Noninvasive and Continuous
Hemoglobin (SpHb)
SpHb Overview
• Methods
• Accuracy
• Bleeding and Transfusion Challenges
• Outcomes Study
• Clinical Uses and Guidelines
Masimo SpHb:
Continuous, Noninvasive, Immediate
Absorption of Hemoglobin and
Dyshemoglobin Species
Dyshemoglobins and hemoglobin absorb different amounts of red (RD) and infrared (IR) light at various frequencies
Noninvasive Pulse CO-Oximetry: Method
Spectrophotometry-based
Emission
Site
•Multiple visible and
infrared lights applied to
measurement site
.
.
.
Detection, Signal Condition &
Analog-to-Digital Conversion
• Light is received by a photo detector
• Generates electrical analog signals
• Signals amplified, conditioned, and converted
to digital signals
Analog
Front End
AD
Converter
Digital Signal
Processing Estimation
• Advanced
algorithms process digital signals
• Analyzed by a multivariate estimation processor
• Predicted hemoglobin density
Filtering, Multivariate
Decimation, Estimation
Averaging Algorithm
Noninvasive
Hb
Hb Measurement Comparison
Device
CO-Oximeter, Hematology
Analyzer, Point-of-Care Device
Pulse CO-OximetryTM
Method
Spectrophotometry
Multiple wavelengths of light
Invasive, Delayed, Intermittent
Noninvasive, Immediate,
Continuous
Blood
Blood
Cuvette
Finger
Needle Stick Hazard
Yes
No
Biohazard Waste Disposal
Yes
No
Special Training/Quality Control
Yes
No
Calibration
Yes
Internal
Moderate to High
Low
Characteristics
Substrate for Analysis
Sample Chamber
Patient Apprehension
Variability of Hb Measurement
• CO-Oximeter Devices
• Comparison of 2 identical CO-Oximeters from each of 5 different
manufacturers
• Average standard deviation of 0.5 g/dL1
• Point-of-Care Devices
• Capillary blood sample comparison to reference lab
• Standard deviation ranged from 0.5 – 1.3 g/dL2,3,4,5
• Physiology
• Standing vs. sitting position blood samples
• Standing measurements up to 1g/dL higher than sitting6
• Left hand vs. right hand blood samples
• Up to 0.5 g/dL difference7
1 Gehring H et al. Anesthesia and Analgesia. 105(6);2007:524-530. 2 Gomez-Simon A et al. Transfusion and Apheresis Science. 2007;36:235-242; 3 Patel et al. JECT. 2007; 39:1017. 4 van de Louw A et al. Intens Care Med. 2007; 33:355-358. 5 Argawal R et al. ASAIO J. 2001. 47(3):240-3. 6 Gore et al. Eur Jour Ap Phys and Occup Phys. 1992;65:302-310.
7 Morris SS, et al.. Am J Clin Nutr 1999 ;69 :1243-8
Variation in Hemoglobin Measurement by Lab Devices:
CO-Oximeter vs. Coulter
•
N=471 samples from 33 patients
undergoing liver transplantation
•
After 10 ml waste, 10 ml sample
analyzed for tHb by the COULTER®
Ac·T diff2™ analyzer (Beckman
Coulter, Miami, FL, USA)
•
Immediately after, 2 ml sample for
tHb by the pHOx CO-Oximeter
(Nova Biomedical, Waltham, MA,
USA)
Torp KD et al. Anesthesiology 2009 (ASA abstract): A937. In press.
Accuracy of Point of Care Hemoglobin Devices
Using Capillary Blood
N=195 blood donors
N=140 surgical samples
Hemocue POC device
Hemocue POC device
Gomez-Simon et al. Transfusion & Apheresis Science 2007.
Rippman et al. J Clin Monit 1997.
Variation in Hb:
Arterial vs. Venous
•N=107 healthy volunteers
aged 18-30 years
•Four time-matched venous
and arterial hemoglobin
samples
•By 2 peripheral
intravenous and 1 radial
artery line
•Hemodilution with Isolyte®
(40cc/kg) following
phlebotomy of 1 unit whole
blood
Rook JL et al. Anesthesiology 2009 (ASA abstract): A1294. In press.
