1
|
Villela-Franyutti D, Hackett K, Lumbreras-Marquez MI, Farber MK. Incorporating a postpartum hemorrhage bundle on the labor and delivery unit: a state-wide survey of anesthesiologists in Massachusetts. Int J Obstet Anesth 2023; 55:103893. [PMID: 37142509 DOI: 10.1016/j.ijoa.2023.103893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Affiliation(s)
- D Villela-Franyutti
- Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA.
| | - K Hackett
- Department of Anesthesiology, Northside Hospital, Atlanta, GA, USA
| | | | - M K Farber
- Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Lopez CE, Salloum J, Varon AJ, Toledo P, Dudaryk R. The Management of Pregnant Trauma Patients: A Narrative Review. Anesth Analg 2023; 136:830-840. [PMID: 37058718 DOI: 10.1213/ane.0000000000006363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.
Collapse
Affiliation(s)
- Carmen E Lopez
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joe Salloum
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Paloma Toledo
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| |
Collapse
|
3
|
Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
Collapse
Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Shahin Z, Shah GH, Apenteng BA, Waterfield K, Samawi H. A Nationwide Study of the “July Effect” Concerning Postpartum Hemorrhage and Its Risk Factors at Teaching Hospitals across the United States. Healthcare (Basel) 2023; 11:healthcare11060788. [PMID: 36981445 PMCID: PMC10048184 DOI: 10.3390/healthcare11060788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
Objective To assess the “July effect” and the risk of postpartum hemorrhage (PPH) and its risk factors across the U.S. teaching hospitals. Method This study used the 2018 Nationwide Inpatient Sample (NIS) and included 2,056,359 of 2,879,924 single live-birth hospitalizations with low-risk pregnancies across the U.S. teaching hospitals. The International Classification of Diseases, Tenth Revision (ICD-10) from the American Academy of Professional Coders (AAPC) medical coding was used to identify PPH and other study variables. Multivariable logistic regression models were used to compare the adjusted odds of PPH risk in the first and second quarters of the academic year vs. the second half of the academic year. Results Postpartum hemorrhage occurred in approximately 4.19% of the sample. We observed an increase in the adjusted odds of PPH during July through September (adjusted odds ratios (AOR), 1.05; confidence interval (CI), 1.02–1.10) and October through December (AOR, 1.07; CI, 1.04–1.12) compared to the second half of the academic year (January to June). Conclusions This study showed a significant “July effect” concerning PPH. However, given the mixed results concerning maternal outcomes at the time of childbirth other than PPH, more research is needed to investigate the “July effect” on the outcomes of the third stage of labor. This study’s findings have important implications for patient safety interventions concerning MCH.
Collapse
Affiliation(s)
- Zahra Shahin
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30458, USA
- Correspondence:
| | - Gulzar H. Shah
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30458, USA
| | - Bettye A. Apenteng
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30458, USA
| | - Kristie Waterfield
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30458, USA
| | - Hani Samawi
- Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30458, USA
| |
Collapse
|
5
|
Albright CM, Steiner J, Sienas L, Delgado C, Buber J. Main operating room deliveries for patients with high-risk cardiovascular disease. Open Heart 2023; 10:openhrt-2022-002213. [PMID: 36787936 PMCID: PMC9930549 DOI: 10.1136/openhrt-2022-002213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/27/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND High-risk cardiovascular disease (CVD) prevalence in pregnant patients is increasing. Management of this complex population is not well studied, and little guidance is available regarding labour and delivery planning for optimal outcomes. OBJECTIVE We aimed to describe the process for and outcomes of our centre's experience with the main operating room (OR) caesarean deliveries for patients with high-risk CVD, including procedural and postpartum considerations. STUDY DESIGN We performed a retrospective evaluation of pregnant patients with high-risk CVD who delivered in the main OR at a large academic centre between January 2010 and March 2021. Patients were classified by CVD type: adult congenital heart disease, cardiac arrest, connective tissue disease with aortopathy, ischaemic cardiomyopathy, non-ischaemic cardiomyopathy or valve disease. We examined demographic, anaesthetic and procedure-related variables and in-hospital maternal and fetal outcomes. Multidisciplinary delivery planning was evaluated before and after formalising a cardio-obstetrics programme. RESULTS Of 25 deliveries, connective tissue disease (n=9, 36%) was the most common CVD type, followed by non-ischaemic cardiomyopathy (n=5, 20%). Scheduled deliveries that went as initially planned occurred for six patients (24%). Fourteen (56%) were unscheduled and urgent or emergent. Patients in modified WHO Class IV frequently underwent unscheduled, urgent deliveries (64%). Most deliveries were safely achieved with neuraxial regional anaesthesia (80%) and haemodynamic monitoring via arterial lines (88%). Postdelivery intensive care unit stays were common (n=18, 72%), but none required mechanical circulatory support. There were no in-hospital maternal or perinatal deaths; 60-day readmission rate was 16%. Some delivery planning was achieved for most patients (n=21, 84%); more planning was evident after establishing a cardio-obstetrics programme. Outcomes did not differ significantly by CVD group or delivery era. CONCLUSIONS Our experience suggests that short-term outcomes of pregnant patients with high-risk CVD undergoing main OR delivery are favourable. Multidisciplinary planning may support the success of these complex cases.
