Welcome to weekly Scientific Session

Venue: Casualty Block 1

Dhaka Medical College HospitalDhaka 1000

Topics

•Shock

•Blood and Blood products

Presented By:

Dr. Mominul Haider

Resident (Phase A)

Department of Urology

BSMMU

Shock

Definition

• Shock may be defined as a clinicopathologicalcondition of profound haemodynamic and metabolic disturbance, characterized by inadequate supply of metabolic needs – cum –failure of circulatory system to maintain adequate tissue perfusion.

Or,

• Shock may be defined as a state of systemic hypoperfusion which is inadequate for normal cellular respiration.

Aetiological classification

1. Hypovolaemic shock

It is due to a reduced circulatory volume

– Haemorrhagic

– Non haemorrhagic

• Poor fluid intake

• Severe vomiting

• Diarrhoea

• Evaporation

• Third space loss

2. Cardiogenic shock

Due to primary failure of the heart to pump blood to the tissue.

–MI

–Cardiac dysrhythmia

–Valvular heart disease

–Blunt myocardial injury

–Cardiomyopathy

3. Obstructive shock – in this type, there is a reduction in the preload due to mechanical obstruction of cardiac filling.

–Cardiac tamponade

–Tension pneumothorax

–Massive pulmonary embolus

–Air embolism

4. Distributive shock – inadequate organ perfusion is accompanied by vascular dilatation with hypotension, systemic vascular resistance, inadequate after load and a resulting abnormally high cardiac output.

• Neurogenic

• Anaphylactic

• Septic shock

5. Endocrine shock - Combination of hypovolaemic, cardiogenic, distributive shock

Clinical classification of shock

1. Mild shock: < 20% blood volume loss

2. Moderate shock: 20 - 40 % blood volume loss

3. Severe shock: > 40% blood volume loss.

Pathogenesis of hypovolaemic shock

Pathophysiology of septic shock

Management of Shock

1. Assessment of the patient (Quick assessment of the patient):

a. Minimum monitoring (non-invasive): 1. Pulse 2. BP 3. Temperature 4. Respiratory rate 5. Urine output 6. ECG 7. Oxygen saturation by pulse oximeter8. Level of consciousness.

b. Additional (invasive):

1. Central venous pressure (CVP)

2. Serial arterial blood gas analysis

3. Pulmonary artery wedge pressure for cardiac output

4. Blood urea and serum creatinine (Mandatory → Shahid sir)

5. Base deficit and serum lactate

6. Serum electrolytes.

Resuscitation of the patient

Maintenance of airway and cervical spine protection:

– Inspect for any secretion foreign body in the airway and clean it by suction.

– Inspect for fallen back tongue- if present then pulled out and then intubate by an endotracheal tube (if necessary)

– Maintain airway by

• neck fixation

• left lateral position

– intubation

Resuscitation of the patient cont.

• Maintenance of breathing and ventilation: • Give high flow oxygen by using oxygen mask (pure

oxygen from oxygen cylinder)

• If above measures failed intubate with PPV in ICU.

Resuscitation of the patient cont.

Controlled of bleeding and maintenance of circulation.

Controlled of bleeding: 1. Pressure

2. Pack

3. Position and rest- Elevation of limb.

4. Procedure: Operation technique-1) Vessel occlusion by clamping by artery forceps

2) By ligation of vessel

3) Diathermy coagulation

4) Sclerosing agent

5) Repair of the vessel

6) Spongesten

7) Tourniquet

Resuscitation of the patient cont.

Maintenance of circulation by:

– Open two intravenous channels with short and wide bore cannula that allow rapid infusion of fluid

– Collect blood and send for grouping and cross matching

– Initial resuscitation by crystalloid solution – Normal saline, Hartmann‘s solution, 5% DNS (But never DA).

– Blood loss should be replaced by blood if Hb < 8gm/dl

– Plasma expanaders (Dextran 70, haemaccel, Gelofusine, Hetastarch) can be used.

Resuscitation of the patient cont.

Prevention of renal failure:

– Catheterization and keeping urine output >0.5ml /Kg/Hour

– Treatment of acidosis by NHCO3 (50 ml of 8.5% NaHCO3).

Resuscitation end points:

• Mean BP > 70 mmHg

• Resolving tachycardia

• Improved peripheral circulation

• Urine output > 0.5 ml/Kg/hr

• Falling lactate and resolving acidosis

• Treatment of the underlying cause: e.g. Control haemorrhage, (treat MI, treat sepsis, and Treat anaphylaxis)

Blood and Blood products

Blood constituents available for clinical use

• Whole blood [ (450 ml of whole blood + 75 ml of CPD) → at (2-6)0C → 35 days]

• Blood components-

– Packed red cells –

» Plasma reduced

» Leukocyte poor

» frozen

» phenotyped

–White cells (buffy coat)

– Platelets

– Fresh frozen plasma

– Cryoprecipitate.

