Fluid Management of Maternal Hemorrhage

Fluid Management of Maternal Hemorrhage New York City Department of Health and Mental Hygiene Bureau of Maternal, Infant and Reproductive Health Hemorrhagic Shock - Fluid Management - 2 Hemorrhagic Shock - Management - 3 Hemorrhagic Shock - Management - Maintain aerobic metabolism O2 Delivery = C.O. x Sa O2 x Hb% Fluid management  Oxygenation Transfusion CO = cardiac output SaO2 = Systemic arterial oxygen saturation 4 Hemorrhagic Shock - Management - 5 Hemorrhagic Shock - Management Cardiac Index 6 Hemorrhagic Shock - Management - Acute Blood Loss Loss of circulatory Volume Loss of O2 carrying capacity Restore volume 1 - Crystalloid 2 - Colloid  SaO2  O2 carrying capacity Supplemental O2 Transfusion 7 Hemorrhagic Shock - Fluid Management - 1 - Basic Fluid Management of the surgical patient 2 - Principles of blood loss replacement 8 Hemorrhagic Shock - Management - Fluid management: -Balanced *(0.9% NaCl, lactated Ringers.) 1 - Crystalloid -Hypertonic (3.5,5, 7.5% NaCl) -Hypotonic (0.45% NaCl) -Albumin (5%, 25%) 2 – Colloid -Dextran, glucose polymers (40, 70) -Hydroxyethyl starch (Hespan) 3.- Blood/Blood Products * Same electrolyte concentration as the extracellular compartment 9 Hemorrhagic Shock - Fluid Management - 1 - Vascular changes 2nd to anesthesia 2 - Fluid Deficit 3 - Maintenance 4 - Redistribution of fluids during surgery (edema) Hemorrhagic Shock - Fluid Management - Changes in intravascular volume, cardiac output during anesthesia: Regional anesthesia: Vasodilation Decreased venous return Decreased cardiac output General anesthesia: Myocardial depression Decreased cardiac output Hemorrhagic Shock - Fluid Management Prior to administering regional anesthesia  1,000cc of crystalloid within 30-60 min. of administering anesthesia *Critical for maintaining utero-placental perfusion - Vasodilation -  Venous return -  Cardiac output Fetal well-being Hemorrhagic Shock - Fluid Management - 2 - Fluid Deficit -Lack of intake prior to procedure (Maintenance fluid 110cc/hr x Time) 3 - Ongoing Maintenance - Determine by duration of procedure 100cc/hr 4 - Redistribution - Loss of intravascular volume in the interstitial space (tissue edema)  2 - 6 cc/kg/hr Hemorrhagic Shock - Fluid Management During Surgery  500-1.000cc/hr - Deficits - Maintenance - Redistribution 1- Start replacing extra-cellular fluid early in the procedure to a maximum of 2-3L during a 4hr major abdominal surgery 2.-Use crystalloid solutions for this purpose Hemorrhagic Shock - Fluid Management Acute Blood Loss Crystalloid  Ideal type of fluid for the initial resuscitation in hypovolemic shock  most commonly used are balanced sol. i.e. 0.9%NaCl LR’s  Hypertonic sol reserved for special circumstances (Brain edema etc.)  Glucose solution not to be used initially (most patients are already hyperglycemic) Maintain Cardiac Output 15 Hemorrhagic Shock - Fluid Management Severe Hypovolemic shock: (BP, Neuro signs)  Admin 20cc/Kg (1,500cc) x 5-15min if not responding admin another 1-2 fluid boluses (1,500cc) - Intra-op:  Administration of crystalloid should match the EBL “on a real time basis”  Crystalloid should be given in a 3:1 ratio to the EBL (3,000cc NS for 1,000cc EBL) Surgeon  Anesthesiologist communication critical) 16 Hemorrhagic Shock - Fluid Management - Blood Loss 25-30%(15-1800cc) Crystalloid/Colloid  Healthy Consider transfusion  Medical complications Crystalloid/Colloid Consider transfusion Crystalloid/Colloid Blood transfusion Clotting factors (FFP, Cryo) 17 30-50%(18-3000cc) > 50% ( > 3000cc) Hemorrhagic Shock - Fluid Management - 1 Signs & Symptoms of Hypovolemic Shock Bp, Pulse, Urine Output, O2 Sat pH, BD, Clinical signs Cardiac (can’t  CO, etc) pulmonary disease Lack of surgical hemostasis  results in coagulopathy Underestimated  40-50% 18 2 Pre-existing medical complications 3 Likelihood of further bleeding 4 Blood Loss ??? Hemorrhagic Shock - Fluid Management - Crystalloid 3:1 ratio to EBL  Circulatory volume  Interstitial fluids v. Colloid 1:1 ratio to EBL  Circulatory volume does not  Interstitial fluid may  Risk pulmonary edema and (ARDS) may  Risk coagulopathy Hypovolemic Shock  Crystalloid best initial intervention  Colloid is a temporizing measure 19 Hemorrhagic Shock - Fluid Management - Compatibility testing 1 - Type & Rh Bl type O, A, B, AB Rh (D) , Rh (D)  2 - Ab’s screen 3 – Cross matching ID’s the more common Ab’s “Trial transfusion in vitro”  donor RBCs are mixed with recipient serum to detect any reaction. Completed in 45-60min 20 Hemorrhagic Shock - Fluid Management - Successful Transfusion 1 Type & Rh alone 2 Type & screen 3 Cross matching 99.8% 99.94% 99.95% 21 Hemorrhagic Shock - Fluid Management - Safety of Transfusion 1 – Cross matched