HEMORRHAGEHEMORRHAGE& BLOOD PRODUCTS& BLOOD PRODUCTS

Learning objectivesLearning objectives

To define To define hemorrhage hemorrhage and and classifyclassify it. it. To enumerate the To enumerate the various typesvarious types of hemorrhage of hemorrhage

and their and their clinical features.clinical features. To describe the To describe the clinical effectsclinical effects of hemorrhage of hemorrhage

and outline the and outline the management principlesmanagement principles.. To know about the various To know about the various blood productsblood products

available , their uses in surgical practice and available , their uses in surgical practice and common common complications of transfusion.complications of transfusion.

What is What is hemorrhage ?hemorrhage ?

Hemorrhage is the medical term for bleeding Hemorrhage is the medical term for bleeding ( loss of blood from the body) ( loss of blood from the body)

Commonly, hemorrhage indicates particularly Commonly, hemorrhage indicates particularly severe bleeding ; but technically, it means severe bleeding ; but technically, it means escape of blood to extravascular space.escape of blood to extravascular space.

The complete loss of blood is referred to as The complete loss of blood is referred to as exsanguination.exsanguination.

Definition of HemorrhageDefinition of Hemorrhage

Hemorrhage:Hemorrhage:

Extravasation of blood from living blood Extravasation of blood from living blood vesselvessel

OROR

Leakage of blood from a living blood vesselLeakage of blood from a living blood vessel

Causes of hemorrhageCauses of hemorrhage

TraumaTrauma – blunt injury or penetrating injury or – blunt injury or penetrating injury or iatrogenic trauma, surgical procedures.iatrogenic trauma, surgical procedures.

Underlying pathologyUnderlying pathology – peptic ulcers, – peptic ulcers, aneurysms, AV malformations, malignancy, aneurysms, AV malformations, malignancy, uremia, etc.uremia, etc.

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

DrugsDrugs – NSAIDs, warfarin, etc. – NSAIDs, warfarin, etc.

ClassificationClassificationAccording to visibilityAccording to visibility InternalInternal Hemorrhage (concealed )Hemorrhage (concealed ) ExternalExternal Hemorrhage ( revealed)Hemorrhage ( revealed)

According to Timing of BleedingAccording to Timing of Bleeding Primary HemorrhagePrimary Hemorrhage Delayed Primary HemorrhageDelayed Primary Hemorrhage Secondary HemorrhageSecondary Hemorrhage

Internal Vs ExternalInternal Vs External

ClassificationClassificationAccording to source of bleedingAccording to source of bleeding Arterial HemorrhageArterial Hemorrhage Venous HemorrhageVenous Hemorrhage Capillary HemorrhageCapillary Hemorrhage

Arterial hemorrhageArterial hemorrhage

Bright redBright red in color (oxygenated blood) in color (oxygenated blood) Spurting jetSpurting jet which rises and falls in time with which rises and falls in time with

the pulse ( from high pressure artery)the pulse ( from high pressure artery) Can Can become waterybecome watery in appearance if excess of in appearance if excess of

intravenous intravenous fluidsfluids are given are given

Venous hemorrhageVenous hemorrhage

Dark redDark red in color in color Steady and Steady and copiouscopious flow flow Can be rapidCan be rapid if large veins are opened like if large veins are opened like

common femoral or common femoral or jugularjugular vein vein Can be from veins under increased pressure Can be from veins under increased pressure

e.g. ruptured varicose veins, esophageal e.g. ruptured varicose veins, esophageal varicesvarices

Capillary hemorrhageCapillary hemorrhage

Bright redBright red in color in color Hemorrhage is often rapid and Hemorrhage is often rapid and oozingoozing Can be serious if prolonged for many hours Can be serious if prolonged for many hours

e.g. in hemophiliae.g. in hemophilia

Primary hemorrhagePrimary hemorrhage

Occurs Occurs at theat the time of injury or operationtime of injury or operation Can be arterial, venous or capillaryCan be arterial, venous or capillary If due to injury, can be If due to injury, can be revealed or concealedrevealed or concealed If during surgery, usually revealed and hence If during surgery, usually revealed and hence

can be controlled with proper carecan be controlled with proper care

Reactionary hemorrhageReactionary hemorrhage

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

Mainly due to Mainly due to ‘slipping’ of ligature‘slipping’ of ligature or or dislodgment of clotdislodgment of clot or or cessation of reflexcessation of reflex vasospasmvasospasm..

