eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.

HEMORRHAGE

Learning objectives

.     To define hemorrhage and classifyit.

.    To enumerate the various types ofhemorrhage and their clinical features.

.    To describe the clinical effectsof hemorrhage and outline the management principles.

.  To know about the various bloodproducts available , their uses in surgical practice and common complicationsof transfusion.

Definition of Hemorrhage

Hemorrhage:

     Bleeding or  the abnormal flow of blood.

  internalhemorrhage 

.    invisible

      externalhemorrhage

     .visible on the outside of the body.

What is hemorrhage ?

.    Hemorrhage is the medical term forbleeding     ( loss of blood from thebody)

.     Commonly, hemorrhage indicatesparticularly severe bleeding ; but technically, it means escape of blood toextravascular space.

.     The complete loss of blood isreferred to as exsanguination.

Causes of hemorrhage

.     Trauma – blunt injury orpenetrating injury or iatrogenic trauma, surgical procedures.

.     Underlying medical conditions –peptic ulcers, aneurysms, AV malformations, malignancy, uremia, etc.

.     Coagulation disorders – e.g.hemophilia, DIC, Von- Willebrand disease etc.

.     Drugs – NSAIDs, warfarin, etc.

 Types of hemorrhage

.     Based on the source of bleeding–Arterial, venous or capillary

.     Based on the onset – Primary,reactionary or secondary

.     Based on the site of bleeding  – External on internal

Arterial hemorrhage

.     Bright red in color

.     Spurting jet which rises and fallsin time with the pulse

.     Can become watery in appearance ifexcess of intravenous fluids are given  

Venous hemorrhage

.     Dark red in color

.     Steady and copious flow

.     Can be rapid if large veins areopened like common femoral or jugular vein

.     Can be from veins under increasedpressure e.g. ruptured varicose veins, esophageal varices

Capillary hemorrhage

.     Bright red in color

.     Hemorrhage is often rapid andoozing

.     Can be serious if prolonged formany hours e.g. in hemophilia

 Primary hemorrhage

.     Occurs at the time of injury oroperation

.     Can be arterial, venous orcapillary

.     If due to injury, can be revealedor concealed

.     If during surgery, usuallyrevealed and hence can be controlled with proper care

Reactionary hemorrhage

.     Occurs within 24hours (usually 4-6hrs) after injury / surgery.

.     Mainly due to ‘slipping’ ofligature or dislodgment of clot or cessation of reflex vasospasm.

.    Can be arterial or venous

.     Precipitating factors – rise inB.P , restlessness, vomiting, coughing.

Secondary hemorrhage

.     Occurs 7-14 days after the insult.

.     Due to infection and sloughing ofpart of the wall of a vessel.

.     Predisposing factors – presence ofdrainage tube, presence of a fragment of bone, ligature in an infected area,cancer.

.     Very common with anorectal wounds.

External hemorrhage

 .    Bleeding which is visible.

  .   Also called revealed hemorrhage.

.     Easy to assess the blood loss andto control the hemorrhage.

.     E.g. hemorrhage due to cut wounds,ruptured varicose veins, hematemesis etc.

Internal hemorrhage

.     Invisible bleeding.

.     Also called concealed hemorrhage.

.     E.g. ruptured spleen or liver,cerebral hemorrhage, etc.

.     May become ‘revealed’ e.g.hematemesis or melena in a case of peptic ulcer bleed, hematuria from a injuredkidney, etc.

Quantifying blood loss

.     Blood clot – a clot the size of aclenched fist is roughly equal to 500 ml

.     Swelling – moderate swelling in aclosed fracture of tibia equals 500-1000 ml of blood loss, whereas in fractureshaft of femur, it amounts to about 1000-2000 ml.

.     Swab weighing- useful in operatingtheatres. 1gm= 1 ml. For lengthy surgery, it is multiplied by 1.5 and forprolonged surgery like APR, by 2.

Effects of blood loss

.     Relates to the pre-existingcirculating blood volume.

        (Adults:65-75ml/kg ;Infants:80-85ml/kg )

.     Hb level – No immediate change inacute hemorrhage but, levels fall after some hours due to influx ofinterstitial fluid into vascular compartment or due to i.v. fluids.

.     Blood volume starts to recoverimmediately.

.     Plasma proteins are replaced bythe liver.

.     Red cell recovery takes about 5-6weeks.

