Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewRisk assessment tools to predict postpartum hemorrhage.
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, and accurate risk assessments may allow providers to anticipate and prevent serious hemorrhage-related adverse events. Multiple category-based tools have been developed by national societies through expert consensus, and these tools assign low, medium, or high risk of hemorrhage based on a review of each patient's risk factors. ⋯ However, there are no published studies demonstrating external validation or successful clinical use of such models. Future work should include refinement of these models, study of best practices for implementation, and ultimately linkage of prediction to improved patient outcomes.
-
Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewProtocol for postpartum haemorrhage including massive transfusion.
Postpartum haemorrhage (PPH) is one of the most common causes of maternal mortality worldwide. Management of PPH depends on the severity of bleeding. If the bleeding is severe, aorta compression can reduce bleeding. ⋯ During severe ongoing bleeding, haemostasis care includes early tranexamic acid, transfusion in ratio 4:4:1 (blood:plasma:platelets), and extra fibrinogen intravenously. If not severe PPH, use goal-directed therapy. During general anaesthesia and uterine atony, stop volatile anaesthesia and change to intravenous anaesthesia.
-
Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewPoint-of-care coagulation testing for postpartum haemorrhage.
The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. ⋯ There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.
-
Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewProcedural techniques to control postpartum hemorrhage.
Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. ⋯ From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.
-
Best Pract Res Clin Anaesthesiol · Dec 2022
ReviewThe role of tranexamic acid in the management of postpartum haemorrhage.
In the last decades, tranexamic acid (TXA) has emerged as an essential tool in blood loss management in obstetrics. TXA prophylaxis for postpartum haemorrhage (PPH) has been studied in double-blind, placebo-controlled, randomized clinical trials (RCTs). Given the small observed preventive effect, the systematic use of TXA for vaginal and/or caesarean deliveries remains controversial. ⋯ The TRACES in vivo analysis of biomarkers of TXA's antifibrinolytic effect have suggested that a dose of at least 1 g is required for the treatment of PPH. The TRACES pharmacokinetic model suggests that because TXA can be lost in the haemorrhaged blood, a second dose should be administered if the PPH continues or if severe coagulopathy occurs. Future pharmacodynamic analyses will focus on the appropriateness of TXA dosing regimens with regard to the intensity of fibrinolysis in catastrophic obstetric events.