Download Vinnitsa Nathional Medical University named after N.I. Pyrogov

Vinnitsa Nathional Medical University named after N.I. Pyrogov
Head of Obstetrics and Gynaecology department № 2
PhD, prof. Bulavenkо О.V.__________
the «____» ____________of 20___ year
METHODICAL RECOMMENDATIONS
FOR THE STUDENT’S OF STOMATOLOGICAL FACULTY
FOR PREPARING TO PRACTICAL CLASS
Academic discipline
Module 1.
Modules 1.
Study subject
Obstetrics
Physiological and pathological pregnancy,
childbirth and the postpartum period.
Perinatal complications
Physiological and pathological pregnancy,
childbirth and the postpartum period.
Perinatal complications
Emergency conditions in obstetrics.
Course
4
Faculty
Dental
Author
Assistant Goncharenko AM
Vinnitsa-2013
1. Background: This topic is relevant for future physicians as family medicine and
obstetrician-gynecologists and for dentists, as in modern obstetrics in recent years
marked upward trend in the number of pregnancy-related complications that require
emergency care physician of any specialty in place of complication. Therefore,
knowledge of the topic ennyu contributes to reduced maternal mortality. Mastering the
algorithm acts in urgent situations helps save the patient's life.
2. Specific objectives:
1. Know classification of obstetric hemorrhage.
2. To analyze the etiology and pathogenesis of ectopic pregnancy.
3. Classify n ozamatkovu pregnancy depending on the location.
4. Explain the clinic and symptoms of ectopic pregnancy.
5. Be able to identify the symptoms of internal bleeding and hemodynamic violation.
6. Learn to evaluate the results puncture the abdominal cavity through the posterior fornix
(differentiate blood from the veins and the abdominal cavity).
7. Know the basic principles of diagnosis and diagnostic tical errors in ectopic pregnancy.
8. Make a plan of examination of patients with ectopic pregnancy.
9.
Read and evaluate the results of clinical and laboratory examination of patients with
ectopic pregnancy.
10. To conduct differential diagnostics in patients with ectopic pregnancy and other
nosological forms.
11. Know the basic principles of treatment of ectopic pregnancy.
12. Know the clinic and the doctor tactics placenta previa and abruption of placenta.
13. Differentiate causes of bleeding during pregnancy.
14. To be able to diagnose placenta previa or premature detachment of her.
15. Identify and describe the degree of placenta previa.
16. Develop and justify individual plan delivery with placenta previa and placental
abruption with.
17. To be able to assess the amount of blood loss.
19. The base and knowledge
Names of previous disciplines
Normal anatomy
Normal physiology
Physiopathology
Endocrinology
General Surgery
These skills
Apply knowledge of the anatomical structure
of the female genital organs
krovozabezpechen-tion of the uterus and
fallopian tubes, uterine ligaments.
Phases of the menstrual cycle (uterine and
ovarian cycle).
Pathophysiological changes in the human
body at different shocks origin (hemorrhagic,
septic).
Female sex hormones, place their synthesis,
communication and the phase of the
menstrual cycle.
Determination of blood group and Rh
belonging, of samples of individual (group
and Rh) and biological compatibility in blood
transfusions.
18. Tasks for independent work in preparation for employment.
List of key terms that a student must learn in preparation for the class:
Term
1. The physiological blood loss during delivery
2. Hemorrhagic Shock
Definition
- of 0.5% of body weight women.
- Acute cardiovascular failure due to
mismatch of blood volume capacity of the
vascular bed, which is caused by blood loss,
and is characterized by an imbalance between
the need for oxygen in the tissues and speed
its actual delivery.
3. Septic shock
4. Shock index (index Algovera)
4. Eclampsia
- it is extremely difficult degree of late
preeclampsia, which is accompanied by a set
of complex symptoms that indicate a violation
of all systems and organs.
