Responding to Amniotic Fluid Embolism - AORN

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JUNE 2009, VOL 89, NO 6Dobbenga-Rhodescase, caregivers should transport the patient tothe OR as quickly and safely as possible. Ongoingcare should be shared between the perinataland perioperative nursing staff members. Manyperinatal units do not require staff members tobe certified in advanced cardiac life support, sothe advanced education and experience of perioperativenurses will complement the basic lifesupport measures already implemented.CIRCULATORY SUPPORT. In accordance with thebasics of cardiopulmonary resuscitation, circulatorysupport is the next goal in the resuscitationof the patient with AFE. Medical andnursing staff members should quickly establisha large-bore peripheral IVcatheter, a central venouspressure catheter, a pulmo -nary artery catheter, and aperipheral arterial line. Gatheringadditional resources andmanpower from the anesthesiaand critical care staffs will helpsupport the resuscitation teamduring this emergency. 36,37Transthoracic or transesopha -geal echocardio graphy (TEE) isoften necessary to evaluate cardiacfunction and to guidetreatment, along with a 12-leadECG. 3 As time allows and asequipment is made available,the TEE may demonstrate theacute right ventricular overload,severe pulmonary arteryhypertension, and marked diastolic dysfunctionof the left ventricle secondary to a dilated rightventricle. 29,38Use of the peripheral IV catheter should belimited to loading with crystalloid, colloid,packed cells, fresh frozen plasma, and platelets.If profound hemorrhage occurs, a transfusionof uncross-matched O-negative packed cells isrecommended so transfusion is not delayed bywaiting for type-specific and cross-matchedblood. 15 Hemofiltration 39 or plasma exchange 40may be effective in clearing the maternal plasmaof potential fetal debris. 10 Hemofiltration isthe removal of waste product from the bloodby passing it through extracorporeal filters.Plasma exchange consists of removal of blood,These patients arepredisposed to pulmonaryedema so their centralline readings should bemonitored closely toavoid over-hydration.separation of blood cells from plasma, and returnof these blood cells to the body’s circulation,diluted with fresh plasma. A transfusion of1.5 times the maternal blood volume may act asa complete exchange transfusion; 41 however,cryo precipitate is particularly useful in AFEbecause it can be used to replenish clotting factorsin lieu of fresh frozen plasma in volumerestrictedpatients. In addition, cryoprecipitatecontains both fibrinogen and fibronectin, whichfacilitate the removal of cellular and particulatematter from the blood via the reticuloendothelial(ie, the mononuclear phagocyte) system. 33,42Thrombocytopenia can be treated with the administrationof platelets. 36Arterial lines can be used toregulate pressures, monitoroxygen saturation, and assistwith titration of inotropes.Specific inotropic medicationssuch as dopamine, dobutamine,and norepinephrine enhancehemodynamic stabilityby maintaining cardiac outputand blood pressure. Readingsfrom central lines should bemonitored closely to avoidover-hydration of these patientswho are predisposed topulmonary edema. Noncardiogenicpulmonary edemadevelops in 70% of AFE patients,possibly because of theeffect of various mediators ofanaphylaxis such as histamine and bradykininsleading to capillary leak syndrome. 43 The anesthesiacare provider can draw blood specimensfrom these lines and send them for analysis toassist with interpretation and correction of coagulopathyas well as for cytologic analysis foramniotic fluid in the maternal patient’s circulation.33 Rapid assessments may be availablefrom a point-of-care device, typically accessiblein the perioperative setting.Nursing personnel should see that coagulationstudies for prothrombin time, partialthromboplastin time, D-dimer, fibrin split products,and platelets are sent immediately to thelaboratory for analysis. Coagulopathy and hemorrhageare common and often occur after the1084 • AORN JOURNAL
Dobbenga-Rhodes JUNE 2009, VOL 89, NO 6clinical diagnosis of AFE is made. 42 Disseminatedintravascular coagulation (DIC) is found in83% of patients with AFE. Half of these patientsmay develop coagulopathy within four hours ofthe onset of the clinical symptoms. 36 Anesthesiapersonnel may use low-dose heparin to slowthe coagulation cascade and thus treat the consumptivecoagulopathy, although this practice iscontroversial. 15Coexistent hemorrhage may be related touterine atony; however, the etiology of thehemorrhage is obscure, and it is thought thatconsumptive coagulopathy may lead to it. 44 Incontrast, increased fibrinolysis has been shownto occur in AFE, and it has been suggested thatan elevated plasminogen activator inhibitor-1antigen in amniotic fluid may become active inthe maternal blood and contribute to DIC. 45Nursing staff members may implementuterine massage, and the physician may administerthe traditional oxytocic medicationssuch as oxytocin, methylergonovine maleate,carboprost tromethamine, or misoprostol tocorrect uterine atony. 34 These medications maybe given intravenously or directly into theuterine musculature during life-saving measuresto control the uterine atony and bleeding.If the atony or hemorrhage remains uncontrolled,many obstetricians attempt other surgicalinterventions such as ligation or embolizationof the inguinal or uterine arteries ormay resort to performing a total abdominalhysterectomy to arrest the hemorrhage. 33,46NEWER TREATMENT MODALITIES. Newer, breakthrough,modalities of treatment and supportivemanagement with AFE haveshown promise in individualcase presentations and havedemonstrated the uncommonnature of AFE, in that no twopatients will respond the sameway to the insult or to the therapy.Many of these items aremore easily accessed in themain OR than in the labor anddelivery department (Table 2).These items include extracorporealmembrane oxygenation,intra-aortic balloon counterpulsation, 47 cell salvage, cardio -pulmonary bypass, 45 nitric oxide administrationunder TEE guidance, 29,48 administration ofrecombinant factor VIIa, 37,49,50 and placement ofa right ventricular assist device to treat pulmonaryhypertension. 37 Cell salvage with man -datory leukocyte depletion filters also may offerthe ability to clear the maternal vasculature ofcontaminants. 51 Hemodialysis for renal failure 18has been used as well. Inhaled prostacycline hasbeen used to treat refractory hypoxemia. 52Clark et al 30 have suggested that in light ofthe similarities of AFE to anaphylaxis, high-dosecorticosteroids and epinephrine may be usefuladjuvants. 30 Administration of hydrocortisonesodium succinate will control an inflammatoryresponse. 33 This unique emergency also has beentermed “anaphylactoid syndrome of pregnancy”because of its similarities to anaphylaxis. 36After initial resuscitative efforts after AFE,nurses should focus on longer-term stabilizationand prevention of side effects from transfusionreactions. 15 A vital noninvasive measurefrequently overlooked in an emergency but inherentin perioperative care is patient warming.Use of warmed IV fluids, blood warmers,and a forced-air patient warming system mayprevent hypothermia and avoid such detrimentalresults as peripheral tissue ischemia,altered mentation, and increased hemoglobinaffinity for oxygen. 15 RECOVERYIn situations where the maternal patient respondsfavorably to these interventions and survivesAFE, postpartum nursing activities willTABLE 2Surgical Treatments and TechniquesValuable in Obstetric EmergenciesCardiopulmonary bypassCell salvageExtracorporeal membrane oxygenationIntra-aortic balloon counter pulsationInvasive cardiac and hemodynamic monitoringNitric oxide therapyRapid infusers for blood productsTransesophageal echocardiographyVentricular assist deviceAORN JOURNAL • 1085
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