1. No category

IMPLEMENTACION
DECODIGOROJO
OBSTETRICO
1
A California Toolkit to Transform Maternity Care
Improving Health Care Response to
Obstetric Hemorrhage
THIS COLLABORATIVE PROJECT WAS DEVELOPED BY:
THE OBSTETRIC HEMORRHAGE TASK FORCE
THE MATERNAL QUALITY IMPROVEMENT PANEL
CALIFORNIA MATERNAL QUALITY CARE COLLABORATIVE
MATERNAL, CHILD AND ADOLESCENT HEALTH DIVISION; CENTER FOR FAMILY HEALTH
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
jour nal homepage: www. elsevier.com/locate/ijgo
Rosemarie Fernandez, MD
P
CLINICAL ARTICLE
ostpartum hemorrhage (PPH) is the leading cause of ma- management of the PPH p
ternal mortality worldwide, contributing to approximately (nonoperative) managem
140,000 deaths per year.1 Because of readily available medical decompensating patient. F
and surgical management, the number of deaths in the United for the (1) identification o
States is low; nonetheless, PPH remains a leading cause of behaviors and (2) detectio
pregnancy-related morbidity and mortality. Early recognition ficiencies before an actual
of known risk factors for PPH and the use of third-stage in- the development, content
a,
b
b
b
travenous oxytocin
have been shown to significantly lower the tionbof a standardized pa
incidence of PPH.2Y4 Unfortunately, diagnosing clinically sig- scenario. The training rec
nificant PPH is notoriously difficult because health care pro- University of Washington
a
St George's University, London, UK
viders typically underestimate blood loss and, in pregnancy,
b
Department of Obstetrics and Gynecology, St George's Healthcare NHS Trust, London, UK
signs of hypovolemia are also delayed. Appropriate management of PPH therefore typically requires an urgent interdis- PARTICIPANTS/LEARN
Report/Simulation
ciplinary coordinated effort to safely administer aCasevariety
of Scenario This simulation invo
medications and perform any necessary procedures to stop residents (n = 19), obstet
anesthesiology residents (
the patient’s blood loss.
article info
abstract
425-452)
In situ simulation of PPH is a particularly valuable pro- ing physicians (n = 5). A
cess. First and foremost, it provides a platform for interdis- still successfully complete
Article history:
Objective: To evaluate whether the algorithm “HEMOSTASIS”
(help;
establish
the uterus;
Artículo de revisión
position consists of 6 to 8
ciplinary
team practice
whileetiology;
maintaining massage
the environmental
Received 3 June 2010
3 disciplines/specialties
oxytocin infusion and prostaglandins; shift to operating theater;
tamponade
test;
apply
and system
factors present
during
actualcompression
patient care events.sutures;
Received in revised form 5 November 2010
Second,
it allows the entire
interdisciplinary
team to practice wassia.)
systematic pelvic devascularization; interventional radiology;
subtotal/total
abdominal
hysterectomy)
ofA total of 83 learner
Medical
Center Labor an
Accepted 27 January 2011
value in the systematic management of postpartum hemorrhage (PPH). Methods: A retrospective analysis was
the scenario.
Outcome of the management of massive postpartum hemorrhage using the
algorithm “HEMOSTASIS”
Lavanya Varatharajan ⁎, Edwin Chandraharan , Julian Sutton , Virginia Lowe , Sabaratnam Arulkumaran
An In Situ Standardized PatientYBased Simulation to Train Postpartum
Hemorrhage and Team Skills on a Labor and Delivery Unit
Guía de práctica clínica paraperformed of all women who experienced
massive
Michael F. Fialkow,
MD;primary PPH (blood loss N1500 mL) in 2008 at St George's
of the HEMOSTASIS mnemonic in PPH management was determinedSCENARIO
by
DEVELOPME
la prevención y el manejO deHospital,
la London, UK. The successChristine
R. Adams, BSN;
assessing clinical outcome following adherence to the protocol. Results: Patient notes were available Needs
for Assessment and Lea
Leslie Carranza,
MD;
95 (83.3%) of the 114 cases of primary
PPH. Hemostasis
was achieved in 63 (66.3%) women via use ofA robust needs assess
hemOrraGia pOspartO y cOmplicaciOnes
viaJ. suture
of tears and 10 (10.5%) via tamponade (“T”); 1 (1.1%) ofviaeffective training pro
Simon
Golden, BS;
1 additional oxytocics (“O”); 19 (20.0%)
began with a need
del chOque hemOrráGicO application of compression suture (“A”); 1 (1.1%) via systematic devascularization (“S”); and 1 (1.1%) ment
via
Washington
Medical Cen
From the Division of Emergency Medicine (R.F.), and Department of Obstetrics and
Gynecology (M.F.F., L.C., T.J.B.), University of Washington School of Medicine,
Washington, DC; University of Washington Medical Center (C.R.A.), Seattle, WA;
Department of Obstetrics and Gynecology (L.C.), David Geffen School of Medicine at
UCLA, Los Angeles, CA; Department of Psychology (S.J.G.), Michigan State University,
East Lansing, MI.
