产科失血:输注液选择的优先事项

Kim Jong-Din
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The main causes of bleeding in obstetrics include uterine atony, premature placental abruption, uterine rupture, placental abruption, hereditary blood diseases, coagulopathy, sepsis, amniotic fluid embolism. \nObjective. To describe infusion therapy (IT) for obstetric bleeding. \nMaterials and methods. Analysis of literature data on this issue. \nResults and discussion. Strategies for the treatment of obstetric hemorrhage include restriction of the traditional massive crystalloid-based IT, applying the principle of antihypertensive resuscitation, using of adequate doses of tranexamic acid, fibrinogen concentrate and prothrombin complex concentrate, early informed use of blood components, and low-volume IT. Routine use of unbalanced crystalloid solutions in critically severe patients is dangerous. Infusion of large amounts of 0.9 % NaCl may cause metabolic hyperchloremic acidosis. Therefore, except in cases of hypochloremia, it is advisable to replace saline with balanced solutions. Reosorbilact (“Yuria-Pharm”) is the most suitable solution for this purpose. It mobilizes the own fluid of the organism, helping it to move from the intercellular space into the vessels. Hypotensive resuscitation involves the introduction of limited amounts of fluid in the early stages of treatment of hemorrhagic shock (until the bleeding stops). Low-volume IT program is a part of hypotensive resuscitation. In this case, the following solutions can be used: Reosorbilact, Sorbilact, Gekoton (“Yuria-Pharm”), 130/0.4 hydroxyethyl starch (HES), hypertonic NaCl solutions (including combined solutions with colloids), polyhydric alcohols. It should be noted that the new generation of HEC has less effect on coagulation than older drugs. Due to the risk of kidney damage, HEC solutions should be used in the lowest effective dose for as shortest period of time as possible. HEC infusion should be stopped as soon as hemodynamic targets are reached. Solutions containing polyhydric alcohols (Reosorbilact, Sorbilact, Xylate) occupy an important position in IT of critically ill patients. Due to their high osmolarity, Reosorbilact and Sorbilact cause fluid to move from the intercellular space into the vascular bed, improving microcirculation and tissue perfusion. The polyhydric alcohol sorbitol contained in these solutions creates increased osmotic pressure in the renal tubules, which provides a diuretic effect. In case of the blood loss volume of I-II functional class up to 1500 ml and stopped bleeding, IT is performed in a limited mode. The volume of intravenous infusion together with blood components should not exceed 200 % of the blood loss volume. Reosorbilact (10-15 ml/kg) is an initial solution in combination with 0.9 % NaCl (20-30 ml/kg). In case of unstable hemodynamics HEC may be added (up to 1,5 L). Blood components are used only in case of confirmed coagulopathy and continued bleeding. In case of massive critical blood loss >1500-2000 ml, it is advisable to use the protocol of massive blood transfusion 1:1:1:1. In order to reduce the pathological response of the endothelium to IT, it is advisable to use a substrate for the nitric oxide synthesis, namely, Tivortin (“Yuria-Pharm”). To stop life-threatening obstetric bleeding, CBV must be refilled using the protocol of massive blood transfusion and automatic blood reinfusion, oxytocin and prostaglandin analogues for the correction of uterine tone, uterine massage, correction of coagulopathy, balloon tamponade of the uterus. \nConclusions. 1. Emergency care for massive bleeding in obstetrics is one of the priorities in reducing maternal morbidity and mortality. 2. Intensive therapy of blood loss should be based on modern recommendations and the use of modern drugs. 3. 