• Plasma products: –Human albumin solution

–Coagulation factor concentrate:

–Recombinant factor VIII, factor IX

–Recombinant factor VIIa

–Fibrinogen concentrate.

– Immunoglobulins:

»Specific

»Standard.

Criteria for ideal blood donor:

• Age: 18-57 year.

• Weight: >100 lb

• BP: 100/60 mmHg < desired BP < 200/100 mmHg

• PR: 60-100 beats/min

• Medical History:

– No fever

– No tooth extraction within 3 weeks

– No vaccination within 3 weeks

– No surgery within 3 months

– Not in menstruation

• Haematological parameter:

– Hb>12 gm/dl

– No history of anaemia, leukaemia, lymphoma, multiple myeloma, thrombocytopenia or coagulopathy.

Storage of Blood

• Storage Temp – 4-60C

• Anticoagulants Used (Blood : Anticoagulant = 6:1)

– Acid citrate dextorse (ACD)

– Citrate Phosphate Dextrose with Adenine (CPDA)

• Duration of storage

– If ACD used – 21 days

– If CPDA used – upto 42 days

Complications of blood storage

• RBCs loose their capacity to release oxygen with in 7 days

• WBC are destroyed rapidly within hours

• Platelet remain normal upto 3 days

Pre requisite for Blood transfusion

• ABO blood grouping and Rh typing prior to collection of blood

• Cross matching of donors blood with patients blood before transfusion

• Detection of antibody by Coomb’s test

• Screening for – HIV, HCV, HBV, Syphilis, Malaria

Indication/uses of whole blood

–To increase blood volume in hypovolaemia

» Acute blood loss

• Trauma

• Ruptured liver, spleen, kidney

• Ruptured ectopic pregnancy

• Ruptured aortic aneurysm

» Any surgery where there is chance of blood loss > 10% of total blood volume

• Severe deep burn

• > 15% in children

• > 20% in adults

–To increase oxygen supply at the tissue level

»Preoperative anaemia

• Hematemsis

• Malignancy

• Haemorrhoids

»Leukaemia

»Exchange transfusion in case of incompatibility

• To increase resistance power of the patient• Post operative debilitating patient

• Severe Infection

• Septicaemia

• DIC

• Malignancy

• Incase of coagulopathy• Haemophillia

• Thrombocytopenia

Packed red blood cells

• Packed red blood cells are spun-down and concentrated packs of red blood cells.

• Packed RBC is obtained by centrifuging one unit of whole blood at 2000-3000 g for 15-20 minutes.

• Preparation available: Each unit is approximately 330 mL and has a haematocritof 50–70 per cent. One unit of Packed cell increases hematocrit by 3 % and Hb by about 1 gm/dl in an average weight adult.

• Packed cells are stored in a SAG-M solution (saline–adenine–glucose–mannitol) to increase shelf life to 5 weeks at 2–6°C.

• Uses of packed red cells:

–Chronic anaemia

– Extreme of age e.g. Children and old age

–Patent at risk of cardiac failure.

• Buffy coat – Severe infection

Platelet concentrate

• Platelet concentrates may be produced by the pooling of platelets from four standard whole blood donations or may be from donors who give platelets alone via an apheresis (Greek apo = from + haireein = to take; to separate) machine, in which case only one donor's platelets are present in each adult dose.

• standard adult dose in either case is 2.4 x 1011

platelets, suspended in 150-200 ml of plasma.

• This product has a shelf life of 5 days and is stored at 22°C on a platelet agitator.

• Platelets express ABO antigens but not Rhantigens and therefore they should be ABO matched as far as possible.

• There are a small number of red cells present in platelet concentrate and therefore women of child-bearing age should receive RhD matched platelets.

• If a RhD-negative women has to be given RhDpositive platelets she should be given anti-D cover as appropriate.

• A standard adult dose of platelets normally raises the count by 10 x 109 /L at 1 h posttransfusion.

Uses of platelets concentrate

– Thrombocytopenia prior to an invasive procedure

– Significant haemorrhage in the presence of thrombocytopenia

– Platelet count <50,000/μL of blood (to cover surgical intervention)

– Prophylactic and therapeutic transfusion in patient with primary platelet function disorder

– Massive blood transfusion

– Consumption coagulopathy- DIC.

Fresh Frozen Plasma

• FFP is prepared by centrifugation of donor whole blood within 8 h of collection, and frozen at -40 to -50°C.

• Each unit of fresh frozen plasma is obtained from a single unit of whole blood and consists of 200-300 ml of plasma with 40-60 ml of citrate anticoagulant nutrient mixture (CPD-Citrate Phosphate Dextrose).