Reprints: Michael Fialkow, MD, Department of Obstetrics and Gynecology, University
of Washington School of Medicine, 1959 NE Pacific St, Box 356460, Seattle, WA 98195
(e<mail: [email protected]).
The authors declare no conflict of interest.
Keywords:
Cesarean delivery
Hemostasis
Hysterectomy
Postpartum hemorrhage
Thomas J. Benedetti, MD;
FIGURE 1. Scenario flow
and prompts.hysterectomy (“S”).
FIGURE
Scenario
flow deaths.
and prompts.
subtotal/total
There 1.
were
no maternal
Conclusion: The decremental patternticipating
of disciplines (nu
This process focused on
Fernandez,that
MD the algorithm can provide a logical management pathway
clinical practice guidelines for the more
prevention
complex interventions usedRosemarie
demonstrates
clinical objectives. Traini
to reduce blood transfusions, hysterectomies, admissions to intensive care units, and maternal deaths.
procedural skills were no
and management of post-partum bleeding
and
Crown Copyright © 2011 Published
Elsevier Ireland
Ltd. on
Federation
of Gynecology
were therefore not a com
Vol. 9, Number 1, February 2014
Vol. by
9, Number
1, February
2014behalf of* International
2014 Society for Simulation
in Healthcare
67 and
Obstetrics. All rights reserved.
of hemorrhagic shock complications
Postpartum hemorrhage (PPH) is the leading cause of ma- management of the PPH patient, including diagnosis, medical
This study was supported by the Department of Defense US Army Medical Research
and Material Command under award number W81XWH-10-2-0023.
Views and opinions of, and endorsement by the author(s) do not reflect those of
the US Army or the Department of Defense.
Copyright * 2014 Society for Simulation in Healthcare
DOI: 10.1097/SIH.0000000000000007
Vol. 9, Number 1, February 2014
ternal in
mortality
worldwide,Unauthorized
contributing to©approximately
(nonoperative)
and resuscitation
of the acutelyUnauthorized repr
Copyright © 2014 by the Society for Simulation
Healthcare.
Copyright
2014
reproduction
by theCopyright
ofSociety
this© article
formanagement,
Simulation
is prohibited.
in Healthcare.
2014 by the Society for Simulation in Healthcare. Unauthorized reproduction
Representantes del Grupo Desarrollador de la Guía - Universidad Nacional de
Colombia - Alianza Cinets*
1. Introduction
Recibido: agosto 20/13 – Aceptado: noviembre 8/13
The success of modern obstetrics continues to be challenged
140,000 deaths per year.1 Because of readily available medical decompensating patient. Finally, the debriefing process allows
and surgical management, the number of deaths in the United for the (1) identification of gaps in knowledge and teamwork
States is low; nonetheless, PPH remains a leading cause of behaviors and (2) detection of environmental and system depregnancy-related
and mortality. Early
recognition London,
ficiencies before
adverse event.
article describes
staff atmorbidity
St George's
Hospital,
UK,an actual
so that
eachThisstep
in the
of known risk factors for PPH and the use of third-stage in- the development, content validation, and in situ implementaalgorithm
would
followed
rapid
succession
untilinterdisciplinary
bleedingPPH
was
travenous
oxytocin have been
shown to be
significantly
lower the in tion
of a standardized
patient-based,
2Y4
of PPH. Unfortunately,
diagnosingofclinically
scenario.
received expedited
approval from
The details
eachsig-stage
of The
thetraining
updated
mnemonic
aretheas
by incidencearrested.
CODIGOROJOOBSTETRICO
OBJETIVOS
•  Diagnos(carchoqueenhemorragiaobstétrica.
•  Ac(varelcódigorojoobstétrico.
•  Asignarfunciones-roles.
•  AplicarelABCDEdelareanimación.
•  Definirlascondicionesparamanejoycuidadodefini(vo.