2011 Radical 7
Noninvasive Hemoglobin:
Study Methods for FDA Submission
•
Data collected at three sites
•
•
•
•
Hb measurement
•
•
•
Noninvasive: Masimo Rainbow SET platform (SpHb)
Invasive: Radiometer ABL-820 CO-Oximeter (tHb)
492 data pairs collected from 59 total subjects
•
•
•
•
Loma Linda Medical Center (Loma Linda, CA)
Mayo Clinic (Jacksonville, FL)
Masimo Corporation (Irvine, CA)
35 (59%) healthy adults
16 (27%) hemodilution subjects
8 (14%) from surgical subjects
Collected tHb values had a range of 6 to 18 g/dL
•
•
•
220 (45%) <12 g/dL
145 (29%) <11 g/dL
74 (15%) <10 g/dL
Continuous & Noninvasive Hemoglobin (SpHb):
Accuracy Study Results for FDA Submission
24
SpHb (g/dL) from Pulse CO-Oximetry
22
Precision improves at
lower Hb levels – when
it matters most
20
18
16
14
12
S
10
> N=492
> 59% healthy subjects
> 27% hemodilution subjects
> 14% from surgical subjects
8
6
4
2
0
0
2
4
6
8
10
12
14
16
18
20
Reference tHb (g/dL) from Laboratory CO-Oximeter
22
24
Noninvasive Hemoglobin:
Study Results for FDA Submission
Difference Between SpHb and tHb
N (%)
tHb Range
<1.0 g/dL
<1.5 g/dL
<2.0 g/dL
<10 g/dL
80%
97%
100%
10 - 11.9 g/dL
68%
96%
99%
12 - 18 g/dL
67%
87%
94%
6 – 18 g/dL
69%
91%
97%
N=492
Accuracy of SpHb from Rainbow vs.
tHb from CO-Oximeter
• N=20 healthy volunteers aged 18-30 years,
335 paired measurements
• Hemodilution with Isolyte® (40cc/kg) following
phlebotomy of 1 unit whole blood
• Invasive tHb measurement by CO-oximeter
(ABL-820)
• Noninvasive Hb measurement by Pulse COOximetry (Masimo SpHb from Radical-7)
Macknet MR et al. Anesth Analg 2010;111:1424–6.
Accuracy of SpHb from Rainbow vs.
tHb from CO-Oximeter
Macknet MR et al. Anesth Analg 2010;111:1424–6.
Validation of a New Non-Invasive Hemoglobin Algorithm in
Patients Undergoing Liver Transplantation
Torp et al. Anesthesiology 2009 (ASA abstract): A184.
Comparison of New Non-Invasive Continuous Spectrophotometry
vs. RBC Count for Hemoglobin During Surgery
• N=20 patients subjected to an urologic surgery
with hemorrhagic risk
• Spectrophotometric hemoglobin measurement
(Radical-7 Rainbow) and RBC count (laboratory)
• Measurements performed at beginning and end
of each intervention and before and after each
transfusion (54)
• Correlation between laboratory and noninvasive
values of 0.88, bias of 0.26 g/dL with a standard
deviation of 1.11 g/dL
Lamhaut L, et al. European Journal of Anesthesiology. 2010; 27(suppl 47):3AP7-1.
SpHb Compared to tHb in Pediatric
Patients
• Method
•
•
•
15 patients from a variety of surgery cases enrolled; mean age 9.3 +/- 5.9 years
Average of 2.7 arterial blood samples per patient taken during surgery
49 CO-Oximeter tHb measurements, 46 POC tHb and 92 SpHb measurements compared
• Results
SpHb – Lab Hb
N = 92
POC –Lab Hb
N = 45
Bias (g/dL)
0.18
-0.26
Standard Deviation (g/dL)
1.10
0.46
ARMS (g/dL)
1.12
0.53
• Conclusion
•
All significant directional changes in tHb form the CO-Oximeter were indicated by changes in
SpHb.
Jou C, et al. Anesthesia and Analgesia. 2010; S401.
Continuous Hemoglobin Monitoring
• Real time view of changes in total hemoglobin
SpHb
• Rising 
• Falling 
• Stable →
Time
Noninvasive Hemoglobin:
Accuracy Trend
12
Invasive Hb
10
Hemoglobin (g/dL)
Co-Oximeter
SpHb
8
6
4
2
0
0
10000
20000
30000
Time (secs)
MackNet MR et al. Anesthesia and Analgesia. 2007;104;S-31 (abstract).