Collapse
Affiliation(s)
- Catherine M Albright
- Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, Washington, USA
| | - Jill Steiner
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Laura Sienas
- Women’s Healthcare Associates, Northwest Perinatal Center, Portland, Oregon, USA
| | - Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Jonathan Buber
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| |
Collapse
|
6
|
Ahmad N, Ramlan N, Ganeshan M, Bhaskaran KS, Ismail F, Razak T, Hassan A, Amin N. Massive transfusion protocol for postpartum hemorrhage case management in Hospital Kuala Lumpur; Five years implementation and outcome. Asian J Transfus Sci 2022. [DOI: 10.4103/ajts.ajts_102_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
7
|
Knoll W, Phelan R, Hopman WM, Ho AMH, Cenkowski M, Mizubuti GB, Ghasemlou N, Klar G. Retrospective review of time to uterotonic administration and maternal outcomes following post-partum hemorrhage. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:490-495. [PMID: 34844004 DOI: 10.1016/j.jogc.2021.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Despite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH, would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion. METHODS We reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH. RESULTS Of 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively. CONCLUSION In this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.
Collapse
Affiliation(s)
- William Knoll
- Queen's University School of Medicine, Department of Anesthesiology and Perioperative Medicine, Department of Molecular and Biological Sciences, Queen's University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston ON K7L 2V7 Canada
| | - Wilma M Hopman
- Kingston Health Sciences Research Institute, KGHRI, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Marta Cenkowski
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Nader Ghasemlou
- Department of Molecular and Biological Sciences, Department of Anesthesiology and Perioperative Medicine, ueen's University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada.
| |
Collapse
|
8
|
Kjaer K. Quality Assurance and Quality Improvement in the Labor and Delivery Setting. Anesthesiol Clin 2021; 39:613-630. [PMID: 34776100 DOI: 10.1016/j.anclin.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.
Collapse
Affiliation(s)
- Klaus Kjaer
- Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA.
| |
Collapse
|
9
|
Kogutt BK, Kim JM, Will SE, Sheffield JS. Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit. Jt Comm J Qual Patient Saf 2021; 48:120-128. [PMID: 34952828 DOI: 10.1016/j.jcjq.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the United States, and timely treatment is imperative. Delay in treatment of PPH can lead to significant blood loss and increased morbidity and mortality. Supplies and medications essential for treating PPH are typically not located in close proximity to the hemorrhaging patient, leading to inefficiency and delay in timely response to hemorrhage. METHODS An in situ hemorrhage simulation was created dictating the collection of a prespecified list of supplies commonly used in response to PPH on labor and delivery (L&D). Baseline data were collected, then Lean Six Sigma tools were used to construct a process map, including recording times and cumulative distance traveled for collection of each item. The simulation was repeated after development, creation, and deployment of each intervention. For the first intervention, a PPH cart was created containing the supplies most used in response to PPH. Second, a PPH medication kit was created consisting of a refrigerated box containing all medications typically administered during a PPH. RESULTS The average time to collect a prespecified list of supplies and medications in response to a PPH scenario was 11 minutes 5 seconds (standard deviation [SD] = 3 minutes 33 seconds), with an average cumulative distance traveled of 4,092 feet. Following Intervention 1, the time decreased to 4 minutes 0 seconds, with 918 feet traveled (only one trial performed). Intervention 2 further reduced the average time and cumulative distance to 2 minutes 14 seconds (SD = 16 seconds) and 462 feet, respectively. This represents a 79.8% reduction in time and an 88.7% reduction in distance from baseline to postintervention. CONCLUSION A PPH cart and medication kit can significantly reduce the amount of time and distance traveled to obtain materials necessary to treat hemorrhage, thus optimizing a team's ability to efficiently treat PPH.