•  Remisión–SalasdeCirugía–CuidadoIntensivo
DIAGNOSTICODELCHOQUEHIPOVOLEMICO
Perdida
devolumen
(%)ymlparauna
mujerentre
50-70Kg
Sensorio
Perfusión
Pulso
10-15%
500-1000mL
Normal
Normal
60-90
>90
Compensado
Usualmente
norequerida
16-25%
1000-1500mL
Normaly/o
agitada
Palidez,frialdad
91-100
80-90
Leve
Posible
Agitada
Palidez,frialdad,más
sudoración
101-120
70-79
Moderado
Usualmente
requerida
Letárgicao
inconciente
Palidez,frialdad,más
sudoraciónyllenado
capilar>3segundos
Severo
Transfusión
Masiva
probable
26-35%
1500-2000mL
>35%
>2000mL
>120
Presión
Arterialsistólica Gradodelchoque
(mm/Hg)
<70
Trasfusión
Evaluacióndelgradodechoquehemorrágicoualizando
Paralaclasificaciónelparametromasalterado
ACTIVACIONDELCODIGOROJO
OBSTETRICO
Donde?
Como?
Quien?
Haycódigo
rojoenel
hospital?
Cualesel
sistemade
ac(vación?
Cualesel
equipo?
•  Obstetra
•  Anestesiólogo
•  Enfermería(jefe)
•  Enfermería(auxiliar)
•  Instrumentadora
•  Camillero
•  Laboratorioclínicoyserviciodetransfusión
•  Salasdecirugía
•  Cuidadosintensivos
•  Transporte.
EQUIPO
MANAGEMENTOFMASSIVEPOSTPARTUMHEMORRHAGE
ORGANIZINGTHETEAM
Cabeza
Utero
Brazos
Cabeza
• 
• 
• 
• 
Chequeeviaaerea.
Administreoxigeno
Vigileestadodeconciencia
Tome(empodelossucesos
Brazos
Utero
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
ManagementofMassive
POSTPARTUMHEMORRHAGE
OrganizingtheTeam
Chequeepulsos
Canalizardosvenasdegruesocalibre.
Realizarlaboratorios
Cruzar4-6unidades
RepongaperdidasconbolosdeLEV
Inicieoxitocina,metergyn,misoprostol
Inicieaquí
Pidaayudantes
Ayudante1encabeza
Ayudante2y3enbrazos
Realizarmasajebimanual
Piense4’tsparamanejo
PienseenCirugíaoportuna
ASIGNACIONDE
FUNCIONES
Cabeza.
Brazoizquierdo.
Pelvis. Registro
No1
No2
No2
No1
COMUNICACIÓNENCRISIS
CODIGOROJOOBSTETRICO
ABCDE
A: Víaáreapermeable
B: Ven(laciónadecuada–O2suplementario.
C: Pareelsangrado–Accesosvenosos2–tomade muestrasUsodeFluidos(definirrespondedorono
respondedor)–Fármacos–UsodeHemoderivados
D: Diagnós(cos:4T’s
E: Evitarhipotermia.
CODIGOROJOOBSTETRICO
ABCDE
A: Víaáreapermeable
B: Ven(laciónadecuada–O2suplementario.
C: Pareelsangrado–Accesosvenosos2–tomade muestrasUsodeFluidos(definirrespondedorono
respondedor)–Fármacos–UsodeHemoderivados
D: Diagnós(cos:4T’s
E: Evitarhipotermia.
CODIGOROJOOBSTETRICO
ABCDE
A: Víaáreapermeable
B: Oximetríadepulso–Ven(laciónadecuada–O2suplementario
-
•  Mascaraconbolsareservorio
10Lt/min.
CODIGOROJOOBSTETRICO
ABCDE
Víaaérea
Venalación
CODIGOROJOOBSTETRICO
ABCDE
A: Víaáreapermeable
B: Ven(laciónadecuada–O2suplementario.
C: Pareelsangrado–Accesosvenosos2–tomade muestrasUsodeFluidos(definirrespondedorono
respondedor)–Fármacos–UsodeHemoderivados
D: Diagnós(cos:4T’s
E: Evitarhipotermia.
