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Medical Stabilization a bleeding patient

Medical Stabilization a bleeding patient. Mohammad Faranoush,MD Associate Professor Rasool Akram Medical Center. Preparation. Women with known or suspected medical problems should be identified and evaluated.

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Medical Stabilization a bleeding patient

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  1. Faranoush,Gyn seminar

  2. Medical Stabilization a bleeding patient Mohammad Faranoush,MD Associate Professor Rasool Akram Medical Center Faranoush,Gyn seminar

  3. Preparation • Women with known or suspected medical problems should be identified and evaluated. • Plans for care and monitoring in the immediate postoperative period should be made in conjunction with an anesthesiologist, the woman's primary care provider, and medical specialists, as indicated. Faranoush,Gyn seminar

  4. Preparation • Arrangements may also be necessary for home health care nursing services and rehabilitation centers for care of frail patients or those with complications that require more intensive management. Faranoush,Gyn seminar

  5. PREOPERATIVE EVALUATION  • Preoperative evaluation with a focus on preventing and preparing for perioperative hemorrhage Faranoush,Gyn seminar

  6. Hematologic • Hematologic assessment may lead to the identification of disorders such as anemia, inherited or acquired coagulopathy, or a hypercoagulable state. • Substantial morbidity may derive from failure to identify these abnormalities preoperatively. • The need for perioperative prophylaxis for venous thromboembolism must be carefully reviewed in every surgical patient. Faranoush,Gyn seminar

  7. Anemia • Anemia is the most common laboratory abnormality encountered in preoperative patients. • It is often asymptomatic and can require further investigation to understand its cause. • The history and physical examination may uncover subjective complaints of energy loss, dyspnea, or palpitations, and pallor or cyanosis may be evident Faranoush,Gyn seminar

  8. Anemia • Patients are evaluated for lymphadenopathy, hepatomegaly, or splenomegaly, and pelvic and rectal examinations are performed. • A CBC, reticulocyte count, and serum iron, total iron-binding capacity, ferritin, vitamin B12, and folate levels are obtained to investigate the cause of anemia. Faranoush,Gyn seminar

  9. Transfusion • The decision to transfuse a patient perioperatively is made with consideration of the patient's underlying risk factors for ischemic heart disease and the estimated magnitude of blood loss during surgery. Faranoush,Gyn seminar

  10. Anemia • Generally, patients with normovolemic anemia without significant cardiac risk or anticipated blood loss can be managed safely without transfusion, with most healthy patients tolerating hemoglobin levels of 6 or 7 g/dL Faranoush,Gyn seminar

  11. Guidelines for Red Blood Cell Transfusion for Acute Blood Loss • Evaluate the risk for ischemia • Estimate/anticipate the degree of blood loss. • Less than 30% rapid volume loss probably does not require transfusion in a previously healthy individual Faranoush,Gyn seminar

  12. Transfusion • Measure the hemoglobin concentration: <6 g/dL, transfusion usually required; • 6-10 g/dL, transfusion dictated by clinical circumstance; • >10 g/dL, transfusion rarely required Faranoush,Gyn seminar

  13. Transfusion • Measure vital signs/tissue oxygenation when hemoglobin is 6-10 g/dL and the extent of blood loss is unknown. Tachycardia and hypotension refractory to volume suggest the need for transfusion; O2 extraction ratio >50%, decreased Vo2, suggest that transfusion is usually needed Faranoush,Gyn seminar

  14. Assessment • All patients undergoing surgery are questioned to assess their bleeding risk. • Coagulopathy may result from inherited or acquired platelet or factor disorders or may be associated with organ dysfunction or medications Faranoush,Gyn seminar

  15. History • The inquiry begins with direct questioning about a personal or family history of abnormal bleeding. • Supporting information includes a history of easy bruising or abnormal bleeding associated with minor procedures or injury. Faranoush,Gyn seminar

  16. History • A history of liver or kidney dysfunction or recent common bile duct obstruction needs to be elicited, as well as an assessment of nutritional status. • Medications are carefully reviewed, and the use of anticoagulants, salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), and antiplatelet drugs are noted Faranoush,Gyn seminar

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  21. Physical examination • Physical examination may reveal bruising, petechiae, or signs of liver dysfunction. Faranoush,Gyn seminar

  22. thrombocytopenia • Patients with thrombocytopenia may have qualitative or quantitative defects as a result of immune-related disease, infection, drugs, or liver or kidney dysfunction. Faranoush,Gyn seminar

  23. Platelets • Qualitative defects may respond to medical management of the underlying disease process, whereas quantitative defects may require platelet transfusion when counts are less than 50,000 in a patient at risk for bleeding Faranoush,Gyn seminar

