Damage Control Surgery for the Management of Major Obstetric Hemorrhage: Experience from the Fundación Valle Del Lili, Cali, Colombia

Abstract

Objective: The aim of this case series is to describe the experience of implementing damage control resuscitation (DCR) in patients with major obstetric hemorrhage (MOH) between January 2005 and December 2015 in the Fundación Valle del Lili, Cali, Colombia. Materials and methods:This is a prospective descriptive study of a case series from 108 patients with MOH who were subjected to DCR. All patients were operated on using a standardized surgical technique in accordance with the institutional protocol. Results:The median age was 28 years, with a gestational age of 38 weeks. The principal associated diagnosis was severe preeclampsia (in 39% of cases). A total of 96 patients presented massive postpartum hemorrhage, and 75% of these cases presented after a cesarean section. In all patients, normal control of bleeding was achieved, 60% during the first surgical period. The Acute Physiology and Chronic Health Evaluation score was 14, with an overall mortality of 6.48%, far below the expected mortality according to the clinical severity of these patients. Conclusion:This study includes the biggest series of pregnant women with MOH, in a critical condition, in whom DCR was used, during which rapid control of bleeding was achieved, associated with a significantly lower mortality than expected. RESUMENObjetivo: El objetivo de esta serie de casos es describir la experiencia de la aplicación de la CCD (Cirugía de control de daños) en pacientes con hemorragia obstétrica mayor (HOM) entre enero del 2005 y diciembre del 2015 en la Fundación Valle del Lili, Cali, Colombia.Métodos: Estudio descriptivo prospectivo de una serie de casos de 108 pacientes con HOM sometidas a CCD. Todas las pacientes fueron operadas usando una técnica quirúrgica estandarizada, acorde al protocolo institucional.Resultados: La mediana de edad fue de 28 años, con edad gestacional de 38 semanas. El diagnosticó principal asociado fue pre eclampsia severa (en 39% de los casos). 96 presentaron hemorragia postparto masiva (HPP) y el 75% de los casos se presento después de cesárea. En todas las pacientes se logro el control del sangrado, 60% en el primer tiempo quirúrgico. El APACHE II promedio fue de 14 con una mortalidad global de 6,48%, muy por debajo de la mortalidad esperada para la severidad clínica de estas pacientes. Conclusiones:Este estudio incluye la serie más grande de gestantes con HOM en condiciones críticas, en quienes se utilizó CCD, con rápido control del sangrado, asociado a una mortalidad considerablemente menor a la esperada.Palabras Clave: Choque hipovolémico, Cuidados intensivos quirúrgicos, Hemorragia postparto, Tratamiento de urgencia. PAJT ORIGINAL ARTICLE

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage

“…Administration of prophylactic antibiotics may be considered while abdominal packing is in place. 109 , 114 …”

“…DCS therefore remains an invaluable and potentially life-saving technique for the management of critical, refractory PPH. 114 …”

“…Administration of prophylactic antibiotics may be considered while abdominal packing is in place. 109,114 The second step of DCS involves transfer to the ICU to correct the patient's underlying coagulopathy and metabolic derangements. 115 Resuscitation parameters should be continuously monitored with a goal of reversing tissue hypoxia and acidosis.…”

“…109 Complications of DCS are primarily related to the timing of abdominal fascial closure, and include wound infection in up to 28% of cases, intraabdominal collections in up to 20% of cases, and evisceration in up to 10% of cases. 114 However, DCS has been shown to successfully control refractory PPH with an overall mortality benefit for critically ill obstetric patients. The largest study on obstetric DCS by Ordonez et al demonstrated that bleeding was controlled with the first surgical intervention in 60% of cases, with subsequent control in 98% of cases.…”