The theoretical questions to the studies:
1. What hemorrhagic shock?
2. Classification of hemorrhagic shock on the degree of severity and clinical course
4. Tactics medication arya in the development of hemorrhagic shock.
5. Basic principles of treatment of hemorrhagic shock, depending on the severity.
6. What is septic shock?
7. Diagnosis of different phases of septic shock.
8. Tactics doctor in the development of septic shock.
9. Basic principles of treatment of septic shock.
9. Define eclampsia.
10. Phases of an attack of eclampsia.
11. Algorithm actions doctor during an attack of eclampsia.
The practical works (tasks) to be performed in class:
1. Identify the shock index.
2. To chart the treatment of hemorrhagic shock in varying degrees of severity.
3. Work out on a mannequin tactics physician in obstetric hemorrhage.
4. To make the table stops methods of obstetric hemorrhage.
5. To chart treatment of septic shock.
6. Develop a scheme of rehabilitation of women who have suffered hemorrhagic
shock.
7. Work out sequence of actions during the attack of eclampsia.
Eclampsia.
The high risk of eclampsia indicate symptoms: severe headache, high levels
of hypertension (diastolic blood pressure levels> 120 mm Hg. Cent.), Nausea,
vomiting, blurred vision, pain in the right upper quadrant and / or epigastric region.
Eclampsia - it is extremely difficult degree of late preeclampsia, which is
accompanied by a complex set of symptoms that indicate a violation of all systems
and organs. Eclampsia may occur during delivery (48-50%), pregnancy (2-29%)
and postpartum (22-23%).
The clinical picture is characterized by attacks of convulsions, which are superimposed on
preeclampsia. Each attack goes on for 1-2 minutes and consists of periods consistently change:
1.
Peredsudomyy time - there are shallow twitching of facial muscles, closed lashes
lowered mouth corners. This period lasts 20-30 seconds. At the beginning of this period, the
patient is breathing.
2.
Period tonic convulsions - typical titanium contractions of muscles of the body.
Body pulled and strained face blidniye, jaw tight close up, eyes became fixed, immovable. The
patient during this period is not breathing. Pulse was not palpable, duration 10-20 sec. This
period is the most dangerous for the fetus and mother.
3.
Period clonic cramps - the woman who lay motionless, began to beat in clonic
convulsions, which continuously follow one after another and spread through the body from top
to bottom, so that she jumps up in bed abruptly moving his hands and feet. The patient is not
breathing. Pulse is not defined. The face becomes purplish-blue strain jugular vein. Gradually the
spasms weakened and suspended. The patient makes a deep breath, accompanied by wheezing,
mouth allocated foam. This period lasts for 20-30 seconds.
4.
Period end attack - patient begins to breathe slowly and deeply, mouth allocated
foam painted with blood as a result prykushuvannya tongue, face gradually rozoviye. Starts
defined pulse. Pupils are gradually narrowed. After the attack the patient is in a coma and that
happened, do not remember. This period is in each case an individual amount of time.
Sometimes, after the first attack, the second starts, etc. It can also be observed bezsudoma form
eclampsia when no court a woman falls into a coma. This form is rare, but the weather when it is
even more dangerous.
The main purpose of emergency:
• termination of the court;
• restoration of the airway.
Role of intensive care after the elimination of the court: the prevention of
repeated seizures, eliminating hypoxia and acidosis (respiratory and metabolic),
prevention of aspiration syndrome, prompt delivery.
First aid for the development of an attack of eclampsia.
1. Treatment in case of attack trial begins at place.
2. Expands intensive care or hospitalized pregnant to the department of
anesthesiology and intensive care.
3. The patient laid on a flat surface on the left side, quickly dismissed the
airways, opening his mouth and pushing the lower jaw parallel evacuate
content of the oral cavity. If preservation of spontaneous breathing
injected air duct and carry oxygen inhalation.
4. In case of prolonged apnea immediately begin forced ventilation
nasal-face mask with 100% oxygen supply in the mode of positive end
expiratory pressure. If seizures recur or the patient remains in a coma,
injected muscle relaxants (suksametoniyu bromide 2 mg / kg) and
convert it to an artificial lung ventilation (ALV) in a mode of moderate
hyperventilation.
5. Along with measures to restore adequate gas exchange exercise
peripheral vein catheterization and start putting anticonvulsants
(magnesium sulfate injected bolus of 4 g for 5 min, then spend
supportive therapy speeds the introduction of 1-2 g / h) under the close
control of blood pressure and heart rate. If seizures continue,
intravenously injected another 2 g of magnesium sulfate (8 ml of 25%
solution) for 3-5 min. Instead, an additional bolus of magnesium sulfate
can be used diazepam intravenously (10 mg) or thiopental sodium (450500 mg) for 3 min. If the assault trial continues for more than 30
minutes, this condition is considered as eklamptychnyy status.
