Transcript OB Emergencies For Dummies [PPTX]

Presenters: Maj Karin Van Doren, Maj Niki Kamboris &
Capt Gretchen Waldvogel
Goals/Objectives
1.
2.
3.
4.
5.
Collegial sharing of lessons learned
Checklists; what works
OB checklists: what’s out there
AF attempt at standardized protocols
Drugs and dosages commonly used in some
emergency situations
6. TeamSTEPP principles in communications &
drills
CHECKLISTS
General background info
• 30 Oct 1935: Test flight of Boeing’s Model 299
Maj Hill, expert pilot…Fiery crash; deaths due
to “pilot error”— “too much airplane for one
man to fly”.
• 2001: Peter Pronovost: central line placement
"Safe Patients, Smart Hospitals” (2010).
• Dr Atul Gawande (2007) Classic Article “The
Checklist” (2009) The Checklist Manifesto:
How to Get Things Right (book)
Effective Checklists & Strategies
from Aviation to Medicine
•
•
•
•
Checklists are focused, unambiguous, succinct
No unintended consequences from checklist use
Evidence based, discrete tasks identified
Team work training, improve communication-Time outs/pt hand-offs
• Non punitive incident reporting
• Standardization
• Simulator training
Checklists
What they can’t solve
• Errors due to lack of skills, training or
experience
– Checklists can standardize behavior but not
“attention”
• Practice issues when there is no established
“gold standard”
• Support/cultural change when Leadership is
not engaged
The original Pronovovst “checklist”
for central line placement
Based on CDC recommendations:
Wash hands
Use full-barrier precautions (drape pt from
head to toe)
Clean skin with chlorhexidine
Avoid use of femoral site, if possible
Remove any unnecessary catheters
Success aided by:
• Involvement from the top down: senior
executives of health care system requested
participation in study
• “Daily goal sheets” implemented to improve
clinician-to-clinician communication
• Comprehensive unit –based safety program:
assisted by patient safety/infection control depts
• At least one MD and one RN team led each new
step
Success…
• Terminology standardized—NNIS (Nat’l Nosocomial
Infections Surveillance System/CDC) definition of catheterrelated blood stream infection used
• Exact definition of central catheter, which
could include a central catheter which was
peripherally inserted
• Defined “catheter day” so time of indwelling
catheters would match
Post Partum Hemorrhage
• Rate of maternal death by PPH increased 26 –
28% since 1994: uterine atony not explained by
increased rates of c/s, VBAC, maternal age,
multiple birth, HTN, diabetes Callaghan (2010) Bateman
(2010)
• Maternal deaths tripled between 1996-2006
(CMQCC)
• Nationwide, blood transfusions increased 92%
during deliveries between ‘97-’05 Kuklina (2009)
• Aviano: Sentinel event
Changes of pregnancy
• Maternal blood volume  50%; plasma
volume more than RBC vol: slight  hgb/hct
-fulfills perfusion demands of low-resistance
uteroplacental unit, reserve for blood loss
Coagulation system: Increase in clotting
factors/decrease fibrolytic activity
Uterine ctx: crisscrossing muscle bundles,
occlude, contract, retract following expulsion
of placenta: living ligature/physiologic sutures
Can we have an effective checklist?
• Response to PPH is reactive not proactive
• There is no established “Gold Standard” for
PREVENTION of PPH
• There is no one consensus for management of
PPH, but many avenues
• Triggers: Response based on clinical appearance
(it may be too late…)
• IN US clinically accepted >500 ml (vag) 1000 ml
(c/s) Does not take into account initial volume
status, arbitrary, may be clinically irrelevant to
hemodynamic compromise (CMQCC)
Current recommendations
• “Known” risk factors: 39% of cases had one or
more: Numerically, more women die with no
known risk factors
WHO, ACOG, SGOC recommendations (1A):
• Injectable Oxytocin by skilled provider. 10 mu
IM or 20 mu+ IV in IVF after delivery of
anterior shoulder
Recommendations
• Objective quantification of blood loss:
Graduated collection containers, weigh blood
soaked chux/pads (CMQCC, WHO)
• Vital sign triggers (NHS, CMQCC)
• If it isn’t working, don’t waste time…move on
(CMQCC)
• After 2 units PRBC start FFP then 1RBC:1FFP:1
PLT (CMQCC, Iraq theatre: Borgman, M. )
NHS Triggers
• RR (red) < 10 > 30
• RR (Amber) 21-29
• O2 sat less than 95%
(red)
• T greater than 38 C
(red)
• Pulse (red) > 120 <40
• P (Amber) > 100 <50
• Pain 2-3 (red) but not 23/10: 2 means
moderate, 3 severe pain
• SBP >170 <80 (red)
• >160 < 90 (amber)
• DBP >110 (red)
• > 100 ( amber)
• DBP No lower limit
• No uterine tone
CMQCC Triggers
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•
•
•
EBL > 500 ml or hemodynamic instability (vag)
HR ≥ 110
BP ≤ 85/45 or noted > 15% drop
02 sat < 95%
Current AF triggers
Calculate MAP every 15 min for first 6 hours ;
Want MAP > 65 mmHG
MAP = (2x DBP) + SBP 120/80 = MAP of 93
3
Or SBP-DBP = x , then x ÷ 3, then add that
number to DBP
RR first trigger
Emergency OB Medications
Capt Gretchen Waldvogel
Uterotonic Agents
• Oxytocin (Pitocin)
• Methylergonovine (Methergine)
• Carboprost (Hemabate)
• Misoprostol (Cytotec)
Oxytocin
**First line treatment for PP Hemorrhage
Action:
Stimulates the upper uterine segment of the
myometrium to contract rhythmically, constricts spiral
arteries and decreases blood flow to uterus.