Can be arterial or venousCan be arterial or venous Precipitating factors – rise in Precipitating factors – rise in B.P , B.P ,

restlessness, vomiting, coughing.restlessness, vomiting, coughing.

Secondary hemorrhageSecondary hemorrhage

Occurs Occurs 7-14 days7-14 days after the insult. after the insult. Due to Due to infection and sloughinginfection and sloughing of part of the of part of the

wall of a vessel.wall of a vessel. Predisposing factors – presence of drainage Predisposing factors – presence of drainage

tubetube, presence of a fragment of , presence of a fragment of bonebone, ligature , ligature in an infected area, in an infected area, cancer.cancer.

External hemorrhageExternal hemorrhage

Bleeding which is Bleeding which is visible.visible. Also called revealed hemorrhage.Also called revealed hemorrhage. Easy to assess the blood loss and to control the Easy to assess the blood loss and to control the

hemorrhage.hemorrhage. E.g. hemorrhage due to cut wounds, ruptured E.g. hemorrhage due to cut wounds, ruptured

varicose veins, hematemesis etc.varicose veins, hematemesis etc.

Internal hemorrhageInternal hemorrhage

InvisibleInvisible bleeding. bleeding. Also called Also called concealedconcealed hemorrhage. hemorrhage. E.g. ruptured spleen or liver, cerebral E.g. ruptured spleen or liver, cerebral

hemorrhage, etc.hemorrhage, etc. May become ‘revealedMay become ‘revealed’ e.g. hematemesis or ’ e.g. hematemesis or

melenamelena in a case of peptic ulcer bleed, in a case of peptic ulcer bleed, hematuria from a hematuria from a injured kidneyinjured kidney, etc., etc.

Quantifying blood lossQuantifying blood loss Blood clotBlood clot – a clot the size of a clenched fist is – a clot the size of a clenched fist is

roughly equal to 500 mlroughly equal to 500 ml SwellingSwelling – moderate swelling in a closed – moderate swelling in a closed

fracture of tibia equals 500-1000 ml of blood fracture of tibia equals 500-1000 ml of blood loss, whereas in fracture shaft of femur, it loss, whereas in fracture shaft of femur, it amounts to about 1000-2000 ml.amounts to about 1000-2000 ml.

Swab weighing-Swab weighing- useful in operating theatres. useful in operating theatres. 1gm= 1 ml. For lengthy surgery, it is 1gm= 1 ml. For lengthy surgery, it is multiplied by 1.5 and for prolonged surgery multiplied by 1.5 and for prolonged surgery like APR, by 2.like APR, by 2.

Effects of blood lossEffects of blood loss

Relates to the pre-existing circulating blood Relates to the pre-existing circulating blood volume. volume.

(Adults: 65-75ml/kg ;Infants:80-85ml/kg )(Adults: 65-75ml/kg ;Infants:80-85ml/kg ) Hb levelHb level – – No immediate changeNo immediate change in acute in acute

hemorrhage but, levels fall after some hours hemorrhage but, levels fall after some hours due to influx of interstitial fluid into vascular due to influx of interstitial fluid into vascular compartment or due to i.v. fluids.compartment or due to i.v. fluids.

Blood volume starts to recover immediately.Blood volume starts to recover immediately.

Effects of blood loss…Effects of blood loss…

Plasma proteins are replaced by the liver.Plasma proteins are replaced by the liver. Red cell recovery takes about 5-6 weeks.Red cell recovery takes about 5-6 weeks. The clinical features of hemorrhage depends The clinical features of hemorrhage depends

on the on the amount of blood lossamount of blood loss and and the rapiditythe rapidity of of loss of blood.loss of blood.

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

Classes of hemorrhageClasses of hemorrhage

Class IClass I – – upto 15%upto 15% blood loss blood loss - usually, no change in BP, pulse pressure or - usually, no change in BP, pulse pressure or

respiratory rate.respiratory rate. - minimal tachycardia may be there- minimal tachycardia may be there - CRT > 3 seconds - CRT > 3 seconds ≈ volume loss of 10%≈ volume loss of 10%

Class IIClass II – blood loss – blood loss 15-30 %15-30 % - tachycardia, tachypnea, decreased pulse - tachycardia, tachypnea, decreased pulse

pressure, cool clammy skin, delayed capillary pressure, cool clammy skin, delayed capillary refill, slight anxiety.refill, slight anxiety.

