ABSTRACT
The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.
Subject(s)
Critical Care , Hemorrhage , Peripartum Period , Shock, Hemorrhagic , Humans , Austria , Germany , Switzerland , Guidelines as TopicABSTRACT
Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.
Subject(s)
Algorithms , Postpartum Hemorrhage/therapy , Adult , Anesthesiology/standards , Austria , Consensus , Emergency Medical Services , Female , Germany , Guidelines as Topic , Humans , Infant, Newborn , International Cooperation , Obstetrics/standards , Patient Care Team , Postpartum Hemorrhage/diagnosis , Postpartum Hemorrhage/mortality , Pregnancy , Risk Factors , SwitzerlandABSTRACT
PURPOSE: Venous thromboembolism (VTE) is a common but often overlooked life-threatening complication of critical illness. The aim of this cross-sectional survey was to assess current practice of thromboprophylaxis as well as adherence to international guidelines. METHODS: After ethics committee approval, all intensive care units in Austrian hospitals treating adult patients were invited to participate in this web-based survey. Anonymized data on each patient treated at the participating intensive care units on Coagulation Day 2010 were collected using an electronic case report form. Risk assessment, choice and monitoring of anticoagulants, means of mechanical prophylaxis, and demographic data were recorded. RESULTS: Data from 325 critically ill patients were collected. Patients had a median of four risk factors for thrombosis and 6 % suffered from VTE. Of the 325 patients, 80 % received low molecular weight heparins subcutaneously, 10 % received unfractionated heparin intravenously, 1 % received alternative anticoagulants and 9 % received no pharmacological prophylaxis. Mechanical prophylaxis was used in 49 % with a predominant use of graduated compression stockings. In 39 % a combination of pharmacological and mechanical prophylaxis was applied and 5 % received no prophylaxis at all. Overall guideline adherence was 40 % on Coagulation Day 2010. CONCLUSION: Current practice of thromboprophylaxis is predominantly based on the administration of low molecular weight heparins prescribed at rather arbitrary doses without a discernible relationship to drug monitoring, thromboembolic risk factors, vasopressor use or fluid balance. The use of mechanical prophylaxis, evaluation of risk scores and overall guideline adherence must be further encouraged by education, training and communication.
Subject(s)
Intensive Care Units , Thromboembolism/prevention & control , Aged , Aged, 80 and over , Austria , Female , Health Care Surveys , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Male , Middle Aged , Practice Patterns, Physicians'/statistics & numerical data , Risk Factors , Stockings, Compression , Surveys and Questionnaires , Thromboembolism/etiologyABSTRACT
Unexpected bleeding in the perioperative period is largely caused by impaired inherited or drug-induced primary haemostasis. Standard tests for plasma coagulation are predominantly employed to gauge the risk of bleeding. In accordance with several reports the subcommittee for perioperative coagulation (AGPG) of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care (OGARI) recommends the use of a standardised questionnaire to detect an increased risk of bleeding. Accordingly, healthy patients of the American Society of Anesthesiologists (ASA) grades I and II without any suspicion of impaired haemostasis who are scheduled for procedures without expected transfusion requirements, need no standard tests for coagulation. In all other patients (including patients taking medication affecting coagulation, or patients who are unable to provide adequate information) platelet count, platelet function, aPTT, PT, and fibrinogen levels should be assessed.
Subject(s)
Hemorrhage/therapy , Preoperative Care , Blood Coagulation Tests , Blood Transfusion , Fibrinogen/analysis , Hemorrhage/prevention & control , Hemostasis , Humans , Intraoperative Complications/blood , Intraoperative Complications/prevention & control , Medical History Taking , Partial Thromboplastin Time , Platelet Count , Platelet Function Tests , Prothrombin Time , Risk Assessment , Surveys and QuestionnairesABSTRACT
The instability of the gestational and puerperal equilibrium of haemostasis is affected by a shift of primary and plasmatic haemostasis in a procoagulatory direction, whereas the regulation mechanism of the fibrinolytic system can easily cause disproportional peri- and postpartal reaction leading to massive haemorrhage. Peripartal injuries or an atonic uterus can lead to massive haemorrhage and cause a classic haemorrhagic coagulopathy. Complications like amniotic fluid embolism, puerperal sepsis, eclampsia or HELLP syndrome can lead through DIC to rapidly developing and possibly fulminant hyperfibrinolysis. This article depicts different forms of haemorrhage in the peripartal situation, their particular pathologies and specific possibilities for management. A case study demonstrates the diagnostic and therapeutic options in the case of eclampsia with early abruption of placenta.
Subject(s)
Hemorrhage/therapy , Puerperal Disorders/blood , Abruptio Placentae/blood , Abruptio Placentae/therapy , Dacarbazine , Female , HELLP Syndrome/blood , HELLP Syndrome/therapy , Humans , Placenta Previa/blood , Placenta Previa/therapy , Pre-Eclampsia/blood , Pre-Eclampsia/therapy , PregnancyABSTRACT
More efficacious anticoagulant and antiplatelet agents have been introduced in vascular medicine and in the prevention of perioperative venous thromboembolisms. Patient management should be guided by familiarity with the pharmacology of coagulation-altering drugs and by consensus statements. The present paper reviews recommendations from the Austrian Task Force for Perioperative Coagulation which are based on thorough evaluation of the available pharmacological information and case reports. The consensus statement focuses on neuraxial and peripheral techniques and is designed to encourage safe and quality patient care.
