miércoles, 10 de mayo de 2017

Hemorragia obstétrica / Obstetric hemorrhage

Abril 21, 2017. No. 2666

Manejo del sangrado masivo en pacientes obstétricas Testigos de Jehova. La abrumadora importancia de un protocolo multidisciplinario preestablecido.
Management of massive bleeding in a Jehovah's Witness obstetric patient: the overwhelming importance of a pre-established multidisciplinary protocol.
Blood Transfus. 2016 Jul 12;14(6):541-544. doi: 10.2450/2016.0229-15. [Epub ahead of print]
Life-threatening massive bleeding is doubtlessly one of the biggest challenges in health care, especially in patients who reject allogeneic transfusion, such as Jehovah's Witnesses. However, according to the principle of patients' autonomy, our job is to accept their decision and provide them with the best possible assistance. We present a protocol for the management of massive post-operative bleeding successfully applied in a Jehovah's Witness after a Caesarean section (CS).

Listas de verificación y desempeño multidisciplinario del equipo durante la hemorragia obstétrica simulada.
Checklists and multidisciplinary team performance during simulated obstetric hemorrhage.
Int J Obstet Anesth. 2016 Feb;25:9-16. doi: 10.1016/j.ijoa.2015.08.011. Epub 2015 Aug 21.
BACKGROUND: Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS: Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS: The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS: Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.
KEYWORDS: Checklist; Multidisciplinary; Obstetrics; Postpartum hemorrhage; Simulation

Manejo transfusional y de la coagulación en hemorragia obstétrica severa
Transfusion and coagulation management in major obstetric hemorrhage.
Curr Opin Anaesthesiol. 2015 Jun;28(3):275-84. doi: 10.1097/ACO.0000000000000180.
PURPOSE OF REVIEW: Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage. RECENT FINDINGS: Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels.
SUMMARY: A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.

Foro Internacional de Medicina Crítica
Ciudad de México, Julio 13-15, 2017
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