OB case, massive blood loss: thoughts?

[tennisballs]

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30 year old G4 with history of C-section x 3 comes in for scheduled C-section due to placenta previa. Otherwise healthy. Starting Hct 42. Normal weight and airway exam for a pregnant person. 16g PIV with 2L bolus pre-operatively. We decide to have 2 units of blood in the room, already checked in. We put on standard monitors, proceed with spinal anesthesia, baby comes out without any problems.

But as they try to pull the placenta out, some of it is stuck to the uterus. Pitocin is running, the surgeons fish around for a couple of minutes, there is notable bleeding at the surgical field, and they keep saying "Her hematocrit is 42" and "we think we have the bleeding under control." Meanwhile the patient's MAP dips down to the 40s and the patient starts vomiting.

Now there are like 3 anesthesiologists in the room. We immediately start giving blood through a high flow ranger, put in a 2nd IV, induce with etomidate and succinylcholine, intubate with a C-MAC, and then throw in an arterial line.

The patient ends up losing almost 4 liters of blood, getting 7U pRBC and 2U FFP, we keep her intubated and send her to PACU. She ends up doing fine.

What would you guys do differently in retrospect? Action was taken quickly and effectively in this case, but I'm sure others on this discussion board have different ways of approaching a potentially undiagnosed accreta.

 

[OB1🤙]

2nd IV from the start, otherwise sounds fine.

 

[pgg]

I don't think I'd have done anything much different. Maybe had a 2nd good IV from the start since she had a couple risk factors for some blood loss. Maybe closer to 1:1 RBC:FFP ater the first few units of RBCs with ongoing bleeding, but it worked out.

 

[OB1🤙]

For the trainees, the single most important thing to do in these situations is GET HELP. Other pairs of hands are vital.

 

[gasp]

As others have said, 2nd IV from the start connected and ready for all C/S especially an elective with placenta previa with past c/s x3. Otherwise I would have done the same thing. Some anesthesiologist I know would push for GETA from the beginning for a case like this because of the potential for bleeding and further hemodynamic instability complicated by neuroaxial blockade, so that's another option...

 

[Planktonmd]

I am curious... what was the Hct after 7 units of PRBCs?

 

[jetproppilot]

30 year old G4 with history of C-section x 3 comes in for scheduled C-section due to placenta previa. Otherwise healthy. Starting Hct 42. Normal weight and airway exam for a pregnant person. 16g PIV with 2L bolus pre-operatively. We decide to have 2 units of blood in the room, already checked in. We put on standard monitors, proceed with spinal anesthesia, baby comes out without any problems.

But as they try to pull the placenta out, some of it is stuck to the uterus. Pitocin is running, the surgeons fish around for a couple of minutes, there is notable bleeding at the surgical field, and they keep saying "Her hematocrit is 42" and "we think we have the bleeding under control." Meanwhile the patient's MAP dips down to the 40s and the patient starts vomiting.

Now there are like 3 anesthesiologists in the room. We immediately start giving blood through a high flow ranger, put in a 2nd IV, induce with etomidate and succinylcholine, intubate with a C-MAC, and then throw in an arterial line.

The patient ends up losing almost 4 liters of blood, getting 7U pRBC and 2U FFP, we keep her intubated and send her to PACU. She ends up doing fine.

What would you guys do differently in retrospect? Action was taken quickly and effectively in this case, but I'm sure others on this discussion board have different ways of approaching a potentially undiagnosed accreta.

Nothing different.
You did a
GREAT JOB!!!!

I've never understood why some obstetricians are willing to risk a patient's life in an an attempt to save the uterus in a situation like this as opposed to making a

QUICK DECISION,

clamp off it's blood supply and remove it.

 

[jetproppilot]

For the trainees, the single most important thing to do in these situations is GET HELP. Other pairs of hands are vital.

