Haemorrhage Archives - obsgynaecritcare

Hi Everyone,

Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into:

Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years.

https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0

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Hi Everyone,

This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following:

King Edward Memorial Hospital website – The Placenta Accreta Spectrum guideline

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Hi Everyone,

Whole blood, freeze dried plasma, refrigerated or frozen platelets….

On Oct 31st – Nov 3 Graeme, Emelyn and I attended the THOR – THUNDER conference hosted here in Perth at the Rendezvous Hotel in Scarborough.

Who is THOR? In their own words:

The THOR (trauma haemostasis oxygenation resuscitation) organization is a resuscitation and blood network, originating in Norway a decade ago, and now boasting global reach. It has built an avid following of both civilian and military resuscitation clinicians and scientists, covering both pre-hospital and hospital management of critically unwell patients.

The THOR vision is to improve outcomes from traumatic haemorrhagic shock by optimising the acute phase of resuscitation. The mission is to develop and implement the best practices for haemorrhagic shock resuscitation from pre-hospital care right through to the completion of the acute phase of hospital resuscitation.

Thor group website: Trauma Hemostasis and Oxygenation Research Network (rdcr.org)

We sat down to reflect on the different topics that were presented at this fascinating conference. A big shout out to Tania Rogerson for organising such an amazing bunch of speakers. It was great to hear how resuscitation of major haemorrhage is done in other parts of the globe and to be educated about some different resuscitation products that are not available here in Australia.

If you also want to hear a great deep dive into the scientific evidence base for the management of massive haemorrhage then I highly recommend listening to Casey Parker and Justin Morgenstein discussing this topic here (thanks for a great balanced summary of the evidence):

Massive Haemorrhage: Science and Practice – Broome Docs – Nov 2023

Massive hemorrhage: a very deep dive – First10EM – Nov 2023

Evaluation of freeze dried plasma for use in NSW – https://aci.health.nsw.gov.au/networks/trauma/resources/freeze-dried-plasma

There has even been a pilot study comparing whole blood for use in accrete spectrum surgery in San Antonio:

Whole blood transfusion reduces overall component transfusion in cases of placenta accreta spectrum: a pilot program.J Matern Fetal Neonatal Med 2022 Dec;35(25):6455-6460.

The Use of Whole Blood Transfusion in Trauma – Curr Anesthesiol Rep Jan 2022

Warming Up to Cold-stored Platelets Anesthesiology December 2020, Vol. 133, 1161–1163. 

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Hi everyone,

Join us this week as we briefly celebrate the 100th episode – almost exactly 5 years after the first episodes aired. Then we sit down to discuss some real haemorrhage cases – a follow up on our promise from the earlier episode 97 where we discuss the basics of managing obstetric haemorrhage.

Thanks Graeme, Shilpa and Matt!

097 Obstetric haemorrhage

MBRRACE-UK – Maternal mortality and morbidity reports UK

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Welcome to this podcast, the eighth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss all things relating to obstetric haemorrhage, a much feared and common obstetric emergency.

Thanks Shilpa, Matt & Roger!

The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area.

1 – Epidural analgesia in labour part 1

2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting

3 – Accidental dural puncture and intrathecal catheters

4 – Post-dural puncture headaches and management

5 – Pre-eclampsia, eclampsia and hypertensive disorders

6 – General anaesthesia for Caesarean Delivery part 1

7 – General anaesthesia for Caesarean Delivery part 2

8 – Obstetric Haemorrhage

9 – Neuraxial anaesthesia for Caesarean Delivery

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Case History (*hypothetical patient)

A 33yr old woman presents to a GP complaining of hair loss, cold intolerance, dizziness, extreme fatigue and weight gain. On further questioning the patient states this is her third attempt to seek help over a number of years. She initially sought help for amenorrhoea after her second delivery and was started on oestrogen / progesterone tablets. The second doctor gave her a diagnosis of postpartum depression after eliciting a history of anxiety, tachycardia and feelings of stress and started her on an antidepressant. However the medication didn’t help and she tapered them off and didn’t return.