C:Pareelsangrado
CODIGOROJOOBSTETRICO
ABCDE
C:Posición
CODIGOROJOOBSTETRICO
ABCDE
C:AccesosvenososNo.2-Calibre
Diámetro
14-16
corto
CODIGOROJOOBSTETRICO
ABCDE
C:AccesosvenososNo.2-Ubicación
CODIGOROJOOBSTETRICO
ABCDE
C: AccesosvenososNo.2–Tomademuestras(Lab–BancodeSangre)
CODIGOROJOOBSTETRICO
ABCDE
C:AccesosvenososNo.2
Cristaloides
Calientes
SSN–LR
Bolos500ml
Evaluarrespuesta
EVALUACIÓNRESPUESTAAINFUSIONDEVOLUMEN
CRISTALOIDES500ml.
Respuestarápida
Respuestatransitoria
Norespuesta
Retornaalonormal
Hipotensiónrecurrente
(PAS<90mmHg);sensorio
comprome(do;pulsoradial
débil;taquicardia
Permanecenanormalesono
seconsiguenmetasenningún
momento
10-25%ó500-1500mL
(choquecompensadooleve)
26-40%ó1500-2000mL
(choquemoderado)
Transfusiónimprobable
Probable
Paqueteglobularde
emergencia:2UGRE
Paquetetransfusionalde
emergencia:4UGRE/6UPFC/
6UPLT,ABOcompa(bles
Paqueteglobularde
emergencia(poespecífica
sinpruebascruzadas(15
minutos).Encasodeno
disponibilidad,O-uO+
Inmediato:paqueteglobular
O-(uO+);PFCO-(uO+);PLT
ORhcompa(bles
Sangre(pocompa(blecon
pruebascruzadas
(45-60minutos)
>40%ó>2000mL
(choquesevero)
NODARCARGASPREDETERMINADASDE1-2lt.
Evitarfórmulasdees(maciónpararemplazos.3:1
Bolos500cc.CristaloidesIVa39ºc
Pulsoradial–sensoriointacto
Tipoderespuesta
Parámetrosclínicos
Intervención
Mejoríasostenida
Ningunaadicional
Mejoríaparcial
Retosdevolumen
Cristaloides/coloides
Nomejoraconretos
Devolumen
Hemoderivados
Cirugia
Ningunarespuesta
Controlquirúrgicoinmediato
CODIGOROJOOBSTETRICO
ABCDE
C: MedidasFarmacológicasparapararelsangrado.
Uterotonicos
• 
Oxitocina
• 
Methergina
• 
Misoprostol
Ac.Tranexamico
WHO recommendations
for the prevention
and treatment of
postpartum haemorrhage
•  Masaje uterino externo de forma con(nua y permanente durante el manejo integral y hasta
queelsangradohayacedido
•  Masaje uterino bimanual durante al menos 20 minutos o hasta que haya cedido el sangrado
cuandoelmasajeuterinoexternohasidoineficaz
•  Oxitocina a dosis de 80 miliunidades por minuto: 20 U diluidos en 500mL de SSN 0.9% para
pasaren4horas(a125mL/horaporbombadeinfusión;20gotasminutopormacrogotero10
gotas=1ccó125microgotasminutopormicrogoterode60microgotas=1cc).
•  Methergynampx0,2mg:1ampollaIM,seguidaporotradosisalos20minutosydespués0,2
miligramosIMcada4horashastauntotalde5dosiscomodosismáximaen24horas(sinohay
hipertensión).
•  Misoprostol 800 mcg por vía sublingual solo si no se cuenta con oxitocina o maleato de
me(lergonovina
ACIDOTRANEXAMICOENHEMORRAGIAOBTETRICA
•  El ácido tranexámico se puede ofrecer como un tratamiento para
hemorragia posparto si la administración de UTEROTÓNICOS no ha
sido efec(va o como complemento a la sutura de trauma(smos del
canaldelpartoodelútero.
•  Dosis:1grporvíaIVen1min
•  Sepuederepe(r(1grIV)alos30minutos
•  Temprano:primeras3horas
CODIGOROJOOBSTETRICO
ABCDE
C:medidasfarmacológicasparaprevenirlainfección
An(bió(cos
• Ampicilina-Gentamicina
• Cefazolina1gr
• Clindamicina600mgIV
CODIGOROJOOBSTETRICO
ABCDE
C:Hemoderivados
Paquetedetransfusióndeglóbulos
rojosdeemergencia:
2ugreo(-)ó2ugreo(+)
Sinpruebascruzadas
CODIGOROJOOBSTETRICO
ABCDE
C:Hemoderivados
PROTOCOLODETRANSFUSIÓNMASIVA:
GRE:PFC:plaquetas,1:1:1
GRE6unidades,PFC6unidades,1aféresisó6unidadesdeplaquetas
American Journal of Obstetrics & Gynecology.2011: 205:6 526-532
International Journal of Obstetric Anesthesia (2013) 22, 87–91
0959-289X/$ - see front matter c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.01.002
!
