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BLOOD TRANSFUSION
By;
Col Abrar Hussain Zaidi
Definitions
Haemorrhage--bleeding
Escape of blood from a blood-vessel
[Encyclopedia Britannica]
Subject’s importance
trauma/operations
Coagulation defects
Platelet defects or disorders of coagulation factors
Congenital - H.Ph
Aquired - DIC
- Autoimmune disorders
Etiology Of Haemorrhage-
causes
• INJURY /TRAUMA [+ operations]-It commonly results in
tearing or cutting of a blood-vessel-integrity of
wall breached - Trivial OR Major
• Bruise or ecchymosis .
Extravasation of blood /pouring out of blood
into the areolar tissues, which become boggy
Class I Hemorrhage
up to 15% of blood volume. [750mls]
no change in vital signs
fluid resuscitation is not usually necessary.
Haemorrhage Types
Class II Hemorrhage
15-30% of total blood volume. (750 - 1500mls)
Tachycardic
narrowing between the systolic and diastolic blood
pressures.
The body attempts to compensate with peripheral
vasoconstriction.
Skin may start to look pale and be cool to the touch.
slight changes in behavior.
Volume resuscitation with crystalloids typically required
Saline solution or
Lactated Ringer's solution.
Blood transfusion is not typically required.
Haemorrhage Types
Class III Hemorrhage
loss of 30-40 (1500 - 2000mls) % of circulating
blood volume.
The patient's blood pressure drops
the heart rate increases,
peripheral perfusion such as capillary refill
worsens, and the mental status worsens.
STATE OF SHOCK
Fluid resuscitation with crystalloid
Blood transfusion are usually necessary.
Haemorrhage Types
Class IV Hemorrhage
• Blood Transfusion
Management of
haemorrhage
ABCDE of Resuscitation
Management of
haemorrhage
Surgical treatment of
haemorrhage
General measures
Treat the cause -specific
measures
Management of
haemorrhage
Think, listen, see, feel, act
• Anticipate a problem
Blunt chest /abdominal injury
A major limb fracture
• Assess expected volume of loss
Haemorrhage has already occurred- injury
Significant haemorrhage is expected-major surgery
Management of
haemorrhage
General measures
Splenectomy
Resection and repair of Gut
Ectopic pregnancy -surgery
Management of
haemorrhage
surgical methods of haemorrhage control
Minor means of arresting bleeding are:
cold, which is most valuable in general oozing and local
extravasations;
very hot water, 130° to 16o F., a powerful haemostatic;
position, such as elevation of the limb, valuable in bleeding
from the extremities;
Vasoconstrictors, applied locally, Adrenaline
perchloride of iron, tannic acid and others, the most valuable
being suprarenal extract .
Direct Pressure and dressings
must be accurately applied . If the bleeding point cannot be
reached, the
pressure should be applied to the main artery between the
bleeding point and the heart . In small blood-vessels
pressure
will be sufficient to arrest. haemorrhage permanently .
Management of
haemorrhage
surgical methods of haemorrhage control
Ligature
In large vessels it is usual to pass it round the vessel and
tie it with a reef-knot . Apply the ligature, if possible, at
the bleeding point, tying both ends of the cut vessel . If
this cannot be done, the main artery of the limb must be
exposed by dissection at the most accessible point
between the wound and the heart, and there ligatured .
Sutures
Diathermy
Fibrin glue
Part 2
Blood transfusion
• Indications
• Blood products
• Grouping and cross match
• Screening
• General technique and Precautions
during transfusion
• Complications of transfusion
Indications for blood transfusion
in surgical practice
• Major Trauma
• Major operative procedures
Pre-op
Per op
Post-op
• Coagulation disorders
Blood products
Whole blood
can provide improved O2-carrying capacity,
volume expansion, and replacement of clotting
factors and was previously recommended for rapid
massive blood loss
RBCs: Packed RBCs are ordinarily the component of
choice with which to increase Hb. Indications
depend on the patient. O2-carrying capacity may
be adequate with Hb levels as low as 7 g/L in
healthy patients, but transfusion may be indicated
with higher Hb levels in patients with decreased
cardiopulmonary reserve or ongoing bleeding. One
unit of RBCs increases an average adult's Hb by
about 1 g/dL
Blood products
Fresh frozen plasma:
• Fresh frozen plasma (FFP) is an
unconcentrated source of all clotting
factors without platelets. Indications
include correction of bleeding
secondary to factor deficiencies for
which specific factor replacements are
unavailable, multifactor deficiency
states (eg, massive transfusion,
disseminated intravascular coagulation
[DIC], liver failure), and urgent warfarin
Blood products
• Cryoprecipitate: Cryoprecipitate is
a concentrate prepared from FFP.
