Presentation on theme: "Hemostasis, BLOOD PRODUCTS & TRANSFUSION"— Presentation transcript:
1Hemostasis, BLOOD PRODUCTS & TRANSFUSION M K Alam MS;FRCSProfessor of Surgery
2ILOs At the end of this presentation students will be able to: Understand the mechanism of normal hemostasis.Describe disorders associated with coagulopathies.Describe investigations for coagulation abnormalities.Understand about blood donation and red cell serology.Describe the blood components and plasma products.Explain indications and adverse effects of blood transfusion.Describe the autologous transfusionDescribe methods to reduce the need for blood transfusion
3HemostasisHemostasis is a complex process that prevents or terminates blood loss from a disrupted intravascular space.Four major physiologic events: Vascular constriction, platelet plug formation, fibrin formation, and fibrinolysis occur in that general order.
4Components of hemostasis Vessel integrity, endothelium, subendotheliumPlatelets and red blood cellsPro-coagulant factors (fibrinogen (I), prothrombin (II), factors VII,IX, and X)Anti-coagulant factors (plasminogen, protein C, protein S & antithrombin III)CalciumBlood flow, temperature and pH
5Hemostasis Primary hemostasis: Secondary hemostasis: Vasoconstriction and platelets aggregation in response to vascular injurySecondary hemostasis:Generation of thrombin and fibrin clot formation at the site of vascular injury
6Normal hemostasisPlatelets: Endothelial injury→ exposes collagen, which activates them. Von Willebrand factor (vWF)→ promote platelet adhesion, platelet aggregation and thrombus formation.The coagulation cascade :The extrinsic pathway-activated factor VIIa + tissue factor→ IX , XThe intrinsic pathway- initiated by factor XI to XIa by factor XIIa, .The common path- Xa+ Va→ prothromb. to thrombin→ fibrinogen to fibrin
7Anticoagulant factors Antithrombin III- inhibits coagulation by binding to clotting factors (e.g., thrombin, factor Xa). Heparin accelerates AT-induced factor inhibition.Protein C–protein S system: Activated protein C inactivates factors Va and VIIIa in the presence of protein S.Plasmin degrade fibrin, which allows for natural dissolution of a clot. Exogenous streptokinase and urokinase help to activate fibrin-bound plasminogen into plasmin.
8Congenital or acquired abnormalities of: Defects of hemostasisCongenital or acquired abnormalities of:Platelets -Von Willebrand’s disease, thrombocytopenia, aspirinPro-coagulant factors- Vitamin. K dependent factors- II, VII, IX, and XAnticoagulant factors deficiencies: Protein C and S
9Platelet disordersThrombocytopenia: < 140,000/μL , increased bleeding <50,000/μL.Drug induced:↓ production: Thiazide, chemotherapy agents, estrogens.↑ destruction: Heparin- HIT I (non-immune)-HIT II (heparin-dependent antibodies),Rifampicin, sulfonamides.Dilutional: massive blood transfusion.Others: DIC, sepsis, ITP, dialysis.
11Acquired factor deficiencies Vitamin K deficiency : Production of inactive forms of prothrombin, factors VII, IX, and X, and proteins C and S.Sepsis- protein C, protein S, and antithrombin III are decreased (microvascular thrombi form).Liver disease: Decreased synthesis of clotting factors and inhibitors.DIC: Sepsis, extensive trauma, antibody–antigen reactions, malignancies, liver failure, obstetric complications Inappropriate generation of thrombin within the vasculature → formation of fibrin thrombi, consumption of coagulation factors, particularly fibrinogen, and activation of fibrinolysis
12Inherited factor deficiencies Hemophilia : Deficiency of factor VIII (hemophilia A) or factor IX (hemophilia B, Christmas disease).Diagnosis -by history, elevated PTT, normal PT, & normal bleeding time.Treatment: Bleeding (e.g., during a surgical procedure) requires factor VIII replacement. Cryoprecipitate (factor VIII, vWF, and fibrinogen) for hemophilia A . Purified factor IX for hemophilia B.
13Hypercoagulable disorders Antithrombin deficiency : Autosomal dominant disorder. AT-deficient patients- level restored to > 80% with AT concentrate prior to operation or childbirth.Protein C & S deficiency : Factors Va and VIIIa are not adequately inactivated → unchecked coagulationFactor V Leiden- a genetic mutation in factor V that renders it resistant to breakdown by activated protein C. Increased risk for thromboembolism.Pregnancy, malignancy, estrogen therapy
14Preoperative Evaluation of Hemostasis History: Excessive bleeding after tooth extraction, child birth, or surgery. Nose bleedsAspirin, NSAID (platelet function) intakeWarfarin ( Vit. K inhibitor) intakeLiver disease - ↓production of coagulant factors clearance of activated anticoagulation factorsRenal failure diminishes platelets functionVit. C deficiency (diet)- lead to defect of subendotheliumPhysical examination: Mucosal bleeding, petechiae, or purpura, splenomegaly
15Laboratory Evaluation of Hemostasis PT- (11-14 sec.) measures factor VII, factor X, prothrombin/thrombin, fibrinogen, and fibrin. Warfarin and vitamin K deficiency deplete prothrombin; factors VII, IX, and X; protein C and S and prolong the PT.INR (International normalized ratio)- measures function of I, II,V,VII, & X Monitoring patients on warfarinaPTT (partial thromboplastin time) sec. Measures above factors and VIII. to XII Monitor patients on heparin.Normal PT & ↑ aPTT- deficiency of the intrinsic pathway factors.↑PT & normal aPTT- abnormalities of the vitamin K–dependent factors.Platelets count- prolonged bleeding time in deficiency.Bleeding time min.Hematology consultation -more specialized investigations.