6. If diastolic blood pressure is high (> 110 mm Hg. Cent.) Transmitting
antihypertensive therapy.
7. Catheterization of the bladder.
8. All manipulations (venous catheterization, bladder, obstetric
manipulation) is performed under general anesthetic thiopental sodium
or nitrous oxide and oxygen.
9. After the elimination of the court conducting the correction of
metabolic disorders, fluid and electrolyte balance and acid-base status,
protein metabolism.
A survey carried out after the termination of an attack by the court: consult a
neurologist and ophthalmologist, laboratory tests: complete blood count (platelet
count, hemoglobin level) determination of hematocrit and clotting time, fibrinogen
and its degradation products, prothrombin and prothrombin time, blood chemistry (
total protein, [including albumin fraction], glucose, urea, creatinine, transaminases,
sodium, potassium, calcium, magnesium), urinalysis, determination of daily
protein loss in the urine, blood pressure monitoring, determination of hourly
diuresis and clinical assessment symptoms of conduct compulsory registration of
births in the history of every hour.
Artificial respiration - is the main method of treatment of eclampsia, but the
elimination of hypoxia (most important pathogenetic factor in the development of
multiple organ failure) - a prerequisite for the other events.
Indications:
Absolute:
• eclampsia during pregnancy;
• eklamptychna eklamptychnyy coma or status;
• Adult acute RDS (stage III);
• convulsive readiness of the background surface anesthesia;
• combination of preeclampsia / eclampsia with a shock of any origin.
Relative:
• progression of acute coagulopathy;
• blood loss during surgery than 15 ml / kg (prolonged mechanical
ventilation to stabilize vital functions and restore VCB).
Criteria for discontinuation of mechanical ventilation: the full recovery
of consciousness, absence seizures and seizure without the use of anticonvulsants,
hemodynamic stabilization, termination of drugs that suppress breathing (muscle
relaxants, narcotic analgesics, hipnotyky etc..) No signs of acute RDS adults;
stability parameters of hemostasis , restored the oxygen capacity of blood
(hemoglobin concentration of 80 g / l); SaO2> 95%, PaO2> 80 mm Hg. century.
with FiO2 <0,4 (PaO2 / FiO2> 200).
Mentioned criteria and normalization of hemodynamic primarily be
achieved during the first day and plan termination ventilation with complete
abolition of sedative therapy.
In the case of a brain hemorrhage and coma pregnant on the termination
of mechanical ventilation discussed not more than two days. Intensive care
continues in full.
Intensive therapy of eclampsia without mechanical ventilation is
possible under the following conditions:
• Assault Court came under the influence of extreme stimuli (contractions
powers) or in the postpartum period;
• after an attack of eclampsia saved items consciousness;
• blood pressure during an attack less than 170/100 mm Hg. century.;
• Lack of subarachnoid hemorrhage;
• Absence of focal neurological symptoms;
• absence of other indications for mechanical ventilation.
Supervised patient that suffered eclampsia, carried out in a chamber intensive
care or arranging individual post.
Delivery is urgent. If obstetric situation does not allow for immediate delivery
through the vaginal route (eklamptychnyy attack came in the second stage of
labor), perform a cesarean operation. Delivery is carried out immediately after the
liquidation court offense against a background of continuous administration of
magnesium sulfate and antihypertensive therapy.
Subject to continued attacks by the court conduct an urgent delivery after the
transfer of the patient to the ventilator. After surgery ventilator continues to
stabilize the patient. After delivery, treatment is carried out according to the
situation of the patient. Magnesium therapy should last at least 48 hours.
Monitoring the patient that suffered preeclampsia / eclampsia after discharge
from the maternity hospital.
In the women's clinic with a therapist conduct clinical supervision of a woman
who suffered moderate or severe preeclampsia / eclampsia:
• nursing at home;
• consulting relevant experts (if necessary);
• a comprehensive examination at 6 weeks postpartum.
