Haemorrhage classification diagnosis management blood transfusion

Professor Panna Lal Saha

Professor of Surgery & Head Department of Surgery

BGC Trust Medical College Chittagong

Definition
Escape of circulating blood from the

vascular system. 60-70 percent of the blood volume is accommodated in low pressure venules and veins and in the sphlanchnic vessels, and a loss of up to 10% (500-600ml) is adequately compensated for by the venoconstriction and therefore the

Types of hemorrhage

According to time

According to Blood vessels Arterial Venous capillary

Primary Secondar y Tertiary

According to visibility

Concealed revealed

Signs

External blood loss is obvious, but a serious internal hemorrhage must be recognized without delay by the general signs of blood loss:

Signs
Restlessness
Deep sighing

Increasing

pulse rate Decreased blood pressure Increasing pallor

respiration Cold and clammy skin Empty veins Thirst, tinnitus and blindness

Effects
Blood loss threatens the oxygen supply to

tissue cells Pending the arrest of hemorrhage and the replacement of blood, the function of vital structures such as the heart and brain stem is largely preserved by the increasing pulse rate peripheral vasoconstriction Unchecked and untreated blood loss results in failure of the heart and vasomotor centre to maintain a sufficient perfusion of oxygen for their own purposes and death follows.

Effects
Vasoconstriction fails to maintain the

blood pressure when blood loss increases beyond 20-30% Hypotension becomes severe with a 50% loss and the perfusion of myocardium and brain stem is affected. Thus the heart fails and vasoconstriction of venous reservoir fails each affecting the others in a vicious cycle which ends in death

Natural blood volume and red cell recovery The recovery of blood volumes begins immediately by the withdrawal of fluid from the tissues from the circulation. There is hemodilution. Plasma proteins are replaced by the liver
Red cell recovery takes some five

to six weeks

Chronic hemorrhage
Examples of causes in surgical practice

are bleeding hemorrhoids, fibroids, carcinoma colon, peptic ulcer etc. There is no diminution of blood volume as there is time for plasma replacements, but red cell replacement lags behind resulting in a state of anaemic hypoxia, requiring an increased cardiac out put.

Chronic hemorrhage
These patients develop high output

cardiac failure They must not be transfused with normal blood, but require packed cells instead. Acute hemorrhage in such cases is poorly compensated, as oxygen carriage is already depleted.

Measurement of hemorrhage
Bed side observation

Record keeping
Hemoglobin level The hematocrit Measuring blood loss
Blood clot Swelling in closed fracture Swab weighing

Blood volume determination

Measurement of CVP

TREATMENT

Stop the blood loss by Pressure and packing Position and rest Operation Ligation Repair Excision

Restore blood volume

byBlood transfusion Saline Dextran Plasma

Pressure and packing

Pressure dressing to be applied in

the wound Simple pressure over the bleeding site by finger stop bleeding Packing by roll gauge is an important tool to control bleeding in special circumstance Tourniquets applied in special place and circumstance to stop bleeding

Position and rest

Elevation of limbs

Position of patient during

operation Absolute rest Sedation

Hemorrhage management during operation

Artery forceps

Bleeding vessels are ligated with cat gut,

silk, vicryl, etc. or coagulated with diathermy. Management of scalp hemorrhage during operation by special technique Pressure by gauze pack helps to stop oozing Gel-foam or oxygel application stops bleeding in special circumstance

Blood transfusion

Indication of blood transfusion in surgical practice

Following

traumatic incidents where there has been severe blood loss, or hemorrhage from pathological lesion, e.g. from gastrointestinal tract During major operative procedures where a certain amount of blood loss is inevitable,

Indication of blood transfusion in surgical practice

Following severe burns where,

despite initial fluid and protein replacement there may be associated haemolysis Post operatively in a patient who has become severely debilitated and anaemic as the result of infection, septicaemia

Indication of blood transfusion in surgical practice

Pre operatively in cases of chronic anaemia

where surgery is indicated urgently, i.e. where there is inadequate time for iron and other replacement therapy, or where the anaemia is unresponsive to therapy, that aplastic anaemia To arrest hemorrhage or as a prophylactic measure prior to surgery, in a patient with a haemorrhagic state such as thrombocytopenia, hemophilia or liver disease

Preparation of blood products

It is important that blood donors should be

fit and no history of serious diseases, in particular hepatitis, AIDS, malaria which are transmitted in donor blood Blood is collected into a sterile commercially prepared plastic bag with needle and plastic tube attached in a complete, closed sterile unit Usually 410 ml blood is collected from a donor and mixed with 75 cc anticoagulant (CPD).

