|
|
 |
 |
 |
|
|
|||
|
||||
|
||||
Re: My case list...From: Dr Eberhard W Lisse (el@linux.lisse.na)Sat May 30 13:30:18 1998
Jane, In message <199805301518.KAA11490@talk.obgyn.net>, Jane Helwig, MD writes:
> I have a related question for the members of the list. Last week I Why did you do that? I can reluctantly agree to managing ectopics by laparoscopy if retaining fertility is the issue and the ectopic is small. But a previously sterilized patient with a large ectopic? Whatever for? (Rethoric question, I know, because of the HMOs running your professional life). With the high Beta-HCG (and a nice ultrasound picture?) I'd not even scoped her for confirmation but just gone and done a laparotomy. And I say this while I scope every suspected ectopic I can lay my hands on :-)-O, reducing the number of ruptures from 95% to 20%. But *ALL* of our ectopics get a Pfannenstiel-Salpingectomy. And not only because we don't have a TV set connected. I also think it's the better procedure in our setting at least.
> I was using a blunt probe to figure out the anatomy when it ruptured This I can not follow. Approach it as "fetal distress" and you should be in the cavity in less then 1 minute through any up and down. But then I learned from a colleague in the North who consistently would have the Pfannenstiel-Salpingectomy done and double tied before I was finished sucking the usual litre and a half of blood of the ruptured ectopic out of the cavity.
> There was 1000 cc in the suction container in less than 5 minutes. Was this fresh blood?
> A clamp on the IP solved the bleeding problem (turned out to be a I have yet to see a ruptured ectopic not responding well to clamping and ivi cristalloids.
> Now to my question. We have all seen pts with stable BPs, no This depends on the preoperative Hb (or Hk) and whether signs and symptoms persist. 1000ml is two units of packed cells or abouts. At the most you can drop the Hb by 4. Acute Blood loss however, is clearly trated with cristalloids first, because it is a volume (pressure) problem, not a problem of oxygen carrying capacity. I have stopped taking blood with to the OR unless I see free fluid on Ultrasound preoperatively, or the patient displays signs or symptoms, for example Hb below 8 *AND* dropping, fall in BP raise in PR etc. But, then of course I preload all suspected ectopics with cristalloids (and if I have, also a bottle of colloid) and they get two drips with large bore canula, one in each arm.
> Guess this is the same "decisive action" vs. "methodical" issue, but I Yes indeed. Blood is one of the most dangerous products we are allowed to prescribe and one should not treat the lab result but the patient with it. We had this fascinating effect in the central hospital in Windhoek some years back when the BTS director published a weekly list with the names of doctors and number of units ordered which according to the diagnoses listed on the orders was felt to have been inappropriate. After the second list, the usage of blood products dropped to such an extent that the BTS started to experience financial difficulties :-)-O. There was no increase in morbidity or mortality. We have a nationwide HIV infection rate of between 17 and 25 percent and our BTS is of such high quality that we do not have one single incident of HIV transmission through Blood products in the country.
> My anesthesiologist was most alarmed by this case, called for blood Ah well, pucker factor, probably. I would suggest you ask him what the rationale was, and (without putting him on the defensive) how many ruptured ectopics he had done before. If you have access to a big trauma center, ask one of the younger attendings there what they think about rescuscitating a *CONTROLLABLE* blood loss of 1000ml. In our small hospital we have only three medical practitioners. We all give anesthetics and we all operate, though not at the same time :-)-O and it does make a big difference if you are used to operate on ruptured ectopics when you have to dope one. el -- Dr. Eberhard W. Lisse\ / Swakopmund State Hospital <el@lisse.NA> * | Resident Medical Officer Private Bag 5004 \ / +264 81 124 6733 (cell) 64 461005(h) 461004(f) Swakopmund, Namibia ;____/ Domain Coordinator for NA-DOM (el108) Vice-Chairman, Board of Trustees, Namibian Internet Development Foundation,
|
|
Return to
|
Mail a New Message to the Forum: ob-gyn-l@obgyn.net Forum Administrator: geffrey.klein@obgyn.net Report Technical Problems: webmaster@obgyn.net Last Updated: Mon Nov 2 05:27:51 2009 |
The American Medical Association is no longer designating CME hours for AMA Category II CME credit. However, physicians themselves may self designate learning activities as Category II CME credit hours if they feel it is of sufficient educational merit and meets the formal definitions of continuing medical education. OBGYN.net believes these interaction in this forum meets these criteria. For further information see the AMA web site.