Surgical Bleeding and Transfusion

Thamrongroj Temudom, MD Department of Surgery Phramongkutklao Hospital Bangkok, Thailand

Preoperative Screening for Bleeding Risk Take a good history 1.personal history of abnormal bleeding 2.family history of bleeding 3.history of drug use

Preop evaluation of hemostasis

Prolonged bleeding after biting the lip  Bruises without apparent injury  Prolonged bleeding after dental extraction  Excessive menstrual bleeding  Medications: aspirin  Relative with bleeding problem


findings show presence and etiology of a bleeding disorder

Physical Splenomegaly, hepatomegaly, hemarthroses, petechiae, ecchymoses (Platelet disorder p Petechiae ; Coagulation pathways p Ecchymosis )

Preoperative screening tests for asymptomatic patient

1. Platelet count Platelet clotting disorder with normal count p von Willebrands disease. PT - Prothrombin time. Extrinsic path. (A)PPT - (Activated) Partial Thromboplastin Time. intrinsic and common paths. Bleeding Time: Prolonged : drugs (ASA, NSAIDs, steroids), platelet disorder. Thrombin Time :Prolonged TT low or abnormal fibrinogen, presence of split products, heparin therapy.

Surgical patient as a hemostatic risk

Level I : negative history, minor operations Level II : negative history, Major operations -platelet count, blood smear, PTT Level III: suggestive history,intracranial operations - platelet count, bleeding time, PT PTT,TT Level IV: highly suggestive history -platelet count, bleeding time ,PT PTT TT and hematology consultation

Causes of excessive surgical bleeding

Congenital bleeding disorders Type A hemophilia (Factor VIII ) von Willebrands disease (v Ws factor, ; platelet adhesion; Rx = Cryoprecipitate or Desmopressin [DDAVP]) Type B hemophilia (Factor IX = Christmas disease, less common than A) Factor XI deficiency (commonest among Ashkenazi Jews) Congenital platelet dysfunction (uncommon)

Acquired Thrombocytopenia
1. Decreased platelet production (e.g. aplastic anemia) 2. Increased destruction (e.g. idiopathic thrombocytopenia purpura [ITP] or DIC) 3. Splenomegaly (splenic pooling) 4. Combination of these disorders, as in alcoholic liver failure Platelet dysfunction (ASA - N.B. irreversible for life of platelets; NSAIDs) Uremia p platelet dysfunction

Acquired bleeding disorders

Liver disease (decreased levels of prothrombin and Factors V, VII, and X [! not VIII] p prolonged PT and PTT. Alcohol ingestion p acute thrombocytopenia Hypersplenism p thrombocytopenia Obstructive jaundice p factor deficiencies (Rx = Vitamin K) Cirrhosis p factor deficiencies (not amenable to Vitamin K) Anticoagulant Therapy - Coumadin

Evaluation of intraop or postop bleeding

Ineffective local hemostasis Complication of blood transfusion Previously undetected hemostatic defect Consumptive coagulopathy Fibrinolysis: prostate, pancreas, liver op.

Local Hemostasis
Surgical bleeding- usually caused by ineffective local hemostasis Goal: prevent the flow of blood from incised or transected blood vessels Classified as 1.mechanical 2.thermal 3.chemical

Mechanical Procedures
Digital pressure, pack, tourniquet Hemostat Ligature transfixing sutures,suture ligatures Nonabsorbable: silk, polyethelene, wire Absorbable: catgut, polyglycolic acid (Dexon),polyglactic(Vicryl) Infection: monofilament are preferable

Thermal agents
HeatHeat-Protein denature Electrocautery (caution; EtherEtherflammable) Hypohermia - vasoconstriction Cryosurgery (-20 to -180 degree (celcius) dehydrate and denature of fatty tissue

Chemical agents
Epinephrine-vasoconstrictor Gelatin foam(Gelfoam) no hemostatic activity Oxidized regenerated cellulose Surgicel-antibacterial Fibrin glue-fibrinogen

Intraoperative diffuse bleeding

1. Platelet deficiency after massive transfusion 2. Hypothermia-induced coagulopathy 3. DIC 4. Elevated level of circulating anticoagulants

Postoperative Bleeding
Immediately after operation 1. An unligated vessel 2. Hematologic problem developed as a result of the operation

Postoperative Bleeding
Unstable Reoperate immediately Stable - Reassess history,medications given - Stop transfusion, send sample to blood bank - Check body temp. if low, warm patient - Check PT PTT and platelet function

Postoperative Bleeding
Platelet function PT&PTT Abnormal Abnormal Normal Normal Normal Abnormal Abnormal Normal Management Give platelet order DIC screen Give FFP Reoperate

Transfusion reactions
incidence per unit of blood Fever, chill, urticaria 1:100 Hemolytic reaction 1:6000

Indications for blood transfusion

Oxygen carrying capacity Volume replacement Replacement of clotting factors

Replacement of Blood
Indications Volume replacement blood loss> 25-30% of TBV improvement in oxygen carrying capacity Hct.<30 or Hb<10

Typing and Crossmatching

Major crossmath donorsRBC and recipients sera Rh positive blood is acceptable if Rh-ve is not available (should not be transfused in Rh-ve childbearing aged female) Group O,Rh-ve for emergency (>4units, risk of hemolytic reactions)

Blood preservatives
Acid citrate dextrose Citrate phosphate dextrose Citrate phosphate double dextrose adenine Adsol (add manitol)

Characteristics of blood
Vehicular organ that profuses all organs Transportation of oxygen, nutrient Removes by products CO2 RBC oxygen carrying capacity WBC body defense process Platelets hemostatic process

Banked Whole Blood

Shelf life 35-45 days poor source of platelets Factors II,VII,IX,X are stable within 3 weeks: pH lactic acid,K,ammonia

Fresh Whole Blood

Administered within 24h. Of its donation rarely indicated only available untested

Packed Red Cells

Product of choice for most Na, K, NH4, citrate provides oxygen carrying capacity Leukocyte reduced RBC previous history of febrile reaction

Autologous blood
Predeposited: 40days before surgery every 4-7 days Upto 5-6unit

Fresh Frozen Plasma

Provides factors V, VIII indicated in multiple coagulation factor deficiency Liver disease DIC Dilutional coagulopathy

Platelet Concentrates
Indications -thrombocytopenia due to massive transfusion or inadequate production -qualitative platelet disorders for surgery: elevate level to 50,000-100,000

Massive transfusion
Single transfusion>2,500 ml. >5,000 ml over 24h. Problems DIC, dilutional thrombocytopenia deficiency of factors V,VIII, XI hypothermia, decreased oxygen delivery

Complications of Transfusion
Hemolytic reactions Febrile, allergic reactions Bacterial sepsis Embolism, Thrombophlebitis Overtransfusion Transmission of Disease- viral hepatitis

Hemolytic Reactions
Incompatability of blood groups intravascular destruction of RBC hemoglobinemia, hemoglobinuria S&S-sensation of heat and pain chills, fever, resp.distress, hypotension, tachycardia abnormal bleeding in anesthetized patients

Hemolytic Reaction: Treatment

If suspected, Stop transfusion immediately send sample to blood bank diuresis, alkalinizing urine restrict fluid intake and K if develop ARF

DIC
combination of shock and a clotting stimulus, activation of fibrinolysis

DIC
precipitating causes
shock , massive transfusion difficult operation, sepsis, transfusion reactions, disseminated cancer, tissue ischemia,drug reactions, dead fetus

DIC
DIC is a clinical diagnosis classic- fibrinogen<100, platelet<50,000 D-dimer level>500 Management: Rx underlying causes