Dose: 10mu injected Intramuscularly or 20-60mu in
1000ml
Methergine
• Action: Causes smooth muscle contraction in
upper/lower uterine segments
• Dose: 0.2mg IM, may be repeated PRN every
two to four hours or Intrauterine by MD
• Contraindicated in pts with Pre-Eclampsia or
Hypertension because it causes raised blood
pressure
• Adverse Effects: nausea and vomiting
Hemabate
• Action: Enhances uterine contractility and causes
vasoconstriction
• Dose: 0.25mg intramuscularly or Intrauterine by
provider, can be repeated every 15 min for a total
dose of 2mg
• Contraindicated in pts with Asthma, Cardiac
disease
• Side Effects: Nausea, vomiting, DIARRHEA,
hypertension, and flushing
• Consider Immodium therapy as countermeasure
Cytotec
• Action: Increases uterine tone and decreases
postpartum bleeding
• Dose: 200mcg-1000mcg sublingually, orally,
vaginally, or rectally
• **Recommended 1000mcg rectally
• Side Effects: Shivering, pyrexia, and diarrhea
• ** Not approved by FDA for this indication
Magnesium Sulfate
Hypertensive Disorder
Magnesium Sulfate
• Action: Acts peripherally to produce
vasodilation
• Dose: Adjusted for situation, Loading VS.
Maintenance dose
• ---Can be given IM if no IV access
• Side Effects: Flushing, sweating, nausea,
fatigue, hypotension, CNS depression,
depressed reflexes and respiratory effort
Safety Issues
• ** Use pre-mixed preparations from the
pharmacy
• ---Compatible with LR or NS
• All doses given should be on IV pump and
Buretrol/Volutrol should be used
• For all boluses, set VTBI at 100ml
• Total IV intake should be 125ml/hr unless
otherwise ordered by MD
Hypertension Box Aids
• Labetalol
• Hydralazine Hydrochloride
• Diazepam (Valium)
• Calcium Gluconate 10%
Labetalol
– Use multidose vial 100mg/20ml (5mg/ml)
– Compatible with LR, NS, D5LR, D5W, D5 1/4NS
Give IVP over 2 min
Take B/P every 5 min
Initial dose usually 20mg with increasing doses of 40-80mg every
10min until max dose of 300mg
Doses using 100mg/20ml vial:
-20mg ordered: give 4ml
-40 mg ordered: give 8ml
-80mg ordered: give 16ml
Hydralazine
Use 20mg/ml single use vial
Dose is 5mg (0.25ml)
Compatible with LR, NS
Give IVP over 1min, SLOW IVP
Take B/P every 5min
Initial dose done, then wait 20min before giving next dose, onset of action is
10-20min
Repeat doses 5mg (0.25ml) to 10mg (0.50ml) every 20min up to total dose of
20mg
If giving 10mg dose(0.50ml) give slowly over at least 2 min
DO NOT GIVE HYDRALAZINE IN THE SAME IV LINE AS MAGNESIUM SULFATE
(Either turn off the Magnesium Sulfate and flush the line or start a second IV)
Diazepam
Use 10mg/2ml Tubex (5mg/ml)
**Turn off Magnesium Sulfate Infusion and Disconnect
From IV**
Compatibility: give directly into IV at closest port to
patient. Not recommended to mix with any solution.