Classes of hemorrhageClasses of hemorrhage Class IIIClass III - loss of - loss of 30-40%30-40% - marked tachycardia and tachypnea, decreased - marked tachycardia and tachypnea, decreased

systolic BP, oliguria, altered mental status like systolic BP, oliguria, altered mental status like confusion or agitation.confusion or agitation.

- most will require blood transfusion- most will require blood transfusion Class IV-Class IV- loss of loss of > 40%> 40% blood volume blood volume -marked tachycardia, decreased BP( diastolic may -marked tachycardia, decreased BP( diastolic may

be unrecordable), markedly decreased or no urinary be unrecordable), markedly decreased or no urinary output, depressed mental status ( or loss of output, depressed mental status ( or loss of consciousness), cold and pale skin.consciousness), cold and pale skin.

- immediately life threatening.- immediately life threatening.

Treatment of hemorrhageTreatment of hemorrhage

Treatment of hemorrhageTreatment of hemorrhage Urgent treatment requiredUrgent treatment required ResuscitationResuscitation -stabilize the patient and assess -stabilize the patient and assess

ABCABC ( airway, breathing, circulation) and ( airway, breathing, circulation) and follow basic life support protocol if required.follow basic life support protocol if required.

Minimize further blood loss Minimize further blood loss (Arrest of (Arrest of Bleeding)Bleeding)

- - direct pressuredirect pressure: digital pressure or pressure : digital pressure or pressure dressings or use of balloon catheters.dressings or use of balloon catheters.

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

- - elevationelevation of the affected area. of the affected area.

-- drugs drugs: vasopressin, adrenaline can be used : vasopressin, adrenaline can be used in various circumstancesin various circumstances

Operative techniquesOperative techniques

- - hemostats hemostats (artery forceps) , clips, ligatures(artery forceps) , clips, ligatures

- - electrocauteryelectrocautery

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

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

RestorationRestoration of intravascular volumeof intravascular volume

- isotonic - isotonic i.v fluidsi.v fluids..

- plasma - plasma expandersexpanders..

- blood and blood - blood and blood productsproducts.. Identify the Identify the primary causeprimary cause of bleeding and of bleeding and

treat it. E.g peptic ulcer, hemophilia etc.treat it. E.g peptic ulcer, hemophilia etc.

BLOOD AND BLOOD PRODUCTSBLOOD AND BLOOD PRODUCTS

- China, 1000 BC The soul was contained in the blood.

- Egyptians bathed in blood for their health.

- Romans drinking the blood of fallen gladiators to gain strength and vitality and to cure

epilepsy.

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

Blood in History

.. Animal to animal --- Richard Lower ,1665Animal to animal --- Richard Lower ,1665 Animal to human --- Jean Denis , 1667Animal to human --- Jean Denis , 1667

.. Human to human Human to human -- --1818, James Blundell 1818, James Blundell

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

-- -- 1914 Lewisohn1914 Lewisohn - - used citrateused citrate

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

Composition of bloodComposition of blood

Red Blood cells + PlasmaRed Blood cells + Plasma Plasma contains Plasma contains

-white blood cells, -white blood cells,

-platelets, fibrinogen,-platelets, fibrinogen,

-all the clotting factors,-all the clotting factors,

-proteins like albumin.-proteins like albumin.

Whole Whole bloodblood

Blood componentsBlood components Plasma fractionsPlasma fractions

-FreshFresh-oldold

Packed Packed red cellsred cells

plateletsplatelets Fresh Fresh Frozrn Frozrn PlasmaPlasma

CryoprecCryoprecipitateipitate

Massive Massive haemorrhahaemorrhagege

Major liver Major liver traumatrauma

Bleeding Bleeding associated associated with liver with liver diseasedisease

-Washed -Washed RBC’sRBC’sPts with allergic Pts with allergic reactions to reactions to plasma proteinsplasma proteins