.     The clinical features ofhemorrhage depends on the amount of blood loss and the rapidity of loss ofblood.

.     Classified into 4 classes ( ATLSclassification) according to the amount of blood lost.

Classes of hemorrhage

.     Class I – upto 15% blood loss

      - usually, nochange in BP, pulse pressure or respiratory rate.

      - minimaltachycardia may be there

      - CRT > 3seconds  ≈  volume loss of 10%

.     Class II – blood loss 15-30 %

       - tachycardia,tachypnea, decreased pulse pressure, cool clammy skin, delayed capillaryrefill, slight anxiety.

.     Class III -  loss of 30-40%

     - markedtachycardia and tachypnea, decreased systolic BP, oliguria, altered mentalstatus like confusion or agitation.

     - most willrequire blood transfusion

.     Class IV- loss of > 40% bloodvolume

      -markedtachycardia, decreased BP( diastolic may be unrecordable), markedly decreasedor no urinary output, depressed mental status ( or loss of consciousness), coldand pale skin.

      - immediatelylife threatening.

Treatment of hemorrhage

.     Urgent treatment required

.     If traumatic , stabilize thepatient and assess ABC ( airway, breathing, circulation) and follow basic lifesupport protocol if required.

.     Minimize further blood loss

     - application ofpressure: digital pressure or pressure dressings or use of balloon catheters.

     - packing withrolls of wide gauze with or                 without adrenaline(1:1000).

        - elevation ofthe affected area.

        - drugs:vasopressin, somatostatin, omeprazole, adrenaline can be used in variouscircumstances

.      Operative techniques

     - hemostats (arteryforceps) , clips, ligatures

     - electrocautery

     - topicalhaemostatic agents: gelatin sponge (oxygel), crushed patch of muscle,adrenaline soaked gauze, Russell viper venom etc

     - removal of bleeding organ may be required e.g. splenectomy.

- Restoration of intravascularvolume

      - isotonic i.vfluids.

      - plasmaexpanders.

      - blood andblood products.

.     Identify the primary cause ofbleeding and treat it. E.g peptic ulcer, hemophilia etc.

BLOOD AND BLOOD PRODUCTS

Blood in History

- China,1000 BC

   The soul wascontained in the blood.

- Egyptians bathed in blood for their health.

- Romans drinking the blood of

    fallengladiators to gain strength and vitality and to cure epilepsy.

- the practice of bathing in blood as it cascaded from asacrificial bull, was practiced by the Romans.

.  Animal toanimal --- Richard Lower ,1665

.    Animal to human --- Jean Denis ,1667

 . Human tohuman       --1818, James Blundell

                           -- 1900 The elucidation of the ABO   blood group system by Landsteiner

                                -- 1914 Lewisohn - usedcitrate

                                         --1940 Landsteiner and Wiener, in, describe Rh typing

Composition of blood

.     Red blood cells + Plasma

.     Plasma contains

        -white bloodcells,

        -platelets,fibrinogen,

        -all theclotting factors,

        -proteins likealbumin.

Why blood transfusion ?

.     Severe blood loss following traumaor from any pathology e.g. GI bleed

.     During major operative procedurese.g. APR , cardiovascular surgery etc.

.     Postoperatively in a patient whohas become severely anemic.

.     Following severe burns (hemolysis)

.     Preoperatively in pts of chronicanemia who require urgent surgery.

.     Pts with hemorrhagic states e.g.hemophilia, thrombocytopenia, liver disease etc.

Blood products available..

.     Whole blood

.    Packed cells ( RBCs)

.     Platelet concentrate

.     Fresh frozen plasma

.     Cryoprecipitate

.     Factor VIII, factor IX concentrates, fibrinogen

.     Others- Granulocytes, washed RBCS,leukoreduced RBCs, SAG-M blood, human albumin

Blood Vs Blood components

.     Whole blood is more likely carrierof transfusion transmitted diseases.

.     Most patients require only oneparticular component of whole blood.

.     Blood products have a better selflife than whole blood.

.     Blood products can often beinfused regardless of ABO blood group.

.     Hence whole blood is rarely usednow a days.