40000
50000
60000
Continuous and Noninvasive Hemoglobin Monitoring:
Potential for Earlier and Better Clinical Decision-Making
SpHb
Continuous
Hemoglobin
Trend
tHb outside
target range
Target
hemoglobin
range
SpHb data blinded during case
Undetected Bleeding Challenges
•
Significant bleeding is common in surgical and critical care patients
• Up to 35% of patients1
•
Bleeding is a significant risk factor for surgical, critical care, and OB
patients
• Late detection further increases the risk2
•
Bleeding significantly increases the cost of treatment2
•
Low hemoglobin identifies almost 90% of patients with bleeding
• However, traditional laboratory measurements are infrequent and
delayed3
1 Hebert PC. Crit Care. 1999: 3(2):57-63. 2 Herwaldt LA. Infect Control Hosp Epidemiol. 2003; 24(1):44-50.
3 Bruns B et al. J Trauma. 2007; 63(2):312-5.
Impact of Continuous and Noninvasive
Hemoglobin Monitoring on
Intraoperative Blood Transfusions
Jesse M. Ehrenfeld MD, MPH
Justin P. Henneman MS
Warren S. Sandberg, MD, PhD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Harvard Medical School
Ehrenfeld JM et al. ASA. 2010. LB05.
Background
• Blood transfusions increase patient risk for adverse outcomes1-3
• Up to 40% increase in 30-day morbidity
• Up to 38% increase in 30-day mortality & 67% increase in 6-month mortality
• Blood transfusions are costly4
• $522 to $1,183 per unit, without short- or long-term morbidity included
• Annual estimates for surgical blood costs at $1.6 to $6.0 million per hospital
• Laboratory hemoglobin (Hb) values used to determine need for blood
transfusion,5 but testing is intermittent and delayed
• Lack of Hb values is associated with inappropriate transfusions6
• Noninvasive and continuous (SpHb) monitoring is now possible
• Pulse CO-Oximetry and a multi-wavelength adhesive sensor
• Hypothesis
• SpHb monitoring could reduce intraoperative blood transfusions
Ehrenfeld JM et al. ASA. 2010. LB05. 1 Taylor RW et al. Crit Care Med. 2006; 34(9):2302-8. 2 Bernard AC et al. Journal of the American College of Surgeons. 2009;208:931-937. 3
Surgenor SD et al, for the Northern New England Cardiovascular Disease Study Group. Anesthesia & Analgesia 2009;108:1741-1746. 4 Shander A et al. Transfusion.
2010;50(4):753-65 5 ASA Task Force on Perioperative Blood Transfusion. Anesthesiology. 2006 Jul;105(1):198-208. 6 Tartter PI et al. Transfusion. 1985;25:113-115.
Methods: Patient Selection and
Randomization
• Orthopedic surgery patients at academic medical center
• Massachusetts General Hospital (Boston, MA)
• Patients randomized to either:
• Standard Care Group: Treat as normally would
• SpHb Group: Treat as normally would but add SpHb to guide test and
transfusion decisions
• Utilized Radical-7 with ReSposable adhesive sensors (Rev E)
• Study funded by NIH and MGH, Masimo provided equipment/sensor
• Retrospective cohort
• Case matched to study subjects by gender, age, procedure
• Allows comparison to Standard Care and SpHb Groups
Ehrenfeld JM et al. ASA. 2010. LB05.
Methods: Outcome Variables
• Primary outcome variables
• Frequency of intraoperative blood transfusions
• Mean number of blood transfusions per patient
• Secondary outcome variables
• Frequency of laboratory Hb testing
• Safety Variables
• Post-operative transfusion frequency
• 28 day complication rates
Ehrenfeld JM et al. ASA. 2010. LB05.
Results: Patients
• Patient recruitment occurred over a six-month period
• February 2010 through July 2010
• 350 patients screened, 327 patients enrolled
• 157 Standard Care, 170 SpHb
• Procedures included:
• Hip replacement
• Knee replacement
• Spinal surgery
31%
29%
14%
• 327 subjects in matched retrospective cohort
• From six-month period prior to study commencement
• Received no intervention
Ehrenfeld JM et al. ASA. 2010. LB05.