-Leuko--Leuko-poor poor RBC’sRBC’sPts with febrile, Pts with febrile, non-hemolytic non-hemolytic reactions to reactions to plasma WBC’splasma WBC’s

when platelet. when platelet. count less count less than than 50000/cmm 50000/cmm

or when or when massive blood massive blood loss or loss or replacement replacement has occurredhas occurred

when PT & when PT & PTT are PTT are

higher than higher than 1.5 times 1.5 times control control levels levels

All clotting All clotting factors; no factors; no plateletsplatelets

Can supplement Can supplement RBC’s when whole RBC’s when whole blood not available blood not available for exchange for exchange transfusiontransfusion

when when fibrinogen fibrinogen

level is level is less than less than

80-80-100mg/dl100mg/dl

Initially a tx for VW Initially a tx for VW Dz, HemophiliaDz, Hemophilia

Now a source of Now a source of fibrinogen in fibrinogen in obstetric obstetric emergenciesemergencies

Clotting factor Clotting factor concentratesconcentratesImmunoglobulin Immunoglobulin preparationspreparationsSaline albumin Saline albumin solutionsolutionSalt-poor Salt-poor albuminalbumin

Platelet Platelet concentrates concentrates

(1 (1 pack/10kg) pack/10kg)

dose : 6unitsdose : 6units

normal normal dose: 12 - dose: 12 - 15ml/ kg 15ml/ kg

(4-(4-5packs)5packs)

dose: 1- dose: 1- 1.5 -2 1.5 -2 packs/ 10 packs/ 10 kg kg

(8-10 (8-10 packs)packs)

Clotting disorders Clotting disorders

HaemophiliaHaemophilia

Liver disease Liver disease

Why blood transfusion ? (Indication)Why blood transfusion ? (Indication) Severe Severe blood lossblood loss following trauma following trauma or from any or from any

pathology e.g. GI bleedpathology e.g. GI bleed During During major operativemajor operative procedures e.g. APR , procedures e.g. APR ,

cardiovascular surgery etc.cardiovascular surgery etc. Postoperatively Postoperatively in a patient who has become severely in a patient who has become severely

anemic.anemic. Following Following severe burnssevere burns (hemolysis) (hemolysis) Preoperatively Preoperatively in pts of chronic anemia who require in pts of chronic anemia who require

urgent surgery.urgent surgery. Pts with Pts with hemorrhagic diseasehemorrhagic disease e.g. e.g. hemophilia,hemophilia,

thrombocytopenia, liver disease etc.thrombocytopenia, liver disease etc.

Blood products available..Blood products available..

Whole bloodWhole blood Packed cells ( RBCs)Packed cells ( RBCs) Platelet concentratePlatelet concentrate Fresh frozen plasmaFresh frozen plasma Cryoprecipitate Cryoprecipitate Factor VIII, factor IX concentrates, fibrinogenFactor VIII, factor IX concentrates, fibrinogen Others- Granulocytes, washed RBCS, Others- Granulocytes, washed RBCS,

leukoreduced RBCs, SAG-M blood, human leukoreduced RBCs, SAG-M blood, human albuminalbumin

Blood Vs Blood componentsBlood Vs Blood components

Whole blood is more likely carrier of Whole blood is more likely carrier of transfusion transmitted transfusion transmitted diseasesdiseases..

Most patients require Most patients require only oneonly one particular particular component of whole blood.component of whole blood.

Blood products have a better Blood products have a better self lifeself life than than whole blood.whole blood.

Blood products can often be infused regardless Blood products can often be infused regardless of of ABOABO blood group. blood group.

Hence whole blood is Hence whole blood is rarely rarely used now a days.used now a days.

Whole bloodWhole blood

Collected from a healthy and fit donorCollected from a healthy and fit donor 410 ml410 ml of blood is collected into a bag of blood is collected into a bag

containing 75 ml of CPD (anticoagulant)containing 75 ml of CPD (anticoagulant) Stored at 4Stored at 4°C ± 2°C for up to 3-5 wks°C ± 2°C for up to 3-5 wks

(CPDA – 5 wks)(CPDA – 5 wks) Uses – Uses – “fresh“fresh”” blood is used for resuscitation blood is used for resuscitation

in a pt in a pt severe acutesevere acute blood loss blood loss

Changes in stored bloodChanges in stored blood

White blood cellsWhite blood cells are rapidly are rapidly destroyeddestroyed.. Platelets Platelets are functional only up to are functional only up to 24 hours24 hours ( due to cold temperature).( due to cold temperature). Clotting factorsClotting factors VIII and V are labile and their VIII and V are labile and their

levels fall rapidly after levels fall rapidly after 7 days7 days.. 2,3 DPG level is decreased2,3 DPG level is decreased causing reduced causing reduced

oxygen release into tissues.oxygen release into tissues. Higher Higher temptemp can lead to transmission of can lead to transmission of

infections.infections.