Great advice man. 👍

 

[risnwb]

A previa with a history of c-section x 3 has an extremely high chance of having an accreta. Start with 2 Big lines, I'd have an a-line set up too, and I'd have more blood ready in the room. The high HCT shouldn't be reassuring as it likely means she is dry. (She should have physiologic anemia is pregnancy as plasma volume increases more than the RBCs.)

 

[rsgillmd]

30 year old G4 with history of C-section x 3 comes in for scheduled C-section due to placenta previa. Otherwise healthy. Starting Hct 42. Normal weight and airway exam for a pregnant person. 16g PIV with 2L bolus pre-operatively. We decide to have 2 units of blood in the room, already checked in. We put on standard monitors, proceed with spinal anesthesia, baby comes out without any problems.

But as they try to pull the placenta out, some of it is stuck to the uterus. Pitocin is running, the surgeons fish around for a couple of minutes, there is notable bleeding at the surgical field, and they keep saying "Her hematocrit is 42" and "we think we have the bleeding under control." Meanwhile the patient's MAP dips down to the 40s and the patient starts vomiting.

Now there are like 3 anesthesiologists in the room. We immediately start giving blood through a high flow ranger, put in a 2nd IV, induce with etomidate and succinylcholine, intubate with a C-MAC, and then throw in an arterial line.

The patient ends up losing almost 4 liters of blood, getting 7U pRBC and 2U FFP, we keep her intubated and send her to PACU. She ends up doing fine.

What would you guys do differently in retrospect? Action was taken quickly and effectively in this case, but I'm sure others on this discussion board have different ways of approaching a potentially undiagnosed accreta.

With previous C/S x 3 AND a previa, her risk of accreta is in the range of 60%. Did they investigate for evidence of an accreta prior to taking her back? If accreta was suspected, did they consider doing an elective C-hys and not even messing with the placenta (obviously need to involve the patient in this decision making).

Either way, I would do a CSE. This way if the bleeding isn't too bad, you can consider extending the duration of your block via epidural. But if it looks like I'm going to be giving lots of fluid and products I am aggressive about converting to GA early because it's amazing how fast people develop facial/airway edema.

Hct of 42 in a term pregnant woman is suspicious for dehydration. Usually around 35-36% or lower (we get a lot of patients who run around 30% or less in my area).

I don't know what your MAPs were to begin with, but remember (as a general rule of thumb), by the time you see hypotension the patient has lost at least 20-25% of her blood volume. When deciding about replacing blood, keep in mind that you need to consider not only how much has already been lost, but ongoing losses, and predicted future losses as well. Although there is some controversy around it these days, I still tend to keep my acute blood replacement cases at 1:1 or 1:1.5 FFP😛RBC.

Don't forget to redose your antibiotic when your blood loss stabilizes.

Second IV to start with, as others have said.

Other than being prepared (which it sounds like you mostly were), not much else you could have done differently.

 

[Lurch]

1:1.5 FFP to PRBC and redosing abx in the setting of massive transfusion are both new concepts to me. Are these specific to your institution or are these becoming more established/based on papers I should know about? Thanks.

 

[Ignatius J]

2nd IV from the start, otherwise sounds fine.

Yep, and if she had good veins, I would probably have just let it ride like yourself. Arms are out and easily accessible, veins are popping and ready to be cannulated, just wait and see like you did.

If you are at least average at getting IVs, it should take an extra minute to thread off a catheter in a vein.

If she didn't have the best veins, I would have thrown another one in before the surgery to be safe.

Looks like you did good. These stories are a dime a dozen in OB land, and sounds like you handled it with aplumb (sp?)

 

[gasp]

Yep, and if she had good veins, I would probably have just let it ride like yourself. Arms are out and easily accessible, veins are popping and ready to be cannulated, just wait and see like you did.

If you are at least average at getting IVs, it should take an extra minute to thread off a catheter in a vein.

If she didn't have the best veins, I would have thrown another one in before the surgery to be safe.

Looks like you did good. These stories are a dime a dozen in OB land, and sounds like you handled it with aplumb (sp?)