Results: Baseline Characteristics
Standard
Care
Group
SpHb Group
Retrospective
Cohort
Retrospective
Cohort
(Matched to
Standard Care
Group)
(Matched
to SpHb Group)
N=327
N=170
N=157
N=170
ASA Status
4
3 (2%)
1 (1%)
3 (2%)
2 (1%)
3
30 (19%)
43 (25%)
29 (19%)
41 (24%)
2
117 (75%)
107 (63%)
117 (75%)
107 (63%)
1
7 (4%)
19 (11%)
8 (5%)
20 (12%)
Male gender, %
54%
48%
54%
48%
Age (years)
61
62
61
62
Ehrenfeld JM et al. ASA. 2010. LB05.
Results: Patient Characteristics
• No differences in pre-operative laboratory Hb value
• 13.5 +/- 1.6 vs. 13.6 +/- 1.5, p=ns
• No differences in intraoperative estimated blood
loss
• 157 +/- 212 vs. 210 +/- 280 mL, p=ns
• No differences in procedure type
Ehrenfeld JM et al. ASA. 2010. LB05.
Summary of Procedures
Standard Care Group N=157
SpHb Group N=170
Procedure
N
%
N
%
Hip Replacement
52
33%
49
29%
Knee Replacement
52
33%
44
26%
Spine
21
13%
24
14%
Leg Injury
8
5%
9
5%
Knee Injury
4
3%
5
3%
Shoulder Replacement
3
2%
6
4%
Shoulder Injury
4
3%
3
2%
Ankle Injury
4
3%
2
1%
Knee injury
0
0%
5
3%
Hip Injury
4
3%
1
1%
Ankle Hardware
3
2%
0
0%
Leg Hardware Removal
1
1%
2
1%
Wrist Injury
2
1%
0
0%
Ankle replacement
0
0%
2
1%
Elbow Injury
1
1%
1
1%
Leg Tumor
1
1%
1
1%
Achilles Repair
1
1%
0
0%
Ankle Tumor
1
1%
0
0%
Back Injury
1
1%
0
0%
Elbow Hardware
1
1%
0
0%
Foot Replace
1
1%
0
0%
Hip Tumor
1
1%
0
0%
Knee Tumor
1
1%
0
0%
Neck Injury
1
1%
0
0%
Shoulder Tumor
1
1%
0
0%
Finger injury
0
0%
1
1%
Skin Graft
1
1%
0
0%
Irrigation and Debride
0
0%
1
1%
Ehrenfeld JM et al. ASA. 2010. LB05.
Results: Primary Outcome Variables
Matched
Retrospective
Cohort
N=327
Standard Care
Group
N=157
Patients receiving RBC transfusion, N
(%)
15 (4.6%)
7 (4.5%)
1 (0.6%)*
†
Total RBC units transfused, N (mean)
26 (0.08)
15 (0.10)
2 (0.01)**
††
* p=0.03 vs. Standard Care Group; † p=0.02 vs. Matched Retrospective Cohort;
**p<0.0001 vs. Standard Care Group; †† p<0.0001 vs. Matched Retrospective Cohort
Ehrenfeld JM et al. ASA. 2010. LB05.
SpHb Group
N=170
Frequency of Introoperative Blood Transfusions
Frequency of Patients Receiving RBC
Transfusion (%)
5%
4.6%
4.5%
4%
3%
2%
*†
1%
0.6%
0%
Retrospective Cohort Standard Care Group
* p=0.03 vs. Standard Care Group; † p=0.02 vs. Matched Retrospective Cohort
Ehrenfeld JM et al. ASA. 2010. LB05.
SpHb Group
Results: Other Outcome Variables
• Secondary Variables
• Frequency of patients receiving intraoperative Hb testing similar in
the SpHb and Standard Care Groups
• 11.8% vs. 16.3%, p=ns
• Mean number of Hb tests performed were similar in the SpHb and
Standard Care Groups
• 0.24 vs. 0.21 tests per case, p=ns
• Safety Variables
• No patient from either group received a transfusion during the
immediate twelve-hour postoperative period
• No differences at 28 days in the rate of post-operative complications
between the SpHb and Standard Care Groups
• 1.9% vs. 3.0%, p=ns
Ehrenfeld JM et al. ASA. 2010. LB05.
Post-hoc Analysis: Potential Cost Savings
• RBC transfusion reduction per patient with SpHb (0.09 units per case)
• Applied over range of RBC cost estimates
Range of Total Cost Estimates
per RBC Unit Transfused
Potential Cost Savings per
Patient with SpHb Monitoring
$
250
$
23
$
500
$
45
$
750
$
68
$ 1,000
$
90
$ 1,250
$
113
$ 1,500
$
135
Note: Estimates of RBC cost vary due to consideration of direct, indirect, and RBC-related
complications.
