Masui. The Japanese journal of anesthesiology
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Hemorrhage is the leading cause of maternal death. Pregnant woman can tolerate a larger amount of blood loss than non-pregnant woman, but obstetric hemorrhage is characterized by a high incidence of coagulopathy. The Japanese Society of Anesthesiologists and four related academic societies published "Guidelines for management of critical bleeding in obstetrics" in April 2010. ⋯ Declaration of an emergency is also essential for calling supportive medical personnel. To deal rapidly with critical bleeding, hospital actions to be taken should be prepared, and simulation exercise should be performed to correct inappropriate actions prior to an actual crisis. A systematic, not individual, approach is required to save the life of a bleeding pregnant woman.
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The "Guideline for Management of Critical Bleeding in Obstetrics" was implemented by five obstetrics-related societies in April 2010 to improve management strategies and outcomes of massive bleeding in obstetrics. Besides emergency transfusion replacing acute blood loss, the Guideline contains a flow chart of instructions for autologous blood transfusion in obstetric patients with rare blood types, irregular antibodies, or with an increased risk and/or history of massive bleeding. In this chapter, based on the characteristics of bleeding in the field of obstetrics, indication, contraindication, patient selection, preparation, and pitfalls regarding actual practices of autologous blood transfusion are detailed in terms of efficacy and limitations. The pros and cons of autologous blood transfusion are discussed together with the feasibility of intra/post-operative blood salvage and hemodilutional autologous blood transfusion during bleeding to reduce the total amount of transfusion and thereby improve the outcome of critical bleeding in obstetrics.
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Peripheral nerve block (PNB) is now widely performed in operating room by anesthesiologists. PNB is associated with multiple benefits compared to general anesthesia, but we should consider the complications of PNB. ⋯ Ultrasound guided PNB has become very popular now, and it has many potential advantages, such as direct visualization of nerves and anatomical structures, and direct and indirect visualization of spread of local anesthetics during injection with the possibility of repositioning the needle in case of maldistribution of local anesthetic. The half of these complications can be prevented by use of ultrasound guided PNB.
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"Identification error between patient and blood product" is the main cause of ABO-incompatible blood transfusion, but "Phlebotomy error" also has serious consequences. In order to prevent ABO-incompatible transfusion, it is important to establish a management system of blood transfusion in the hospital, including a hospital transfusion committee and a responsible medical doctor. In addition, in large hospitals routinely carrying out a considerable number of blood transfusions, it is important to employ specialists in blood banking. ⋯ Because there is little residual plasma in leukocyte-reduced red cell concentrate (RCC-LR), acute hemolysis is not detected on minor ABO mismatch blood transfusion. In the case of emergent blood transfusion, concerning the risk of acute hemolytic reaction, type-O RCC-LR blood transfusion is safer than ABO-identical RCC-LR when the blood of the patient is tested only once. When red cell antibody screening is not performed, there is a risk of hemolysis due to incompatible blood transfusion irrespective of the ABO blood group system, including a delayed hemolytic transfusion reaction.
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Rapid and massive bleeding has to be counteracted by efficient volume restoration against rapid loss of intravascular volume. There are two phases of volume management for massive bleeding, uncontrolled phase and controlled phase. During initial uncontrolled phase, rapid infusion of crystalloid with RCC (red cell concentrate) is the first choice of volume management to prevent shock and profound decline of hemoglobin level. ⋯ A new generation of hydroxyethyl starch is a promising blood substitute, designed with minimum side effect. Although renal damage especially in septic patient and coagulation disorder are theoretically suspected, beneficial effect as volume expansion overwhelms these stochastic side effects. Since the side effect depends on the dose and how much it remains in the body, a purposeful use during volume expansion phase should be recommended.