Just because she had good veins doesn't mean you will be able to get an IV if/when s*** hits the fan. Even if you're great at IV's, the adrenaline rush during a situation like that may impair your technique. Also if the pt has acute blood loss complicated by vasodilation in the LE (from your spinal), all her "good" veins in the upper extremities may dissapear. Its always a good idea to just have 2 running IV's so you dont' have to worry about it...my 2 cents.

 

[OB1🤙]

I have never, not even once, thought to myself, "Man, putting in that extra IV was a bad decision. Wish I hadn't done that."

It's an IV, not a swan. If I go so far as to have blood in the room and checked, I'm gonna have two big IVs to run them in.

 

[dhb]

2L bolus pre-operatively

Probably wouldn't give 2l pre-op unless she was dehydrated (which might have been the case eg. the hct) diluting blood factors is not what you want in this situation although if it was a placenta acreta it wouldn't be a game changer.

 

[jwk]

We activate our massive transfusion protocol for these types of cases (we do far more OB disasters than trauma and vascular) as soon as it is apparent blood loss will be an issue. Inherent in that is we automatically get more help, including an additional circulating nurse who is assigned whose and who's sole responsibility is to deal with us and the blood bank - arranging for blood pick up, checking crossmatched blood with us, etc. Having the 2nd IV and blood in the room prior to incision is always a great idea.

Our MTP calls for 4 PRBC, 4 FFP in the first pack and 1 platelet pheresis pack. The 2nd pack gets the same + 20 units of cryoprecipitate. Each even numbered pack is the same, and each odd numbered pack is the same. With the 4th pack, the pharmacy adds NovoSeven. Each time a pack is released, the blood bank starts working on the next one until we say stop.

 

[dhb]

We activate our massive transfusion protocol for these types of cases (we do far more OB disasters than trauma and vascular) as soon as it is apparent blood loss will be an issue. Inherent in that is we automatically get more help, including an additional circulating nurse who is assigned whose and who's sole responsibility is to deal with us and the blood bank - arranging for blood pick up, checking crossmatched blood with us, etc. Having the 2nd IV and blood in the room prior to incision is always a great idea.

Our MTP calls for 4 PRBC, 4 FFP in the first pack and 1 platelet pheresis pack. The 2nd pack gets the same + 20 units of cryoprecipitate. Each even numbered pack is the same, and each odd numbered pack is the same. With the 4th pack, the pharmacy adds NovoSeven. Each time a pack is released, the blood bank starts working on the next one until we say stop.

Good work!

 

[Idiopathic]

ill say this. having seen several true accreta/percreta cases, I always want to know what the placental status is of any definite previa. occasionally these patients will have had MRI or some other staging exam in order to determine that, but I think i would agree that 2nd IV up front would be reasonable regardless in a patient with known previa, although i dont routinely place that second IV in uncomplicated cesarean.

a little curious about HCT of 42 preop, that suggests significant volume depletion, as it should be 30-35 at term, perhaps this is why 2L of crystalloid up front.

essentially, you had postpartum hemorrhage in the OR, for which abnormal placentation is a known risk factor, managed it appropriately, and your patient did well. i think your patient was more hypovolemic up front than you realized and perhaps a colloid preload would have been more beneficial at staving off hypotension later in the case. still would have needed blood and plasma.

low threshold for DIC labs here too, you didnt comment, but I assume you sent them

good work

 

[jetproppilot]

We are

SUPPORTING CAST

PHYSICIANS.

We sometimes are left with

CLEANING UP THE MESSES OF SURGEONS.

I find it remarkable that noone has realized that the

OB/GYN "surgeon" 🙂laugh🙂

could've prevented this

DEBACLE

with decisive decisions.

 

[jwk]

We are

SUPPORTING CAST

PHYSICIANS.

We sometimes are left with

CLEANING UP THE MESSES OF SURGEONS.

I find it remarkable that noone has realized that the

OB/GYN "surgeon" 🙂laugh🙂

could've prevented this

DEBACLE

with decisive decisions.

