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AN INTERESTING CASE OF POST PARTUM HAEMORRHAGE

AN INTERESTING CASE OF POST PARTUM HAEMORRHAGE. AN ANESTHETIST PERSPECTIVE Dr.Senthil Kumar Post Graduate Dr.Anand Associate Professor Dr.Yachendra Assistant Professor DEPT. OF ANESTHESIOLOGY MEENAKSHI MEDICAL COLLEGE A ND RESEARCH INSTITUTE. HISTORY. 24 YEAR OLD PRIMI

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AN INTERESTING CASE OF POST PARTUM HAEMORRHAGE

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  1. AN INTERESTING CASE OF POST PARTUM HAEMORRHAGE AN ANESTHETIST PERSPECTIVE Dr.Senthil Kumar Post Graduate Dr.Anand Associate Professor Dr.Yachendra Assistant Professor DEPT. OF ANESTHESIOLOGY MEENAKSHI MEDICAL COLLEGE AND RESEARCH INSTITUTE

  2. HISTORY • 24 YEAR OLD PRIMI • 32 WEEKS GESTATIONAL AGE • BOOKED CASE • NO COMORBID ILLNESSES • ADMITTED WITH ABDOMINAL PAIN AND FEATURES OF U.T.I.

  3. HISTORY …. • PRECIPITATE LABOUR • DELIVERED A PRETERM LIVE MALE CHILD VIA NATURALIS WEIGHING 1.8 Kg • POST PARTUM BLEEDING NOTICED WITH VAGINAL AND FORNICIAL TEARS • POSTED FOR EXPLORATION AND SUTURING UNDER ANESTHESIA

  4. PRE OP INVESTIGATIONS • Hb : 10 gm% • P.C.V. : 32% • BLOOD UREA : 12 mg/dl • SERUM CREATININE : 0.8 mg/dl • RANDOM BLOOD SUGAR : 134 mg/dl • BLEEDING TIME : 1 min 35 sec • CLOTTING TIME : 3 min 10 sec • BLOOD GROUP : A +VE

  5. MANAGEMENT

  6. PREOPERATIVE ASSESMENT • CLINICAL EXAMINATION:- - CONCIOUS, ORIENTED - PERIPHERIES COLD, FEEBLE PULSE - PALLOR : ++++ - HEART RATE : 136/min - BLOOD PRESSURE : 96/60mmHg - SPO2 : 100% (O2 6 l/min) • PROFUSE BLEEDING PER VAGINUM

  7. PREPARATION & OPTIMISATION • I.V. ACCESS : 14 G VENFLON LEFT ELBOW 18 G VENFLON RIGHT WRIST • MONITORS : E.C.G., N.I.B.P., SPO2 • FLUID RESUSCITATION : - 6% HETA STARCH 500 ML - BLOOD MOBILISED • ANESTHETIC PLAN : I.V. SEDATION

  8. 1st exploration • Under IV sedation – 1 hour • INPUT : - CRYSTALLOIDS : 2500 ml - COLLOIDS : 500 ml - WHOLE BLOOD : 3 UNITS • OUTPUT : - BLOOD LOSS : 1.5 – 2 lts - URINE : 50 ml

  9. Shifted to Surgical ICU • VITALS END OP : - CONCIOUS, ORIENTED - H.R. : 112/ min - B.P. : 116/68 mm Hg - SPO2 : 1OO% • WITHIN 20 MIN : - HYPOTENSION 80/40 mm Hg - REBLEEDING PER VAGINUM • SHIFTED TO O.T. FOR RE-EXPLORATION

  10. 2nd Exploration • GENERAL ANESTHESIA : - RAPID SEQUENCE INTUBATION - INJ. THIOPENTONE : 125mg I.V. - INJ. KETAMINE : 50mg I.V. - INJ. SCOLINE : 75mg I.V. • ENDOTRACHEAL INTUBATION : 7.0 mm CUFFED TUBE • N2O/02 : SEVOFLURANE : CONTROLLED VENTILATON WITH VECURONIUM • RIGHT I.J.V. CANNULATED

  11. SURGERY • RE-EXPLORATION AND SUTURING OF VAGINAL TEARS • ULTRASONOGRAM WITH NO EVIDENCE OF INTRA ABDOMINAL COLLECTION • EXPLORATORY LAPAROTOMY • UTERINE ARTERY LIGATION • HYSTERECTOMY