Collapse
|
10
|
Ahmadzia HK, Phillips JM, Kleiman R, Gimovsky AC, Bathgate S, Luban NL, Amdur RL. Hemorrhage Risk Assessment on Admission: Utility for Prediction of Maternal Morbidity. Am J Perinatol 2021; 38:1126-1133. [PMID: 32446252 PMCID: PMC9016410 DOI: 10.1055/s-0040-1710501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Hemorrhage is a major cause of maternal morbidity and mortality prompting creation of innovative risk assessment tools to identify patients at highest risk. We aimed to investigate the association of hemorrhage risk assessment with maternal morbidity and to evaluate maternal outcomes after implementation of the risk assessment across hospital sites. STUDY DESIGN We conducted a retrospective cohort analysis of a multicenter database including women admitted to labor and delivery from January 2015 to June 2018. The Association of Women's Health, Obstetric and Neonatal Nurses risk assessment tool was used to categorize patients as low, medium, or high risk for hemorrhage. Multivariate logistic regression was used to describe the association between hemorrhage risk score and markers of maternal morbidity and evaluate maternal outcomes before and after standardized implementations of the risk assessment tool. RESULTS In this study, 14,861 women were categorized as low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk (N = 56,671 births). For women with high-risk scores, the relative risk (RR) ratio compared with low-risk women was 4.9 (RR: 95% confidence interval [CI]: 3.2-7.4) for blood transfusion and 5.2 (RR: 95% CI: 4.6-5.9) for estimated blood loss (EBL) ≥ 1,000 mL. For the second objective, 110,633 women were available for pre- and postimplementation analyses (39,027 and 71,606, respectively). A 20% reduction in rates of blood transfusion (0.5-0.4%, p = 0.02) and EBL ≥ 1,000 mL (6.3-5.9%, p = 0.014) was observed between pre- and postimplementations of the admission hemorrhage risk assessment tool. CONCLUSION Women who were deemed high risk for hemorrhage using a hemorrhage risk assessment tool had five times higher risk for blood transfusion and EBL ≥ 1,000 mL compared with low-risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment works moderately well to identify patients at risk for peripartum morbidity. KEY POINTS · This study aimed to understand the utility of the AWOHNN hemorrhage risk assessment tool for predicting hemorrhage-related morbidity and to evaluate maternal outcomes before and after tool implementations.. · A high score using a hemorrhage risk assessment tool on admission is associated with five times higher risk for blood transfusion and/or estimated blood loss ≥ 1,000 mL, compared with a low score.. · Use of a hemorrhage risk assessment tool works moderately well to identify patients at highest risk for hemorrhage-related morbidity..
Collapse
Affiliation(s)
- Homa K. Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine & Health Sciences, Washington DC
| | - Jaclyn M. Phillips
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rose Kleiman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine & Health Sciences, Washington DC
| | - Alexis C. Gimovsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine & Health Sciences, Washington DC
| | - Susan Bathgate
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine & Health Sciences, Washington DC
| | - Naomi L.C. Luban
- Department of Pediatrics and Pathology, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Richard L. Amdur
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia Am J Perinatol
| |
Collapse
|
11
|
Institution of prothrombin complex concentrate protocols is associated with a reduction in plasma administration at a Tertiary Care Hospital. J Clin Anesth 2021; 70:110164. [PMID: 33485109 DOI: 10.1016/j.jclinane.2021.110164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE Explore how the introduction of 4-factor prothrombin complex concentrates (4F-PCC) protocols for reversing anticoagulation and the treatment of critical bleeding influenced blood product utilization. DESIGN A retrospective analysis of the utilization rate of plasma and 4F-PCC from September 2012 through December 2018. SETTING Blood bank and pharmacy records of a single large tertiary care medical center. PATIENTS Admitted patients except obstetric during the study period (n = 283,319). INTERVENTION Five institutional protocols providing guidelines for 4F-PCC administration were deployed over a 3-year period. MEASUREMENTS The utilization rate of plasma and 4F-PCC was the primary outcome and analyzed using an interrupted time series analysis. Utilization of platelets and cryoprecipitate as well as the impact of the intervention on the service prescribing the blood products were evaluated as secondary outcomes. Data were evaluated using a segmented time series regression. RESULTS When adjusted for seasonality, the monthly rate of plasma administration was 24.7 ± 2.0 units per 100 admissions in the 6-month period prior to the 1st intervention (May-October 2013) and decreased to 9.9 ± 2.2 units per 100 admissions in the same six-month period following the 5th intervention (May-October 2018), median difference - 14.5, 95% CI -16.0 to -13.2, P < 0.001. During the 6-month period prior to the 1st intervention (May-October 2013) the monthly rate of 4-F PCC use was 1.2 ± 0.8 doses per 1000 admissions and increased to 2.8 ± 1.0 doses per 1000 admissions 6-months following the 5th intervention (May-October 2018), median difference 1.6, 95% CI 0.3 to 1.9, P = 0.014. The monthly utilization of platelets was decreased and cryoprecipitate slightly increased following the implementation of the PCC protocols. CONCLUSIONS AND RELEVANCE Our findings demonstrate that establishing institutional protocols for the use of 4F-PCC to reverse the effects of anticoagulation and to treat critical bleeding with associated coagulopathy was associated with reduced plasma utilization.