I think you can definitely avoid the unexpected cluster - f c k - these are cases that should almost always be known about and planned for ahead of time. But the accreta problem itself keeps coming more frequently as we do more and more repeat C-sections.

 

[anonperson]

30 year old G4 with history of C-section x 3 comes in for scheduled C-section due to placenta previa. Otherwise healthy. Starting Hct 42. Normal weight and airway exam for a pregnant person. 16g PIV with 2L bolus pre-operatively. We decide to have 2 units of blood in the room, already checked in. We put on standard monitors, proceed with spinal anesthesia, baby comes out without any problems.
.

Speaking from the OB side. Was there a discussion of a likely accreta in this situation? A patient with 3 prior C/Ds and a current previa has a fairly high likelihood of having a placenta accreta and although they are picked up often by U/S, no imaging test is perfect.

This would lead into the additional IV placement and having blood products available and like others have echoed having the massive transfusion protocol ready to go. Another thought is potentially having a cell saver available which again would require advance notice.

The other issue would be where the case would be done. I would probably be more likely to do this case in the main OR rather than in a L and D OR and have additional back up in the form of gyn onc.

The other option if interventional radiology was available would be for prophylactic uterine artery balloon catheters which have been shown to be fairly effective.

I would have a low threshold for a hysterectomy in this situation.

The main thing with this case is the need for a lot of advanced planning. It's hard to gauge whether this was adequately done in this scenario because this surgery requires a lot of cross coordination with anesthesia, OB, and the transfusion service.

 

[anonperson]

We are

SUPPORTING CAST

PHYSICIANS.

We sometimes are left with

CLEANING UP THE MESSES OF SURGEONS.

I find it remarkable that noone has realized that the

OB/GYN "surgeon" 🙂laugh🙂

could've prevented this

DEBACLE

with decisive decisions.

It's a little lame to see the quote around the word surgeon. Way to diminish another colleague. It's also easy to be a monday morning quarterback on a second hand account and say that a hysterectomy was the best option. It most likely would have been but we don't have all the facts. A cesarean hysterectomy has a decent amount of morbidity and can be technically challenging. The average blood flow to a term uterus is ~500-600 cc/min. This isn't some post menopausal hysterectomy we're dealing with.

 

[VentdependenT]

duplicate

 

[VentdependenT]

We activate our massive transfusion protocol for these types of cases (we do far more OB disasters than trauma and vascular) as soon as it is apparent blood loss will be an issue. Inherent in that is we automatically get more help, including an additional circulating nurse who is assigned whose and who's sole responsibility is to deal with us and the blood bank - arranging for blood pick up, checking crossmatched blood with us, etc. Having the 2nd IV and blood in the room prior to incision is always a great idea.

Our MTP calls for 4 PRBC, 4 FFP in the first pack and 1 platelet pheresis pack. The 2nd pack gets the same + 20 units of cryoprecipitate. Each even numbered pack is the same, and each odd numbered pack is the same. With the 4th pack, the pharmacy adds NovoSeven. Each time a pack is released, the blood bank starts working on the next one until we say stop.

Why do you have Novo7 added if you are giving cryo. Slappen in plates after 4&4 seems premature. Anyhoots Ive used novo7 in refractory bleeding but I havent standardly added it after replacement of one blood volume. Tranexamic may be good. Just curious.

 

[Idiopathic]

other options are available if thought out preoperatively. the poster above mentioned prophylactic securing of the uterine arteries, we have sent people to IR before the OR for this very thing, and they will place balloons under imaging that can be inflated to obstruct uterine artery blood flow, has saved us more than once. also, the placenta does not have to be removed at this time, right? some people deliver the baby and then leave the placenta, administer methotrexate, allow it to involute and come back some time later (?) for D&C. This is pretty conservative, though and it isnt frequently done.

ive called in cell saver and not used them, ive put more than a couple of these patients to sleep and placed big lines, a few unnecessarily - these cases get my tone up more than the average AAA, honestly, and id much rather a patient go to PACU with a bandaid on their neck and a sore throat then intubating under the drapes an hour into the case.

