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! "

Justine A. Lee, DVM, DACVECC, DABT

CEO, VETgirl

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Garret Pachtinger, VMD, DACVECC

COO, VETgirl

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The ECC axiom,

"all bleeding stops eventually"

True but ultimately, we hope to stop bleeding before the patient expires.

#  Gastrointestinal hemorrhage #  Trauma/surgery #  Coagulopathies #  Bleeding neoplasms #  External parasites #  Epistaxis #  Urogenital blood loss

#  Congenital / acquired #  Primary disorders rare, r/o

inherited defect #  Most in veterinary medicine

are secondary

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#  vonWillebrands disease o  Decreased or deficient

production of vonWillebrands factor.

o  Doberman dogs most common

#  Other common coagulation factor disorders o  Deficiencies of Factors X, X!, XII,

hemophilia A and B, and prothrombin deficiency.

# Decreased production or increased destruction of # platelets #  Ingestion of toxic substances (warfarin / rodenticide)

# Point of care testing o CBC / Blood Smear o PT/PTT o BMBT?

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# Platelets: o CBC provides

minimum number o Each platelet / oil

immersion field = ~15K platelets • Evaluate 4-5 fields

o Check feathered edge closely for clumps

PACKED CELL VOLUME AND TOTAL SOLIDS

High PCV/ High TP

Low PCV/ Normal TP

N/L PCV/ L TP

Normal PCV/ Low TP

Hemoconcentration - Hemolytic anemia - Anemia of chronic disease - Pure red blood cell aplasia

- Blood loss - GI - Body cavity (abdominal, thoracic, etc)

- Protein Losing Enteropathy (PLE) - Protein losing nephropathy (PLN) - Acute blood loss, splenic contraction - Liver disease / failure

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# Point of care testing o  PT

•  Extrinsic and common

o  PTT •  Evaluates the intrinsic

and common pathways

#  Point of care testing o  Spring-loaded lancet o  Blotting paper o  Stopwatc o  Anesthetized and? o  Lateral recumbency. o  Strip of gauze is used to tie the

upper lip back o  1 mm deep incision is made o  Blotting paper used to blot the

incision site. o  Lightly touching the paper to the

drop of blood

# Radiography o Loss of detail? o Mass effect?

# Ultrasonography o F.A.S.T. exam

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#  Focused Assessment with Sonography for Trauma o  Triage/Tracking/Trauma

#  New standard of care, human ER

#  2-minute test

#  Helps pay off your ultrasound machine

#  Evidence of free abdominal fluid / Air / Mass / Other

! Depiction of the 4-point A-FAST protocol ! Diaphragmatic-hepatic (DH) ! Spleno-renal view (SR) ! Cysto-colic view (CC) ! Hepato-renal view (HR)

# von Willebrand disease (vWD) # Anticoagulant Rodenticide Toxicosis # Immune Mediated Thrombocytopenia # Surgical and Traumatic Hemostasis # Blood Transfusion Pearls

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# Most common inherited bleeding disorder of dogs

# Quantitative and/or qualitative deficiency

# Large, multimeric glycoprotein

# Mediates platelet adhesion to exposed subendothelium after vascular injury, promotes platelet aggregation under high shear conditions, and serves as a carrier for coagulation factor VIII.

http://www.merckvetmanual.com/media/pet/figures/DDD_blood_clot_formation.gif

# Type 1 vWD - partial quantitative deficiency of vWF o  Doberman Pinschers most

commonly. # Type 2 vWD low concentration of

high molecular weight multimers of vWF o  German Wirehaired and German

Shorthaired Pointer # Type 3 vWD is a severe

quantitative deficiency of vWF o  Scottish Terriers, Shetland

Sheepdogs, Chesapeake Bay Retrievers, and Dutch Kooikers

#  Screening o  BMBT o  Platelet function analyzer (PFA-100;

Dade-Behring, Deerfield, IL, USA) #  Definitive tests

o  ELISA technique and genetic diagnosis. #  Genetic testing is available - type 1

vWD o  Doberman Pinscher, Bernese Mountain

Dog, Manchester Terrier, Pembroke Welsh Corgi, Papillon, Kerry Blue Terrier and Poodle. Genetic diagnosis is also available for type 3 vWD in the Scottish Terrier, Shetland Sheepdog and Dutch Kooiker

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# Local pressure or cautery - small, accessible wounds.