Blood 2 - Type specific partially cross matched blood (1-5min) 3 - Type specific un-cross matched blood 4 - Type O Rh neg blood 22 Hemorrhagic Shock - Decreasing Maternal Mortality - Clinical management of PPH -Delay in diagnosis -Inadequate assessment of blood loss -Delay in surgical intervention -Inadequate replacement therapy Maternal Mortality 23 Managing blood loss by hemorrhage classification Class Blood Loss Volume Deficit Spx Rx I < 1000 cc 15% Orthostatic tachycardia Incr. HR, orthostasis, mental Decr cap refill Incr HR, RR Decr BP, Oliguria Obtunded Crystalloid II 1001-1500 15-25% Crystalloid, Crystalloid Colloid, RBCs III 1501-2500 25-40% > 40% IV > 2500 Oliguria/anuria CV collapse RBC, Crystalloid, Colloid 24 Replacement Fluids Restore volume with crystalloid • NS preferred • 3:1 ratio to blood loss Transfuse RBCs • Signs of O2 deficiency Consider colloid • Albumin • Hetastarch 25 Replacement Fluids (Colloid) • Albumin- 5% or 25% solution in isotonic saline • • IV infusion 1gm albumin increases plasma volume by 18cc • 100ml of 25% Albumin increased plasma volume by 450cc over 30-60 min • 500ml of 5% albumin increases plasma volume by 450cc • • ½ life in plasma –16 hrs Full intra and extra vascular equilibration – 7-10 days • Can increase colloid osmotic pressure for up to 2 days in shock patients 26 Replacement Fluids (Colloid) Hetastarch • Synthetic colloid resembles glycogen • Increases colloid osmotic pressure the same • May expand volume greater than Albumin • Maximum daily dose 1500ml/70kg • > 1500ml/kg can cause DIC 27 as albumin Transfusion NS only • D5W – hemolysis • RL - neutralizes citrate anticoagulant Blood used within 4 hours • Return to blood bank < 30 minutes Blood warming • Administered > 100cc/min • Cold => arrhythmia, coagulopathy 28 Transfusion Risks Febrile Rxn (> 38C) Allergic Rxn Acute lung injury Septic Rxn (temp increased >2 Deg) Blood born infection • • • • HIV - 0.9/1million HTLV - 1/641k Hep C – 1/103K Hep B – 1/250K Calcium depletion Coagulopathy Dilution of clotting factors 29 Blood Components Indication/ Product Volume Components Utility Whole blood 450-500 cc Hct. 36-44% 1u =1g/dl Hb PRBC 200-250 cc Hct. 70-80% 1u = 1g/dl Hb Platelets 30-50cc Platelets WBC Ag 1u = 5000uL FFP 100cc Fibrinogen, clotting factors PT, PTT> 1.5 x nl, INR > 1.6 Cryo50-75cc precipitate Factor 8c, Von Willebrand’s factor, Fibrinogen Fibrinogen replacement 30 Maternal Mortality - Obstetrical Hemorrhage - Optimize hemodynamic status 1 - Acute isovolemic hemodilution 2 - Acute hypervolemic hemodilution 3 - Autologous donation 4 - Preoperative transfusion 31 Maternal Mortality - Obstetrical Hemorrhage - Acute hemodilution Decreases pre-op Hb concentration For same blood volume lost Lower RBC’s loss - Transfusion rates - Final Hct’s 32 Maternal Mortality - Obstetrical Hemorrhage 1.- Acute isovolemic hemodilution Withdraw 2-4 u. of Blood  Replace the volume with crystalloid  Lower the pre-op Hct  Replace the blood at end of surgery 2.- Acute hypervolemic hemodilution Admin 1500-2000cc Crystalloid  Hemodilution (Lowers pre-op Hct) 33 Maternal Mortality - Obstetrical Hemorrhage - 34 Maternal Mortality - Obstetrical Hemorrhage - Acute isovolemic/hypervolemic hemodilution Initial Hb Blood loss Hb loss Preop 45%15g Hb% 2,000cc 300g  (27%) After hemodilution Preop 30% 10g Hb% 3,000cc 300g  (27%) 35 Maternal Mortality - Obstetrical Hemorrhage - 36 Maternal Mortality - Obstetrical Hemorrhage - Optimize hemodynamic status 1.- Acute isovolemic hemodilution 2.- Acute hypervolemic hemodilution 3.- Autologous donation 4.- Preoperative transfusion 37 Maternal Mortality - Obstetrical Hemorrhage - Patients at risk Pre-delivery management 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance 38 Tools for fluid management Indwelling bladder catheter Arterial line Central venous pressure catheter Pulmonary artery catheter 39 Indwelling bladder catheter Principle: Maintain urine output - 0.5cc/kg/hr Adequate urine output can imply: Adequate intravascular volume Adequate cardiac output Cardiac function Renal function 40 Arterial line Utility Continuous arterial blood pressure monitoring Continuous access for arterial blood sampling (Blood gas) 41 Central Venous Pressure Catheter (CVP) In pregnancy may not provide exact measures of CVP but is useful to determine relative fluid balance Utility Relative measurement of fluid status Large volume fluid administration Administration of potent vasoconstrictors epinephrine, norepinephrine 42 Pulmonary Artery Catheter Swan-Ganz Utility Trends in cardiac output Intravascular volume status (CVP) Assists diagnosis of pulmonary edema vs ARDS Large fluid volume administration Administration of potent vasoconstrictors Epinephrine Norepinephrine 43