E. Guasch

Hemorragia obstétrica: estudio observacional sobre 21.726 partos en 28 meses

Resumen Objetivo Describir el manejo de las pacientes que sufrieron una hemorragia obstetrica grave. Material y Metodos Estudio observacional prospectivo desde julio de 2005 a noviembre de 2007 en mujeres que precisaron ingreso en la Unidad de Reanimacion de un hospital terciario de referencia, por hemorragia obstetrica. Se analizo la incidencia, prevalencia, morbi-mortalidad y factores de riesgo asociados. Resultados Hubo 21.726 partos (124 de ellos con hemorragia grave). La odds ratio para la aparicion de hemorragia obstetrica fue 4,54 para el parto instrumental y 2,86 para la cesarea. Los factores de riesgo identificados en la poblacion evaluada fueron embarazo multiple y muerte fetal anteparto. Una paciente fallecio debido a una coagulacion intravascular diseminada. La causa principal de hemorragia fue la atonia uterina en el 45,2%, seguida por los desgarros vaginales (26,6%). En el tratamiento de 96,8% de pacientes se uso concentrado de hematies, fibrinogeno en el 49,2%, complejo protrombinico en el 7,25% y factor VII activado en el 3,2%. Se realizo embolizacion arterial selectiva en el 10,5% de los casos (tasa de exito del 84,6%). Fue necesaria la histerectomia en el 13,7% de pacientes. Las principales complicaciones fueron: ventilacion mecanica postoperatoria (11,3%), isquemia miocardica (4%), edema pulmonar (4,8%), fallo renal agudo (8,9%), fibrilacion ventricular (0,8%) y muerte (0,8%). Conclusion La incidencia de hemorragia grave en las pacientes atendidas en nuestro hospital es baja, como lo es la tasa de mortalidad. El uso de fibrinogeno es frecuente y dio buenos resultados. La embolizacion angiografica es muy efectiva, aunque finalmente el porcentaje de histerectomias es elevado aun. Los embarazos multiples y los fetos muertos anteparto son factores de riesgo asociados.

Treatment of Postpartum Hemorrhage With Blood Products in a Tertiary Hospital: Outcomes and Predictive Factors Associated With Severe Hemorrhage

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide. This retrospective observational study describes patient characteristics and hemostatic therapies administered to 352 parturients experiencing PPH and analyzes risk factors for developing severe PPH. During the study period, bleeding was controlled in all cases and 99.4% survived. The majority (98%) of patients received packed red blood cells. The most frequent hemostatic therapies administered were fibrinogen concentrate (56%), fresh frozen plasma (49%), and platelets (30%). A total of 124 (35%) women experienced severe PPH. Significant independent predictors for evolution to severe PPH were age, obstetric comorbidity, and plasma fibrinogen concentration. The latter was based on records from 267 (76%) patients. Plasma fibrinogen concentration before labor was the only modifiable prepartum risk factor independently associated with severe PPH, indicating that fibrinogen monitoring is warranted in these patients.

Metodología CUSUM en la curva de aprendizaje de la punción epidural obstétrica en un hospital universitario

Resumen Introduccion: El aprendizaje de las habilidades en anestesia muestra una amplia variabilidad interindividual. Nuestro objetivo fue establecer y probar una herramienta individualizada de monitorizacion de la capacitacion tecnica (CUSUM), que permitiera establecer de forma objetiva si un individuo alcanzaba un nivel minimo y cuando ocurria esto. Material Y Metodos Participaron 9 medicos residentes de Anestesiologia y Reanimacion en su tercer ano de residencia, para que recogiesen sus 100 primeros procedimientos de analgesia epidural obstetrica, anonimamente en una base de datos. Estos datos, fueron analizados con el metodo CUSUM. Se tomo como una tasa de exito aceptable 80% al primer intento y una necesidad de ayuda del 20%. Resultados Se analizaron 765 bloqueos, 84,7±22,8 por residente, rango 47-100. Tres de los residentes no completaron los 100 bloqueos. Siete de ellos alcanzaron la destreza con 23 bloqueos y 2 residentes no alcanzaron la destreza. En tres residentes, la supervision fue necesaria en mas del 20% de casos al final del periodo de estudio. La recogida de datos, parece variable entre los residentes, infra o sobreestimando los fallos y/o la necesidad de ayuda. La puncion dural accidental se dio en 6 casos (0,78%) y la hematica en 40 (5,2%). Discusion: Aunque la tasa de exito es alcanzada rapidamente por algunos residentes de tercer ano, creemos que el elevado grado de supervision es util para controlar el progreso de la curva de aprendizaje en casos individuales que precisen mas control.