17Blood donation Healthy adults. 480 ml. ABO grouped, Rhesus typed, antibody screened.Screened for diseases- HBV, HCV, HIV,HTLV, CMV and others.Donated whole blood- collected in an anticoagulant (citrate) and nutrient (phosphate, dextrose & adenine) solution (CPDA).Stored- at 4°C, shelf life days
18RBC serology ABO antigens- (carbohydrate) in cell membrane. anti-A or anti-B antibodies- in plasma.Group O: Both anti-A & anti-B antibody Can only receive O blood.Group O: Universal donor. Processing removes plasma, hence reduces antibodies.RhD antigens: Positive or negative individuals.RhD- negative- do not have anti- RhD.Child bearing age female: Not given RhD positive blood to avoid production of RhD antibodies.
20Packed red blood cells (PRBC) Symptomatic anemia-fatigue, tachycardia, mental sluggishness. (Hb. ˂ 7 g/dl or 7-9 g/dl in cv disease sufferers)Acute blood loss.Adult infusion rate: 1 unit over 1-3 hours.1 unit of PRBC: increases Hb. by 1Gm.Irradiated PRBC (prevent graft-versus-host disease from viable lymphocytes) Congenital immune deficiency syndrome, Organ and stem cell transplant , Lymphoid malignancies, Active treatment for carcinoma
21Platelets Normal platelet count 150-400 x10⁹/ L Indications for transfusion: ThrombocytopeniaPlatelet-function abnormalities (aspirin)1 unit platelet concentrate increase the circulating platelet count by about 10,000/L in the average 70-kg person.Pediatrics: 1 unit/ 10kg patient weight
22Fresh frozen plasma (FFP) IndicationsMultiple/specific coagulation factor deficiency (specific factor not available)Reversal of warfarin effectLarge volume (10 units) blood transfusion within few hoursBefore any invasive procedures if INR >1.5Deficiency of antithrombin III before surgeryReplacement of deficient factor to 25% of normal - adequate for hemostasisDose of FFP: ml/kg body weight (2-4 units/ patient)
23Cryoprecipitate Indications for use Derived from plasma that has been frozen and then thawedRich source of fibrinogen and factor VIIIInfused rapidly (10 ml/ min.) in adultsIndications for useBleeding due to fibrinogen deficiencyFactor VIII deficiency, if specific factor not availableGlue to patch dura mater or lacerated liver
24Albumin Chief plasma protein Treatment of shock Replace fluid loss in burnOedema due to hypoproteinemiaPersists in intravascular space for >24 hoursFree from danger of transmitting diseases (unlike RBC, platelets and plasma)
25Recombinant Factor VIIa Treatment of bleeding in hemophiliacsExcessive bleeding due to trauma or thrombocytopeniaProfuse postoperative bleeding due ulcer or inflammatory bowel disease*Complications: thromboembolic, myocardial infarction, cerebrovascular accidents
26Massive blood transfusion Definition: “one blood volume” replaced within 24 hoursDilutional coagulopathy- prompt clinical/ lab. assessmentHematocrit maintained above 25% until bleeding stops (RBC assist in flow of platelets along vessel wall)Platelets maintained >50,000/ml, preferably 100,000/mlFFP at 2-4 hours interval - maintain normal INR & PTTCryoprecipitate for low fibrinogenIf bleeding persists- DIC screen
27Adverse effects of transfusion Acute hemolytic reaction: ABO compatibility, develops within minutes. Chills, fever, infusion site pain, shock, renal failure. May be fatal.Febrile non-hemolytic reaction: Abs in donor plasma react with recipient leucocytes. Mild.Allergic reaction to plasma proteins. Urticaria or anaphylaxis.Bacterial contamination during collection or storage. Symptoms/signs of sepsis. May be fatal.Circulatory overload.Transmitted infection.
28Blood saving techniques Autologous transfusion: Collected from fit patients preoperatively, stored and given to the patient later during surgery, if needed. Not popular.Cell salvage: During surgery blood collected from suction, processed by salvage machine, then given back to patient. Appropriate when heavy blood loss. Contraindicated in sepsis or malignancy.