# Desmopressin (DDAVP) can increase factor concentrations in type 1 vWD dogs

# Cryoprecipitate # FFP

#  Rodenticide vs. other (owners Coumadin – blood thinner as an example) o  2 year old dog that went missing for 4 days?

#  Anticoagulant rodenticides vs other - IMPORTANT

These patients are often presented in 1 of 2 ways.

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# PT vs PTT # The actual value

o Consumptive o Vs o Coagulopathic

(primary)

Normal 12-17 seconds 21 vs OOR

# Although surface bleeding) may occur

# Bleeding into body cavities is more common.

% Vitamin K % 5mg/kg SQ % 2.5mg/kg PO BID

% FFP % 10-20ml/kg over 1-4 hours % Repeat as needed. % Minimal albumin!

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#  Problem or not? #  Clinical signs that correlate? #  Confirm on blood smear? #  Hereditary asymptomatic

thrombocytopenia with macroplatelets #  Greyhounds often have asymptomatic

mild thrombocytopenia #  Polish ogar dog.

#  Usually acquired in dogs and cats. o  Reduced platelet production o  Increased consumption o  Increased destruction

#  Spontaneous, immediate, excessive and prolonged bleeding

#  Often at multiple sites. o  Petechiae o  Ecchymoses o  Mucosal bleeding (epistaxis, petechiae,

melena, hematuria) o  Cavity bleeding

#  Accelerated rate of destruction by the organs of the mononuclear phagocytic system o  Spleen and (to a lesser extent) liver

#  Antibody-coated platelets #  Primary, auto-immune #  Secondary, immune mediated

o  Neoplasia o  Infectious disease o  Vaccination o  Medication.

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#  Blood smear / CBC #  Each platelet per oil immersion field

represents 10,000–15,000/µL. #  Further diagnostics to r/o underlying

cause o  Serum biochemistry o  Heartworm testing o  Urine analysis o  Rickettsial serology o  Abdominal & thoracic radiography o  Immunologic tests (Coomb's, ANA) o  Abdominal ultrasonography o  Bone marrow evaluation

#  Restore platelet numbers to a level sufficient to maintain primary hemostasis o  Greater than approximately 50,000

#  Glucocorticoids o  Prednisolone or dexamethasone o  Azathioprine

#  Doxycycline? #  Vincristine #  Transfusion medicine

1) PRBC 2) Fresh whole blood 3) Platelet-rich plasma

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#  The clinician has many options available to help control bleeding o  Pressure o  Hemostats o  Topical agents o  Ligatures o  Electrocautery o  Harmonic scalpel o  Ligasure

#  Pressure prevents blood from escaping

#  Allows clotting mechanisms time to plug the leak

#  Formation of the fibrin clot

#  Blood at the site must be blotted with gauze and not wiped up, which would carry the freshly formed clot away.

% Control abdominal hemorrhage / oozing

% Incorporate the limbs to avoid trapping of blood in the lower limbs.

% Compression generated by wrapping from the toes and moving rostrally.

% Removal staged from the cranial to toes.

% Contraindications / Concerns?

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%  Biologically inert metal (steel, titanium, etc) %  Serve the same purpose as ligatures. %  Quick and easy to apply. %  Valuable in small, deep, and tight spaces %  Cost $1-2 US per clip.

%  Sterile, absorbable hemostatic agent. %  Provides a matrix for clot to form

Absorbed in 4-6 weeks - invaded by fibrous tissue. Reports of this scar tissue contracting and causing compression when it is placed against the spinal cord.

%  Granulomatous reaction has also been reported.

%  Thick and retains its shape and does not conform well to the tissue on which it is placed.

#  Non-absorbable material #  Soft and malleable when warmed. #  Hemostatic effect based on physical

rather than biochemical properties #  Bone surgeries #  Not for combat/accident casualty care #  Complications:

o  Allergic o  Granuloma o  Cord compression o  Infection o  Interferes with bone healing (?)

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%  Use of electric current passing through metal applying heat to tissues.

%  Heat causes tissue protein coagulation & blood coagulation.