Patients requiring treatment with antihypertensive drugs after discharge from
the hospital undergoing review with mandatory weekly laboratory control level of
proteinuria and creatinine concentration in plasma.
In the case of hypertension for 3 weeks postpartum patient admitted to the
therapeutic department.
Duration of clinical supervision recovering from mild preeclampsia /
eclampsia or severe - 1 year.
Hemorrhagic shock IN OBSTETRICS
Hemorrhagic shock - the acute cardiovascular failure due to mismatch in
blood volume capacity of the vascular bed, which is caused by blood loss, and is
characterized by an imbalance between the need tissues for oxygen and its real
speed of delivery.
The risk of hemorrhagic shock occurs when blood loss 15 - 20% of BCC
(0.8 - 1.2% of body weight) or 750 - 1000 ml. Bleeding in excess of 1.5% of body
weight or 25-30% of BCC (≈ 1500 ml) is massive.
Risk factors for hemorrhagic shock in obstetrics:
1.
Pathological premorbid background:
- Hypovolemia pregnant;
- Congenital defects of hemostasis;
- Acquired hemostatic disorders.
2.
Bleeding in early pregnancy and term:
- Abortion;
- Ectopic pregnancy;
- Cystic drift.
3.
Bleeding in late term pregnancy or in childbirth:
- Premature detachment of the placenta;
- Placenta previa;
- Rupture of the uterus;
- Embolism navkoloplodovymy waters.
4.
Bleeding after childbirth:
- Hypo-or uterine atony;
- Retention of placenta or fragments;
- Gaps birth canal.
TABLE 1. Classification of hemorrhagic shock on the clinical course and
severity (Chepka LP et al., 2003)
The severity of Phase shock
Volume of blood loss
shock
% BCC
% Of body weight
1
Compensated
15 - 20
0.8 - 1.2
2
Subcompensated
21 - 30
1.3 - 1.8
3
Decompensated
31 - 40
1.9 - 2.4
4
Irreversible
> 40
> 2, 4
Table 2. Criteria for severity of hemorrhagic shock.
Index
The degree of shock
0
1
2
3
4
Volume ≈ ml
<750
750-1000 1000-1500
1500-2 5 00 > 2500
of
% Of <0.8
0.8 - 1.2
1.3 - 1.8
1.9 - 2.4
> 2, 4
blood
body
loss
weight
%
<1 5% 15 - 20%
January 2 - January 3 - > 40%
BCC
30%
40%
Pulse rate, beats <100
100 - 110 110 - 120
120 - 140
> 140 or <4
/ min
0*
Ical systole and N
90 - 100
70 - 90
50 - 70
<50 **
blood pressure,
mm Hg
Shock index
0.54 - 0.8 - 1
1 - 1.5
1,5 - 2
>2
0.8
CVP, mm.vod.st 60 - 80 40 - 60
30 - 40
0 - 30
≤0
Test
"white N (2 s) 2 - 3 s
>3c
>3c
>3c
spots"
Hematocrit l / l 0.38 - 0.30 - 0.38 0.25 - 0.30
0.20 - 0.25
<0.20
0.42
Respiratory rate 14 - 20 20 - 25
25 - 30
30 - 40
> 40
per minute ..
Speed diuresis 50
30 - 50
25 - 30
5 - 15
0-5
ml / h
Mental Status
Peace Slight
Anxiety,
Anxiety, fear Confusion
concern
moderate
or confusion or coma
anxiety
Note: * - the great arteries; ** - the method of Korotkov, can not be determined
The difficulty of determining the amount of blood loss in obstetrics
hemodilution caused significant blood flowing amniotic fluid and concealing large
amount of blood in the vagina or uterus.
To determine the approximate volume of blood loss in pregnant women may
use a modified formula Moore:
HF = M ∙ 75 ∙ Ht ref - Ht f
Ht ref
Where: KO - blood loss (ml) M - pregnancy weight (kg); Ht ref - output a patient
hematocrit (L / L); Ht f - actual patient's hematocrit (l / l).
Hypotension is a late and unreliable clinical symptom of obstetric
hemorrhagic shock. Thanks physiological hipervolemichniy autohemodilyutsiyi
pregnant AD may be altered as long as the volume of blood loss reaches 30%.
