Surgery

1) Preoperative assessment of hemostasis.

Tests of hemostasis and blood coagulation: The most valuable part of this assessment is a careful history and physical examination. Specific questions should be asked to determine if there was a prior history of transfusion, untoward bleeding during a major surgical procedure, any bleeding after a minor operation, any spontaneous bleeding, or any family history of bleeding difficulties. The history should include a list of medications and underlying medical disorders (e.g., malignancy, liver or kidney disease) that may affect normal hemostasis. Laboratory studies also provide important clues of hemostatic ability. Platelet Count Spontaneous bleeding rarely occurs with a platelet count of greater than 50,000/mm3. Platelet counts in this range are usually adequate to provide hemostasis following trauma or surgical procedures if other hemostatic factors are normal. Bleeding Time This assesses the interaction between platelets and a damaged blood vessel and the formation of a platelet plug. Deficiencies in platelet number, platelet function, or some coagulation factors will yield a prolonged bleeding time. Prothrombin Time (PT) This test measures the extrinsic pathway of blood coagulation. Thromboplastin, a procoagulant, is added with calcium to an aliquot of citrated plasma, and the clotting time is determined. Partial Thromboplastin Time (PTT) A screen of the intrinsic clotting pathway. This test has a high sensitivity; only extremely PTT, used in conjunction with the PT, can help place a clotting defect in the first or second stage of the clotting process. Thrombin Time (TT) This screen detects abnormalities in fibrinogen and will detect circulating anticoagulants and inhibitors of anticoagulation. Tests of Fibrinolysis Fibrin degradation products (FDPs) can be measured immunologically. Preoperative Evaluation of Hemostasis There are four levels of concern (given the patients history and the proposed operation) that should dictate the extent of preoperative testing. Level I: The history is negative, and the procedure is relatively minor (e.g., breast biopsy or hernia repair). No screening tests are recommended. Level II: The history is negative and a major operation is planned, but significant bleeding is not expected. A platelet count, blood smear, and PTT are recommended to detect thrombocytopenia, circulating anticoagulant, or intravascular coagulation.

Level III: The history is suggestive of defective hemostasis, and the patient is to undergo a procedure in which hemostasis may be impaired, such as operations using pump oxygenation or cell savers. This level also applies to situations where minimal postoperative bleeding could be detrimental, such as intracranial operations. A platelet count and bleeding time should be done to assess platelet function. A PT and PTT should be used to evaluate coagulation, and the fibrin clot should be checked to screen for abnormal fibrinolysis. Level IV: These patients have a known hemostatic defect or a highly suggestive history. The same tests suggested for level III should be checked, and a hematologist should be consulted. In case of an emergency, assessment of platelet aggregation and a TT are indicated to detect dysfibrinogenemia or a circulating anticoagulant. Patients with liver disease, obstructive jaundice, kidney failure, or malignancy should have the platelet count, PT, and PTT checked preoperatively.

2. Bleeding: types and causes, conservative treatment. Local hemostasis. Types of bleeding: four classes by the American College of Surgeons'

Class I Haemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary. Class II Haemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference 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. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required. Class III Haemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral perfusion (shock), such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary. Class IV Haemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.

Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment of these patients. According to WHO:Grade 0 no bleeding ,Grade 1 petechial bleeding; Grade 2 mild blood loss (clinically significant); Grade 3 gross blood loss, requires transfusion (severe); Grade 4 debilitating blood loss, retinal or cerebral associated with fatality

Causes of bleeding
Traumatic Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:

Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause Hematoma - Caused by damage to a blood vessel that in turn causes blood to collect under the skin. Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision. Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery. Puncture Wound - Caused by an object that penetrated the skin and underlying layers, such as a nail, needle or knife Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin Crushing Injuries - Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself. Ballistic Trauma - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Due to underlying medical conditions

underlying anatomic deformities, such as weaknesses in blood vessels (aneurysm or dissection),

arteriovenous malformation, ulcerations,tissue death, cancer, or infection may lead to bleeding. non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, classic Hemophilia A ,Christmas disease(hemophilia B), von Willebrand disease warfarin ,This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting factors in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors. Treatment The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the

course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category. Blood products Blood for transfusion is obtained from human donors by blood donation and stored in a blood bank. There are many different blood types in humans, the ABO blood group system, and the Rhesus blood group system being the most important. Transfusion of blood of an incompatible blood group may cause severe, often fatal, complications, so crossmatching is done to ensure that a compatible blood product is transfused. Other blood products administered intravenously are platelets, blood plasma, cryoprecipitate, and specific coagulation factor concentrates. Intravenous administration Many forms of medication (from antibiotics to chemotherapy) are administered intravenously, as they are not readily or adequately absorbed by the digestive tract.After severe acute blood loss, liquid preparations, generically known as plasma expanders, can be given intravenously, either solutions of salts (NaCl, KCl, CaCl2 etc...) at physiological concentrations, or colloidal solutions, such as dextrans, human serum albumin, or fresh frozen plasma. In these emergency situations, a plasma expander is a more effective life-saving procedure than a blood transfusion, because the metabolism of transfused red blood cells does not restart immediately after a transfusion.