Collapse
|
12
|
Hulse W, Bahr TM, Morris DS, Richards DS, Ilstrup SJ, Christensen RD. Emergency-release blood transfusions after postpartum hemorrhage at the Intermountain Healthcare hospitals. Transfusion 2020; 60:1418-1423. [PMID: 32529673 DOI: 10.1111/trf.15903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Most low-risk obstetric patients do not have crossmatched blood available to treat unexpected postpartum hemorrhage. An emergency-release blood transfusion (ERBT) program is critical for hospitals with obstetrical services. We performed a retrospective analysis of obstetrical ERBTs administered in our multihospital system. DESIGN AND METHODS We collected data from the past 8 years at all Intermountain Healthcare hospitals on every ERBT after postpartum hemorrhage; logging circumstances, number and type of transfused products, and outcomes. RESULTS Eighty-nine women received ERBT following 224,035 live births, for an incidence of 3.97 transfused women/10,000 births. The most common causally-associated conditions were: uterine atony (40%), placental abruption/placenta previa (16%), retained placenta (11%), and uterine rupture (5%). The mean number of total units transfused was 7.9 (range 1-76). The mean number of red blood cells (RBCs) transfused was 4.8, the median 4, and SD was ±4.4. Massive transfusion protocols (MTPs) for trauma recommend using a ratio of 1:1:1 or 2:1:1 of RBC:FFP:Platelets, however the ratios varied widely for postpartum hemorrhage. Only 1.5% received a 1:1:1 ratio and 7.5% received a 2:1:1 ratio. Nineteen percent (17/89) of women underwent hysterectomy, 7% (6/89) had uterine artery embolization, 36% (32/89) had an intensive care unit admission, and 1% (1/89) died. CONCLUSION Emergency transfusion for postpartum hemorrhage occurred after 1/2500 births. Most women received less FFP and platelets than recommended for traumatic hemorrhage. A potentially better practice for postpartum hemorrhage would be a balanced ratio of blood products, transfusion of low-titer, group O, cold-stored, whole blood, or inclusion in a MTP.
Collapse
Affiliation(s)
- Whitley Hulse
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - David S Morris
- Trauma and General Surgery, Intermountain Medical Center, Murray, Utah, USA
| | - Douglas S Richards
- Division of Maternal/Fetal Medicine, University of Utah Health and Intermountain Medical Center, Murray, Utah, USA.,Women and Newborn's Clinical Program, Intermountain Healthcare, Murray, Utah, USA
| | - Sarah J Ilstrup
- Department of Pathology, Intermountain Healthcare Transfusion Services and Intermountain Medical Center, Murray, Utah, USA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA.,Division of Maternal/Fetal Medicine, University of Utah Health and Intermountain Medical Center, Murray, Utah, USA.,Division of Hematology-Oncology, University of Utah Health, Salt Lake City, Utah, USA
| |
Collapse
|
13
|
Hutcheon JA, Chapinal N, Skoll A, Au N, Lee L. Inter-hospital variation in use of obstetrical blood transfusion: a population-based cohort study. BJOG 2020; 127:1392-1398. [PMID: 32150336 DOI: 10.1111/1471-0528.16203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify the extent of hospital-to-hospital variation in use of obstetrical blood transfusion. DESIGN Population-based cohort study linking provincial perinatal and blood transfusion registries. SETTING British Columbia, Canada, 2004-2015. POPULATION All pregnant women delivering at or beyond 20 weeks' gestation at any British Columbia hospital. METHODS Mixed-effects regression models were used to estimate hospital-specific transfusion rates after sequentially accounting for (1) the role of random variation, (2) maternal medical and obstetrical characteristics (i.e. patient case mix) and (3) institutional and delivery factors (such as use of instrumental or caesarean delivery). MAIN OUTCOME MEASURES Hospital-specific use of obstetrical red blood cell transfusion. RESULTS Among 44 hospitals, crude institutional transfusion rates across the study period ranged from 3.7 to 23.6 per 1000, with an average of 8.3 per 1000. After adjusting for maternal characteristics, institution and delivery risk factors, a nearly three-fold difference in rates between the 10th and 90th percentile remained (5.4-14.5 per 1000). Twelve sites had rates significantly higher or lower than the provincial average. Women residing in remote areas were 2.5-fold (95% CI 1.8-3.5] more likely to receive a blood transfusion than were women residing in metropolitan areas. CONCLUSIONS Meaningful variation between hospitals in use of blood transfusion during pregnancy was not explained by differences in patient case-mix or institutional factors, suggesting that over- or under-utilisation of this resource may be occurring in obstetrical care. TWEETABLE ABSTRACT Use of blood transfusion in pregnant women varied broadly between hospitals in British Columbia, Canada.