FFP• Adult dose: 12-15 ml/kg • Shelf life: 2 years • Storage: at −40 to −50°C; before use it is rapidly

thawed at 27oC and transfused within 2-4 hours thawing, otherwise clotting factors maybe degraded at room temperature

• Contents: – Plasma proteins in a similar concentration of plasma – Coagulation factors, including the labile factors V and VIII

and the vitamin K-dependent factors II, VII, IX and X.. – Albumin, Immunoglobulin.

• Compatibility testing is not required, but group compatible units are used.

Uses of Fresh frozen plasma

• Congenital clotting factors deficiency- Haemophilia(factor-VIII deficiency), Christmas disease (Factor IX deficiency)

• Surgery in patients with abnormal coagulation factor due to liver failure, liver disease or poor synthetic function

• Reversal of oral anticoagulation (warfarinization) –Haemorrhage due to over anticoagulant

• Plasma exchange in- Thrombotic thrombocytopenic purpura (TTP) and haemolytic-uraemic syndrome (HUS)

• Massive blood transfusion • Consumption coagulopathy- DIC.

Cryoprecipitate

• This is prepared from FFP by freezing and thawing plasma and then separating the white precipitate from the supernatant plasma. Cryoprecipitate (Greek kryos = frost) contains half of the factor VIII, fibrinogen and fibronectin from the donation and also the majority of the von Willebrand factor.

• it is stored at -30°C for up to 12 months.

• the volume of each pack is only 10-20 ml, the product thaws very quickly and can be ordered when it is about to be given.

• the effectiveness of the product decreases rapidly once it has been thawed.

• A standard adult dose is 10 units, which should be ABO compatible but not crossmatched

Indications

• Haemophilia

• Von-Willebrand‘s disease

• Fibrinogen deficiency and dysfibrinogenaemia

• Massive blood transfusion

• Disseminated intravascular coagulation (DIC) -If fibrinogen is less than 0.8 gm/L.

Albumin Preparation

–4.5% Albumin – Burn, infection

–10% Albumin – Septic shock

–20% Albumin – Acute pancreatitis

Complications of blood transfusion

• Immunological– Haemolytic transfusion reaction due to incompatibility

• Non-immunological reaction– Pyrogenic reaction– Allergic reaction due to vasoactive amine (when

stored for 2-3 days)– Citatrate toxicity– Potassiaum toxicity– Air embolism– Volu,e overload– Hypocalcaemia (if > 3 units)

• Transmission of disease

– Viral

• HBV, HCV, HIV, CMV, EBV

– Bacteria

• Syphilis

– Protozoal

• Malaria, Filaria, Kala-azar, Toxplasmosis

Management of a case of mismatched blood transfusion

• Clinical Features:– Sensation of heat and pain along the vein through

which transfusion is going on

– Chest pain and feeling of chest tightness

– Rigor and fever

– Loin pain

– Hypotension

– Oliguria, ARF

– In anesthetized patient - the only signs may be persistent hypotension and unexplained oozing from the wound

• Management:– Stop the transfusion immediately– O2 inhalation – Check clerical details and send samples from the

donor unit and recipient for analysis for compatibility and haemolysis.

– Infuse Normal Saline to maintain blood pressure and promote diuresis to prevent renal failure.

– Intravenous steroids and antihistamines may be needed, with the use of adrenaline (epinephrine) in severe cases.

– Cardiac monitoring– ICU care if respiratory distress and > 2 organ

dysfunction.

Massive blood transfusion

• Massive blood transfusion may be defined as transfusion of a volume of blood that is equal to or is greater than the recipient‘s total blood volume within less than 24 hours (usually within 12 hours).

• Indications– Young adult trauma victims

– Patients with major bleeding disorder

– Obstetric complications.

Complications

• Cardiac complications– Ventricular extrasystole– Ventricular fibrillation – Cardiac arrest

• Electrolyte imbalance: – Hyperkalaemia– Hypocalcaemia

• Failure of haemostasis• Consumption coagulopathy → DIC.• ARDS

Prevention of Complications of massive blood transfusion

• Appropriate patient selection: Massive blood transfusion should not be given in children and old aged (extreme of age); and patient with cardiac, renal and hepatic disease

• Repeated coagulation screen and hematological tests (platelet count, fibrinogen level as far as possible).

• FFP (15 ml /kg) corrects the abnormalities of coagulation and may need to be given without the benefit of laboratory results in an emergency if 10 units or more of red cells have been given

• Use of blood warmer prevents cardiac complications.

• Blood should be transfused within 14 days of donation

• Platelet concentrates, if 1.5 L or more of the patient‘s blood has been replaced.

Autologous Blood Transfusion

• Transfusion of blood or blood products derived from same individual during the perioperativeperiod is termed as autologus blood transfusion.

• Types of autologus blood transfusion: Three types –

– Intraoperative or/ and postoperative cell salvage

– Preoperative autologous deposition (PAD)

– Acute normovolaemichaemodilution (ANH)

Thank You