13.haemorrhage,classification,diagnosis,management,blood transfusion c
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Professor Panna Lal SahaProfessor of Surgery & Head
Department of SurgeryGC Trust Medical CollegeChittagong
Haemorrhage classificationdiagnosis management blood
transfusion
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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 upto 10% (500-600ml) is adequately
compensated for by the
venoconstriction and therefore the
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Signs
External blood loss is
obvious, but a serious
internal hemorrhage must berecognized without delay by
the general signs of bloodloss:
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Signs
Restlessness
Increasing
pulse rateDecreased
blood pressure
Increasing
pallor
Deep sighing
respiration
Cold and
clammy skin
Empty veins
Thirst, tinnitusand blindness
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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 stemis largely preserved by the increasing pulse
rate peripheral vasoconstriction
Unchecked and untreated blood loss resultsin failure of the heart and vasomotor centre
to maintain a sufficient perfusion of oxygen
for their own purposes and death follows.
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Effects
Vasoconstriction fails to maintain theblood pressure when blood loss
increases beyond 20-30%
Hypotension becomes severe with a50% loss and the perfusion of
myocardium and brain stem is affected.
Thus the heart fails and vasoconstrictionof venous reservoir fails each affecting
the others in a vicious cycle which ends
in death
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Natural blood volume and red cell
recovery
The recovery of blood volumesbegins immediately by thewithdrawal of fluid from the tissues
from the circulation. There ishemodilution. Plasma proteins arereplaced by the liver
Red cell recovery takes some fiveto six weeks
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Chronic hemorrhage
Examples of causes in surgical practiceare bleeding hemorrhoids, fibroids,
carcinoma colon, peptic ulcer etc.
There is no diminution of blood volumeas there is time for plasma
replacements, but red cell replacement
lags behind resulting in a state ofanaemic hypoxia, requiring an increased
cardiac out put.
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Chronic hemorrhage
These patients develop high outputcardiac failure
They must not be transfused with
normal blood, but require packed
cells instead.
Acute hemorrhage in such cases ispoorly compensated, as oxygen
carriage is already depleted.
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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
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Pressure and packing
Pressure dressing to be applied inthe wound
Simple pressure over the bleeding
site by finger stop bleeding
Packing by roll gauge is an
important tool to control bleeding inspecial circumstance
Tourniquets applied in special place
and circumstance to stop bleeding
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Position and rest
Elevation of limbs
Position of patient during
operationAbsolute rest
Sedation
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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 stopoozing
Gel-foam or oxygel application stops
bleeding in special circumstance
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Blood transfusion
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Indication of blood transfusion in
surgical practice
Following traumatic incidentswhere there has been severe
blood loss, or hemorrhage frompathological lesion, e.g. from
gastrointestinal tract
During major operativeprocedures where a certain
amount of blood loss is inevitable,
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Preparation of blood products
It is important that blood donors should befit 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).
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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. Bacterialtesting forplatelets5. Malaria testing
for at-risk donors
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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
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Giving blood
Selection and preparation of the site
Careful checking of the donor blood. This
should bear a compatibility label stating the
patientsname, hospital reference no., wardand 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
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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 anothersite must be used.
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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
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A m ild react ion may be the ear ly stages o f a severe react ion
- DONT IGNORE IT!
Signs & Symptoms of aTransfusion ReactionMild Reaction Severe Reaction
Fever Pyrexia, rigors
Urticaria HypotensionRash Loin/Back Pain
Pruritis Increasing anxiety
Pain at infusion site
Respiratory Distress
Dark urineSevere Tachycardia
Unexpected bleeding (DIC)
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1. Stopthe transfusion
(check patient and component compatibility)
2. Seek medical advice
3. Assess patient
4. Commence appropriate treatment
If s igns & sym ptoms worsen wi th in 15 m inutes
treat as a severe react io n
Management of a Mild AcuteTransfusion Reaction
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1. Stop the transfusion
Replace the administration setIV 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 required4. Inform the HTL and return the component
5. Document event in patient case notes
Management of a SevereTransfusion Reaction
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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 chi ld in a pro fessional and safe manner.Mrs Green 15/12/98
C li ti f bl d
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Complications of blood
transfusion
Congestive cardiac failure
Transfusion reactions
IncompatibilitySimple pyrexial reaction
Allergic reaction
Antibody reaction
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