1、医院管理案例剖析医院管理案例剖析-美国医院产妇大出血的管理美国医院产妇大出血的管理Massive transfusion Most common cause trauma,less AAA and obstetric MT to maintain hemodynamic stability and improve tissue oxygenationHigh mortality from hemorrhagic shock.Early recognition of associated coagulopathy is essential to improve outcome.Survival
2、advantage of increased plasma and platelet:red cell ratioIn the obstetric patient,massive bleeding may routinely consume fibrinogen despite available thrombin,hence differences might exist in mechanism of coagulopathy in different patient populations.PRACTICE GUIDELINE:MASSIVE TRANSFUSION PROTOCOL(M
3、TP)PURPOSE:To outline the process of providing rapid restoration of intravascular blood volume,maintain oxygen carrying capacity,and coagulability of the blood.PRINCIPLE:The transfusion service will maintain a readily available supply of blood products in the blood bank to expedite a request for eme
4、rgent uncrossmatched transfusion.That supply will include Packed Red Blood Cells(PRBC),Fresh Frozen Plasma(FFP)(plasma takes approximately 30 minutes to thaw),and a single donor platelet(apheresis product)and Cryoprecipitate,if needed.Pharmacy will store Recombinant Factor VIIa and Factor IX Complex
5、.Products will be administered and patient monitored to promote optimal outcomes.MTP-INITIATION:Initial blood specimen must be drawn,properly labeled and sent for type and cross matching.Telephone Blood Bank at x5330 to activate Massive Transfusion Protocol and request release of 4 units PRBCs,4 uni
6、ts FFP,and 1 Single Donor Platelet(apheresis product).This order will initiate MTP provide patients name,gender,age or date of birth or MR#.Blood Bank will notify the Blood Bank Medical Director that an MTP has been activated.MTP INITIATION 2:4-4-1While waiting for the specimen,Blood Bank will relea
7、se uncrossmatched products as needed per physician order.Form filled and signed by a physician will be sent to the Blood Bank.NP/designee pick-up products.Blood product availability O-blood is available immediately.4 units will be released.Due to limited supply of O-blood,O+blood should be considere
8、d for all adult males and for females over 50.Uncrossmatched ABO,Rh compatible blood:Up to 4 units available in 15 minutes after sample received.Compatible Crossmatched type compatible blood:4-8 units available in 45 minutes after sample received.Blood product availability Type Compatible Fresh Froz
9、en Plasma:up to 4 units available 45 minutesPlatelet Pheresis:available in 15 minutes or delivery from blood center.Cryoprecipitate:up to a pool of 10 available in 45 minutesAll packed cells will be administered through a large bore intravenous catheter via warming device and/or rapid infuser.Labs:H
10、gb/Hct,Na+,K+,Glucose,ABG/VBG,PT/PTT,Platelets,Fibrinogen,D-Dimer,INRRecord all fluid infused,all blood products given,and all output on flow sheet.Nurse NurseMonitor vital signs including temperature every 15 min.Obtain recombinant factors and anti-fibrinolytic medications from pharmacy as requeste
11、d by the physician.Platelet products not transfused immediately must be returned to the Blood Bank within 30 minutes of issue.PRBC and plasma may be stored in validated blood coolers for up to four hours,but should be returned to the laboratory as soon as it is determined they will not be required f
12、or transfusion.MTP-DiscontinuationThe MTP must be discontinued by the ordering trauma surgeon/obstetrician/anesthesiologist or designee.BLOOD BANK MUST BE CALLED.All patients treated under protocol will be reviewed to assure quality is maintained.Quality assurance indicators will include:timeliness,
13、quality/appropriateness of products used,wastage,adjunct use(warmer,infuser),and documentation.MT-ComplicationsHypothermia(低温）Acidosis（酸中毒）Coagulopathy（凝血障碍）Hyperkalemia and Hypokalemia(高钾和低钾症)Citrate Toxicity(柠檬酸中毒)HypothermiaHypothermia due to rapid transfusion of large amounts of cold blood can c
14、ause arrhythmias or cardiac arrest.Hypothermia is avoided by using an IV set with a heat-exchange device that gently warms blood.Other means of warming blood(eg,microwave ovens)are contraindicated because of potential RBC damage and hemolysis.AcidosisLack of adequate tissue perfusion can lead to met
15、abolic acidosis(base deficit and lactic acid concentration)pH in units of red blood cells declines throughout the course of their storageCitrate(anticoagulant)CharacteristicPre-storagePost-storagepH6.86.4ATP(mol/g Hb)4.12.9DPG(mol/g Hb)9.00.3Potassium(mEq/L)2.463Glucose(mg/dl)608402Plasma Hb(mg/dl)3
16、9372Hemolysis(%)-0.61Coagulopathy Important clinical problem-multifactorial event.Dilution of platelets and clotting factorsHypothemia Patients may have a complex coagulation disorder involving dilution of pro-coagulant,anti-coagulant,pro-fibrinolytic and anti-fibrinolytic factors x,xi,xii.Acute coa
17、gulopathy of trauma appears to be due to activation of anticoagulant and fibrinolytic pathways,xiiiCycle#1#2#3RBCs4 u4 u4 uFFP4 u4 u4 uPlatelets1 pack 1 pack1 packCryo/Fibgn -10 u10 uRFVIIa-ConsiderStrongly considerOB PATIENTSCycle#1#2#3RBCs4 u4 u4 uFFP4 u4 u4 uPlatelets1 pack1 pack1 packCryo/Fibgn
18、-Consider 10 uRFVIIa-ConsiderConsiderPCC-Consider TXA Consider continuing pre-hospital protocol or initiating*Caution with combinations TXA,RFVIIa or PCCTRAUMA PATIENTSHyperkalemia and Hypokalemia(高钾和低钾症)Intracellular K+of stored RBCs leaked into plasma.Usually transient but can be problem in renal
19、failure patient.Hypokalemia happens when K+depleted donor RBCs take ion intracellularly and citrate also causes move of K+into cells.Treatment is usually not necessary.Citrate ToxicityCitrate(柠檬酸)antocoagulant,binding to calcium resulting in hypocalcemia(低钙症).With a normal live function,citrate is r
20、apidly metabolized.Hypocelcemia causes neuronal excitability,tingling,lightheadedness,shivering,muscle camps,spasmlung(hyperventilation)and depresses heart function.Usually treated by slowing the transfusion.Consider calcium replacement when Ca2+50%of normal value.Complications of TransfusionCommon complicationsFebrile nonhemolytic reactionsAllergic reactionSerious complicationsTransfusion-related acute lung injury(1 in 5,000-10,000)Acute hemolytic reaction due to ABO incompatibilityGVHDOther:infection,circulatory overloadThank You.