  24. coagulation studies • Although are not routinely ordered, patients with a history suggestive of coagulopathy undergo coagulation studies before surgery. • Coagulation studies are also obtained before the procedure if considerable bleeding is anticipated or any significant bleeding would be catastrophic. Faranoush,Gyn seminar

  25. Consultation • Patients with documented disorders of coagulation may require perioperative management of factor deficiencies, often in consultation with a hematologist Faranoush,Gyn seminar

  26. INR • Patients receiving anticoagulation therapy usually require preoperative reversal of the anticoagulant effect. • In patients taking warfarin, the drug is withheld for four scheduled doses preoperatively to allow the international normalized ratio (INR) to fall to the range of 1.5 or less (assuming that the patient is maintained at an INR of 2.0-3.0). Faranoush,Gyn seminar

  27. Risk-benefit analysis • Additional recommendations for specific diagnoses requiring chronic anticoagulation are based on risk-benefit analysis. • Patients with a recent history of venous thromboembolism or acute arterial embolism frequently require perioperative IV heparinization because of an increased risk for recurrent events in the perioperative period Faranoush,Gyn seminar

  28. Thromboembolism • Systemic heparinization can often be stopped within 6 hours of surgery and restarted within 12 hours postoperatively. • When possible, surgery is postponed in the first month after an episode of venous or arterial Thromboembolism. • Patients taking anticoagulants for less than 2 weeks for pulmonary embolism (PE) or proximal DVT are considered for inferior vena cava filter placement before surgery Faranoush,Gyn seminar

  29. Assessment • All surgical patients are assessed for their risk for venous thromboembolism and receive adequate prophylaxis according to current guidelines. • Patients are questioned to elicit any personal or family history suggestive of a hypercoagulable state. • Levels of protein C, protein S, antithrombin III, and antiphospholipid antibody can be obtained Faranoush,Gyn seminar

  30. Risk factor • Risk factor stratification is achieved by considering multiple factors, including age, type of surgical procedure, previous thromboembolism, cancer, obesity, varicose veins, cardiac dysfunction, indwelling central venous catheters, inflammatory bowel disease, nephrotic syndrome, pregnancy, and estrogen or tamoxifen use. Faranoush,Gyn seminar

  31. Prophylaxis • A number of regimens may be appropriate for prophylaxis of venous thromboembolism, depending on assessed risk. • Such regimens include the use of unfractionated heparin, low-molecular-weight heparin, intermittent compression devices, and early ambulation. • Initial prophylactic doses of heparin can be given preoperatively, within 2 hours of surgery. Faranoush,Gyn seminar

  32. Medical history  • Important elements of the history are a personal or family history of prolonged bleeding, transfusion, or persistent anemia • Nongynecologic etiologies of bleeding symptoms may be present. • For example, menorrhagia, a common indication for gynecologic surgery, can be a presenting symptom of von Willebrand disease (VWD) • Further evaluation by a hematologist is warranted if a bleeding disorder is suspected. • Timely diagnosis allows for preoperative correction of coagulation defects. Faranoush,Gyn seminar

  33. Medication history  • Prescription, over-the-counter, or alternative medications can act as anticoagulants. • Deciding whether to discontinue a medication perioperatively depends upon the risk of bleeding versus the risk of morbidity from a hiatus of medical treatment. Faranoush,Gyn seminar

  34. Laboratory evaluation • If a patient has abnormal uterine bleeding or another cause for anemia, testing should be performed early in the surgical planning process to allow time for correction of anemia • A blood sample for ABO and Rh typing and antibody screen is typically sent to the blood bank for patients undergoing surgery in which the expected blood loss is greater than minimal; if significant bleeding is anticipated, it is prudent to prepare two to four units of donor blood by crossmatching with the patient's serum with the donor red cells to incompatibility Faranoush,Gyn seminar

  35. Routine tests • Routine tests of hemostasis (prothrombin time [PT], activated partial thromboplastin time [aPTT], platelet count) are NOT necessary unless the patient has a known bleeding diathesis, an illness associated with bleeding tendency, or takes a medication that may cause anticoagulation Faranoush,Gyn seminar

  36. Transfusion • Women with blood transfusion incompatibilities or religious beliefs that preclude allogeneic blood transfusion should be identified prior to surgery. • In addition to careful surgical technique, strategies to avoid allogeneic blood product transfusion include correction of anemia, autologous blood donation, cell salvage, and hemodilution. Faranoush,Gyn seminar

  37. Correction of anemia  • Women planning gynecologic surgery to treat bleeding issues have typically declined or failed medical therapy. • Most women will accept a short course of preoperative therapy with the goal of increasing Hct and, thereby, avoiding the need for blood transfusion. • Iron deficiency anemia associated with menorrhagia or dietary deficiency is the most common cause of anemia in the gynecologic population Faranoush,Gyn seminar