Blood componentsBlood components Plasma fractionsPlasma fractions

Packed red cellsPacked red cells plateletsplatelets Fresh Fresh Frozrn Frozrn PlasmaPlasma

CryoprecCryoprecipitateipitate

--Washed RBC’sWashed RBC’sPts with allergic reactions to plasma Pts with allergic reactions to plasma proteinsproteins

-Leuko-poor -Leuko-poor RBC’sRBC’sPts with febrile, non-hemolytic Pts with febrile, non-hemolytic reactions to plasma WBC’sreactions to plasma WBC’s

when platelet. when platelet. count less count less than than 50000/cmm 50000/cmm

or when or when massive blood massive blood loss or loss or replacement replacement has occurredhas occurred

when PT & when PT & PTT are PTT are

higher than higher than 1.5 times 1.5 times control control levels levels

All clotting All clotting factors; no factors; no plateletsplatelets

Can supplement Can supplement RBC’s when whole RBC’s when whole blood not available blood not available for exchange for exchange transfusiontransfusion

when when fibrinogen fibrinogen

level is level is less than less than

80-80-100mg/dl100mg/dl

Initially a tx for VW Initially a tx for VW Dz, HemophiliaDz, Hemophilia

Now a source of Now a source of fibrinogen in fibrinogen in obstetric obstetric emergenciesemergencies

Clotting factor Clotting factor concentratesconcentratesImmunoglobulin Immunoglobulin preparationspreparationsSaline albumin Saline albumin solutionsolutionSalt-poor Salt-poor albuminalbumin

Platelet Platelet concentrates concentrates

(1 (1 pack/10kg) pack/10kg)

dose : 6unitsdose : 6units

normal normal dose: 12 - dose: 12 - 15ml/ kg 15ml/ kg

(4-(4-5packs)5packs)

dose: 1- dose: 1- 1.5 -2 1.5 -2 packs/ 10 packs/ 10 kg kg

(8-10 (8-10 packs)packs)

Clotting disorders Clotting disorders

HaemophiliaHaemophilia

Liver disease Liver disease

Packed red cellsPacked red cells Obtained by centrifuging whole blood at 2000-Obtained by centrifuging whole blood at 2000-

2300 g for 15-20 minutes and then removing the 2300 g for 15-20 minutes and then removing the plasma.plasma.

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

Hematocrit – about 70-80 %Hematocrit – about 70-80 % Solutions like AS-1, AS-5, optisol etc is addedSolutions like AS-1, AS-5, optisol etc is added No viable WBCsNo viable WBCs, platelets or clotting factors., platelets or clotting factors. Uses- Uses- chronic anemia, elderly, children, chronic anemia, elderly, children,

deranged cardiacderanged cardiac function. function.

Red blood cellsRed blood cells

Other RBC products..Other RBC products..

Washed red blood cells – Packed Cells are Washed red blood cells – Packed Cells are washed with saline to remove the plasma and washed with saline to remove the plasma and proteins; reduces transfusion reactions.proteins; reduces transfusion reactions.

Leukoreduced red blood cells- WBCs are Leukoreduced red blood cells- WBCs are removed using filters; reduces incidence of removed using filters; reduces incidence of non-hemolytic febrile reactions.non-hemolytic febrile reactions.

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

Platelet concentratePlatelet concentrate

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

This is This is again centrifugedagain centrifuged at 1200-1500 g for at 1200-1500 g for 15-20 minutes to obtain 15-20 minutes to obtain platelet concentrateplatelet concentrate..

Usually 4-6 platelet concentrates are pooled in Usually 4-6 platelet concentrates are pooled in a single bag.a single bag.

Platelets can also be obtained by “apheresis”.Platelets can also be obtained by “apheresis”.

Platelet concentrate…Platelet concentrate…

Stored at room temperature.Stored at room temperature. Platelets viable for up to 72 hours.Platelets viable for up to 72 hours. Uses- bleeding due to Uses- bleeding due to thrombocytopeniathrombocytopenia, ,

platelet dysfunction or some combination of platelet dysfunction or some combination of the two conditions. ( avoid platelet transfusion the two conditions. ( avoid platelet transfusion in ITP with mild symptoms).in ITP with mild symptoms).