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Low-volume IT program is a part of hypotensive resuscitation. In this case, the following solutions can be used: Reosorbilact, Sorbilact, Gekoton (“Yuria-Pharm”), 130/0.4 hydroxyethyl starch (HES), hypertonic NaCl solutions (including combined solutions with colloids), polyhydric alcohols. It should be noted that the new generation of HEC has less effect on coagulation than older drugs. Due to the risk of kidney damage, HEC solutions should be used in the lowest effective dose for as shortest period of time as possible. HEC infusion should be stopped as soon as hemodynamic targets are reached. Solutions containing polyhydric alcohols (Reosorbilact, Sorbilact, Xylate) occupy an important position in IT of critically ill patients. Due to their high osmolarity, Reosorbilact and Sorbilact cause fluid to move from the intercellular space into the vascular bed, improving microcirculation and tissue perfusion. The polyhydric alcohol sorbitol contained in these solutions creates increased osmotic pressure in the renal tubules, which provides a diuretic effect. In case of the blood loss volume of I-II functional class up to 1500 ml and stopped bleeding, IT is performed in a limited mode. The volume of intravenous infusion together with blood components should not exceed 200 % of the blood loss volume. Reosorbilact (10-15 ml/kg) is an initial solution in combination with 0.9 % NaCl (20-30 ml/kg). In case of unstable hemodynamics HEC may be added (up to 1,5 L). Blood components are used only in case of confirmed coagulopathy and continued bleeding. In case of massive critical blood loss >1500-2000 ml, it is advisable to use the protocol of massive blood transfusion 1:1:1:1. In order to reduce the pathological response of the endothelium to IT, it is advisable to use a substrate for the nitric oxide synthesis, namely, Tivortin (“Yuria-Pharm”). 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引用次数: 0

摘要

背景。出血占孕产妇死亡率的34%。每7分钟就有一名妇女在分娩过程中死于出血。对医疗记录的回顾性分析表明,在60- 80%的病例中,致命后果是可以避免的。定义“大量失血”概念的标准是:24小时内失去100%的循环血容量(CBV)或3小时内失去50%的CBV,损失150毫升/分钟,3小时内体重下降2%,血液动力学紊乱合并红细胞压积下降10%,一次性失血超过1500-2000毫升或25- 35%的CBV,需要输血10剂量的红细胞24小时。产科出血的主要原因包括子宫张力不全、胎盘早剥、子宫破裂、胎盘早剥、遗传性血液病、凝血功能障碍、败血症、羊水栓塞。目标。描述输注治疗(IT)产科出血。材料和方法。对这一问题的文献资料进行分析。结果和讨论。产科出血的治疗策略包括限制传统的以大体积晶体为基础的信息技术,应用抗高血压复苏原则,使用足够剂量的氨甲环酸、纤维蛋白原浓缩物和凝血酶原复合物浓缩物,早期知情使用血液成分,以及小容量信息技术。危重病人常规使用不平衡晶体溶液是危险的。大量输注0.9% NaCl可引起代谢性高氯血症性酸中毒。因此,除低氯血症外,建议用平衡溶液代替生理盐水。Reosorbilact(“Yuria-Pharm”)是最适合这一目的的解决方案。它调动机体自身的液体,帮助液体从细胞间隙进入血管。低血压复苏包括在失血性休克治疗的早期阶段引入有限数量的液体(直到出血停止)。小容量IT程序是低血压复苏的一部分。在这种情况下,可以使用以下溶液:Reosorbilact, Sorbilact, Gekoton(“Yuria-Pharm”),130/0.4羟乙基淀粉(HES),高渗NaCl溶液(包括与胶体的组合溶液),多羟基醇。值得注意的是,新一代HEC对凝血的影响小于老药。由于存在肾脏损害的风险,HEC溶液应在最短的时间内以最低的有效剂量使用。HEC输注应在血液动力学指标达到后立即停止。含多羟基醇(山梨醇、山梨醇、木酸酯)的溶液在危重患者的IT中占有重要地位。由于它们的高渗透压,Reosorbilact和Sorbilact使液体从细胞间隙进入血管床,改善微循环和组织灌注。这些溶液中含有的多羟基醇山梨醇会增加肾小管的渗透压,从而起到利尿作用。当I-II功能类失血量达1500ml且止血时,以受限模式进行IT。静脉输注量连同血液成分不应超过失血量的200%。Reosorbilact (10- 15ml /kg)初始溶液与0.9% NaCl (20- 30ml /kg)混合。在血流动力学不稳定的情况下,可以添加HEC(最多1.5 L)。血液成分仅在确认凝血功能障碍和持续出血的情况下使用。大量危重失血1500ml - 2000ml时,宜采用大量输血1:1:1:1的方案。为了减少内皮细胞对IT的病理反应,建议使用一种合成一氧化氮的底物,即Tivortin(“Yuria-Pharm”)。为了防止危及生命的产科出血,CBV必须通过大量输血和自动回注、催产素和前列腺素类似物来纠正子宫张力、子宫按摩、纠正凝血功能障碍、子宫球囊填塞等方案进行补充。结论:1。产科大出血的急诊护理是降低产妇发病率和死亡率的优先事项之一。2. 失血的强化治疗应基于现代建议和现代药物的使用。3.输血时应明确适用血液成分的适应症。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Obstetric blood loss: priorities in the choice of infusion solutions
