Dreifus C. A Conversation with Dr. Peter J. Provonost: Doctor Leads Quest for Safer Ways to Care for Patients. New York Times 0:
Franchini M, Franchi M, Bergamini V, Salvagno GL, Montagnana M, Lippi G. A Critical Review on the Use of Recombinant Factor VIIa in Life-Threatening Obstetric Postpartum Hemorrhage. Semin Thromb Hemost Feb 2008; 34: 104-12.
The objective of this review was to evaluate and summarize the current literature on the unlicensed use of the novel agent recombinant activated factor VII (rFVIIa) in the management of major postpartum hemorrhage. After a systematic electronic search without temporal limits on MEDLINE, EMBASE, OVID and SCOPUS, the bibliographic references of all retrieved studies and reviews were additionally assessed for further reports of clinical trials. Unpublished works were also identified by searching abstracts from the most eminent conferences on this topic. In total, there were 31 studies that fulfilled our inclusion criteria. These studies incorporated 118 cases of massive postpartum hemorrhage treated with rFVIIa. The median age of the patients was 31.4 years, and cesarean section appeared to increase the risk of postpartum hemorrhage. At a median dose of 71.6 mug/kg, rFVIIa was reported to be effective in stopping or reducing bleeding in nearly 90% of the reported cases. Based on the evidence from the literature, we give some recommendations on the use of rFVIIa in massive postpartum hemorrhage. Nevertheless, although these reports suggest the potential role of rFVIIa in treating massive postpartum hemorrhage refractory to standard therapy, we advise particular caution in interpreting these results, as they are derived from few and uncontrolled studies. Further evidence is needed using well-designed clinical trials to better assess the optimal dose, the effectiveness, and the safety of rFVIIa in such critical bleeding conditions.
Korst LM, Gregory KD, Lu MC, Reyes C, Hobel CJ, Chavez GF. A Framework for the Development of maternal quality of care indicators. Matern Child Health Sep 2005; 9: 317-41.
BACKGROUND: In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality. OBJECTIVE: To develop potential indicators for the assessment of maternal health care quality. MATERIALS AND METHODS: A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible. RESULTS: Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits). CONCLUSIONS: These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.
Bell MJ. A Historical Overview of Preeclampsia-Eclampsia. J Obstet Gynecol Neonatal Nurs 39: 510-518.
Preeclampsia is a hypertensive, multi-system disorder of pregnancy whose etiology remains unknown. Although management is evidence-based, preventative measures/screening tools are lacking, treatment remains symptomatic, and delivery remains the only cure. Past hypotheses/ scientific contributions have influenced current understanding of preeclampsia pathophysiology and guided management strategies and classification criteria. To provide insight into how past hypotheses/scientific contributions have shaped current practice trends, this paper provides a historical overview of preeclampsia-eclampsia.
Ho AM, Dion PW, Cheng CA, Karmakar MK, Cheng G, Peng Z, Ng YW. A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Can J Surg Dec 2005; 48: 470-8.
BACKGROUND: Randomized controlled trials of how best to administer fresh frozen plasma (FFP) in the presence of ongoing severe traumatic hemorrhage are difficult to execute and have not been published. Meanwhile, coagulopathy remains a common occurrence during major trauma resuscitation and hemorrhage remains a major cause of traumatic deaths, suggesting that current coagulation factor replacement practices may be inadequate. METHODS: We used a pharmacokinetic model to simulate the dilutional component of coagulopathy during hemorrhage and compared different FFP transfusion strategies for the prevention or correction, or both, of dilutional coagulopathy. Assuming the rates of volume replacement and loss are roughly equal, we derived the hematocrit and plasma coagulation factor concentration over time based on the rate of blood loss and replacement, the hematocrit and coagulation factor concentration of the transfusate, and the hematocrit and plasma factor concentration at the time when FFP transfusion begins. RESULTS: Once excessive deficiency of factors has developed and bleeding is unabated, 1-1.5 units of FFP must be given for every unit of packed red blood cells (PRBC) transfused. If FFP transfusion should start before plasma factor concentration drops below 50% of normal, an FFP:PRBC transfusion ratio of 1:1 would prevent further dilution. CONCLUSION: During resuscitation of a patient who has undergone major trauma, the equivalent of whole-blood transfusion is required to correct or prevent dilutional coagulopathy.
Weinstein L. A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol
Weinstein L. A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol 194: 1160-7.
The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises
are the rising cost of professional liability insurance and a diminishing number of sources available
to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney
contingency fees is a back end approach and will do little to solve this crisis or prevent future
ones. The current situation can only be solved by placing an increased emphasis on improving
patient safety and elimination of all preventable medical errors. A national electronic medical record
must be developed and rapid response teams need to be available in most hospitals. The protective
devices of privileged communication and peer review are counterproductive and must be
eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians
must be taught proper communication skills and the importance of teamwork. Providers
with frequent patient, nursing or medical staff complaints must be critically reviewed. The present
system of risk management needs to move from a reactive position to a role of being proactive for
both patient and physician. Claims management should offer the patient early compensation
when appropriate and pursue a vigorous defense when medical care is adequate. Experts should
be identified who will render fair, unbiased reviews of medical care with all of their findings being
disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for
common medical conditions.
Swanton, R, et al. A National Survey of obstetric early warning systems in the United Kingdom. Intern J Obstetric Anesthesia 18: 253-257.
ABSTRACT
Background: Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health
(CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population,
no validated system currently exists for the obstetric population.
Methods: We performed an Obstetric Anaesthetistsâ Association (OAA) approved postal survey of all UK consultant-led obstetric
anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and
invited comments and samples of systems already in use.
Results: The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric
EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of
UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and
disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed
and implemented a system locally and submitted it to the OAA for consideration.
Conclusions: The survey results support CEMACH recommendations for a nationally agreed obstetric EWS.
c 2009 Elsevier Ltd. All rights reserved.
Keywords: Obstetric Early Warning Systems
PMAD. A new way to think about quitting smoking.
Brees C, Hensleigh PA, Miller S, Pelligra R. A non-inflatable anti shock garment for obstetric hemorrhage. Int J Gynaecol Obstet 87: 119-124.
OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock. METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention. RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death. CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.