Collapse
Affiliation(s)
- J A Hutcheon
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, BC, Canada
| | - N Chapinal
- Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, BC, Canada
| | - A Skoll
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - N Au
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - L Lee
- Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, BC, Canada
| |
Collapse
|
14
|
Non-clinical interventions to prevent postpartum haemorrhage and improve its management: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 240:300-309. [DOI: 10.1016/j.ejogrb.2019.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
|
15
|
Abstract
PURPOSE OF REVIEW Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.
Collapse
|
16
|
Update on Obstetric Hemorrhage. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
17
|
Thomasson RR, Yazer MH, Gorham JD, Dunbar NM. International assessment of massive transfusion protocol contents and indications for activation. Transfusion 2019; 59:1637-1643. [PMID: 30720872 DOI: 10.1111/trf.15149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/18/2018] [Accepted: 12/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) provide blood products rapidly and in fixed amounts. MTPs are commonly used in trauma but may also be used in other clinical settings, although evidence to support fixed-ratio resuscitation in nontraumatic hemorrhage is lacking. The goals of this study were to describe the types and contents of available MTPs and the clinical indications for MTP activation. METHODS A survey was distributed to 353 transfusion medicine specialists to assess the types and contents of available MTPs. Survey participants were invited to provide the clinical indications for consecutive adult and pediatric MTP activations for at least 6 months during 2015 to 2017. RESULTS There were 125 completed surveys (35% response rate) including three from children's specialty hospitals. Most hospitals that treated adult patients (90/122, 74%) utilized only one MTP for all adult bleeding emergencies, while one hospital had no MTP. Of the 31 hospitals that provided more than one adult MTP, 20 provided MTPs specific for obstetric bleeding cases. Of these, 50% (10/20) included at least one pool of cryoprecipitate or fibrinogen concentrate in the first MTP round, compared with 14% (13/90) of the hospitals with one MTP (p = 0.0012). Fifty-seven hospitals provided the clinical indication for 4176 adult and 155 pediatric MTP activations. Although trauma was the single most common indication, the majority of adult (58%) and pediatric (65%) activations were for nontrauma indications. CONCLUSIONS The majority of hospitals use a single MTP to manage massive hemorrhage. The majority of MTP activations were for nontrauma indications.
Collapse
Affiliation(s)
- Reggie R Thomasson
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - James D Gorham
- Department of Pathology, University of Virginia Health System, Charlottesville, Virginia
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | |
Collapse
|
18
|
Harvey CJ. Evidence-Based Strategies for Maternal Stabilization and Rescue in Obstetric Hemorrhage. AACN Adv Crit Care 2019; 29:284-294. [PMID: 30185495 DOI: 10.4037/aacnacc2018966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Obstetric hemorrhage is one of the most frequent causes of maternal death in the United States. More than 70% of maternal deaths from hemorrhage are preventable. State and professional quality care organizations have reduced severe maternal morbidity by more than 20% by implementing evidence-based guidelines. Successful hemorrhage management requires collaborative, multidisciplinary teams of trained health care personnel. Hemorrhage management's primary goal is to stop the bleeding before the occurrence of maternal hypovolemia, acidosis, coagulopathy, and death. Uterine atony is the primary cause of obstetric hemorrhage and can be managed with uterotonic agents, placement of noninvasive uterine tamponade balloons, and surgical procedures if needed. Women experiencing massive hemorrhage should be treated according to resuscitation care guidelines with avoidance of hypothermia, acidosis, and coagulopathy. Use of a massive transfusion protocol is warranted for best outcomes. Resources for institutional adoption of current collaborative standards for managing obstetric hemorrhage are identified in this article.
Collapse
Affiliation(s)
- Carol J Harvey
- Carol J. Harvey is Clinical Specialist, Women's Services and Patient Care Administration, Northside Hospital, 1000 Johnson Ferry Rd, Atlanta, GA 30342
| |
Collapse
|
19
|
A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes. Anesthesiology 2019; 129:192-215. [PMID: 29561267 DOI: 10.1097/aln.0000000000002182] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.
Collapse
|
20
|
Weiniger CF, Yakirevich-Amir N, Sela HY, Gural A, Ioscovich A, Einav S. Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol. Int J Obstet Anesth 2018; 36:34-41. [PMID: 30245260 DOI: 10.1016/j.ijoa.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/21/2018] [Accepted: 08/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol. METHODS The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables. RESULTS 273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol. CONCLUSIONS Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.