Background. Bleeding accounts for 34 % of maternal mortality. Every 7 minutes 1 woman dies from bleeding during the labour. Retrospective analysis of medical records shows that in 60-80 % of cases, fatal consequences can be avoided. Criteria for defining the concept of “massive blood loss” are the loss of 100 % of circulating blood volume (CBV) within 24 hours or 50 % of CBV within 3 hours, loss of 150 ml/min, of 2 % of body weight within 3 hours, reduction of hematocrit by 10 % in combination with hemodynamic disturbances, one-time blood loss more than 1500-2000 ml or 25-35 % CBV, the need for transfusion of >10 doses of erythromass for 24 hours. The main causes of bleeding in obstetrics include uterine atony, premature placental abruption, uterine rupture, placental abruption, hereditary blood diseases, coagulopathy, sepsis, amniotic fluid embolism. Objective. To describe infusion therapy (IT) for obstetric bleeding. Materials and methods. Analysis of literature data on this issue. Results and discussion. Strategies for the treatment of obstetric hemorrhage include restriction of the traditional massive crystalloid-based IT, applying the principle of antihypertensive resuscitation, using of adequate doses of tranexamic acid, fibrinogen concentrate and prothrombin complex concentrate, early informed use of blood components, and low-volume IT. Routine use of unbalanced crystalloid solutions in critically severe patients is dangerous. Infusion of large amounts of 0.9 % NaCl may cause metabolic hyperchloremic acidosis. Therefore, except in cases of hypochloremia, it is advisable to replace saline with balanced solutions. Reosorbilact (“Yuria-Pharm”) is the most suitable solution for this purpose. It mobilizes the own fluid of the organism, helping it to move from the intercellular space into the vessels. Hypotensive resuscitation involves the introduction of limited amounts of fluid in the early stages of treatment of hemorrhagic shock (until the bleeding stops). Low-volume IT program is a part of hypotensive resuscitation. In this case, the following solutions can be used: Reosorbilact, Sorbilact, Gekoton (“Yuria-Pharm”), 130/0.4 hydroxyethyl starch (HES), hypertonic NaCl solutions (including combined solutions with colloids), polyhydric alcohols. It should be noted that the new generation of HEC has less effect on coagulation than older drugs. Due to the risk of kidney damage, HEC solutions should be used in the lowest effective dose for as shortest period of time as possible. HEC infusion should be stopped as soon as hemodynamic targets are reached. Solutions containing polyhydric alcohols (Reosorbilact, Sorbilact, Xylate) occupy an important position in IT of critically ill patients. Due to their high osmolarity, Reosorbilact and Sorbilact cause fluid to move from the intercellular space into the vascular bed, improving microcirculation and tissue perfusion. The polyhydric alcohol sorbitol contained in these solutions creates increased osmotic pressure in the renal tubules, which provides a diuretic effect. In case of the blood loss volume of I-II functional class up to 1500 ml and stopped bleeding, IT is performed in a limited mode. The volume of intravenous infusion together with blood components should not exceed 200 % of the blood loss volume. Reosorbilact (10-15 ml/kg) is an initial solution in combination with 0.9 % NaCl (20-30 ml/kg). In case of unstable hemodynamics HEC may be added (up to 1,5 L). Blood components are used only in case of confirmed coagulopathy and continued bleeding. In case of massive critical blood loss >1500-2000 ml, it is advisable to use the protocol of massive blood transfusion 1:1:1:1. In order to reduce the pathological response of the endothelium to IT, it is advisable to use a substrate for the nitric oxide synthesis, namely, Tivortin (“Yuria-Pharm”). To stop life-threatening obstetric bleeding, CBV must be refilled using the protocol of massive blood transfusion and automatic blood reinfusion, oxytocin and prostaglandin analogues for the correction of uterine tone, uterine massage, correction of coagulopathy, balloon tamponade of the uterus. Conclusions. 1. Emergency care for massive bleeding in obstetrics is one of the priorities in reducing maternal morbidity and mortality. 2. Intensive therapy of blood loss should be based on modern recommendations and the use of modern drugs. 3. The indications for transfusion of blood components should be clearly applied.
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