Post on 12-Nov-2014
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SHOCK & BLOOD TRANSFUSIONBY: R. NANDINII
GROUP K1
Overview:
• SHOCK
-Definition
-Pathophysiology
-Classification
-Severity
-Management
-Monitoring
• HAEMORRHAGE
-Definition
-Classification
-Management
• BLOOD TRANSFUSION
-Definition
-Indication
-Blood products
-Complication
SHOCK
Pathophysiology:Cellular
When perfusion to the tissue reduces
↓ O2 delivery to tissue
Cell Metabolism (aerobic anaerobic)
Accumulation of lactic acid in blood
Systemic metabolic acidosis
Glucose within cells are exhausted
Anaerobic respiration ceases
Failure of Na/K pump in the cell membrane & intracellular
organelle
Intracellular lysosome release autodigestive enzymes
Cell lysis
Intracellular content including K released into the bloodstream
Pathophysiology:Microvascular
Tissue ischemia progresses
Activation Of Immune
& Coagulation System
Hypoxia & acidosis
Activate complement &
prime neutrophils
Tissue oedema ensues →
exacerbating cell hypoxia
Generation of oxygen free radicals & cytokine release
Injury of the capillary
endothelial cells
Fluid leaks out
Cardiovascular:
Respiratory:
Pathophysiology:Systemic
Compensatory baroreceptor
response
↑ sympathetic
activity
Catecholamines release into the
circulation
Systemic vasoconstriction
Tachycardia
↓ Preload & Afterload
Metabolic acidosis
Tachypnea
Compensatory Respiratory
alkalosis
↑ sympathetic
responseExcretion of
CO2 increased
Renal:
Endocrine:
↓ Glomerular filtration
↓ urine output
↓ Kidney Perfusion
Stimulate Renin-angiotensin-
aldosterone
↑ Na & water
reabsorption
Hypothalamus
Adrenal Cortex
Vassopressin
Cortisol
vasoconstriction
Na & water reabsorption
Sensitizing cell to
catecholamine
Classification of shock:
Classification of shock:
Classification of shock:
Severity of Shock
Compensated
Decompensated
Mild Moderate Severe
Consciousness Normal Mild Anxiety Drowsy Comatose
Blood Pressure
Normal Normal Mild ↓ Severe ↓
Pulse Rate Mild Increase ↑ ↑ ↑
Resp Rate Normal ↑ ↑ Laboured
Urine Output Normal Normal Reduced Anuric
Lactic Acidosis + ++ ++ +++ Compensated : Compensatory responses reduce flow to non-essential
organs to preserve preload & flow to the lungs & brain. Decompensated : Further loss body’s compensatory mechanisms,
Progressive renal, respiratory & CVS decompensation; Occurs when there’s 30-40% loss of Blood Volume.
ResuscitationA. Conduct of resuscitation:
ResuscitationB. Fluid therapy:
SHOCK STATUS:
ResuscitationC. Vasopressor & Inotrope Support:
MONITORING
HAEMORRHAGE
Further haemorrhage ↓ Perfusion to the tissue unable to
generate heat
Trauma Triad of Death
Coagulopathy
Hypothermia
Acidosis
Decrease function of coagulation proteases coagulopathy
Definitions:
Degree & Classification
Management:
After control aggressively resuscitated, warmed and coagulopathy corrected
TransfusionDefinition:
Process of transferring whole blood or blood components from one person (donor) to another (recipient).
Indications:Acute blood loss
to replace circulating volume & O2 delivery
Perioperative anemia
To ensure adequate O2 delivery during perioperative phase.
Symptomatic chronic anemia without haemorrhage or impending surgery
Hb < 6 g/dl
Perioperative red blood cell transfusion criteria
Source: Bailey & Love’s Short Practice of Surgery 25th ed
Blood & Blood Products
Blood component Explanation
Whole blood[can be broken down to: RBC, platelets, fresh frozen plasma (FFP)]
• Very rarely used• Carries greater risks of adverse reactions
owing to the presence of leucocytes.
Packed Red Cell[do not provide viable platelets or neutrophils]
• Each unit is approximately 330 ml and has a haematocrit of 50–70%.
• For use in substantial hemorrhage & anemia, symptomatic anemia
Platelet[for the coagulation; also contain plasma (coagulation factors), some red cells and some white cells (leukocytes)]
• For patients with bleeding due to either thrombocytopenia, platelet dysfunction
• Temporary thrombocytopenia occuring after radio- and chemotherapy,
• Bleeding in patients with thrombocytopenia or functional platelet abnormality,
• After massive transfusion (RBC) and thrombocytopenia
Blood & Blood Products
Blood component Explanation
Fresh frozen Plasma (FFP)[contains all coagulation factors in normal amounts and is free of red cells, leukocytes and platelets]
• Corrections of known congenital or acquired coagulation factor deficiencies.
• Treatment of microvascular hemorrhage in the presence of prolonged PT, aPTT
Cryoprecipitate[supernatant precipitate of FFP and is rich infactor VIII and fibrinogen]
• For Hemophilia A, von Willebrand disease, DIC, Hypofibrinogenemia (<100 mg/dl)
Factor VIII concentrates • Hemophilia A, & low titer factor VIII inhibitors
Factor IX Concentrates • Hemophilia B
ComplicationSingle transfusion incompatibility haemolytic
transfusion reaction; • febrile transfusion reaction; • allergic reaction; • infection: – bacterial infection (usually as a
result of faulty storage); – hepatitis; – HIV; – malaria; • air embolism; • thrombophlebitis; • transfusion-related acute lung
injury (usually from FFP).
Massive transfusion • coagulopathy;
• hypocalcaemia;
• hyperkalaemia;
• hypokalaemia;
• hypothermia.
Patients who receive repeated transfusions over long periods of time (e.g. patients with thalassaemia) develop iron overload. (Each transfused unit of red blood cells contains approximately 250 mg of elemental iron.)
Management of coagulopathy
Correction of coagulopathy is not necessary if no active bleeding/ haemorrhage
However, coagulopathy following during massive transfusion should be anticipated and managed aggressively
Standard guidelines: FFP : if PT or PTT > 1.5 X normal;
Cryoprecipitate : if fibrinogen < 0.8 g/l
Platelet : if platelet count < 50 x 109 ml
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