Platelet concentratePlatelet concentrate

Fresh frozen plasma (FFP)Fresh frozen plasma (FFP)

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

Stored at -40Stored at -40°C to -50°C.°C to -50°C. A unit is about 200-250 cc in volume.A unit is about 200-250 cc in volume. Good source of all coagulation factors.Good source of all coagulation factors. Uses- severe liver failure, mild form of Uses- severe liver failure, mild form of

individual clotting factor deficiencies e.g. individual clotting factor deficiencies e.g. Christmas disease (IX) , hemophilia (VIII)Christmas disease (IX) , hemophilia (VIII)

Fresh frozen plasmaFresh frozen plasma

CryoprecipitateCryoprecipitate

FFP is allowed to thaw at 4FFP is allowed to thaw at 4°C and the °C and the supernatant plasma is removed. The glutinous supernatant plasma is removed. The glutinous precipitate is called cryoprecipitate.precipitate is called cryoprecipitate.

1 unit contains about 10-20 cc.1 unit contains about 10-20 cc. Stored at -40°C.Stored at -40°C. Very rich source of factor Very rich source of factor VIII & fibrinogen.VIII & fibrinogen. Used in Used in hemophilia, hypofibrinogenemiahemophilia, hypofibrinogenemia

Cryoprecipitate Cryoprecipitate

Individual factor concentratesIndividual factor concentrates

E.g. factor VIII concentrate, factor IX E.g. factor VIII concentrate, factor IX concentrate, fibrinogen etcconcentrate, fibrinogen etc

Prepared by organic liquid fractionation of Prepared by organic liquid fractionation of plasma and stored in lyophilized powder form plasma and stored in lyophilized powder form (freeze-dried form).(freeze-dried form).

Stored at -50 to -60Stored at -50 to -60°C.°C. Used for respective factor deficiencies.Used for respective factor deficiencies.

Factor VIII concentrateFactor VIII concentrate

SAG - Mannitol bloodSAG - Mannitol blood

Plasma is removed from donated blood and Plasma is removed from donated blood and replaced by 100 cc of a crystalloid solutionreplaced by 100 cc of a crystalloid solution

( SAG-M)( SAG-M) containing containing SSodium odium CChloride, hloride, AAdenine, denine, GGlucose and lucose and MMannitol.annitol.

It increases the shelf life of RBCs (42 days) It increases the shelf life of RBCs (42 days) and provides more volume to the recipient per and provides more volume to the recipient per transfusion.transfusion.

Mainly used for top-up transfusions for Mainly used for top-up transfusions for anemia.anemia.

Complications of Blood Complications of Blood TransfusionTransfusion

FebrileFebrile reactionsreactions Bacterial contaminationBacterial contamination Immune reactionsImmune reactions Physical complicationsPhysical complications

Circulatory overloadCirculatory overload Air embolismAir embolism Pulmonary embolismPulmonary embolism ThrombophlebitisThrombophlebitis ARDSARDS

Metabolic complicationsMetabolic complications HyperkalaemiaHyperkalaemia Citrate toxicity & hypocalcaemiaCitrate toxicity & hypocalcaemia Release of vasoactive peptidesRelease of vasoactive peptides Release of plasticizers from PVC-Release of plasticizers from PVC-

phthalatesphthalates Haemorrhagic reactionsHaemorrhagic reactions

After massive transfusion of stored bloodAfter massive transfusion of stored blood Disseminated intravascular coagulationDisseminated intravascular coagulation

Transmission ofTransmission of diseasedisease Hepatitis, CMV. EBVHepatitis, CMV. EBV AIDS (Factor VIII)AIDS (Factor VIII) SyphilisSyphilis BrucellosisBrucellosis ToxoplasmosisToxoplasmosis MalariaMalaria TrypanosomiasisTrypanosomiasis

HaemosiderosisHaemosiderosis After repeated transfusion in patients with After repeated transfusion in patients with

haematological diseaseshaematological diseases

PLASMA EXPANDERSPLASMA EXPANDERS

Used for re-establishment of blood volume in Used for re-establishment of blood volume in patients suffering from acute blood loss.patients suffering from acute blood loss.

