August 31, 2017

001 Manual aortic compression

6 minutes

“You are called urgently into one of the birth suite rooms. A woman has just given birth, there is blood everywhere, she is moaning & breathing (barely). She is a ghastly pale / mottled colour and you can’t feel a peripheral pulse….. it is a sunday afternoon, you work in a smaller hospital and the theatre team aren’t on site…….”

Being faced with a shocked / peri-arrest obstetric patient who is literally exsanguinating in front of you is one of those nightmare situations that those of us who work in obstetrics dread being faced with.

The sudden uterine rupture, the unexpected placenta accreta, or an amniotic fluid embolism with ensuing severe coagulopathy all spring to mind. This is also not an uncommon event in theatre in women having surgery for placenta accreta/percreta or ruptured ectopics – where we are usually prepared for massive haemorrhage but despite this where we can suddenly find ourselves in a situation where the rate of blood loss is so catastrophic that we have lost control of the patients circulation.

Manual Aortic Compression

Manual aortic compression (occlusion) is a technique which can be applied almost immediately to control the bleeding, to prevent (or treat) cardiac arrest from hypovolaemia and buy precious minutes – to allow transfer to definitive care in theatre, perform surgical interventions, and allow resuscitate with fluid or blood products.

Staffan Bergstrom an obstetrician from Sweden has been teaching this life-saving technique for many years in Africa, with great effect (personal communication). Watch his youtube tutorial where he eloquently describes how he teaches this technique:

https://youtu.be/rc9BYcIhamA

Literature supporting manual aortic compression

Aortic occlusion both manually and using a specific device was introduced as a formal procedure for managing severe haemorrhage in this large egyptian hospital – following it’s introduction deaths due to haemorrhage ceased.

1 – Experience managing postpartum hemorrhage at Minia University Maternity Hospital, Egypt: no mortality using external aortic compression. J Obstet Gynaecol Res. 2011 Nov;37(11):1557-63

Questions that need answering?

How long can it safely be applied.

What complications can occur – and have been reported.

Use in the non-obstetric setting

Trauma

It has been used in the prehospital setting for a patient with massive blood loss from lower extremity gunshot injuries:

1 – Temporization of penetrating abdominal-pelvic trauma with manual external aortic compression: a novel case report. Ann Emerg Med. 2014 Jul;64(1):79-81

Subsequently this same group studied the feasibility of more widespread use if this technique in the prehospital trauma setting:

2 – Abdominal aortic and iliac artery compression following penetrating trauma: a study of feasibility.Prehosp Disaster Med. 2014 Jun;29(3):299-302

What about alternative techniques which can rapidly stop the bleeding vascular occlusion?:

Each of these deserve in depth discussion in their own post but briefly they are:

Interventional radiology techniques like elective internal iliac balloons placed prior to accreta surgery are well described. You need a skilled interventional radiologist, appropriate equipment and know well beforehand that the patient is at risk – so not useful in unexpected situations

REBOA – retrograde endovascular balloon occlusion of the aorta – increasing use throughout the world (traumatic haemorrhage, obstetric haemorrhage and vascular surgery), and with some increasing literature describing its use particularly in women with placenta accreta/percreta.

Aortic cross clamping – general anaesthesia and laparotomy with formal aortic cross clamping by a skilled / trained surgeon is also a lifesaving technique. Getting access to the aorta in the retroperitoneum to allow formal clamp application requires the presence of a surgeon who is trained in this technique ( I am told it is not something any surgeon/obstetrician could do without formal training – personal communication).

Takehome Points:

Manual aortic occlusion – unlike the other methods described above can be applied by anyone, anywhere within seconds and doesn’t require any special equipment.

It could be considered in any severe obstetric haemorrhage but especially those women who are severely shocked and ideally be applied before they actually suffer a cardiac arrest.

Formal teaching and practice / simulation of this technique should be promoted. This will improve its effectiveness and lower the cognitive barrier for healthcare practitioners to actually make the decision to perform this technique in real life.

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By Roger Browning - Anaesthetist

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