%  Also causes necrosis of the surrounding tissues

% Microporous Polysaccharide Hemospheres (MPH) % Sterile % Surgical and topical applications. % Does not increase bacteria growth (foams) % No risk of tissue damage (cautery) % Painless and non-toxic % No discoloration (silver nitrate) % Within days – broken down and been absorbed by the body. % Safe almost anywhere (not IN the eye)

#  Transfusion trigger?

#  What to transfuse? o  Whole Blood o  Component Therapy

#  Treatment of hypoalbuminemia?

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THERE IS NO RIGHT ANSWER! #  Traditionally:

o  PCV <20% (surgical patient <25%) •  Chronic anemia:

patient may not need blood

•  Acute anemia: this may be too low

#  Base decision to transfuse on patient’s clinical signs not a number!

#  Identifies the presence of antibodies to antigens on the red blood cell surface

#  Dogs lack naturally occurring antibodies o  Require sensitization: previous transfusions

#  Cats, however, have naturally occurring antibodies o  Problems can occur on the first transfusion!

Dog Erythrocyte Antigen: DEA

Identified Blood Groups: ( + or – for these groups) #  DEA 1.1 #  DEA 1.2 #  DEA 3 #  DEA 4 #  DEA 5 #  DEA 7

Hemolytic transfusion reaction

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#  All donor’s should be typed for DEA 1.1 #  Give DEA 1.1+ blood ONLY to DEA 1.1+ recipients #  If the recipient’s blood type is unknown, use ONLY DEA 1.1

– cells o  No typing available o  Auto-agglutinating

#  Three blood types: #  Type A: most common in USA – significant geographic

variations #  Type B: Devon Rex, Cornish Rex, British Shorthair (25-50%);

more common in England #  Type AB (extremely rare) #  MIK antigen

#  Type A: o  Weaker naturally occurring

antibodies against Type B cells o  Delayed transfusion life-span, weak

hemolysis

#  Type B: o  Strong naturally occurring

antibodies against Type A cells o  Acute hemolytic transfusion

reaction

#  Type AB: o  No antibodies to either, no

problems!

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#  Especially with cats – if not able to blood type, cross matching is essential!

#  Checks the compatibility of transfused cells / plasma to that of the recipient

o  Detects incompatibility due to: •  Naturally occurring antibodies •  Sensitization from previous transfusions

Dog: no reason to perform on first transfusion

Cat: must perform if blood types are unknown

Any cat if no blood type; any animal previously transfused (beyond 4 days prior)

1.  Collect recipient blood into EDTA tube and donor(s) blood. 2.   Centrifuge tube(s) at 1000 x 9 for 5 min. Remove plasma and transfer

into clean tubes. 3.   Wash RBCs 3 times with 0.9% NaCl 4.   Resuspend RBC to a 3-5% RBC suspension (1 drop RBC:20 drops saline) 5.   Prepare for each donor 3 tubes labeled with Major, Minor, and Recipient

control. o  Add to each tube 2 parts of plasma and 1 part of RBC suspension (chart)

6.   Mix gently and incubate for 15 min. at room temperature 7.  Centrifuge for 15 sec. at 1000 x 9 8.   Examine supernatant for hemolysis 9.   Gently re-suspend button of cells by tapping tube with a finger and

examine for macroscopic agglutination. 10.   If macroscopic agglutination is not observed, transfer a small amount

onto a glass slide and examine for microscopic agglutination.

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#  Filters o  Transfusion sets contain In-line filters

•  170-260 microns o  Decrease risk for thrombosis

#  Temperature o  Warm to room temperature o  Circulating water baths (37 C) o  Commercial blood warmers

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#  Initial rate: SLOW o  0.2 ml / kg for the first 10-15

minutes o  If no adverse effects, can increase

rate upwards of 5-10 ml/kg/hr o  Can bolus if clinically indicated

(rare) #  Should use all blood products within

4 hours of coming to room temperature o  Optimize effectiveness o  Minimize contamination

#  Baseline information (pre-transfusion): o  PCV, TS o  Heart rate o  Respiratory rate o  Body temperature

o  Recheck physical parameters after 15 minutes, then every 30 minutes during transfusion •  Evidence of transfusion

reaction?