Has variable stability in NS, LR, and D5W
Give 5mg/ml over at least 1 min
May repeat doses in 10 min up to a dose of 20mg
(Minimum of 10 min wait time)
Calcium Gluconate 10%
Use 10ml single use vial containing 100mg/ml
(1 GM total dose)
**Discontinue Magnesium Sulfate Infusion and Disconnect From IV**
Compatible with LR, NS, D5LR, D10W, D5NS, D5W
Give Slowly, Use Entire Vial
Give at rate of 2ml/min
OR
Give the entire dose over 3 to 5 min
Patient should be hooked up to an EKG if ableEspecially if you need to repeat doses
Stop After 3 Doses OR 3 GM
Team STEPPS
Principles
in
Communication/
Drills/
Lessons Learned
Why use Team Stepps?
•Goal: Produce highly effective medical teams
that optimize the use of information, people and
resources to achieve the best clinical outcomes.
• Teams of individuals who communicate
effectively and back each other up dramatically
reduce the consequences of human error
PUTTING Team STEPPS IN ACTION
• MOES (Mobile Obstetric Emergency
Simulator)
- simulated various scenarios (breech, stat c/s,
shoulder dystocia, PPH, NRP, etc)
- various “issues” or areas for improvement
brought to light
- continued drills, repetition strengthened use
of Team Stepps principles
MOES TRAINING FEEDBACKS
• COMMUNICATION ISSUES:
• overhead paging system, call phones, training day?,
who is in charge?, communication with clinic to
L&D staff
• SBAR vital to role clarity, proper hand-off and
situational awareness
• Closed-loop communication promotes
understanding of order, report, etc.
• Shared mental model promotes universal
understanding of the scenario and what’s needed
MOES TRAINING FEEDBACKS, cont’d
• LOGISTICAL ISSUES:
• lack of standardization with supplies, medication access,
knowledge of use of equipment, code blue vs. rapid
response
• Creation of emergency med boxes, med cards and
algorithms binder
• Standardized location of supplies in all LDR’s
• Re-trained on use of equipment not consistently utilized
• Revision of code blue MDGI with addition of RRT (Rapid
Response Team)
MOES TRAINING FEEDBACKS, cont’d
• MOTIVATION: staff motivation level high
• increased occurrence/depth of training scenarios
raises awareness of areas of self-improvement,
empowers staff
• Positive feedback on what we did well (debriefs)
• Builds teamwork, rely on strengths of each
member
• Leadership supportive- makes changes when
identified to promote patient safety
Lessons Learned
• MOES, huddles, drills, debriefs promote Team
STEPPS principles
• Proof of importance of SBAR/communication
to decrease patient errors
• Confidence builder for response to emergency
situations
References
ACOG, Practice Bulletin Number 76, Postpartum Hemorrhage, 2006.
Bateman, B. et al (2010), The epidemiology of postpartum hemorrhage in a
large, nationwide sample of deliveries, Anesthesia and Analgesia, 110(5)
1368-1373.
Borgman, M, et al (2007) The ratio of blood products transfused affects
mortality in patients receiving massive transfusions at a combat support
hospital, Journal of Trauma, 63: 805-813
California Maternal Quality Care Collaborative, Obstetric Hemorrhage: New
Strategies, New Protocol (2010)/ Improving Health Care Response to
Obstetric hemorrhage (2010)
Callaghan, W, Kuklina E & Berg C. (2010), Trends in postpartum hemorrhage:
United States 1994-2006, American Journal of Obstetrics and Gynecology,
202(4), 353.
Kuklina, E. et al (2009) Obstetric Morbidity in the US 1998-2005, Obstetrics
and Gynecology (113), 293-299.
References
Matthews, M., Gulmezoglu, A. & Hill, S (2007) Saving womens lives: evidencebased recommendations for the prevention of postpartum haemorrhage,
Bulletin of the World Health Organization, 85(4)
Provonost, P et al (2006), An Intervention to Decrease Catheter-Related
Bloodstream Infections in the ICU, The New England Journal of Medicine, 335
(26), 2725-2732.
RCOG (2009), Prevention and Management of Postpartum Haemorrhage, Green
Top Guideline 52
Smith, J., & Brennan, B. (2009), Management of the Third Stage of Labor,
Medscape, eMedicine Specialties, Obstetric and Gynecology, Labor and
Delivery
SOGC Clinical Practice Guideline: Active Management of the Third Stage of
Labour: Prevention and Treatment of Postpartum Hemorrhage, No 235, Oct
2009.