Managing Major Obstetric Haemorrhage: Pharmacotherapy and Transfusion

Major obstetric haemorrhage is a leading cause of maternal mortality. A prescriptive approach to early recognition and management is critical to improving outcomes. Uterine atony is the primary cause of post-partum haemorrhage. First-line prevention and treatment include the administration of uterine tonic agents; other conservative measures include uterine cavity tamponade and uterine compression sutures. Interventional radiology procedures have been used for both prophylaxis and treatment, but a hysterectomy may be necessary if conservative measures fail. Assessment of anaemia and coagulation status is an important aspect of the management of haemorrhage. Hypofibrinogenaemia is a predictor of severe haemorrhage. Early and empiric use of fixed transfusion red blood cell:plasma:platelet ratios is controversial and may not be justified for all causes of haemorrhage. Cell salvage may be used safely in obstetric haemorrhage. Goal-directed therapy using point-of-care testing (e.g. thromboelastography) has not been well studied but holds promise for individualising resuscitation measures.

Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis

BACKGROUND AND OBJECTIVES Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm(2) or a mean aortic valve gradient >30 mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. CASE REPORT Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. CONCLUSION Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients.

Hipotensión arterial materna con dosis bajas de bupi y levobupivacaína intradural para cesárea más extensión epidural con salino

Resumen Introduccion La extension epidural con suero salino (EVE), puede contribuir a una mayor extension cefalica de los farmacos inyectados en el espacio subaracnoideo en la cesarea. Hemos estudiado la incidencia de hipotension maternal con bupivacaina subaracnoidea o l-bupivacaina y la extension despues de la inyeccion de suelo salino epidural. Material y Metodos Tras la aprobacion del comite de etica, realizamos un estudio prospectivo aleatorizado en mujeres programadas para cesarea. Estas fueron asignadas a uno de los siguientes cuatro grupos: B-5 no EVE, bupivacaina 5 mg 0,25% (n=6) sin inyeccion de salino epidural; B-5, bupivacaina 5 mg 0,25% (n=51), LB-5: l-bupivacaina 5 mg 0,25% (n=50) y LB-6: l-bupivacaina 6 mg 0,3% (n=50). En todos los grupos, se anadio fentanilo 25 μg a la mezcla de 2 ml de anestesico local hiperbarico subaracnoideo. En los primeros 5 minutos tras la inyeccion, se administraron 10 ml de suero salino por el cateter epidural, excepto en el grupo control (B-5 no EVE). Se recogieron datos demograficos y tiempos de cirugia, anestesia, incision-clampaje, incidencia de hipotension, la dosis de efedrina necesaria, el bloqueo motor y sensitivo, la necesidad de analgesia de rescate y los resultados neonatales. Resultados En el grupo B-5 no EVE no se incluyeron mas pacientes tras incluir 6 pacientes debido a que en todos los casos precisaron suplemento analgesico. Los datos demograficos, duracion del procedimiento, intervalo incision-nacimiento y test de Apgar fueron comparables. La incidencia de hipotension arterial fue menor en el grupo LB-5, 26% frente a 52,9% en B-5 y 56% en el grupo LB-6 (p=0,04). Las necesidades de analgesia de rescate fueron mayores en el grupo LB-5 (46%) frente a B-5 (23,5%) y LB-6 (28%) (p=0,039). La hipotension se relaciono con un pH de cordon umbilical mas bajo (p=0,001). Las dosis de efedrina superiores a 20 mg, se asociaron con un pH de cordon umbilical mas bajo (p=0,031). Conclusiones La incidencia de hipotension arterial fue menor en el grupo LB-5, pero la incidencia de necesidad de analgesia complementaria es mayor que en los otros grupos. B-5 y LB-6 pueden ser adecuadas para la cesarea pues aportan un buen bloqueo sensitive. Maternal hypotension with low doses of spinal bupivacaine or levobupivacaine and epidural volume extension with saline for cesarean section.

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Anestesia general y hemorragia obstétrica con transfusión en la cesárea. Experiencia durante un año en un hospital universitario

INTRODUCTION Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population. METHODS A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008. RESULTS General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards. CONCLUSIONS The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

Neuraxial Analgesia: Technical Problems and Solutions

Epidural analgesia is considered the most effective method of pain relief during labor. Advances, in both drugs and equipment, have meant a great improvement in its safety and effectiveness. However, epidural analgesia may fail in its main objective, which is to provide effective analgesia or anesthesia and some of these failures are due to technical problems.

Inserción de balones intraarteriales ilíacos previa a la realización de cesárea ante la sospecha de acretismo placentario

Massive obstetric hemorrhage still remains a major cause of maternal mortality and morbidity. The risk factors associated with this pathology must be identified in order to schedule the appropriate delivery with the necessary resources. A case is presented of an iliac artery occlusion with intravascular balloons for suspected placenta accreta during cesarean section. The perioperative treatment, as well as an analysis of the treatment options is described, along with their advantages and disadvantages, from the use of postpartum hemorrhage protocols, blood transfusion and procoagulant factors, and other maneuvers to control bleeding, until the hysterectomy.