Haemorrhage and blood Tranasfususion

By

Harisha N. L.

Plan of presentation
Introduction to haemorrhage Classification of haemorrhage Pathophysiology Management Indications of blood transfusion Principal aims and complications of blood transfusion

Introduction
Haemorrhage is a serious condition must be recognised and managed aggressively to reduce the severity and duration of shock and to avoid multiple organ failure or death.

CLASSIFICATION OF HAEMORRHAGE

Depending upon nature of bleeding

external haemorrhage
epistaxis haematemesis

Internal haemorrhage
Spinic rupture and Liver laceration following injury

Depending on nature of the vessel involved

Arterial haemorrhage Venous haemorrhage Capillary haemorrhage

Depending on timing of haemorrhage

Primary Reactionary secondary

Depending on duration of haemorrhage

Acute Chronic

PATHOPHYSIOLOGY

Classification of the evolution of haemorrhagic shock

Class I When blood loss is less than 750 ml (<15% of blood volume) it is called mild shock Presence of peripheral venoconstriction and withdrawal of fluid from the interstitial spaces compensates the loss of blood volume Clinically mild tachycardia can be made out

Class II
Loss of 800 to 1500 ml (15-30% blood volume) relults in moderate shock In addition to peripheral venoconstriction adrinaline or noradrinaline causes powerful vasoconstriction of veins and arteries Clinically patient shows heart rate of 100 to 120 beats per minute and elevated diastolic pressure Urine output is reduced to about 0.5 ml/Kg/hr Extremities may look pale and patient is confused and thirsty

Class III
Loss of 1500-2000 ml (30-40% of blood volume) All signs and symptoms of class II get worsened Systolic and diastolic pressure decreases and heart rate increases above 120 beats/minute Pulse becomes thready The respiratory rate increases more than 20 per minute Urine output drops to 10 to 20 ml/Kg/hr Patient appears pale drowsy or confused

Class IV
Blood loss more than 2000 ml Pulse is thready and more than 120 beats per minute BP is very low or unrecordable If blood loss persists organs damage can occur

MANAGEMENT

Treatement
General measures
Hospitalisation Care of air way, breathing and circulation Oxygen should be given by face mask to all patients who are conscious In unconscious endotracheal intubation and ventilation with oxygen may be necessary Intra venous administration of ringer lactate and colloids such as gelatins and hetastarch blood transfusion

Treatement
Specific measures
Pressure and packing Position and rest Tourniquets Surgical methods
Application of artery forceps(spencer wells forceps) Application of ligatures for bleeding vessels Cauterisation (diathermy) Application of bone wax Silver clips are used to control bleeding from cerebral vessels (Cushing's clip)

BLOOD TRANSFUSION

Indications
Acute haemorrhage Major operations where blood loss is inevitable In case of burns Preoperative transfusion when patient is already anaemic and there is no time for iron therapy In anaemic patients when the hemoglobin level is below 10 gm/100 ml In certain coagulation disorders like haemophilia Christmas disease, thrombocytopenic purpura and few blood diseases like leukaemia, aplastic anaemia During chemotherapy for malignant diseases in treating cases of Rh incompatability, erithroblastosis, foetalis

The Principle Aims of Blood Transfusion

Improve oxygen carrying capacity of blood. Symptomatic improvement. Reduce hypovolaemia.
1 UNIT of Blood should increase the Hb by approx.1g/dL. If no improvement or reduction in Hb think about ongoing blood loss or destruction. You need treat the underlying cause.

Blood and Blood Product Transfusion

Whole Blood Packed Cells Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate

complications
Transfusion reactions
Incompatibility Pyrexial reactions Allergic reactions Sensitization to leucocytes and platelets

Transmission of diseases
serum hepatitis AIDS Bacterial infections

Reactions caused by massive transfusion

Acid base imbalance Hyper kalaemia Citrate toxicity Hypothermia Failure of coagulation

Blood Transfusion - Acute Complications I

Complication Acute Intravascular haemolysis Cause ABO incompatibility (Commonest cause is administrative!) Incidence / Likely timing with regard transfusion 1:6x105 Occurs within a few mls of starting transfusion (Mortality 10%) Treatment Shouldnt happen! STOP THE BLOOD! Supportive treatment Treat complications ARF and DIC Unpleasant but not life threatening Paracetamol and cooling.

Febrile Non-haemolytic reactions

Anti Leucocyte Ig or Cytokines in platelet transfusions Commonest in patients receiving multiple transfusions or previously pregnant Transfusion contains plasma proteins or allergens causing an acute IgE mediated allergic response Occurs with plasma and platelet rather than red cell transfusions.

Becoming rarer because of leucocyte depletion in many transfusion practices. Occurs towards the end of or up to hours after transfusion 1 2% of all transfusions Peri-transfusion May occur recurrently

Urticaria

Unpleasant but not life threatening Anti-histamines (can be given prophylactically in known patients)

Infective shock

Bacterial contamination of transfused blood

Rare; 1:5x 105 First 100mls of blood ie early Often fatal! Extremely rare

That of Septicaemia and shock fluids, IV antibiotics

Anaphylaxis

Anti-IgA antibodies ?others Patients are often IgA deficient as well!

Life threatening A.B.C / Crash team call IV / IM adrenaline, steroids, aHistamines, Oxygen Nebulisers.

Blood Transfusion - Acute Complications II

Non-cardiogenic Pulmonary oedema Caused by donor blood containing anti-Leucocyte antibodies Occurs at the start of the transfusion Can be life threatening Treat for
(a) Acute transfusion reaction (b) Respiratory failure (ARDS), Shock and Pulmonary oedema

Blood Transfusion Delayed Complications

Complication Delayed Red cell haemolysis Cause Recipient IgG vs Red cell antigens Occurs in previously transfused or pregnant patients; Initial cross match will not contain IgG but subsequent cross matches should! Immune mediated donor Tcell reaction (often occurs in immunodeficient patients) Fever, Rash, MOF, Pancytopaenia Anti-Platelet antibodies (usually aHPA-1a) Immune medicated TCP Primarily during pregnancy Incidence / Timing 5 10 days after transfusion <1:500 red cell transfusions Treatment No treatment per se but Patient will receive less benefit from transfusion and once present they will cause problems for future transfusions Usually fatal! Haematology specialist care required In susceptible recipients blood is subjected to Gamma irradiation Use HPA-1a negative red cell and platelet transfusions or LDBlood High dose IV Immunoglobulins for 5 days 0.4g / kg Counselling and specialist advice required

Transfusion associated Graft versus Host disease (TA-GvHD)

Rare 1:750,000 units of cellular blood components transfused 4 30 days after transfusion

Post Transfusion Purpura

RHS Rare 5 -10 days after transfusion Often severe TCP causing bleeding

Post Transfusion Viral Infection

Virus (and other infective agents e.g. prions) undetected by UK screening system Multiple transfusions One unit of blood contains 250mg of iron

HIV <1: 3x 106 HBV and HCV < 1: 2 x 105

Iron overload

Only occurs after several years of blood transfusions e.g. Chronic haemolytic disease

Desferrioxamine increases iron excretion

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