Whole blood

.     Collected from a healthy and fitdonor

.     410 ml of blood is collected intoa bag containing 75 ml of CPD (anticoagulant)

.     Stored at 4°C ± 2°C for up to 3wks

     (CPDA – 5 wks)

.     Uses – “fresh” blood is used forresuscitation in a pt severe acute blood loss

Changes in stored blood

.     White blood cells are rapidlydestroyed.

.     Platelets are functional only upto 24 hours

     ( due to coldtemperature).

.     Clotting factors VIII and V arelabile and their levels fall rapidly after 7 days.

.     2,3 DPG level is decreased causingreduced oxygen release into tissues.

.     Higher temp can lead totransmission of infections.

 Packed red cells

.     Obtained by centrifuging wholeblood at 2000-2300 g for 15-20 minutes and then removing the plasma.

.     Contains about 180 cc of RBCs  + 30 cc of plasma.( Total volume – 200-250cc).

.     Hematocrit – about 70-80 %

.     Solutions like AS-1, AS-5, optisoletc is added

.     No viable WBCs, platelets orclotting factors.

.     Uses- chronic anemia, elderly,children, deranged cardiac function.

Other RBC products..

.     Washed red blood cells – PC arewashed with saline to remove the plasma and proteins; reduces transfusionreactions.

.     Leukoreduced red blood cells- WBCsare removed using filters; reduces incidence of non-hemolytic febrilereactions.

.     Pediatric/ divided RBC units-smaller units are prepared, each containing 45-50 cc of RBCs and 15 cc ofplasma.

Platelet concentrate

.     Freshly donated blood iscentrifuged at 150-200 g for 15-20 minutes. The supernatant is removed and iscalled platelet rich plasma.

.     This is again centrifuged at1200-1500 g for 15-20 minutes to obtain platelet concentrate.

.     Usually 4-6 platelet concentratesare pooled in a single bag.

.     Platelets can also be obtained by“apheresis”.

.     Stored at room temperature.

.     Platelets viable for up to 72hours.

.     Uses- bleeding due tothrombocytopenia, platelet dysfunction or some combination of the twoconditions. ( avoid platelet transfusion in ITP with mild symptoms).

Fresh frozen plasma (FFP)

.     Plasma removed from fresh blood(within 4 hrs) is rapidly frozen by immersing into solid CO2 and ethyl alcoholmixture.

.     Stored at -40°C to -50°C.

.     A unit is about 200-250 cc in volume.

.     Good source of all coagulationfactors.

.     Uses- severe liver failure, mildform of individual clotting factor deficiencies e.g. Christmas disease (IX) ,hemophilia (VIII)

Cryoprecipitate

.    FFP is allowed to thaw at 4°C andthe supernatant plasma is removed. The glutinous precipitate is calledcryoprecipitate.

.     1 unit contains about 10-20 cc.

.     Stored at -40°C.

.     Very rich source of factor VIII& fibrinogen.

.     Used in hemophilia,hypofibrinogenemia

Individual factor concentrates

.     E.g. factor VIII concentrate, factorIX concentrate, fibrinogen etc

.     Prepared by organic liquidfractionation of plasma and stored in lyophilized powder form (freeze-driedform).

.     Stored at -50 to -60°C.

.     Used for respective factordeficiencies.

Complications of blood transfusion

.     Transfusion reactions –incompatibility, allergic reactions, simple pyrexial reactions, sensitizationto leucocytes and platelets, immunological sensitization.

.     Infections- HIV, hepatitis,bacterial infections, malaria.

.     Congestive cardiac failure

.     Thrombophlebitis

.     Air embolism

.     Coagulation failure

  .     Disseminatedintravascular coagulation (DIC)

.     Febrile reactions

.     Bacterial contamination

.     Immune reactions

.     Physical complications

.     Circulatory overload

.     Air embolism

.     Pulmonary embolism

.     Thrombophlebitis

.     ARDS

.     Metabolic complications

.     Hyperkalaemia

.     Citrate toxicity &hypocalcaemia

.     Release of vasoactive peptides

.     Release of plasticizers fromPVC-phthalates

.     Haemorrhagic reactions

.     After massive transfusion ofstored blood

.     Disseminated intravascularcoagulation

.     Transmission of disease

.     Hepatitis, CMV. EBV

.     AIDS (Factor VIII)

.     Syphilis

.     Brucellosis

.     Toxoplasmosis

.     Malaria

.     Trypanosomiasis

.     Haemosiderosis

.     After repeated transfusion inpatients with haematological diseases