 

[Idiopathic]

Why do you have Novo7 added if you are giving cryo. Slappen in plates after 4&4 seems premature. Anyhoots Ive used novo7 in refractory bleeding but I havent standardly added it after replacement of one blood volume. Tranexamic may be good. Just curious.

he said in the fourth box (with units 16 of RBC and FFP). im not in favor of using it when there is still surgical bleeding, but i suppose you could give or hold it based on the scenario

 

[ssmallz]

Yep, and if she had good veins, I would probably have just let it ride like yourself. Arms are out and easily accessible, veins are popping and ready to be cannulated, just wait and see like you did.

If you are at least average at getting IVs, it should take an extra minute to thread off a catheter in a vein.

If she didn't have the best veins, I would have thrown another one in before the surgery to be safe.

Looks like you did good. These stories are a dime a dozen in OB land, and sounds like you handled it with aplumb (sp?)

IMO, all high risk OB pts should get 2 PIVs before the case if possible. It's not so much that we can throw it in if the $hit hits the fan, it's that when the $hit hits the fan, the last thing you wanna do is worry about getting more IV access. In the above scenerio we've already checked in blood prior to starting which means we're anticipating this case going pooly and likely going to have to give blood so a 2nd IV should be a no brainer.

 

[VentdependenT]

he said in the fourth box (with units 16 of RBC and FFP). im not in favor of using it when there is still surgical bleeding, but i suppose you could give or hold it based on the scenario

My bad. The new black is 1:1:1 rbc,ffp,plate for the big bleeders. Not sure how i'd run that.

Classically I remember: 1:1 or 1:2 ffp😛rbc then after 10u prbc give plates. (plates shouldnt drop to <50k until >1.5 blood volume lost anyways). After 1 blood volume (approx 16-18 prbc:ffp) give cryo. Need 75% loss of coagulation factors (again roughly 1.5 blood volume) gone to get coagulopathic.

Response to platelet transfusion variable.

One thing is clear: STOP THE BLEEDING.

Soooo
12uprbc:8ffp:6pack plates
add cryo and mass plates once you hit 20 prbc:ffp.
Sound right?

If fibrino his <150 then hit em with cryo.

Perhaps I need to be more heavy handed with the platelets...

I aint talking about bypass folks who get all this funky massive trauma like coagulopathies and micro oozing (whom id have a lower threshold to fling novo7 at.). Them days are over for me.

 

[Idiopathic]

My bad. The new black is 1:1:1 rbc,ffp,plate for the big bleeders. Not sure how i'd run that.

Classically I remember: 1:1 or 1:2 ffp😛rbc then after 10u prbc give plates. (plates shouldnt drop to <50k until >1.5 blood volume lost anyways). After 1 blood volume (approx 16-18 prbc:ffp) give cryo. Need 75% loss of coagulation factors (again roughly 1.5 blood volume) gone to get coagulopathic.

Response to platelet transfusion variable.

One thing is clear: STOP THE BLEEDING.

Soooo
12uprbc:8ffp:6pack plates
add cryo and mass plates once you hit 20 prbc:ffp.
Sound right?

If fibrino his <150 then hit em with cryo.

Perhaps I need to be more heavy handed with the platelets...

I aint talking about bypass folks who get all this funky massive trauma like coagulopathies and micro oozing (whom id have a lower threshold to fling novo7 at.). Them days are over for me.

id argue with your definition of a blood volume. 16 U PRBC equivalent of 4L of PRBC but hematocrit usually 70 or so, couple that with the FFP and thats about 8L of HCT 35 blood. For me I consider 8:8 as a blood volume in almost everybody and Id be giving cryo and would have already given platelets. We certainly arent giving plates at equal ratios, but rather 6:4:2 or 4:4:1 something like that. Skip the clear fluids, dont forget about platelets and cryo and I think thats the new MTP paradign in a nutshell

 

[pgg]

Don't forget to give early TXA a thought too, especially if the bleeding looks significant and likely to be ongoing. Recent thread on that.

