2006; 61:

28  R= reaction time = time to onset of clot formation, elongation = coagulation factor deficiency  Alpha= rapidity of fibrin buildup and cross linking = affected by fibrinogen and platelets  K speed to reach certain level of clot strength = platelets and fibrinogen function  MA= maximum amplitude = strength of clot, affected primarily by platelets but also fibrinogen Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. Trauma: 2006; 61:

29  With similar injuries, NS group had greater overall blood loss and required 2x the amount of fluid to maintain MAP  NS group was more acidotic from 30 minutes on  NS group had lower hematocrit, greater PT and PTT times, and a greater R time, all statistically significant  Conclusion: NS modulates the hypercoagulable state seen after injury, resulting in increased blood loss Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. Trauma: 2006; 61:

30  In 2005, 51 patients undergoing renal transplant were placed in a randomized double blinded study to receive LR or NS intraoperative  LR is typically not used in this population over concern of the development of hyperkalemia in a population with ESRD, standard of care is NS  Rate of fluids was given as clinically indicated and not according to an algorithm  Primary outcome measure was serum creatinine concentrations on POD 3  Secondary outcomes included post op urine output, creatinine clearance, rejection, graft loss, intraoperative acid base balance, intraoperative potassium concentrations, blood loss and transfusions requirements and hospital length stay O’malley CM, Frumento RJ, Hardy MA, etal. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation. Anesthia Analg 2005; 100:

31  Serum creatinine POD 3 NS 2.3±1.8, LR 2.1±1.7  Seven units of packed red blood cells were administered in the NS group versus three units in the LR group.  Potassium concentrations exceeded 6.0mEq/L in 5/26 NS patients, and 0/25 LR patients  The 5 patients in the NS study were treated for hyperkalemia O’malley CM, Frumento RJ, Hardy MA, etal. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation. Anesthia Analg 2005; 100:

32  8/26 NS patients developed metabolic acidosis and required sodium bicarbonate and 0/25 patients in the LR group developed metabolic acidosis  This study was then terminated due to safety concerns of giving patients NS intraoperatively O’malley CM, Frumento RJ, Hardy MA, etal. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation. Anesthia Analg 2005; 100:

33  Difficult to say if isotonic saline’s side effects directly change clinical outcomes  Based on this data, there are benefits to LR over normal saline 33

34  Originally developed to provide calories before the introduction of enteral and pareneral nutrition  D5- 50grams dextrose/1 liter = 170kcal 34

35  D5W – ineffective at expanding plasma volume, less then 10% stays in plasma  2/3 of the volume ends up inside cells, causing cellular swelling  If circulatory flow is compromised, 85% of glucose metabolism is converted to lactate production  This causes a metabolic acidosis when patients with circulatory compromise receive dextrose solutions DeGoute CS, Ray MJ, Manchon M et al. Intraoperative glucose infusion and blood lactate: endocrine and metabolic relationships during abdominal aortic surgery. Anesthesiology 1989;71:

36  Contain large, poorly diffusible, solute molecules designed to keep water in the vascular space  Primary protein doing this in plasma is albumin, responsible for 75% of colloid osmotic pressure  The idea of the colloid fluids is to increase the colloid osmotic pressure in the vascular space and bring water into the circulators system 36 FluidNaClKOsmolality (mOsm/L) Albumin 5%150 < 2300 Hetastarch 6%

37  So, the infusion of 1 Liter of 5% Albumin expands the plasma volume how much?  A – 1000ml  B – 700ml  C – 500ml  D – 275ml  E – 0ml 37

38  700ml increase in the plasma volume and 300ml increment in the interstitial fluid volume  Remembering that about 275ml of NS would stay in the plasma volume  Colloid fluids are 3 times more effective than crystalloids at increasing plasma volume 38

39  Heat treated preparations of human serum albumin, available in 5% (50g/L) and 25% solutions (250g/L)  5% albumin comes in 250ml doses and 25% albumin comes in 50 or 100ml doses  5% albumin has equivalent concentrations and colloid osmotic pressure to plasma  70% of fluid infused stays in plasma volume for several hours, effect lost completely after 12 hours 39