Local hemostasis
The goal of local hemostasis is to prevent the flow of blood from incised or transected blood vessels. The techniques may be classified as mechanical, thermal, or chemical. Mechanical The oldest mechanical device to effect closure of a bleeding point or to prevent blood from entering an area of disruption is digital pressure. The finger has the advantage of being the least traumatic means of hemostasis. Diffuse bleeding from multiple transected vessels may be controlled by mechanical techniques, including direct pressure over the bleeding area, pressure at a distance, or generalized pressure. Direct pressure is preferable and is not attended by the danger of tissue necrosis associated with a tourniquet. Gravitational suits have been used to create generalized pressure. The hemostat represents a temporary mechanical device to stem bleeding. Ligature replaces a hemostat as a permanent method of hemostasis of a single vessel. Thermal Cautery effects hemostasis by denaturation of proteins, which results in coagulation of large areas of tissue. Cooling also has been applied to control bleeding and acts by increasing the local intravascular hematocrit and decreasing the blood flow by vasoconstriction. Cryogenic surgery uses temperatures between 20 and 180C. Chemical

Some chemicals act as vasoconstrictors, others are procoagulants, and others have hygroscopic properties that aid in plugging disrupted blood vessels. Epinephrine is a vasoconstrictor, but because of its considerable absorption and systemic effects, it is generally used only on areas of mucosal oozing. Local hemostatic materials include gelatin foam, cellulose, and micronized collagen.

3. Possibilities of blood saving during the operation.

Blood-loss reduction strategies have numerous benefits for the patient. These include less transfusion reactions and decreased transmission of infections. Decreased requirements for bank blood mitigate the scarcity of this vital resource. The techniques for blood "savings" include lowering the transfusion trigger stimulation of the marrow with erythropoietin pre-donation, normovolemic hemodilution, recovery of shed blood. Anesthetic and/or surgical techniques can be chosen to reduce bleeding, various pharmacology agents can also reduce blood loss. Oxygentransporting artificial hemoglobin perflurocarbon solutions can also reduce dependence on transfusion.

Cell Saver (Intraoperative Cell Salvage Machine)Commonly known as a "cell saver", the intraoperative cell salvage machine suctions, washes, and filters blood so it can be given back to the patient's body instead of being thrown away. One advantage to this is the patient receives his/her own blood instead of donor blood, so there is no risk of contracting outside diseases. Because the blood is recirculated, there is no limit to the amount of blood that can be given back to the patient. The cell saver is also a viable alternative for patients with religious objections to receiving blood transfusions this is one way of donation on autologous blood.

Of the above techniques, the most promising are marrow stimulation, reductions of blood loss, and artificial oxygen transporters.

4. Pathogenesis of blood loss.

To respond to hypovolemia is a task for the body fluid balance systems as well as osmotic balance systems.Following an acute response, this function is accomplished by two sets of receptors; one in the kidneys and the other in the heart. Acute response: The first response to hypovolemia is an inversed baroreflex, where a lack of activation of baroreceptors results in elevation of total peripheral resistance and cardiac output via increased contractility of the heart, heart rate, and arterial vasoconstriction, which tends to increase blood pressure.