Ehrenfeld JM et al. ASA. 2010. LB05.
Study Conclusions
• The use of SpHb monitoring resulted in a lower
frequency of intraoperative RBC transfusions and a
lower number of RBC units transfused during elective
orthopedic surgery
• SpHb monitoring may reduce unnecessary transfusions,
reduce patient risk, and reduce costs
• Future studies will help determine the role of SpHb
monitoring in other settings and populations
Ehrenfeld JM et al. ASA. 2010. LB05.
Blood Transfusions and Nosocomial
Infections
• Post-transfusion nosocomial infection rate
• Number of red blood cell transfusions
• Independently associated with nosocomial infection rates
• Mortality, LOS in both the ICU and hospital
• Significantly higher in transfused patients, even when corrected for illness severity
Taylor RW, et.al. Crit Care Med. 2006; 34(9): 2302-2308.
Effect of Blood Transfusion
on 30 Day Outcomes
• 125,177 general surgery patients
from 121 hospitals
• 4,788 received RBC transfusion
• 30 day risk-adjusted odds ratio for
receiving 1U and 2U of blood
• = Mortality
■ = Morbidity
Bernard AC et al. Journal of the American College of Surgeons. 2009; 208:931-937.
1 Unit
2 Units
Mortality
1.32
1.38
All-cause Morbidity
1.23
1.40
Pneumonia
1.24
1.25
Sepsis
1.29
1.53
Effect of Blood Transfusion
on 6-Month Outcomes
• N= 9,079 cardiac surgery patients at eight hospitals
• 3,254 (36%) pts received transfusion of one or two units of blood
• Risk-adjusted 67% increase in 6-month mortality for transfused patients
Surgenor SD et al. Anesthesia & Analgesia 2009; 108:1741-1746.
TRICC RCT in Adult Critical Care:
Liberal vs. restrictive transfusion strategy
•
•
N=838 total
N=418 to Restrictive group
•
•
Received 54% fewer red
cell units
Overall - at least as
effective as the liberal
strategy
Hebert, et al. N Engl J Med 1999;340:409-17.
Pilot Blood Measures
• New pilot blood measures
• Patients with pre-transfusion hemoglobin or hematocrit
completed AND documentation of clinical indication for each
RBC unit administered
• Documentation that the patient was screened for anemia 14
- 30 days prior to surgery
• Blood measures are being finalized by end of 2010
• Will be optional for hospitals to report
• Pilot measures often become core measures
http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management.htm
Clinical Practice Guidelines:
ASA Guidelines for Perioperative Blood
Transfusion
1.
2.
3.
4.
Monitoring for blood loss.
Visual assessment of the surgical field should be periodically conducted to assess the presence of bleeding
Monitoring for inadequate perfusion and oxygenation of vital organs.
Conventional monitoring systems (e.g., blood pressure, heart rate, oxygen saturation, urine output, electrocardiography)
should be used to assess the adequacy of perfusion and oxygenation of vital organs. Special monitoring systems should
be used when appropriate (e.g., echocardiography, mixed venous oxygen saturation, blood gasses).
Monitoring for transfusion indications.
Measure hemoglobin or hematocrit when substantial blood loss or any indication of organ ischemia occurs. Red blood
cells should usually be administered when the hemoglobin concentration is low (e.g., less than 6 g/dl in a young, healthy
patient), especially when the anemia is acute. Red blood cells are usually unnecessary when the hemoglobin
concentration is more than 10 g/dl. These conclusions may be altered in the presence of anticipated blood loss. The
determination of whether intermediate hemoglobin concentrations (i.e., 6–10 g/dl) justify or require red blood cell
transfusion should be based on any ongoing indication of organ ischemia, potential or actual ongoing bleeding (rate and
magnitude), the patient’s intravascular volume status, and the patient’s risk factors for complications of inadequate
oxygenation.These risk factors include a low cardiopulmonary reserve and high oxygen consumption.
Transfusion of allogeneic red blood cells or autologous blood.
Maintain adequate intravascular volume and blood pressure with crystalloids or colloids until the criteria for red blood cell
transfusion listed above are met. Adequate quantities of red blood cells should be transfused to maintain organ perfusion.