40  25% albumin does not provide replacement volume  It only causes a shift of fluid from interstitial to intravascular  IT IS NOT A VOLUME REPLACEMENT THERAPY and can NOT be used in acute blood loss or dehydration 40

41  In 1998, a Cochrane meta-analysis of 30 randomized control trials of 1419 patients  Results: “Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23).”  “We found no evidence that albumin reduced mortality and a strong suggestion that it might increase the risk of death in patients with hypovolaemia, burns, or hypoproteinaemia. Overall, the risk of death in patients treated with albumin was 6% (95% confidence interval 3% to 9%) higher than in patients not given albumin.”  Needless to say, this hurt the use of albumin for resuscitation Cochrane Injuries Group albumin reviewers. Human albumin administration in critically ill patients: systematic review of randomized, controlled trials. Br Med J 1998;317:

42  In 2004, a double blinded randomized control trial including 7000 patients was published in the NEJM, 3497 received albumin, 3500 received NS  SAFE trial (Saline vs Albumin Fluid Evaluation)  7000 ICU patients, admitted for all reasons, primary outcome was death from any cause at 28 days  726 deaths in albumin group, 729 deaths in normal saline group  In conclusion, similar outcomes of 4% albumin as NS SAFE study investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 2004;350:

43  2011 Cochrane review of mortality in 38 studies, including the safe study  Mortality the primary outcome in all studies  “For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline.” Albumin Reviewers. Human albumin solution for resuscitation and volume expansion in critically ill patients. Chochran Database Systematic Review Oct 5;(10):CD

44  Hydroxyethyl start is a starch polymer available in a 6% solution in isotonic saline  Equivalent to 5% albumin as a plasma volume expander  Is less costly then albumin  When more then 1500ml given in 24 hours, can cause coagulopathy  Inhibits factor VIII, von Willebrand factor, and impair platelet adhesiveness  Broken down by amylase and filtered out of the kidneys, so can also cause a transient hyperamylasemia with no deleterious side effects  Mixed literature results 44

45  Due to the transcapillary refill mechanism in hemorrhage, crystalloids gained a strong following among surgical specialties  The majority of the data is from the SAFE trial  2011 Cochrane review of 3870 and 3884 patients receiving crystalloid or colloid solutions, 56 randomized controlled trials with mortality data  Conclusion: “The review of trials found no evidence that colloids reduce the risk of dying compared with crystalloids.” Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review). The Cochrane Library. 2011, Issue 3 45

46  Any patient undergoing surgery needs LR  Any patient with hemorrhage should get LR  In the ED, especially for operative patients, Isotonic Saline should not be used  Albumin is a fine alternative, but given increased cost, I would not use it routinely 46

47  Only blood product to provide oxygen- carrying capacity  300ml volume  250ml RBCs and 50ml plasma  70kg patient, 1 unit pRBC will raise hemoglobin 1g/dl 47

48  Separated from whole blood and stored in plasma  1 unit will increase platelet count 7,500/mm3  Transfused in concentrations of 5-10  Masonic’s is in concentrations of 5 pooled  Single donor preferred over multiple to decrease risk of antigenic exposure, but very difficult if multiple infusions of platelets is necessary 48

49  Plasma extracted from whole blood  Contents- fibrinogen, antithrombin III, clotting factors V, XI, XII  250ml Volume  Goal- improve coagulation profile and volume resuscitation  Monitor- Fibrinogen- 1 unit should raise fibrinogen level by 5-10mg/dl 49

50  The precipitate from thawed FFP  Rich in fibrinogen, factor VIII, von Willebrand’s factor, factor XIII  Minimal volume- 40ml  Monitor with Fibrinogen- increase by 5- 10mg/dl 50

51  When is blood transfusion recommended?  “Necessary with the extent of blood loss is significant and ongoing, particularly if vital signs are unstable” Martin SR, Strong TH. Transfusion of blood components and derivatives in the obstetric intensive care patient. Obstetric intensive care manual. 2 nd edition. New York. McGraw Hill 2004 American college of obstetricians and gynecologists. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists Number 76, October 2006;108:

52  Level 1 Recommendations for critically ill patients  1. RBC transfusion is indicated for patients with evidence of hemorrhagic shock.  2. RBC transfusion may be indicated for patients with evidence of acute hemorrhage and hemodynamic instability or inadequate oxygen delivery.  3. A “restrictive” strategy of RBC transfusion (transfuse when Hb 7 g/dL) is as effective as a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion in Adult Trauma and Critical Care. Trauma Volume 67, 6;

53  Level 2 Recommendations for critically ill patients  4. The use of only Hb level as a “trigger” for transfusion should be avoided. Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.  5. In the absence of acute hemorrhage, RBC transfusion should be given as single units.  6. Consider transfusion if Hb 7 g/dL in critically ill patients requiring mechanical ventilation. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients requiring mechanical ventilation.  7. Consider transfusion if Hb 7 g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in resuscitated critically ill trauma patients.  8. Consider transfusion if Hb 7 g/dL in critically ill patients with stable cardiac disease. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with stable cardiac disease.  9. RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients. Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion in Adult Trauma and Critical Care. Trauma Volume 67, 6;

54  Level 2 Recommendations for critically ill patients  4. The use of only Hb level as a “trigger” for transfusion should be avoided. Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.  5. In the absence of acute hemorrhage, RBC transfusion should be given as single units.  6. Consider transfusion if Hb 7 g/dL in critically ill patients requiring mechanical ventilation. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients requiring mechanical ventilation.  7. Consider transfusion if Hb 7 g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in resuscitated critically ill trauma patients.  8. Consider transfusion if Hb 7 g/dL in critically ill patients with stable cardiac disease. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with stable cardiac disease.  9. RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients. Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion in Adult Trauma and Critical Care. Trauma Volume 67, 6;

55  4. The use of only Hgb level as a “trigger” for transfusion should be avoided. Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters. 55

56  In 1999, a multicenter randomized control trial was published in the NEJM  Compared “restrictive” vs “liberal” transfusion groups  Restrictive- maintain Hgb g/dl and transfuse at less then 7.0 g/dl  Liberal- maintain Hgb g/dl and transfuse at less then 10.0 g/dl  Primary outcome was death of all causes at 30 days Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM 1999; 340:6,

57  Enrolled 838 patients, 418 to restrictive and 420 to liberal  Primary outcome- Mortality in restrictive group 18.7%, in liberal group 23.3%  Conclusion “The restrictive transfusion strategy was at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients with euvolemia” Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM 1999; 340:6,

58  This study is excellent at helping us to assess critically ill patients who are not hemorrhaging, but what about our bleeding patients 58

59  Decision to initiate by the Attending Physician  Cycle 1 : 4 units pRBC brought to room immediately  Cycle 2: 6 units pRBC, 4 units FFP, 1 single donor platelets, 10 units cryoprecipitate  Cycle 3: Repeat cycle 2  Cycle is to continue to repeat until cancelled by attending physician! 59

60  We will need to trust our friends, the trauma surgeons  We have to trust them, as approximately 1 in 3 Illinois Masonic OB/GYN Physicians are married to trauma surgeons 60

61  Retrospective Cohort Study  Created a Trauma Exsanguination Protocol  Cycle 1: 10 units uncrossed pRBC, 4 units AB neg plasma, 2 units single donor platelets  Cycle 2: 6 units pRBC, 4 units thawed plasma, 2 units single donor platelets  Cycle 3: repeat until ended by attending  Cryoprecipitate available upon request Cotton BA, Gunter OL, Isbell J. et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008;64:

62  Compared 117 pre-TEP patients with 94 TEP patients Cotton BA, Gunter OL, Isbell J. et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008;64: % reduction in the odds of mortality at 30 days Reduced crystalloid use, reduced overall product transfused

63  2009, community hospital in Santa Maria, CA implimented a hemorrhage assessment and response protocal  Patients were assessed for risk upon admission, and protocol algorithms were put in place for differing degrees of hemorrhage  All staff were trained together in the implimentation  Compared the 12 month period prior to implimentation to the 12 month period after Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.63