Each concentrate usually contains
about 80 units each of factor VIII
and von Willebrand factor and
about 250 mg of fibrinogen.
Blood products
WBCs:
• Granulocytes may be transfused
when sepsis occurs in a patient
with profound persistent
neutropenia (WBCs < 500/μL) who
is unresponsive to antibiotics.
Blood products
Immune globulins:
• Rh immune globulin (RhIg), given IM or
IV, prevents development of maternal
Rh antibodies that can result from
fetomaternal hemorrhage.
• Other immune globulins prophylaxis for patients
exposed to a number of infectious diseases, including
cytomegalovirus, hepatitis A and B, measles, rabies,
respiratory syncytial virus, rubella, tetanus, smallpox,
and varicella (for usage, see under specific disease).
Blood products
Platelet concentrates:
• Platelet concentrates are used to prevent
bleeding in asymptomatic severe
thrombocytopenia (platelet count <
10,000/μL), for bleeding patients with less
severe thrombocytopenia (platelet count <
50,000/μL), for bleeding patients with platelet
dysfunction due to antiplatelet drugs but with
normal platelet count, for patients receiving
massive transfusion that causes dilutional
thrombocytopenia, and sometimes before
invasive surgery, particularly with
extracorporeal circulation for > 2 h (which
often makes platelets dysfunctional).
Blood substitutes
• ABO
• Rh
• Hepatitis
• HIV
Technique of Transfusion
•
• Caution: Before transfusion is started, the patient's wristband,
blood unit label, and compatibility test report must be checked at the
bedside to ensure that the blood component is the one intended for the
recipient.
• Use of an 18-gauge (or larger) needle A standard filter should
always be used for infusion of any blood component. Only 0.9%
saline IV should be allowed into the blood bag or in the same tubing
with blood.
• Transfusion of 1 unit of blood or blood component should be
completed by 4 h; If transfusion must be given slowly because of
heart failure or hypervolemia,o
• Close observation is important, particularly during the first 15 min,
and includes recording temperature, BP, pulse, and respiratory rate.
Periodic observation continues throughout and after the transfusion,
during which fluid status is assessed. The patient is kept covered and
warm to prevent chills, which may be interpreted as a transfusion
reaction. Elective transfusions at night are discouraged.
Technique of Transfusion
• Stage 2
• 15-30% blood volume loss (750 - 1500mls)
• Cardiac output cannot be maintained by arterial constriction
• Tachycardia >100bpm
• Increased respiratory rate
• Blood pressure maintained
• Increased diastolic pressure
• Narrow pulse pressure
• Sweating from sympathetic stimulation
• Mildly anxious/Restless
• Stage 3
• 30-40% blood volume loss (1500 - 2000mls)
• Systolic BP falls to 100mmHg or less
• Classic signs of hypovolemic shock
• Marked tachycardia >120 bpm
• Marked tachypnoea >30 bpm
• Decreased systolic pressure
• Alteration in mental status (Anxiety, Agitation)
• Sweating with cool, pale skin
• Stage 4
• Loss greater than 40% (>2000mls)
• Extreme tachycardia with weak pulse
• Pronounced tachypnoea
• Significantly decreased systolic blood pressure of 70 mmHg or less
• Decreased level of consciousness
• Skin is sweaty, cool, and extremely pale (moribund)
Vasoconstriction is mediated through intrinsic mechanisms and various vasoactive agents (thromboxane A2 and serotonin) released
during platelet aggregation.
COAGULATION SYSTEM
• Virchow in 1856 described the famous triad:
• 1. Stasis
• 2. Endothelial damage
• 3. Hypercoaguable states
• The coagulation system is based on the coagulation cascade. The end points of this cascade include the formation of thrombin
and fibrin.
• Throughout this system there can be defects in the multiple enzymes or extrinsic factors contributing to its dysfunction.
Fibrinolysis
Lysis of fibrindeposits is mediated by antithrombin III, protein C and S and plasmin. Antithrombin II as the name suggests blocks thrombin. When
combined with heparin it also blocks factors XII, XI, IX and X (intrinsic pathway).
Tests used to measure fibrinolysis include fibrin degradation products (FDB),fibrinogen, d-dimer
• I Fibrinogen
• II Prothrombin
• III Tissue thromboplastin
• IV Calcium
• V Proaccelerin
• VI
• VII Proconnectin
• VIII Antihemophilic factor
• IX Christmas factor
• X Stuart-Prower factor
• XI Plasma thromboplastin
• XII Hageman factor
• XIII Fibrin stabilizing factor
• Table 3.2. Coagulation cascade
Intrinsic
• Contact Tissue factor + VIIa
• XIa + VIII
Common Pathway
• Xa + V
• IIa
• Clot