Management of major OH begins
medically using uterotonic agents; however, when this method of treatment fails, surgical management is employed which may include caesarean hysterectomy. A multidisciplinary surgical approach is essential with the role of an anaesthetist in resuscitation to ensure circulating volume of the patient is maintained throughout the event. A new and recent addition to the anaesthetists input as part of the holistic surgical team management of this serious complication is IOCS. IOCS, commonly termed ‘cell salvage’,
is a technique where red blood cells, lost at the time of surgery, are collected, washed, and returned to the patient as an ongoing process within minutes of collection. Its use in obstetrics has lagged behind due to the theoretical risk of causing amniotic fluid embolism and possible rhesus incapability. Clinical experience with cell salvage has rapidly grown over recent years and, to date, no single serious complication leading to poor maternal outcome has been directly attributed to use of cell salvage. Its use in OH has been recommended by the American and Royal Colleges of Obstetricians and Gynaecologists, and Anaesthetists. The major advantage is that resuscitation can involve using the patient’s own blood, reducing the need for heterologous transfusions which carry the risks of transmission of infection and transfusion reactions. There is also improved survival and improved oxygen carrying capacity of these red cells compared to blood provided by the blood bank. A review of the success for the use of IOCS at CH is presented.
ImplementatIon of a CollaboratIve SurgICal approaCh The initial indication for use was confined to elective surgeries for cases at high risk of OH (PP and placenta accreta). As part of the quality assurance and familiarisation process, the following were developed and implemented: Education: a series of lectures on machine preparation and operation Competency process: anaesthetists and technicians were privileged to use the cell saver Development of guidelines: specific policies and procedures were developed Patient information: specific patient
Figure 1: Indication for cell salvage (total 39 patients)
Placenta praevia Mult, LSCS
Placenta abruption Jehovah’s Witness Triplets Gynaecology Figure 2: Incidence of caesarean hysterectomies at Corniche Hospital from 2002 - 2010
10 12
2 4 6 8
0 2002 2003 2004 2005 2006 2007 2008 2009 2010
information and consent were developed Multidisciplinary approach: close liaison with the Obstetric Department for early counselling and patient selection in the management of high risk cases who present significant risk of perioperative bleeding; close collaboration and direct involvement with the Blood Bank Once blood is collected, it is only
processed if it is suspected that the patient is likely to need a transfusion. To minimize the risk of amniotic fluid embolism, a different suction device is used from the time of rupture of membranes until delivery of the foetus and placenta. Blood is then aspirated from the surgical field by the suction device attached to the cell saver, and returned via a leucodepletion filter to remove remaining amniotic fluid proteins.
reSultS From 1st
January 2010 to 1st January 2011
there were 2,487 caesarean sections (CS) performed at CH, 42% were elective
deliveries and 58% emergency procedures. Of the 2,487cases of all CS, 117 had major OH (>1500mls), of which 50 cases were for PP and 14 for placenta accreta. There were 10 caesarean hysterectomies performed for intractable bleeding. The cell saver was used in over a third of these cases (n=39). Blood was processed in 32.5% with almost 25% of the amount of EBL processed and re-transfused to the patients. The indications for usage of cell salvage are shown (see figure 1).
DISCuSSIon Our experience at CH over the last year has clearly confirmed the success of IOCS in reducing maternal morbidity associated with major OH. With the increasing trend of caesarean deliveries (currently over 30% at CH) and the incidence of placenta praevia and accreta is also at a rise (see table 1). The most unwanted outcome in major OH is a caesarean hysterectomy, and as seen in figure 2 the incidence
Arab Health OBS/GYNE 2012 19
27 5 1
1 1 3
Elective Emergency
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