Collapse
Affiliation(s)
- C F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center and Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | | | - H Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Israel
| | - A Gural
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - A Ioscovich
- Department of Anesthesiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - S Einav
- Intensive Care Unit of the Shaare Zedek Medical Center and Hebrew University School of Medicine, Jerusalem, Israel
| |
Collapse
|
21
|
Yazer MH, Dunbar NM, Cohn C, Dillon J, Eldib H, Jackson B, Kaufman R, Murphy MF, O'Brien K, Raval JS, Seheult J, Staves J, Waters JH. Blood product transfusion and wastage rates in obstetric hemorrhage. Transfusion 2018. [DOI: 10.1111/trf.14571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mark H. Yazer
- Department of Pathology; Pittsburgh Pennsylvania
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Nancy M. Dunbar
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Jessica Dillon
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Howida Eldib
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Bryon Jackson
- Department of Pathology and Laboratory Medicine; Emory University School of Medicine; Atlanta Georgia
| | - Richard Kaufman
- Brigham and Women's Hospital Adult Transfusion Service; Boston Massachusetts
| | - Michael F. Murphy
- NHS Blood & Transplant, Oxford University Hospitals, and University of Oxford; Oxford UK
| | - Kerry O'Brien
- Department of Pathology; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina, Chapel Hill, North Carolina; the McGowan Institute for Regenerative Medicine; Pittsburgh Pennsylvania
| | | | | | - Jonathan H. Waters
- Departments of Anesthesiology and Bioengineering; University of Pittsburgh; Pittsburgh Pennsylvania
| | | |
Collapse
|
22
|
Lundsberg LS, Lee HC, Dueñas GV, Gregory KD, Grossetta Nardini HK, Pettker CM, Illuzzi JL, Xu X. Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California. Obstet Gynecol 2018; 131:214-223. [PMID: 29324608 PMCID: PMC7020098 DOI: 10.1097/aog.0000000000002437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.
Collapse
Affiliation(s)
- Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; the Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, California; the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California; and Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Shaylor R, Weiniger CF, Austin N, Tzabazis A, Shander A, Goodnough LT, Butwick AJ. National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review. Anesth Analg 2017; 124:216-232. [PMID: 27557476 DOI: 10.1213/ane.0000000000001473] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.
Collapse
Affiliation(s)
- Ruth Shaylor
- From the *Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel; †Departments of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California; ‡Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey; §Departments of Anesthesiology, Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York; and ‖Department of Pathology, Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Orbach-Zinger S, Weiniger CF, Aviram A, Balla A, Fein S, Eidelman LA, Ioscovich A. Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study. J Matern Fetal Neonatal Med 2017; 31:1171-1176. [PMID: 28335653 DOI: 10.1080/14767058.2017.1311315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management. METHODS AND MATERIALS This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases. RESULTS Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p < .001), increased blood components transfusions (p < .001), and significant increase in cesarean hysterectomy rate (p < .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p < .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p < .001). CONCLUSIONS Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.
Collapse
Affiliation(s)
- Sharon Orbach-Zinger
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Carolyn F Weiniger
- b Department of Anesthesia , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | - Amir Aviram
- c Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Alexander Balla
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Shai Fein
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Leonid A Eidelman
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Alexander Ioscovich
- d Department of Anesthesia , Shaare Zedek Medical Center , Jerusalem , Israel
| |
Collapse
|
26
|
Merriam AA, Wright JD, Siddiq Z, D'Alton ME, Friedman AM, Ananth CV, Bateman BT. Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals. J Matern Fetal Neonatal Med 2017; 31:1025-1034. [PMID: 28367647 DOI: 10.1080/14767058.2017.1306050] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study was to characterize risk for and temporal trends in postpartum hemorrhage across hospitals with different delivery volumes. STUDY DESIGN This study used the Nationwide Inpatient Sample (NIS) to characterize risk for postpartum hemorrhage from 1998 to 2011. Hospitals were classified as having either low, moderate or high delivery volume (≤1000, 1001 to 2000, >2000 deliveries per year, respectively). The primary outcomes included postpartum hemorrhage, transfusion, and related severe maternal morbidity. Adjusted models were created to assess factors associated with hemorrhage and transfusion. RESULTS Of 55,140,088 deliveries included for analysis 1,512,212 (2.7%) had a diagnosis of postpartum hemorrhage and 361,081 (0.7%) received transfusion. Risk for morbidity and transfusion increased over the study period, while the rate of hemorrhage was stable ranging from 2.5 to 2.9%. After adjustment, hospital volume was not a major risk factor for transfusion or hemorrhage. DISCUSSION While obstetric volume does not appear to be a major risk factor for either transfusion or hemorrhage, given that transfusion and hemorrhage-related maternal morbidity are increasing across hospital volume categories, there is an urgent need to improve obstetrical care for postpartum hemorrhage. Those risk factors are able to discriminate women at increased risk supports routine use of hemorrhage risk assessment.
Collapse
Affiliation(s)
- Audrey A Merriam
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Jason D Wright
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Zainab Siddiq
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Mary E D'Alton
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Alexander M Friedman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Brian T Bateman
- c Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital; the Department of Anesthesiology, Critical Care, and Pain Medicine , Harvard Medical School , Boston , MA , USA
| |
Collapse
|
27
|
Abstract
Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.