 

[VentdependenT]

id argue with your definition of a blood volume. 16 U PRBC equivalent of 4L of PRBC but hematocrit usually 70 or so, couple that with the FFP and thats about 8L of HCT 35 blood. For me I consider 8:8 as a blood volume in almost everybody and Id be giving cryo and would have already given platelets. We certainly arent giving plates at equal ratios, but rather 6:4:2 or 4:4:1 something like that. Skip the clear fluids, dont forget about platelets and cryo and I think thats the new MTP paradign in a nutshell

Ahh yes. 8L blood volume is a bit high. I guess I was just thinking about prbc. The old vent is gettin rusty. Anypoops by 6:4:2 you are giving 2 "6 packs/single donor units?"

From back in the day I don't recall hangin cryo until later.

 

[Idiopathic]

Ahh yes. 8L blood volume is a bit high. I guess I was just thinking about prbc. The old vent is gettin rusty. Anypoops by 6:4:2 you are giving 2 "6 packs/single donor units?"

From back in the day I don't recall hangin cryo until later.

yeah i typically only hang cryo for fibrinogen levels <150 with bleeding or <300 with bleeding in cardiac cases. I rarely just give it empirically, unless my feeling is that we are falling way behind (which, i suppose, could be indicated by needing a 3rd MTP cooler). TEG is your friend (maybe RO-TEM as well although I dont use it) if you have it.

 

[Idiopathic]

Don't forget to give early TXA a thought too, especially if the bleeding looks significant and likely to be ongoing. Recent thread on that.

yeah in my opinion you really need to have a handle on whether this is DIC or not before giving TXA. It probably should be avoided in severe, ongoing DIC

 

[Ignatius J]

IMO, all high risk OB pts should get 2 PIVs before the case if possible. It's not so much that we can throw it in if the $hit hits the fan, it's that when the $hit hits the fan, the last thing you wanna do is worry about getting more IV access. In the above scenerio we've already checked in blood prior to starting which means we're anticipating this case going pooly and likely going to have to give blood so a 2nd IV should be a no brainer.

That's fine and all, but there's only 20 seconds difference between an IV in a vein and an IV kit on the cart. I don't think getting a second PIV is the wrong thing to do. If the veins are there, I'll save the patient a stick until I need to act. No right or wrong, IMO.

 

[Idiopathic]

That's fine and all, but there's only 20 seconds difference between an IV in a vein and an IV kit on the cart. I don't think getting a second PIV is the wrong thing to do. If the veins are there, I'll save the patient a stick until I need to act. No right or wrong, IMO.

famous last words. my advice is "one IV is no IVs". in a case like this where patients are usually somewhat edematous, larger and every so often prone to pulling IVs out when they come under distress, such as when they know something is wrong, you really need to be confident that you can get that second IV in the midst of ongoing large volume blood loss and with other things going on. what if you are by yourself? i think most all of us would start that IV upfront, especially if you are getting blood into the room preop

 

[pgg]

yeah in my opinion you really need to have a handle on whether this is DIC or not before giving TXA. It probably should be avoided in severe, ongoing DIC

In a previa-turned-accreta with uterine atony and observed uterine bleeding, DIC isn't high on my list. I'd go ahead and give it after the first 4+4 if there was an apparent need for more blood products.

 

[Agast]

I got the sense from my OB rotation that atony of the lower uterine segment is often resistant to pitocin - were there any other agents given? Also, once it became clear that there was an accreta and the surgeons were having some difficulty controlling the bleeding was there any discussion of calling for help from a vascular surgeon? It doesn't matter how great of an anesthesiologist you are if the surgeons can't control the bleeder. What sort of pressors did you use and was there any clamping of the aorta?