When appropriate, intraoperative or postoperative blood recovery and other means to decrease blood loss (e.g., deliberate
hypotension) may be beneficial. Acute normovolemic hemodilution, although rarely used, may also be considered.
ASA Practice Guidelines: 2006
Anemia Challenges in Critical Care
• Anemia has high prevalence in the ICU
• 95% of ICU patients have a below-normal Hb level by ICU day 3
• 35% experience acute bleeding
• Repeated blood draws induce anemia
• Ranges from 40 to 70 mL/day
• 601 to 2,156 mL over entire hospital stay
• Blood transfusion prevalence
• Undetected bleeding a major cause of blood transfusions
• 75% of ICU patients with >1 week LOS receive a transfusion
• 29% have no indication for blood transfusion
• Morbidity and mortality rate lower for restrictive vs. liberal
transfusion strategy
Gould S et al. AJCC. 2007;16:39-47. Corwin HL et al. Chest. 1995. 108;767-771. Von Ahsehn N et al. Crit Care Med.
99;12;2630-2639. Hebert, et al. N Engl J Med 1999;340:409-17. Zimmerman JE et al, Crit Care Med 1997;25:737-48. Smoller
BR et al, NEIM 1986;314:1233-35
Clinical Practice Guidelines:
RBC Transfusion in Adult Trauma and Critical Care
•
Strategies to reduce RBC transfusion
•
•
•
•
Decision for RBC transfusion should be based on an individual patient’s:
•
•
Intraoperative/postoperative blood salvage, reduction in diagnostic laboratory testing is associated
with a reduction in phlebotomy volumes and a reduction in blood transfusion
A “restrictive” strategy of RBC transfusion (Hb transfusion trigger @ 7 g/dL) is as effective as a
“liberal” transfusion strategy (Hb transfusion trigger @ 10 g/dL)
Use of Hb level only as “trigger” for transfusion should be avoided
Intravascular volume status, evidence of shock, duration and extent of anemia, cardiopulmonary
physiologic parameters
All efforts should be initiated to avoid RBC transfusion in patients at risk for acute
lung injury and acute respiratory distress syndrome
Napolitano et al. Critical Care Medicine 2009
Anemia Challenges in the ED
• Challenges in anemia diagnosis
• May be masked by other conditions
• Common during occult bleeding and hemorrhage during trauma
• Associated with higher in-hospital morbidity and mortality
• Laboratory tests delay treatment and disposition
• 34% of all ED visits result in a Complete Blood Count (CBC)
• Long waits fuel ED overcrowding problem
• Increase number patients who leave without being seen
• Decreasing turnaround time for diagnostic tests
• Identified as major solution to increasing ED efficiency
Weiss SJ et al. Am J Emerg Med. 2005; 23:288-294. ACEP Task Force on Boarding, 2008.
Postpartum Hemorrhage
• 2.9% of deliveries had PPH
• Accounting for 19.1% of postpartum hospital deaths
Bateman BT et al. A&A 2010
2010 Sentinel Event Alert: Preventing
Maternal Death
#2 Recommendation Action:
Identify specific triggers for responding to changes
in the mother’s vital signs and clinical condition and
develop and use protocols and drills for responding
to changes, such as hemorrhage and preeclampsia.
http://www.jointcommission.org/sentinelevents/sentineleventalert/sea_44.htm
The Problem: PPH is a Leading Cause of
Pregnancy-Related Mortality
• No single definition exists, various definitions
include:
• > 500 mL EBL after completion of the third stage
• 900 mL EBL, which typically corresponds to 15%
volume deficit
• Any blood loss from the genital tract > 500 mL
• 10% change in hematocrit or need for blood
transfusion
• Accurate measurement of blood loss can be
difficult
Gregory, K, et al. OB Hemorrhage Definitions and Triggers. CMQCC Hemorrhage Task Force. 03/06/2009
CMQCC Recommendations
• Management of all women with cumulative
blood loss
• > 500 ml
• At > 500 ml blood loss: notify MD and proceed
with administration of Methergine 0.2 mg IM,
Fundal Massage
• Clinical Triggers: surveillance and intervention:
• 1. HR > 110
• 2. BP < 85/45
• 3. SpO2 <95%
Gregory, K, et al. OB Hemorrhage Definitions and Triggers. CMQCC Hemorrhage Task Force. 03/06/2009