Kidney:The kidneys have a specialized set of cells called granular cells that enable the recognition of changes in blood flow to the kidneys. Naturally, these cells detect the presence of hypovolemia and react accordingly to the loss of blood volume. These cells secrete a hormone called renin when there is a decrease in the flow of blood to the kidneys. Renin flows into the blood and there, initiates the conversion of a protein called angiotensinogen to angiotensin. In order to exert its effects on the body, angiotensin I must be converted by enzymes into its active form, angiotensin II. Physiologically, angiotensin II stimulates the release of hormones by the posterior pituitary gland (ADH, also known as vasopressin) and the adrenal cortex (aldosterone). Aldosterone causes the kidneys to reabsorb sodium, leading to the reabsorption of water. ADH (vasopressin) also causes the kidneys to reabsorb water. Angiotensin II increases blood pressure by contracting arterial muscles. Heart: The next set of receptors responsible for detecting volumetric insufficiency are located in the heart atria. Commonly referred to as stretch receptors, these atrial baroreceptors detect the amount of blood that is being pumped back into the heart from the veins. The body constantly returns blood to the heart through veins. Therefore, when the volume of blood being transported back to the heart is decreased, these receptors detect the change in the amount of blood thereby reducing the release of atrial natriuretic peptide... Thirst Both the activation of the renin angiotensin system and the decrease in atrial natriuretic peptide, along with their other functions, contribute to elicit thirst, by affecting the subfornical organ. Other responses Furthermore, as intravascular fluid decreases, blood pressure is reduced and some compensation occurs as fluid from other cellular compartments moves into the vasculature. Fluid is passively transferred from all of the fluid compartments in the body, including intracellular, interstitial and other extravascular compartments. Stages of Hypovolemic Shock Stage 1 Up to 15% blood volume loss (750mls) Compensated by constriction of vascular bed Blood pressure maintained Normal respiratory rate Pallor of the skin Slight anxiety Stage 2 15-30% blood volume loss (750 - 1500mls) Cardiac output cannot be maintained by arterial constriction Tachycardia

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)

6. Signs and diagnosis of blood loss, classes of blood loss.

Diagnosis Clinical symptoms may not be present until 10-20% of total whole-blood volume is lost. Hypovolemia can be recognized by elevated pulse, diminished blood pressure, and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of shock. Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia. This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should always be treated aggressively. Also look for obvious signs of external bleeding while remembering that people can bleed to death internally without any external blood loss. Also consider possible mechanisms of injury (especially the steering wheel and/or use/non-use of seat belt in motor vehicle accidents) that may have caused internal bleeding such as ruptured or bruised Landon internal organs. If trained to do so and the situation permits, conduct a secondary survey and

check the chest and abdominal cavities for pain, deformity, guarding or swelling. (Injuries to the pelvis and bleeding into the thigh from the femoral artery can also be life-threatening.) Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment of these patients. Signs: The pale, cool skin noted on examination and the blanching of the bowel with decreased pulses in the mesentery are gross signs seen at the bedside and at laparotomy. A decrease in circulating blood volume also results in tachycardia in response to decreased stroke volume from inadequate preload. Orthostatic testing may unmask cardiovascular instability

7. Principles of treatment of blood loss. Volume Replacement

The most common indication for blood transfusion in the surgical patient is the restoration of circulating blood volume. The hematocrit can be used to estimate blood loss, but up to 72 h is required to establish a new equilibrium after a significant blood loss. In the normal person, reflex mechanisms allow the body to accommodate up to moderate-size blood losses. Significant hypotension develops only after about a 40 percent loss of blood volume. Loss of blood during operation may be estimated by weighing the sponges (representing about 70 percent of the true loss). Approximately 14 percent of all inpatient operations include blood transfusions. Blood provides transportation of oxygen to meet the bodys metabolic demands and removes carbon dioxide. Replacement Therapy Banked whole blood is stored at 4C and has a storage life of up to 35 days. Up to 70 percent of transfused erythrocytes remain in the circulation 24 h after transfusion; 60 days after transfusion, approximately 50 percent of the cells will survive. Banked blood is rarely indicated. Banked blood is a poor source of platelets. Factors II, VII, IX, and XI are stable in banked blood. Factor VIII rapidly deteriorates during storage. During the storage of whole blood, red cell metabolism and plasma protein degradation result in chemical changes in the plasma, including increases in lactate, potassium, and ammonia and a decrease in pH. Typing and Crossmatching Serologic compatibility is routinely established for donor and recipient A, B, O, and Rh groups. As a rule, Rh-negative recipients should be transfused only with Rh negative blood. In the patient receiving repeated transfusions, serum drawn less than 48 h before cross-matching should be used. Emergency transfusion can be performed with group O blood. If it is known that the prospective recipient is group AB, group A blood is preferable. Fresh Whole Blood This term refers to blood given within 24 h of its collection. Packed Red Cells and Frozen Red Cells Packed cells have approximately 70 percent of the volume of whole blood. Use of frozen cells markedly reduces the risk of infusing antigens to which the