Infectious Disease Testing of Blood Donations

1. Syphilis Testing - TPHA

2. Viral Serology Testing - HBsAg, HCV Ab, HIV-1&2 Ab 3. NAT Testing - HIV/HCV/HBV 4. Bacterial testing for platelets

5. Malaria testing for at-risk donors

BLOOD STORAGE
It is essential to store blood at 4 2

C WBC- rapidly destroyed in stored blood Platelets at 4 C survival of platelets considerably reduced Clotting factors like platelets, clotting factors VIII and V are labile and their level falls quickly

Blood fractions
Packed red cells

Platelet rich plasma

Platelet concentrate Plasma Human albumin Fresh frozen plasma Cryoprecipitate Factors VIII and IX precipitate Fibrinogen

Giving blood
Selection and preparation of the site

Careful checking of the donor blood. This

should bear a compatibility label stating the patients name, hospital reference no., ward and blood group. Insertion of needle or canula. The latter may be valuable if intravenous therapy is required for any length of time Giving detailed written instructions as to the rate of flow, for example, 40 drops/min allows one 540 ml unit of blood to be

Giving blood
Site

As routine measure, vein on the forearm,

or on the back of the hand is chosen. In women, young children, and some men, especially when the venous pressure is low, a visible or palpable vein may not be found in the arm; consequently another site must be used.

Giving blood
The external jugular vein, internal jugular

vein, subclavian vein or cephalic vein in the deltopectoral groove, can be selected. Because of the risk of thrombo-phlebitis and pulmonary embolism, a vein of the leg should not be selected if it can be reasonably avoided. This injunction does not hold good for infants and small children, who are singularly immune to thrombophlebitis.

Giving blood
Warming blood during rapid major blood

transfusion, the blood must be warmed before reaching the patient Filtering blood a filter with an absolute filtration rating of 40 m will filter off platelet aggregate and leucocyte membranes in stored blood. Auto transfusion this is an old , welltried method of immediately restoring a patients blood volume, by transfusion of his or her own blood.

Monitoring Procedure-

Two patients with same surname in the same ward

Both having a blood transfusion Patient identification check not undertaken Group O patient transfused with Group A RBCs Patient complained of generalised pain Transfusion continued Patient became very ill and died 6 hours later

Signs & Symptoms of a Transfusion Reaction

Mild Reaction Fever Urticaria Rash Pruritis Severe Reaction Pyrexia, rigors Hypotension Loin/Back Pain Increasing anxiety Pain at infusion site Respiratory Distress Dark urine Severe Tachycardia Unexpected bleeding (DIC)

A mild reaction may be the early stages of a severe reaction - DONT IGNORE IT!

Management of a Mild Acute Transfusion Reaction

1. Stop the transfusion
(check patient and component compatibility)

2. Seek medical advice

3. Assess patient
4. Commence appropriate treatment If signs & symptoms worsen within 15 minutes treat as a severe reaction

Management of a Severe Transfusion Reaction

1. Stop the transfusion
Replace the administration set IV access should be maintained with normal saline (check patient and component compatibility)

2. Call the doctor to see the patient urgently 3. Assess patient - resuscitate as required

4. Inform the HTL and return the component

5. Document event in patient case notes

Safer Practice Takes Seconds

A consistent, professional approach to safe transfusion practice can save lives Id like to know who I can blame I still feel hate. I am furious and angry someone couldnt be bothered to treat my child in a professional and safe manner.
Mrs Green 15/12/98

Complications of blood transfusion

Congestive cardiac failure

Transfusion reactions
Incompatibility

Simple pyrexial reaction

Allergic reaction

Antibody reaction

Complications of blood transfusion

Infections

Serum hepatitis
Bacterial infection

Thrombophlebitis
Air embolism

Disseminated intravascular

coagulation

Introduction