  38. Strategies to correct anemia preoperatively are listed below: • Iron supplementation • Medical treatment of abnormal uterine bleeding • Erythropoiesis-stimulating agents (recombinant human erythropoietin [rHuEPO] and darbepoetin Alfa) • Preoperative rHuEPO reduces risk of allogeneic transfusion Faranoush,Gyn seminar

  39. Attention • Erythropoiesis-stimulating agents are associated with serious cardio- and thrombovascular events and more rapid tumor progression and increased mortality in cancer patients (including cervical cancer) Faranoush,Gyn seminar

  40. Autologous transfusion methods  • Autologous blood donation — A patient scheduled for surgery and are not anemic may bank one or more units of her own blood. • Intraoperative and postoperative blood salvage — Blood that is shed during or after surgery is retrieved, processed, and returned to the patient. • Acute normovolemic (isovolemic) hemodilution — Blood is removed from a patient, either immediately before or shortly after induction of anesthesia, with isovolemia is maintained using crystalloid and/or colloid replacement. The blood withdrawn is anticoagulated and is reinfused into the patient as needed during, or after, the surgical procedure Faranoush,Gyn seminar

  41. Hemodynamic monitoring  • Fluid losses lead to depletion of the extracellular fluid. • This problem, if severe, can cause a potentially fatal decrease in tissue perfusion. • Early diagnosis and treatment can restore normovolemia in almost all cases. • Volume depletion primarily results from sodium and/or water loss Faranoush,Gyn seminar

  42. Volume Depletion • True volume depletion occurs when fluid is lost from the extracellular fluid at a rate exceeding net intake • The urine volume is typically, but not always, low (oliguria) in hypovolemic patients due to the combination of sodium and water avidity • If, however, concentrating ability is impaired as noted above, oliguria may not be present. • Acid-base balance  Faranoush,Gyn seminar

  43. Fluid and electrolyte management • Suspicion of postoperative hemorrhage, fluid resuscitation • Preparation made for possible surgical re-exploration • Large-bore intravenous access • Isotonic fluids given (normal saline or Ringers lactate) • Foley catheter reinserted • Crystalloid fluids should be replaced in a 3:1 ratio of fluid:blood loss. Faranoush,Gyn seminar

  44. Fluid Replacement • Saline solutions are generally preferred for the management of patients with severe volume depletion not due to bleeding. • Saline solutions seem to be as safe and as effective as colloid-containing solutions, and are much less expensive • Hyperoncotic starch solutions should be avoided as they increase the risk of acute kidney injury and mortality Faranoush,Gyn seminar

  45. BUFFER THERAPY  • Patients with marked hypoperfusion may develop lactic acidosis, leading to a reduction in extracellular pH below 7.10. • Sodium bicarbonate can be added to the replacement fluid in this setting, in an attempt to correct both the acidemia and the volume deficit. Faranoush,Gyn seminar

  46. Therapy • Rapid volume repletion is indicated in patients with severe hypovolemia or hypovolemic shock. • Delayed therapy can lead to ischemic injury and possibly to irreversible shock and multiorgan system failure. Faranoush,Gyn seminar

  47. Fluid and electrolyte management • Patients who are stable but anemic may be managed conservatively • Transfusion is given, if appropriate, and hemodynamic status, urine output, and Hct are monitored. • Further evaluation and more aggressive management are indicated if there is suspicion of ongoing blood loss. Faranoush,Gyn seminar

  48. Intraoperative hemorrhage • Intraoperative hemorrhage is generally defined as blood loss exceeding 1000 mL or requires a blood transfusion • Massive hemorrhage refers to acute blood loss of more than 25 percent of a patient's blood volume or bleeding that requires emergency intervention to save the patient's life • Severe postoperative anemia impacts perioperative morbidity and mortality Faranoush,Gyn seminar

  49. Associated abnormalities  • A variety of electrolyte and acid-base disorders may also occur, depending upon the composition of the fluid that is lost. • Muscle weakness due to hypokalemia or hyperkalemia • Polyuria and polydipsia due to hyperglycemia or severe hypokalemia • Lethargy, confusion, seizures, and coma due to hyponatremia, hypernatremia, or hyperglycemia Faranoush,Gyn seminar

  50. MANAGEMENT OF INTRAOPERATIVE BLEEDING • Surgical techniques • Manage diffuse bleeding  • Bleeding from all sites indicates a possible bleeding diathesis, and should be treated medically • Topical hemostatic agents  • Gelatin • ORC • Microfibrillar collagen (MC) • Topical thrombin • Fibrin sealant In women undergoing gynecologic surgery with areas of low volume bleeding, suggest the use of topical hemostatic agents (Grade 2C) Faranoush,Gyn seminar

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