patients have previously been sensitized. The red cell viability is improved, and the ATP and 2,3diphosphoglycerate (2,3-DPG) concentrations are maintained. Platelet Concentrates Platelet transfusions should be used for thrombocytopenia due to massive blood loss replaced with stored blood, thrombocytopenia due to inadequate production, and qualitative platelet disorders. Isoantibodies are demonstrated in about 5 percent of patients after 110 transfusions, 20 percent after 1020 transfusions, and 80 percent after more than 100 transfusions. HLA-compatible platelets minimize this problem. Fresh Frozen Plasma and Volume Expanders Factors V and VIII require plasma to be fresh or freshly frozen to maintain activity. The risk of hepatitis is the same as that of whole blood or packed red cells. In emergency situations, lactated Ringers solution can be administered in amounts two to three times the estimated blood loss. Dextran or lactated Ringers solution with albumincan be used for rapid plasma expansion. Concentrates Antihemophilic concentrates are prepared from plasma with a potency of 2030 times that of fresh frozen plasma. The simplest factor VIII concentrate is plasma cryoprecipitate. Albumin also may be used as a concentrate (25 g has the osmotic equivalent of 500 mL), with the advantage of being hepatitis-free. Improvement in Oxygen-Carrying Capacity Transfusion should be performed only if treatment of the underlying anemia does not provide adequate blood counts for the patients clinical condition. In general, raising hemoglobin levels above 78 g/dL provides little additional benefit. A whole blood substitute, Fluosol-DA, provides oxygen-carrying capacity in the absence of blood products. Replacement of Clotting Factors Supplemental platelets or clotting factors may be required in the treatment of certain hemorrhagic conditions. Fresh frozen plasma is used in the treatment of a coagulopathy in patients with liver disease, but its efficacy is very low. The rigid use of PT and PTT to anticipate the effect of fresh frozen plasma is not justified. If fibrinogen is required, a plasma level greater than 100 mg/dL should be maintained. Massive Transfusion This term refers to a single transfusion of greater than 2500 or 5000 mL over a 24h period. A number of problems may accompany the use of massive transfusion, including thrombocytopenia, impaired platelet function, deficiency in factors V, VIII, and XI, and the increased acid load of stored blood products.

8. Blood components, use of blood components.

The average adult has a blood volume of roughly 5 liters, composed of plasma and several kinds of cells these formed elements of the blood are erythrocytes, leukocytes) and thrombocytes . By volume, the red blood cells constitute about 45% of whole blood, the plasma constitutes about 55%, and white cells constitute a minute amount. Whole blood exhibits non-Newtonian fluid dynamics; its flow properties are adapted to flow effectively through tiny capillary blood vessels with less resistance than plasma by itself. In addition, if all human hemoglobin were free in the plasma rather than being contained in RBCs, the circulatory fluid would be too viscous for the cardiovascular system to function effectively. Cells Further information: Complete blood count One microliter of blood contains:

4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In mammals, mature red blood cells lack a nucleus and organelles. They contain the blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial vessel cells and other cells) are also

marked by glycoproteins that define the different blood types. The proportion of blood occupied by red blood cells is referred to as the hematocrit, and is normally about 45%. The combined surface area of all red blood cells of the human body would be roughly 2,000 times as great as the body's exterior surface. 4,000-11,000 leukocytes: White blood cells are part of the immune system; they destroy and remove old or aberrant cells and cellular debris, as well as attack infectious agents (pathogens) and foreign substances. The cancer of Constitution of normal blood leukocytes is called leukemia. Parameter Value 200,000-500,000 thrombocytes: 45 7 (38 52%) for males thrombocytes, also called platelets, are Hematocrit 42 5 (37 47%) for females responsible for blood clotting (coagulation). pH 7.35 7.45 They change fibrinogen into fibrin. This fibrin creates a mesh onto which red blood base excess -3 to +3 cells collect and clot, which then stops more PO2 10 13 kPa (80 100 mm Hg) blood from leaving the body and also helps to PCO2 4.8 5.8 kPa (35 45 mm Hg) prevent bacteria from entering the body. HCO3 21 mM 27 mM Oxygenated: 98 99% Oxygen saturation Plasma Deoxygenated: 75% About 55% of whole blood is blood plasma, a fluid that is the blood's liquid medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.7 3.0 litres in an average human. It is essentially an aqueous solution containing 92% water, 8% blood plasma proteins, and trace amounts of other materials. Plasma circulates dissolved nutrients, such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins), and removes waste products, such as, carbon dioxide, urea, and lactic acid. Other important components include:

Serum albumin Blood-clotting factors (to facilitate coagulation) Immunoglobulins (antibodies) lipoprotein particles Various other proteins Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have been removed. Most of the proteins remaining are albumin and immunoglobulins. The normal pH of human arterial blood is approximately 7.40 (normal range is 7.35 7.45), a weakly alkaline solution. Blood that has a pH below 7.35 is too acidic, whereas blood pH above 7.45 is too alkaline. Blood pH, partial pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2), and HCO3 are carefully regulated by a number of homeostatic mechanisms, which exert their influence principally through the respiratory system and the urinary system in order to control the acid-base balance and respiration. Plasma also circulates hormones transmitting their messages to various tissues. The list of normal reference ranges for various blood electrolytes is extensive.