Collapse
Affiliation(s)
- Emily J Baird
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode UH2, Portland, OR 97239, USA.
| |
Collapse
|
28
|
|
29
|
Affiliation(s)
- Jason Papazian
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, Mailstop B113, Aurora, CO 80045, USA
| | - Rachel M Kacmar
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, Mailstop B113, Aurora, CO 80045, USA.
| |
Collapse
|
30
|
Weiniger CF, Sultan P, Dunn A, Carvalho B. Survey of external cephalic version for breech presentation and neuraxial blockade use. J Clin Anesth 2016; 34:616-22. [PMID: 27687460 DOI: 10.1016/j.jclinane.2016.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Neuraxial blockade may increase external cephalic version (ECV) success rates. This survey aimed to assess the frequency and characteristics of neuraxial blockade used to facilitate ECV. SETTING AND DESIGN We surveyed Society for Obstetric Anesthesia and Perinatology members regarding ECV practice using a 15-item survey developed by 3 obstetric anesthesiologists and tested for face validity. The survey was e-mailed in January 2015 and again in February 2015 to the 1056 Society of Obstetric Anesthesiology and Perinatology members. We present descriptive statistics of responses. PARTICIPANTS Our survey response rate was 322 of 1056 (30.5%). MAIN RESULT Neuraxial blockade was used for ECV always by 18 (5.6%), often by 52 (16.1%), sometimes by 98 (30.4%), rarely by 78 (24.2%), and never by 46 (14.3%) of respondents. An anesthetic sensory block target was selected by 141 (43.8%) respondents, and analgesic by 102 (31.7%) respondents. Epidural drug doses ranged widely, including sufentanil 5-25 μg; lidocaine 1% or 2% 10-20 mL, bupivacaine 0.0625% to 0.5% 6-15 mL, and ropivacaine 0.2% 20 mL. Intrathecal bupivacaine was used by 182 (56.5%) respondents; the most frequent doses were 2.5 mg used by 24 (7.5%), 7.5 mg used by 35 (10.9%), and 12 mg used by 30 (9.3%). CONCLUSIONS Neuraxial blockade is not universally offered to facilitate ECV, and there is wide variability in neuraxial blockade techniques, in drugs and doses administered, and in the sensory blockade (anesthetic or analgesic) targeted. Future studies need to evaluate and remove barriers to allow for more widespread use of neuraxial blockade for pain relief and to optimize ECV success rates.
Collapse
Affiliation(s)
- Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Pervez Sultan
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK.
| | - Ashley Dunn
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, California, USA.
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, California, USA.
| |
Collapse
|
31
|
Massive obstetric hemorrhage: Current approach to management. Med Intensiva 2016; 40:298-310. [PMID: 27184441 DOI: 10.1016/j.medin.2016.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 01/25/2023]
Abstract
Massive obstetric hemorrhage is a major cause of maternal mortality and morbidity worldwide. It is defined (among others) as the loss of>2,500ml of blood, and is associated to a need for admission to critical care and/or hysterectomy. The relative hemodilution and high cardiac output found in normal pregnancy allows substantial bleeding before a drop in hemoglobin and/or hematocrit can be identified. Some comorbidities associated with pregnancy can contribute to the occurrence of catastrophic bleeding with consumption coagulopathy, which makes the situation even worse. Optimization, preparation, rational use of resources and protocolization of actions are often useful to improve outcomes in patients with postpartum hemorrhage. Using massive obstetric hemorrhage protocols is useful for facilitating rapid transfusion if needed, and can also be cost-effective. If hypofibrinogenemia during the bleeding episode is identified, early fibrinogen administration can be very useful. Other coagulation factors in addition to fibrinogen may be necessary during postpartum hemorrhage replacement measures in order to effectively correct coagulopathy. A hysterectomy is recommended if the medical and surgical measures prove ineffective.
Collapse
|
32
|
Ioscovich A, Shatalin D, Butwick AJ, Ginosar Y, Orbach-Zinger S, Weiniger CF. Israeli survey of anesthesia practice related to placenta previa and accreta. Acta Anaesthesiol Scand 2016; 60:457-64. [PMID: 26597396 DOI: 10.1111/aas.12656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/12/2015] [Accepted: 09/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. METHODS After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. RESULTS The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). CONCLUSIONS In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.