 

[Idiopathic]

In a previa-turned-accreta with uterine atony and observed uterine bleeding, DIC isn't high on my list. I'd go ahead and give it after the first 4+4 if there was an apparent need for more blood products.

sounds like you have a handle on it...my only point is that TXA or amicar is not indicated in all bleeding, and this scenario actually is a setup for DIC.

 

[Idiopathic]

ACOG committee opinion on accreta. worth the read and why i always suspect it in repeat sections with known previa - always try to get an idea of where the placenta is.

http://www.acog.org/Resources And P...e on Obstetric Practice/Placenta Accreta.aspx

Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall (1). When the chorionic villi invade only the myometrium, the term placenta increta is appropriate; whereas placenta percreta describes invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder. Clinically, placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by massive obstetric hemorrhage, leading to disseminated intravascular coagulopathy; the need for hysterectomy; surgical injury to the ureters, bladder, bowel, or neurovascular structures; adult respiratory distress syndrome; acute transfusion reaction; electrolyte imbalance; and renal failure. The average blood loss at delivery in women with placenta accreta is 3,000–5,000 mL (2). As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells. Maternal mortality with placenta accreta has been reported to be as high as 7% (3). Maternal death may occur despite optimal planning, transfusion management, and surgical care. From a cohort of 39,244 women who underwent cesarean delivery, researchers identified 186 that had a cesarean hysterectomy performed (4). The most common indication was placenta accreta (38%).

 

[dhb]

disseminated intravascular coagulopathy

Hate this term

 

[HollATme]

I would do preop 14g PIV x 2 and a-line. also epidural for post-op pain relief.

If they know this is an accreta they should have IR involved or just clamp the vessels, they shouldn't try to tug at the placenta and instead should have discussed a hysterectomy.

 

[SexPanther]

sounds like you have a handle on it...my only point is that TXA or amicar is not indicated in all bleeding, and this scenario actually is a setup for DIC.

While I don't disagree, so are some of the bad traumas we take care of and the anti-fibrinolytics have been beneficial in those settings. We probably should be thinking of these agents more in the setting of massive transfusion. IMO, if given early and in the context of limited non-blood resuscitation, we can possibly prevent the deterioration into DIC that can be seen in any exsanguination/coagulopathy gone wild.

 

[Idiopathic]

You make a good point. when started early, an antifibronolytic may help prevent or minimize the diffuse microvascular oozing often seen with cardiopulmonary bypass or large volume resuscitation. however, it may not always be prudent to start it well into this bleeding. we start these early in traumas and give a bolus well before going on CPB in the heart rooms.

take home message, be careful with TXA and DIC. something i may integrate into my practice: if you have an accreta/increta, start the TXA as soon as the baby is out (I guess? unsure of risk to baby).

 

[fakin' the funk]

As others have said, 2nd IV from the start connected and ready for all C/S

Really? In your routine, non-high-risk, non-previa non-accreta C/S's you start a 2nd IV? How often do you need to give more than 1 good IV wide-open during a C/S? How often do you transfuse in non-hish-risk, non-previa C/S's?

 

[Idiopathic]

also, think about the cost of the IV, tubing and saline, not to mention fluid warmers and time spent placing it. it just isnt needed in 99% of cases, and most of the time you are able to predict up front who may need one

 

[gasp]

Really? In your routine, non-high-risk, non-previa non-accreta C/S's you start a 2nd IV? How often do you need to give more than 1 good IV wide-open during a C/S? How often do you transfuse in non-hish-risk, non-previa C/S's?

Are you asking or mocking? I can't really tell. Anyways, most of my patients are high risk and obese. No, I don't transfuse often but that's besides the point. The OB nurses actually put in 2 IV's for all c/s at my institution as it is the OB dept policy. Someone else on this thread mentioned that having 2 is like having 1 and having 1 is like having none and I agree with that. There's lots of ways to skin a cat, do it how you like best.