On close questioning she recounts that her first delivery was uncomplicated but the second was an emergency caesarean after failure to progress and fetal distress. The surgery was complicated by blood loss of 4 litres and she remembers being told by staff “that the blood was coming out as fast as it was going in”. She spent a number of days in the HDU / ICU and her child was bottle fed because she had difficulty establishing breastfeeding due to the traumatic events.

Join Graeme and I again as we discuss this important but rare complication of pregnancy.

Diagnosis and Treatment Challenges of Sheehan’s Syndrome

Sheehan’s syndrome in modern times: a nationwide retrospective study in Iceland

Which of these is a doctor and which is a serial killer? – and who are they!

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Hi Everyone,

This week I am joined again by Nolan who was involved in writing the recently published international consensus guidelines on the use of uterotonic drugs at caesarean section. We discuss the pharmacology and mechanisms of all the different drugs used in clinical practice.  From a practical point of view these guidelines differentiate between oxytocin naive women, those who have been exposed to oxytocin (in labour) and those practitioners working in less well resourced settings.

A big thank you to Trilby for helping to setup the new audio equipment! Hopefully the quality of these podcasts will start to improve over the next few episodes as we get to grips with how to use all this new stuff!

International consensus statement on the use of uterotonic agents during caesarean section. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14757

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Hi everyone,

Recently Graeme and I were asked to help run a workshop here in WA for the ANZCA Emergency Response CPD programme – thanks for your help Graeme and Paras. Some of the key concepts were understanding blood products and the strategies / philosophies which have been used when deciding what to give in a major haemorrhage. We decided that this would make a great podcast discussion and so voila – here it is!

We discuss:

– massive transfusion protocols utilising empiric ratios of blood products (often heavy in FFP / plasma) versus the more targeted approach often based on rapid assessment of haemostasis using viscoelastic tests such as ROTEM / TEG.

– the four deficits in haemostasis which can develop; 1 fibrinolysis, 2 fibrinogen deficiency, 3 platelet deficiency, 4 thrombin deficiency.

-a description of the types of blood products available their pros / cons.

– why the use of large volumes of plasma probably doesn’t make sense and may in fact involve some harm to patients.

– an alternative strategy for empiric therapy when rapid tests of coagulation are not available empiric treatment with tranexamic acid and fibrinogen.

Thanks for another great dicsussion Graeme!

1. Study showing decreased massive transfusion rate in trauma after change to goal directed ROTEM therapy in Switzerland.
   Anaesthesia. 2017 Nov;72(11):1317-1326. doi: 10.1111/anae.13920. Epub 2017 May 23. Change of transfusion and treatment paradigm in major trauma patients.
2. Before and after the introduction of ROTEM guided fibrinogen concentrate at Liverpool Womens Hospital and improved outcomes. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015 Feb;70(2):166-75. doi: 10.1111/anae.12859. Epub 2014 Oct 7

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Hi Everyone,

This week we have a great four person discussion around the importance of assembling the right team when confronted with a high risk complex case in the after hours period. Interesting points covered include still doing the team huddle and introducing everyone even at midnight, a detailed discussion around manual aortic compression – the IVC, and how to monitor effectiveness – and also using a posterior hysterotomy to deliver the fetus when everywhere else looks bad!

Thanks to IKEA for their contribution to our high tech podcast studio!

Thanks also Parvesh, Matt Epee-Bekima & Matt Rucklidge for this great discussion.

(* The patient discussed in this podcast gave us explicit written consent for her case to be used in this deidentified discussion)

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Hi everyone,

Welcome to part 2 of our series on cell salvage in obstetrics and gynaecology!

Last week we had a great discussion on the basics of cell salvage and focused on what the team in the surgical field need to know to do a great job. If you haven’t listened to that yet check it out here:

Link

This week we welcome back Dr Matt Rucklidge and we have the recording of the talk he gave our department recently on the latest thoughts surrounding the use of cell salvage in obstetrics. If you haven’t been watching this space closely over the last few years you may be unaware that there has been a definite change in approach to many aspects of how obstetric cell salvage is now done. Listen to Matt present a very balanced and thoughtful discussion on the following:

Some of his talk is based on the following recent articles:

https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0

National Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/ics

Great resource from the UK pdfs and free slides on all the various aspects of cell salvage: https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education

If you want to revise the benefits of autologous blood (i.e. the patient’s own blood) then listen to this earlier episode:

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