Compensation hypovolemia in pregnancy is, primarily, due to activation of the
sympathoadrenal system, resulting vasospasm and tachycardia. Early joins
olihouriya.
Intensive therapy of hemorrhagic shock.
General principles of treatment of acute blood loss:
1.
Immediate stop bleeding conservative or surgical methods,
depending on the cause of bleeding (see protocol "and obstetric
haemorrhage").
2.
Restoring BCC.
3.
Ensuring adequate gas exchange.
4.
Treatment and prevention of organ dysfunction organ failure.
5.
Correction of metabolic disorders.
Priority actions in case of hemorrhagic shock:
1.
Evaluate vital functions (pulse, blood pressure, respiratory rate
and character, mental status).
2.
Reportedly responsible duty obstetrician-gynecologist or deputy
chief medical officer of the clinical work of the occurrence of bleeding
and development of hemorrhagic shock and mobilize staff.
3.
Lift leg or foot end of the bed (Trendelenburg position) to increase
venous turn to the heart.
4.
Turning pregnant on the left side for the prevention of aorto-caval
syndrome and reduce the risk of vomiting and aspiration of a free
airway.
5.
Kateteryzuyut one - two peripheral vein catheters of large
diameter (№ № 14 - 16 G).
If access to several peripheral veins should not rush to central venous
catheterization, because there is a high likelihood of complications .
In case of shock 3 - 4 degree requires three venous catheterization, with one
of them must be central. Priority in vein catheterization should be given
venesektsiyi v. Brahiales or puncture and catheterization for Seldynherom v.
Jugularis interna
6.
Gaining 10 ml of blood for determination of group and Rh origin,
cross-compatibility, hemoglobin and hematocrit, and perform LeeWhite test prior to infusion solutions.
7.
Inhalation of 100% oxygen at a speed of 6 - 8 l / min. through a
naso-facial mask or nasal cannula.
Next steps for the elimination of hemorrhagic shock.
1. Starts jet intravenous crystalloid infusion (0.9% sodium chloride
solution, Ringer's solution, etc.) and colloids (helofuzyn). temperature,
volume and infusion therapy components determined by the degree of
shock and hemorrhage size (see Table 3).
In case of shock 2 - 3 degrees, the rate of infusion should be equal to 200 300 ml / min.
Treatment of hemorrhagic shock is more effective if started early infusion therapy
as early as possible within 30 minutes. the development of the first symptoms of
shock (A).
Table 3. infusion-transfusion therapy obstetric hemorrhage
(Klyhunenko A., 2002 as amended)
Volume of blood loss
def.
bcc
% By
weight
Body
Blood loss
(ml)
10 20%
1-1.5%
500,01000,0
2030%
1.52.0%
1000,01500,0
3040%
2.02.5%
1500,02000,0
4070%
2,53,6%
2500,03000,0
More
than
70%
Over
3.6%
Over
3000,0
The total
volume
transfusion
(% of def.
CBV)
Christi
Lois
(0.9%
Mr.
NaCl,
Mr.
Ringer
others)
10-15
ml / kg
Infusion-transfusion environment
Colloids
Er. mass
synthetic
natural
Refortan,
helofu-zyn
* and other
Freshfrozen
wife
plasma
10 ml / kg
-
10 ml /
kg
10 ml / kg
5 -10
ml / kg
180
(Up to 4
liters)
170
(5 l)
7 ml /
kg
7 ml / kg
7 ml /
kg
150
(More
than
6 liters)
Dl 10
ml / kg
200-300
(Up to 2.5
liters)
200
(Up to 3
yrs)
Trombokontsen
the costs **
Albumin
(10 20%)
-
-
-
-
5 ml / kg
-
10-15
ml / kg
200 ml
10 - 20 ml
/ kg
-
10-15 ml /
kg
15-20
ml / kg
200 ml
30 ml / kg
-
Up to 20
ml / kg
More
than 20
ml / kg
More
than 200
ml
More than
30 ml / kg
4 - 10.
Notes: * - modified fluid gelatin (Helofuzyn) is not recommended for use i n p r e g n a n t
women with preeclampsia, in these cases the prefe rred derivative
hidroksyetylkrohmalyu (Refortan, stabizol).