64 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e

65 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e

66 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e

67 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.67

68 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.68

69 Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.69

70  “Maternal hemorrhage pack”  3 units pRBC, 2 units FFP, 1 U platelets, and 10 units cryopercipitate  Blood to FFP was in a 3:2 ratio for the first 2 rounds, then changed to a 1:1 ratio for anything beyond 6 units pRBC and 4 units FFP  Goals: hematocrit >24%, INR 50,000/uL, Fibrinogen >100,000 mg/dl Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.70

71  Compared 2939 preprotocol deliveries with 2874 post protocol deliveries  Overall hemorrhage rate 3.6%  Effects of protocol were decreased severity of hemorrhage overall, decreased average number of pRBC transfused per patient in the stage 3 category from 16.7  6.3, decreased incidence of DIC of 64%, and more confident staff measured via a survey Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.71

72  Acute normovolemic hemodilution  Recombinant factor VIIa 72

73  Remove ml blood before surgery  Replace with crystalloids  Perform surgery  Once bleeding is controlled, re-infuse the removed blood 73

74  Expense  Risk of transfusion reaction  Risk of infectious disease 74

75  Immediate pre operative collection in the OR of patients blood replaced in a 3:1 ratio by crystalloids  Tends to be 2-3 units  Stored in citrated bags, 6 hours at room temp and 12 hours refrigerated  Requirements- Starting Hgb >10.0g/dl, no myocardial disease, pre op EBL >20% blood volume S. Catling, Blood conservation techniques in obstetrics: a UK perspective, International Journal of Obstetric Anesthesia, Volume 16, Issue 3, July 2007, Pages , 75

76  Body compensates for acute loss of blood by increasing O2 extraction and increasing cardiac output  Intraop blood loss is “Hgb poor blood”  Blood is replaced before leaving the OR  Patient receives their own RBC’s and platelets back  If IV tubing is kept in contact at all times, this is acceptable by most Jehovah's witnesses S. Catling, Blood conservation techniques in obstetrics: a UK perspective, International Journal of Obstetric Anesthesia, Volume 16, Issue 3, July 2007, Pages , 76

77  Insufficient level 1 evidence to suggest that ANH reduces allogenic transfusions  Therefore no group has yet to make recommendations for or against this technique 77

78  Precursor to extrinsic clotting cascade  Used in cases of massive procoagulant factor consumption  Can reverse DIC in 10 minutes  IV dose micrograms/kg  Half life is 2 hours  Though intended for use in patients with thrombophilia, has been used off label to reverse DIC 78

79  In a 2010 meta analysis of 35 placebo controlled trials using factor rFVIIa for treatment or prevention of bleeding  9.0% risk of thrombotic event, with an increased risk of an arterial thrombosis  No change in risk of venous thrombotic event Levi M, Levy JH, Andersen HF, Truloff D.Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363:

80  AJOG December 2011  “With the increasing incidence of cesarean sections and resulting placentation abnormalities, it is necessary to explore interventions that can limit transfusion requirements, for example normovolemic hemodilution, recombinant factor VIIa, pelvic vessel embolization, and cell saver” Pacheco LD, Saade GR, Gei AF, et al. Cutting-edge advances in the medical management of obstetrical hemorrhage. AJOG. December ;6:

81  Lactated ringers is preferred over normal saline  Transfusions of pRBC should be given when patient has symptomatic anemia  Intraoperative blood transfusions due to hemorrhage should be given aggressively  Massive transfusion protocol’s are a must 81

82  25y/o G2P1001 undergoing primary cesarean section for breech  Starting Hgb 9.0  Intraoperative EBL suspected at 1000ml, still having difficulty obtaining control of bleeding  Vitals: 110/60, P95, rr18, T36.6  Surgeon requests to start transfusing 2 units pRBC  Anesthesia disagrees and wants to not give the transfusion 82

83  34y/o G4P3003 at 39 and 0 undergoing her 4 th cesarean section  Starting Hgb 11.0  Anterior placenta, no signs of accreta on ultrasound  h/o uterine atony in prior cesarean section 83

84  Thanks to Dr. Rojas and Dr. Witkowski for reviewing my presentation 84

85 85

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