Several products are available:Several products are available: - - Human albuminHuman albumin - Dextrans- Dextrans - Gelatin- Gelatin - Hydroxyethyl starches- Hydroxyethyl starches

Volume expandersVolume expandersWhen a patient has lost a lot of body fluids but does not need When a patient has lost a lot of body fluids but does not need

red blood cells or other specific blood components,red blood cells or other specific blood components, volume expanders may be given to prevent or treat shock volume expanders may be given to prevent or treat shock

caused by fluid losscaused by fluid loss..The most commonThe most common OtherOther

CrystalloidsCrystalloids ColloidsColloids

solutions that contain sodiumsolutions that contain sodium

solutions that contain largesolutions that contain large

molecular weight that do notmolecular weight that do not

readily cross capillary wallsreadily cross capillary walls

normal normal salinesaline

lactated lactated Ringer’sRinger’s

albuminalbumin hydroxyethydroxyethyl starch hyl starch

(HES),(HES),

dextransdextrans purified purified protein protein fractionsfractions

Human albuminHuman albumin

Obtained by repeated fractionation of plasma Obtained by repeated fractionation of plasma followed by heat treatment.followed by heat treatment.

Available as 5% and 20% solutions.Available as 5% and 20% solutions. Can be stored for 1 year at room temperature Can be stored for 1 year at room temperature

and upto 5 years at 2-8 and upto 5 years at 2-8 °C.°C. 5% albumin used for hypovolemia and 20% 5% albumin used for hypovolemia and 20%

for severe hypoalbuminemia.for severe hypoalbuminemia. Considered as Considered as ideal colloid.ideal colloid. S/E: expensive, may transmit diseases.S/E: expensive, may transmit diseases.

Dextrans Dextrans

Synthetic Synthetic polysaccharide polymers.polysaccharide polymers. Iso-osmotic to plasma.Iso-osmotic to plasma. High molecular weight (70,000) is used in High molecular weight (70,000) is used in

hypovolemia (1.5 gms/kg), whereas low hypovolemia (1.5 gms/kg), whereas low molecular weight (40,000) is used to increase molecular weight (40,000) is used to increase microcirculation microcirculation in various conditions.in various conditions.

S/E : interferes with platelet function, S/E : interferes with platelet function, increased rouleuxincreased rouleux formation, deranged formation, deranged hemostasis, anaphylactic reactions.hemostasis, anaphylactic reactions.

Gelatin Gelatin

It is used in a degraded form ( mol. weight It is used in a degraded form ( mol. weight about 30,000) as plasma expander.about 30,000) as plasma expander.

Intermediate duration of action.Intermediate duration of action. Low rate of anaphylactic reaction.Low rate of anaphylactic reaction.

Hydroxyethyl starchesHydroxyethyl starches

Produced from sorghum or Produced from sorghum or maize.maize. Available in various molecular weights and Available in various molecular weights and

degree of substitution (tetra, penta or hepta-degree of substitution (tetra, penta or hepta-starch)starch)

Susceptible to hydrolysis by non-specific Susceptible to hydrolysis by non-specific amylases in the blood.amylases in the blood.

Duration of action > 6 hours.Duration of action > 6 hours. Less adverse effects – coagulopathy, itching, Less adverse effects – coagulopathy, itching,

anaphylactoidanaphylactoid reaction reaction

Blood transfusionBlood transfusion

The blood must be crossed matched for patient The blood must be crossed matched for patient compatibility compatibility ( ABO and Rh factor).( ABO and Rh factor).

Warm the blood to avoid hypothermia.Warm the blood to avoid hypothermia. Filter is used ( 40Filter is used ( 40µm) to filter off platelet µm) to filter off platelet

aggregates and leucocyte membranes.aggregates and leucocyte membranes. Usually given at a rate of Usually given at a rate of 40 drops40 drops per minute per minute

( 1 unit transfused in 4 hours) ; in ( 1 unit transfused in 4 hours) ; in emergency,emergency, 1-2 units1-2 units can be given in 30 mins using a can be given in 30 mins using a pressure cuff.pressure cuff.

AutotransfusionAutotransfusion Patient’s own blood is used.Patient’s own blood is used. Particularly useful in Particularly useful in electiveelective surgery. surgery. Reduces the incidence of transfusion reactions Reduces the incidence of transfusion reactions

and infection transmission.and infection transmission. 3 techniques :3 techniques : i) Predeposit transfusioni) Predeposit transfusion ii) Intraoperative acute normovolemicii) Intraoperative acute normovolemic hemodilutionhemodilution iii) Intraoperative cell salvageiii) Intraoperative cell salvage