** - And platelet unit contains at least 0,5 x10 11 platelets. One therapeutic dose contains
from 4 to 10 units
When blood loss greater than 2 - 2.5% of body weight to therapy is
desirable to connect perenoschyk artificial oxygen - Perftoran dose of 1,5-5
ml / kg.
Contraindicated use of the program infusion-transfusion therapy
glucose solution. We do not recommend the use of dextran
(reopolyglukine), 5% albumin solution (A).
If bleeding is not more than 20% of BCC may enter one crystalloid
(0.9% sodium chloride solution, Ringer's solution) in the amount of 2 - 3 times
greater than the volume of blood loss (C).
Indications Gemotrasfuzii determined individually in each case, but should
focus on the performance of hemoglobin and hematocrit (Hb <70 g / l; Ht <0,25 l
/ l) (B).
In shock the woman did not give fluids orally (A).
2 Stop bleeding by conservative or surgical methods, depending on the
cause of bleeding (see protocol "Obstetrical and bleeding")
3 Warm woman, but do not overheat it, because it improves peripheral
microcirculation, which may result in reduced blood flow to vital
organs (B). Given the large amount of solutions are introduced, they
are also heated to 36 ° C
4 Kateteryzuyut bladder.
5 Continue the inhalation of 100% oxygen at a speed of 6 - 8 L / min,
if necessary - mechanical ventilation.
Indications for mechanical ventilation:
- Hypoxemia (P AO 2 <60 mm t.st. p n p and FiO 2> 0.5);
- Respiratory rate over 40 per minute;
- Low inspipatopne effort (the patient is unable to create a negative
pressure in the airways more than 15 cm of water. Century.
DURING maximum effort);
- Blood loss 3% of body weight or more than 35 ml / kg.
In ykorystovuyut endotracheal tube cuffs large fill volume and low pressure.
Ventilation provided decompensated shock is performed under the control of
the gas composition of the blood.
If pliability lungs preserved - increase the positive pressure at the end of the
trachea (PTKV).
Assess the adequacy of septsevoho output and hemoglobin level. By
neobhodnosti kopyhuyut hypophosphatemia and alkalosis, which eliminates bias
kpyvoyi oxyhemoglobin dissociation.
Criteria for discontinuation of mechanical ventilation:
- Stabilization of the clinical condition of the patient;
- Respiratory rate less than 30 per minute;
- Inspiratory effort less - 15 cm water column;
- PaO 2 / FiO 2 > 80 mm pt.st. / 0.4 DURING PTKV vodn.st. 7 cm;
- The possibility of the patient's own double volume of exhaled air for a
minute.
6
Laboratory observations: complete blood count, platelet count,
clotting time, coagulation, electrolyte composition of blood. If - CBS
and blood gases.
7
Monitor observation: noninvasive determination of blood pressure
(assuming of shock 4., And the presence of hardware - definition of
invasive BP), heart rate, Pulse oximetry, ECG, thermometry,
monitoring hourly urine output. In case of shock 3 - 4. against the
background of infusion-transfusion therapy - CVP monitoring every
30 - 45 minutes.
8 In the absence of signs of reducing cardiovascular disease (increased
blood pressure, tachycardia decrease) conduct inotropic support
myocardium using vasopressors (dopamine 5-20 mcg / kg / min.,
Dobutamine 5-20 mcg / kg / min).
9
If signs of coagulopathy conduct therapy of disseminated
intravascular coagulation, depending on the stage (see protocol
"syndrome of disseminated intravascular coagulation in obstetrics").
10 Correction of acidosis g sodium idrokarbonatom provided that the pH
of the blood and <7,1 (B).
After the withdrawal of the patient from shock continue treatment in the
intensive care unit.
Attachment number 1
Methods for determination of blood loss
1. Method Libova
2. Formula Nelson
3. Shock index Alhovera
Normally Alhovera index = 1.