 

[fakin' the funk]

also, think about the cost of the IV, tubing and saline, not to mention fluid warmers and time spent placing it. it just isnt needed in 99% of cases, and most of the time you are able to predict up front who may need one

+1

That's called patient selection. It rocks.

 

[jetproppilot]

It's a little lame to see the quote around the word surgeon. Way to diminish another colleague. It's also easy to be a monday morning quarterback on a second hand account and say that a hysterectomy was the best option. It most likely would have been but we don't have all the facts. A cesarean hysterectomy has a decent amount of morbidity and can be technically challenging. The average blood flow to a term uterus is ~500-600 cc/min. This isn't some post menopausal hysterectomy we're dealing with.

Indeed it is easy to

ARMCHAIR QUARTERBACK,

"DOCTOR."

I've been involved in many, many,

(Did I mention MANY?)

cases

EXACTLY LIKE THIS

AND I JUST DON'T GET IT.

What don't I get?

Why some obstetricians are willing to

RISK THE MOTHER'S LIFE IN ORDER TO SAVE A

UTERUS.

I'm gonna give you an ESPN

"C'MON MAN!!!??!!!"

I mean,



THIS IS RISKING HER LIFE,

DOCTOR!!!!

HEMODYNAMIC INSTABILITY. MASSIVE BLOOD LOSS. COAGULOPATHY.

7 UNITS OF PRBCS, 2 UNITS OF FFP,

A MOM GOES TO PACU

INTUBATED

AFTER A C-SECTION with accreta and a

FOUR LITER BLOOD LOSS

For what?

I just don't get the logic. Why some obstetricians are SOOOOO bent on SAVING THE UTERUS, even if their patient's life LITERALLY hangs perilously to their decision making, when a

DECISIVE DECISION TO CLAMP THE BLOOD SUPPLY TO THE UTERUS...

...RIGHT NOW

can change the entire outcome of these cases.

I've worked with a FEW

(A VERY FEW)

ROKKSTARR

OB/GYNs whose surgical skills and decision making are on par with a

ROKKSTARR GENERAL SURGEON.

Those dudes/dudettes would've

CLAMPED THE BLOOD SUPPLY TO THE UTERUS

AND YANKED IT OUT

IN A

NEW YORK MINUTE.

No dramatic resuscitation with units and units of packed red blood cells and fresh frozen plasma and your friendly anesthesiologist colleague

BUSTING A SS

TO SAVE YOURS

required.

You refer to the morbidity of a hysterectomy during a C-Section.

I can

confidently tell you said morbidity is dramatically lower than

trying to save an organ while we all watch the mother

Bleed To Death.

 

[jetproppilot]

Are you asking or mocking? I can't really tell. Anyways, most of my patients are high risk and obese. No, I don't transfuse often but that's besides the point. The OB nurses actually put in 2 IV's for all c/s at my institution as it is the OB dept policy. Someone else on this thread mentioned that having 2 is like having 1 and having 1 is like having none and I agree with that. There's lots of ways to skin a cat, do it how you like best.

Unfortunately for you and your response to

FAKIN',

FAKIN' IS RIGHT MAN.

I mean,

REALLY?

You put in two IVs for

EVERY C-SECTION?

Dude,

THE WORLD COULD COME TO AN END TOMORROW. THAT DOESN'T MEAN RIGHT NOW CURRENT DAY I'M STOCK PILING FOOD AND DIGGING BUNKERS LIKE THE COMPLETELY CRAZY PEOPLE ON THAT RIDICULOUS REALITY TV SHOW.

You don't need a second IV for your cases man.

Trust me.

It's gonna be ok.

FAKE IS RIGHT.

Tell your nurses you only need ONE REALLY GOOD IV.

In case you missed it, your policy of 2 IVs on every patient is

STUPID.

THAT'S

NURSE STUPIDVISOR

KINDA S HIT MAN.

Just for the record.

 

[Idiopathic]

I so rarely agree with jet that I bring it up every time it happens.

This is one of those times.