#  Acute Hemolytic #  Antibodies present to donor red blood cells #  Dogs: shouldn’t happen if first transfusion #  Cats: can happen QUICKLY when Type B cat gets Type A

blood (1 ml can trigger #  Clinical Signs:

o  Severe cardiovascular collapse (tachycardia, hypotension)

o  Vomiting o  Fever o  Acute pigmenturia

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#  Acute Hemolytic #  Treatment: #  IMMEDIATELY discontinue transfusion #  Provide cardiovascular support #  Fluids #  Vasopressors #  Consider cortisosteroids, diphenhydramine

#  Most common type of transfusion reactions: o  Urticaria and pruritis o  Fever o  Nausea, vomiting

#  Mild, not life-threatening

#  Reaction to foreign protein or leukocytes

#  Treatment: o  Diphenhydramine (0.5-1 mg/kg SQ or IM) o  Slow rate or temporarily discontinue transfusion

#  Indications: #  Acute hemorrhage

o  Trauma o  Bleeding masses o  Thrombocytopenia

#  Coagulopathy with associated hemorrhage o  Anticoagulant

rodenticide toxicity o  Hemophilia

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#  Used >8 hours since collection #  Refrigerate 1-6°C #  Store 21-35 days (anti-coagulant dependent) #  Oxygen carrying capacity and oncotic effect #  Clotting factors and platelets depleted #  Standard dose: 10-20 ml/kg

#  Higher Hematocrit #  Dose: 6-10 ml/kg #  Store 1-6°C for 21-42 days

(anticoagulant dependant) #  Less 2,3-DPG over time –

carries less oxygen #  Increased NH3 in bag over time –

caution with liver disease

#  Indications: #  No requirement for clotting factors or albumin #  Hemolytic anemia #  Non-regenerative anemia #  Renal failure #  Chronic disease #  +/- Hemorrhage (use with colloids, crystalloids)

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1)  ALL clotting factors in concentrations equivalent to fresh blood

2)  Albumin, globulins 3)  Anti-thrombin III

# Coagulopathy #  Due to secondary hemostasis

abnormalities #  Prolonged PT, PTT, ACT #  Supplementation when using

high rates of artificial colloids (>20 ml/kg/day)

# Dose: o  10 ml/kg (to effect) o  Monitor pre- and post-

transfusion clotting times

1)  Colloidal effect from albumin

2)  Stabile clotting factors: II, VII, IX, X

Factors VIII and V: Avoid in Hemophilia A and von Willebrand’s

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#  Made from FFP o  Slow thaw overnight in refrigerator (<2° C) o  Slushy o  Centrifuge 4° C, 5 minutes, 5000 G o  Remove plasma

o  Concentrated: •  Von Willebrand’s Factor, VIII:C •  Fibrinogen •  Fibronectin

•  Lyophilized cyroppt •  Stable frozen 12 months •  $100/70 ml (cost ABR Int)

1-2 ml/kg VWD 4-5 ml/kg fVIII

# Inefficient # Valuable resource # Volume of FFP needed to transiently raise

albumin by 1 g/dL

% A rapid assessment is required % Identifying the site of hemorrhage % Pressure may applied either just proximal or on top of the injury. % After hemorrhage is controlled, a more through patient assessment may be accomplished. % Treatment is direct at the most critical problems (i.e., oxygen supplementation, fluid therapy). % Goals are to use material that will resolve the issue quickly and without long term complication.

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@VetGirlOnTheRun  

VetGirlOnTheRun  

Garret@vetgirlontherun.com  

Jus3ne@vetgirlontherun.com  

Except as specifically noted otherwise, this material is copyrighted by VETgirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VETgirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed by each presenter are their respective opinions and do not necessarily represent the views of VETgirl, LLC. Medical information here should be referenced by the practitioner prior to use. Under no circumstances shall VETgirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact info@vetgirlontherun.com

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Dr. Justine Lee #  IVECCS, DC, September 2015 #  WVC Oquendo Center, Las Vegas,

NV November 2015

Dr. Garret Pachtinger #  IVECCS, DC, September 2015 #  NCASAM, October 2015 #  GVMA, November 2015 #  CVC, San Diego, Dec 2015