9. Possibilities of use of autologous blood.

Autologous blood can be used for donation: when a person donates blood for their own use, prior to a scheduled elective surgery. There are actually at least three kinds of autologous procedures:

 Pre-operative autologous donation - patient donates his/her own blood prior to surgery. The preoperative autologous donation is the most common of the three procedures. Intra-operative salvage - a way of saving blood lost during surgery so it can be returned to the patient. Utilizes a machine called a cell saver. Cell Saver (Intraoperative Cell Salvage Machine) Commonly known as a "cell saver", the intraoperative cell salvage machine suctions, washes, and filters blood so it can be given back to the patient's body instead of being thrown away. One advantage to this is the patient receives his/her own blood instead of donor blood, so there is no risk of contracting outside diseases. Because the blood is recirculated, there is no limit to the amount of blood that can be given back to the patient. The cell saver is also a viable alternative for patients with religious objections to receiving blood transfusions. Postoperative cell salvage - Done usually after the patient leaves the operating room. During some surgical procedures, there can be an accumulation of blood in the body, which can be collected and returned to the patient via transfusion. The blood which a patient donates prior to their scheduled elective surgery is stored and saved for their use. When the blood is given back to the patient, it is called an autologous blood transfusion. Eliminate the risk of acquiring infectious diseases from blood tranfusions. Though blood from strangers, family, and friends are all screened and tested to minimize any risk of transmitting infectious disease, autologous donation remains the only way to eliminate the risks. Also, by using your own blood you don't reduce the community blood supply and you leave it for people who may need it.

10. Blood substitutes, use of blood substitutes.

Blood substitutes also called artificial blood are used to fill fluid volume and/or carry oxygen and other blood gases in the cardiovascular system. Although commonly used, the term is not accurate since human blood performs many important functions. Red blood cells transport oxygen, white blood cells defend against disease, platelets promote clotting, and plasma proteins perform various functions. The preferred and more accurate are volume expanders for inert products, and oxygen therapeutics for oxygen-carrying products. Examples of these two "blood substitute" categories:

Volume expanders: inert and merely increase blood volume. These may be crystalloid-based (Ringer's lactate, normal saline, D5W (dextrose 5% in water) or colloid-based (Voluven, Haemaccel, Gelofusin). Oxygen therapeutics: mimic human blood's oxygen transport ability. Examples: Perftec, Hemopure, Oxygent, PolyHeme and Perftoran.

Oxygen therapeutics are in turn broken into two categories based on transport mechanism: perfluorocarbon based, and hemoglobin based.

Volume expanders are widely available and are used in both hospitals and first response situations by paramedics and emergency medical technicians. When blood is lost, the greatest immediate need is to stop blood loss. The second greatest need is replacing the lost volume. This way remaining red blood cells can still oxygenate body tissue. Normal human blood has a significant excess oxygen transport capability, only used in cases of great physical exertion. Provided blood volume is maintained by volume expanders, a quiescent patient can safely tolerate very low hemoglobin levels, less than 1/3rd of a healthy person. The body automatically detects the lower hemoglobin level and compensatory mechanisms start up. The heart pumps more blood with each beat. Since the lost blood was replaced with a suitable fluid, the now diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is released to the tissues. These adaptations are so effective that if only half of the red blood cells remain, oxygen delivery may still be about 75 percent of normal. A patient at rest uses only 25 percent of the oxygen available in his blood. In extreme cases, patients have survived with a hemoglobin level of 2 g/dl, about 1/7th the norm, although levels this low are very dangerous. With enough blood loss, ultimately red blood cell levels drop too low for adequate tissue oxygenation, even if volume expanders maintain circulatory volume. In these situations the only alternatives are blood transfusions, packed red blood cells, or oxygen therapeutics (if available). However in some circumstances hyperbaric oxygen therapy can maintain adequate tissue oxygenation even if red blood cell levels are below normal life sustaining levels.