The magnitude of the index can be drawn about the magnitude of blood loss
Index Alhovera
0.8 and less
0,9-1,2
1.3-1.4
1.5 or more
Volume of blood loss (% of CBV)
10%
20%
30%
40%
Note: Code Alhovera not informative in patients with hypertension
4. Hematokrytnyy method of Moore
Appendix number 2
Basic principles of recovery bec
Infusion-transfusion therapy obstetric hemorrhage (Klyhunenko A., 2002 r.z applications)
Volume of blood loss
def.
bcc
% By
weight
Body
Blood loss
(ml)
10 20%
1-1.5%
500,01000,0
2030%
1.52.0%
1000,01500,0
3040%
2.02.5%
1500,02000,0
4070%
2,53,6%
2500,03000,0
More
than
70%
Over
3.6%
Over
3000,0
The total
volume
transfusion
(% of def.
CBV)
Christi
Lois
(0.9%
Mr.
NaCl,
Mr.
Ringer
others)
10-15
ml / kg
Infusion-transfusion environment
Colloids
Er. mass
synthetic
natural
Refortan,
helofu-zyn
* and other
Freshfrozen
wife
plasma
10 ml / kg
-
10 ml /
kg
10 ml / kg
5 -10
ml / kg
180
(Up to 4
liters)
170
(5 l)
7 ml /
kg
7 ml / kg
7 ml /
kg
150
(More
than
6 liters)
Dl 10
ml / kg
200-300
(Up to 2.5
liters)
200
(Up to 3
yrs)
Trombokontsen
the costs **
Albumin
(10 20%)
-
-
-
-
5 ml / kg
-
10-15
ml / kg
200 ml
10 - 20 ml
/ kg
-
10-15 ml
/ kg
15-20
ml / kg
200 ml
30 ml / kg
-
Up to 20
ml / kg
More
than 20
ml / kg
More
than 200
ml
More
than 30
ml / kg
4 - 10.
Notes: * - modified fluid gelatin (Helofuzyn) is recommended not to use i n p r e g n a n t
women with preeclampsia, in these cases the preferred derivative
hidroksyetylkrohmalyu (Refortan, stabizol).
** - And platelet unit contains at least 0,5 x10 11 platelets. One therapeutic dose contains
from 4 to 10 units
Intensive therapy of septic shock:
1. Immediate hospitalization in the NICU.
(Treatment together with resuscitator)
- No veryferiynyh venous catheterization
(Usually three catheters)!!
2. Correction of hemodynamic compromise
A) Infusion Therapy:
rate of 10 ml / min. for 15 - 20 min., and then - 5ml/hv.
-
derivatives hidroksyetylkrohmalyu (venofundyn, Refortan, HAESsteril) and crystalloids (0.9% sodium chloride solution, Ringer's
solution) at a ratio of 1: 2;
-
w / CD. albumin solution 20 - 25%;
-
Fresh frozen plasma as well (600 - 1000 ml);
B) inotropic support:
- CVP - N, AT - ↓: dopamine at a dose of 5 - 10 mcg / kg / min. (Up to
20 mcg / kg / min.) Or dobutamine , which is introduced at 5 - 20 mcg /
kg / min. ,
with no effect : noradrenaline gidrotartrata at a rate of 0.1 - 0.5 mg / kg
/ min. while reducing the dose of dopamine to "kidney" (2 - 4 mg / kg /
min.) and 2.0 mg naloxone.
-
The
ineffectiveness
of
complex
hemodynamic
therapy
hlyukokotykosteroyidy. Dose (in terms of hydrocortisone) - 2000 mg /
day.
3. Maintain adequate ventilation and gas exchange.
Indications for mechanical ventilation:
- RaO2 <60 mmHg;
- PaCO2,> 50 mmHg or <25 mm Hg;
- SpO2 <85%;
- Respiratory rate over 40 per minute.
The flow of oxygen should be minimized by providing RaO2 at least 80 mmHg
(C).
Respiratory therapy of septic shock should also include treatment and positive end
expiratory pressure (3 - 6 cm vodn.st.), but only if adequate recovery BCC.
4. Surgical rehabilitation of the site of infection.
Indications for laparotomy and hysterectomy with uterine tubes:
-
No effect of intensive care;
-
the presence of pus in the uterus;
-
uterine bleeding;
-
suppurative lesions in the region of the uterus;
-
detection by ultrasound presence of residual ovum.