  12. Intra op……. ANESTHESIA TIME : 8 HOURS • INPUT : - CRYSTALLOIDS : 6000 ml - COLLOIDS : 500 ml - WHOLE BLOOD : 10 UNITS • OUTPUT : - BLOOD LOSS : 4 lts - URINE : 150 ml

  13. POST OPERATIVE MANAGEMENT • ELECTIVE VENTILATION • INFUSION : - INJ. MORPHINE 2mg/hr - INJ. PANCURONIUM 2mg/hr • PIPERACILLIN WITH TAZOBACTAM • NEBULISATION • SUPPORTVE MEASURES • I.V.FLUIDS TITRATED TO MAINTAIN URINE OUTPUT &CVP monitoring

  14. WEANED AND EXTUBATED AFTER 36 HOURS • POST EXTUBATION MAINTAINING SATURATION • URINE OUTPUT MAINTAINED THROUGHT POST OPERATIVE PERIOD • LOW GRADE PYREXIA • ORALS STARTED ON THE 4TH P.O.D.

  15. POST OPERATIVE COMPLICATIONS • DUE TO MASSIVE BLOOD TX : -DILUTIONAL THROMBOCYTOPENIA - COAGULATION ABNORMALITIES • RESPIRATORY COMPLICATIONS : -PNEUMONITIS

  16. THROMBOCYTOPENIA

  17. COAGULATION ABNORMALITY • NO SIGNS OF ANY SPONTANEOUS BLEEDING • COAGULATION PARAMETERS NORMAL THROUGHOUT POST OPERATIVE PERIOD • LIVER FUNCTION TESTS NORMAL • REQUIRED FURTHER R.B.C. TRANSFUSION FOR MAINTAINING HAEMOGLOBIN LEVELS

  18. TOTAL BLOOD COMPONENTS TRANSFUSED • WHOLE BLOOD : 16 • FRESH FROZEN PLASMA : 9 • PLATELET CONCENTRATE : 8 Total = 33

  19. RESPIRATORY COMPLICATION • DESATURATON ON 3rd post op • ROOM AIR SPO2 : 87 – 90% • REQUIRING HIGH FiO2 – 60% • R.S. : EXTENSIVE CREPTS WITH WHEEZE • CXR : FEATURES OF RIGHT MID AND LOWER ZONE PNEUMONITIS • A.B.G. : pH : 7.04 pCO2 :33.4 pO2 :92.0 B.E. :0.4 HCO3 :23.4 • ECHO : NORMAL STUDY

  20. CXR A.P. VIEW P.O.D. 3

  21. TREATMENT • MOBILISATION WITH RESPIRATORY EXERCISES • CHEST PHYSIOTHERAPY • INCENTIVE SPIROMETRY • AGGRESSIVE NEBULISATION • I.V. FRUSEMIDE • ANTIBIOTICS

  22. CXR A.P. VIEW P.O.D. 7

  23. DISCHARGED FROM S.I.C.U. ON THE 7TH P.O.D. • MOTHER AND BABY ALIVE AND WELL

  24. MASSIVE TRANSFUSION • DEFINITION - >10 UNITS TX IN 24 HOURS - TX OF ½ OF E.B.V. IN ONE HOUR - TX OF 1 B.V. IN FIRST 12 HRS OF RESUSCITATION • AIM - RESTORE ADEQUATE BLOOD VOLUME - MAINTAIN HEMOSTASIS - MAINTAIN O2 CARRYING CAPACITY - MAINTAIN ACID BASE BALANCE

  25. COMPLICATIONS - MASSIVE TX • DILUTIONAL THROMBOCYTOPENIA • CITRATE TOXICITY – HYPOCALCEMIA • ELECTROLYTE DISTURBANCES • T.R.A.L.I. / A.R.D.S. • COAGULATION ABNORMALITY / D.I.C. • HYPOTHERMIA • ACID BASE DISTURBANCES • O2 AFFINITY CHANGES

  26. RECOMMENDATIONS • ESTABLISH MASSIVE TX PROTOCOL • RECOMMENDED TX RATIOS - F.F.P. : R.B.C. – 2 : 3 (OR) 1 : 1 - PLT. : R.B.C. – 0.8 : 1 • ACTIVE PREVENTION OF HYPOTHERMIA • MAINTAIN END ORGAN PERFUSION

  27. THANK YOU

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