Collapse
Affiliation(s)
- A. Ioscovich
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - D. Shatalin
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - A. J. Butwick
- Department of Anesthesia; Stanford University School of Medicine; Stanford California USA
| | - Y. Ginosar
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
| | - S. Orbach-Zinger
- Department of Anesthesia; Rabin Medical Center (Beilinson Campus); Petah Tikvah; Tel Aviv University; Tel Aviv Israel
| | - C. F. Weiniger
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
| |
Collapse
|
33
|
Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. J Obstet Gynecol Neonatal Nurs 2016; 45:227-38. [PMID: 26852254 DOI: 10.1016/j.jogn.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To identify the presence or absence of 38 postpartum hemorrhage preparedness elements in hospitals in New Jersey and Georgia as a component of the Postpartum Hemorrhage Project of the Association of Women's Health, Obstetric and Neonatal Nurses. DESIGN Quality improvement baseline assessment survey. SETTING Hospitals (N = 95) in New Jersey and Georgia. PARTICIPANTS Key informants were clinicians who were members of their hospitals' obstetric teams and were recognized as knowledgeable about their hospitals' postpartum hemorrhage policies. METHODS An electronic survey was sent by e-mail to each identified hospital's key informant. RESULTS The mean number of elements present was 23.1 (SD = 5.2; range = 12-34). Volume of births, students, magnet status, and other hospital characteristics did not predict preparedness. None of the hospitals had all of the 38 preparedness elements available. Less than 50% of the hospitals had massive hemorrhage protocols, performed risk assessments and drills, or measured blood loss. For every 10% increase in the total percentage of African American women who gave birth, there was a decrease of one preparedness element. CONCLUSION Objective measures of preparedness are needed, because perceptions of preparedness were inconsistent with the number of preparedness elements reported.
Collapse
|
34
|
Abstract
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.
Collapse
|
35
|
Temporal Trends in Anesthesia-related Adverse Events in Cesarean Deliveries, New York State, 2003–2012. Anesthesiology 2015; 123:1013-23. [DOI: 10.1097/aln.0000000000000846] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Cesarean delivery (CD) is associated with significantly increased risks of anesthesia-related adverse events (ARAEs) and nonanesthetic perioperative morbidity compared with vaginal delivery. Temporal trends in these adverse outcomes remain unknown despite efforts to improve maternal safety. This study examines temporal trends in ARAEs and nonanesthetic perioperative complications in CDs in New York hospitals.
Methods
Data are from the State Inpatient Database for New York, 2003–2012. ARAEs, including minor and major ARAEs, and nonanesthetic perioperative complications were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Statistical significance in time trends was assessed using the Cochran–Armitage test and multivariable logistic regression.
Results
Of the 785,854 CDs studied, 5,715 (730 per 100,000; 95% CI, 710 to 750) had at least one ARAE and 7,040 had at least one perioperative complication (890 per 100,000; 95% CI, 870 to 920). The overall annual rate of ARAEs decreased from 890 per 100,000 in 2003 to 660 in 2012 (25% decrease; 95% CI, 16 to 34; P < 0.0001). The rate of minor ARAEs decreased 23% (95% CI, 13 to 32) and of major ARAEs decreased 43% (95% CI, 23 to 63). No decrease was observed in the rate of ARAEs for CDs performed under general anesthesia. The rate of nonanesthetic complications increased 47% (95% CI, 31 to 63; P < 0.0001).
Conclusions
Anesthesia-related outcomes in cesarean deliveries appear to have improved significantly across hospitals in New York in the past decade. Perioperative nonanesthetic complications remain a serious healthcare issue.
Collapse
|
36
|
Dahlke JD, Mendez-Figueroa H, Maggio L, Hauspurg AK, Sperling JD, Chauhan SP, Rouse DJ. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines. Am J Obstet Gynecol 2015; 213:76.e1-76.e10. [PMID: 25731692 DOI: 10.1016/j.ajog.2015.02.023] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/31/2014] [Accepted: 02/19/2015] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH). STUDY DESIGN We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation. RESULTS PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy "sooner rather than later" with the assistance of a second consultant. CONCLUSION Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.
Collapse
|
37
|
Muñoz LA, Mendoza GJ, Gomez M, Reyes LE, Arevalo JJ. Anesthetic management of placenta accreta in a low-resource setting: a case series. Int J Obstet Anesth 2015; 24:329-34. [PMID: 26343175 DOI: 10.1016/j.ijoa.2015.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/04/2015] [Accepted: 05/31/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting. METHODS A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted. RESULTS Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred. CONCLUSION A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.
Collapse
Affiliation(s)
- L A Muñoz
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia.
| | - G J Mendoza
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
| | - M Gomez
- Department of Critical Care, Hospital de San Jose, Bogota, Colombia
| | - L E Reyes
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
| | - J J Arevalo
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
| |
Collapse
|
38
|
|
39
|
Moaveni DM, Cohn JH, Zahid ZD, Ranasinghe JS. Obstetric Anesthesiologists as Perioperative Physicians: Improving Peripartum Care and Patient Safety. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0094-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|