EDITORIAL
www.obstetanesthesia.com
Postpartum hemorrhage and low fibrinogen levels: the past,
present and future International Journal of Obstetric Anesthesia (2013) 22, 87–91
!
0959-289X/$ - see front matter c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.01.002
• ‘‘Change
Fibrinógeno
es parámetro de laboratorio
independientemente
and initiating
fibrin polymerization afterasociado
undergoing
is the law of life. And those who look only to the
9
by thrombin
(secondary hemostasis).
A review
el are
desarrollo
HPP masiva cleavage
y niveles
menores
de 2 g/L
son
pastcon
or present
certain to missde
the future.’’
of studies
thatriesgo
have reported
plasma
fibrinogen
Johnindependiente
F. Kennedy
EDITORIAL
asociados
con incremento
en el
de HPP
masiva
OR
concentrations in pregnant women indicates that these
Are 12.0,95%ci2.6–56.1
rates and outcomes after postpartum hemorrhage
levels are higher in pregnant women compared to non-
(PPH) getting any better? Well . . . there is some good news
pregnant women (Table 1). Fibrinogen levels increase
and bad news. According to recent maternal mortality rewith advancing gestation and are most pronounced in
10–16
views,
the
good
news
is
that
the
proportion
of
maternal
•  Cambios del protocolo de Transfusión
masiva
en obstetriciachanges
con
the third trimester.
Pregnancy-associated
deaths due to hemorrhage appears to be decreasing:
in fibrinogen are likely due to an increase in estrogen lev3.4%CrioprecipitadoyCoadyuvantes
and 12% of maternal deaths in the UK (2006–
els with advancing gestational age. In the postpartum per2008)1 and in the US (1998–2005),2 respectively. The
iod, a mild-moderate decrease in maternal fibrinogen
bad news is that rates of PPH appear to be steadily
levels occurs after removal of the placenta,17 which may
3
increasing in many high-resource countries, which have
persist into the early period after delivery.18,19
been linked to an accompanying increase in maternal
A number of important studies have provided
eviand initiating
Postpartum hemorrhage and low fibrinogen
present and future
4
‘‘Change is the law of life. And those who look only to the
fibri
REANIMACIONHEMOSTATICA
•  PAQUETEDETRANSFUSIÓNDEGLÓBULOSROJOSDEEMERGENCIA:
•  2UGREO(-)ó2UGREO(+)sinpruebascruzadas
•  PROTOCOLODETRANSFUSIÓNMASIVA:GRE:PFC:plaquetas,1:1:1
•  GRE6unidades,PFC6unidades,1aféresisó6unidadesdeplaquetas
•  Crioprecipitado
10-20unidades
•  Concentradosdefibrinogeno 2Gramos.
•  Acidotranexamico. 1Gramo.
CODIGOROJOOBSTETRICO
ABCDE
A:
Víaáreapermeable
B:
Ven(laciónadecuada–O2suplementario.
C:
Pareelsangrado–Accesosvenosos2–toma
demuestrasUsodeFluidos(definirrespondedorono
respondedor)–Fármacos–UsodeHemoderivados
D:
Diagnós(cos:4T’s
E:
Evitarhipotermia.
CODIGOROJOOBSTETRICO
ABCDE
Enfoquedelas4t’s:
Tono
Trauma
Tejido
Trombina
CODIGOROJOOBSTETRICO
ABCDE
A:
Víaáreapermeable
B:
Ven(laciónadecuada–O2suplementario.
C:
Pareelsangrado–Accesosvenosos2–toma
demuestrasUsodeFluidos(definirrespondedorono
respondedor)–Fármacos–UsodeHemoderivados
D:
Diagnós(cos:4T’s
E:
Evitarhipotermia.
CODIGOROJOOBSTETRICO
ABCDE
E:Evitarhipotermia.
TROMBOPROFILAXIS
CODIGOROJOOBSTETRICO
HORADORADADELAREANIMACION
Hemorragiapostparto
Obstetra
Anestesiólogo
Diagnos(co4Ts
Masajeuterino
Manejomedico
Monitoria
Laboratorios
2accesosEV
BolosdeLEV
Balónhidrostá(co
TAN
Suturashemostá(cas
Monitoriainvasiva
Transfusión
Vasopresores
Histerectomía
Controldedaños
Politransfusión
Factorescoagulación
30minutos
30minutos