5. Normalize bowel function and early enteral nutrition .
-
enteral drip of 0.9% sodium chloride or carbonated mineral water 400 - 500
ml per day via gavage
-
expansion of food products subject to the normalization of peristalsis in
"nutritional factor", which corresponds to 2000 - 4000 calories a day.
-
prokinetics (metoclopramide) and glutamic acid;
-
selective bowel decontamination:
4 times a day in a mixture of polymyxin intestines - 100 mg tobramycin - 80
mg and amphotericin B - 500 mg.
6. Antibiotic therapy under constant microbiological control .
-
Tactics deeskalatsiynoyi empirical antibiotic therapy;
after identification of microorganisms and to determine its sensitivity to
antibiotics access to antibiotic treatment according antybiotykohramy.
7. Antymediatorna therapy .
- Bahatoklonalni immunoglobulins in combination with pentoxifylline
Tasks for self- work
Problem number 1 (with the standard answer)
In pregnant women with severe preeclampsia z'yavlys shallow twitching of facial
muscles, fountains eyelashes, mouth corners fallen. Then began a titanium
contractions of muscles of the body. The body tensed and stretched, face zblidnilo,
zmyknulys jaw tight, eyes became fixed, immovable. The patient is not breathing.
Pulse was not palpable. Woman lying motionless, began to beat in clonic
convulsions, which continuously follow one after another and spread through the
body from top to bottom, so that she jumps in bed abruptly moving his hands and
feet. The patient is not breathing. Pulse is not defined. Faces of purplish-blue, tense
jugular vein. Gradually the spasms weakened and halt. The patient took a deep
breath, accompanied by wheezing, mouth allocated foam.
Diagnosis? Emergency? With what you want to the differential diagnosis?
A: Late mellitus. Eclampsia. It is necessary to put a woman on your left side,
clear the airway, give oxygen to inhale, hold bolus 25% solution of magnesium
sulfate in an amount of 16 ml per 30 ml of saline for 5 minutes, then set up an
intravenous drip 25% solution of magnesium sulfate in an amount of 30 ml 220 ml
Phys. solution with a frequency of 8 drops per minute track knee reflexes,
respiratory rate, pulse, heartbeat of the fetus. Catheterize permanent bladder
catheter to monitor hourly urine output, urine protein, enter the nasogastric tube to
decompress the stomach, catheterize the subclavian vein and perform infusion
therapy in full within 2 hours to vaginal examination to determine the obstetric
situation, prepare the fetus's lungs to extrauterine living conditions and raise the
question of operative delivery by cesarean section, given the immaturity of the
birth canal.
Dyfdiahnoz be held from attack of epilepsy.
Problem number 1.
Patient 20 years old, got married 2 years ago. Since pregnancy is not
sterehlasya. Menstruation in 17 years, with a certain rhythm. Last menstrual period
was 6 weeks then m. Sex life routine. On the way to work there was pain in the
lower abdomen, zne prytomnila. Ambulance transported to the gynecological
department in distress: the skin and mucous membranes pale, AT - 80/40 mm Hg. t
pulse 112 beats / min. Periodically neprytomnyuye.
What is the diagnosis? What should I do?
Problem number 2
Sick '30 admitted to hospital with complaints of pain in the lower abdomen,
dark minor bleeding from the vagina for 5 days. Last menstrual period 8 weeks
ago. In the morning ro bot fainted. From history revealed that the last menstrual
period was 2 months ago. Considers herself pregnant. Objectively: skin pale, BP 80/40 mm Hg, Ps - 120 beats / min ..
What complication has developed? Identify the shock index.
Problem number 3
Sick '36 admitted to hospital with complaints of fever up to 39,3 ͦ C, pain in
lower abdomen, bloody vaginal discharge with an unpleasant odor for 5 days.
Genera 14 days ago. In the hospital made scraping the walls of the uterus, and then
the woman's condition deteriorated. OBJECTIVE: complaints of fever, pale skin
with a marble viddinkom, SC - 9 0/40 mm Hg, Ps - January 15 beats / min ..
What complication has developed? What mistakes allowed?
Author: Goncharenko O.M., assistant
Approved at the meeting of the department "___" _________________ 20___,
protocol № __________.
Reviewed by department meeting "___" _________________ 20___,
protocol № __________.