4INTRODUCTION Definitions Haemorrhage--bleedingEscape of blood from a blood-vesselExsanguination- total loss of bloodDesanguination- major loss of blood[Encyclopedia Britannica]
5INTRODUCTION Subject’s importance Haemorrhage is one of the basic problems and considerations in surgeryFrom-trivial trauma or major abdominal organ injuries-to- congenital and acquired coagulation disordersA wide spectrum of problems involves haemorrhageTransfusion of blood is the main remedy
7INTRODUCTION Physiology BODY’S SYSTEM OF HOMEOSTSISINTEGRITY OF EVERY SYSTEMANATOMICALFUNCTIONAL
8INTRODUCTION Claude Bernard’s concepts French physiologist Claude Bernard ( ), the founder of experimental physiology and experimental pharmacology.Bernard believed that the body has mechanisms by which it seeks to maintain a stable internal environment despite changes in the external environment- Homeostasis[ 1851]
9INTRODUCTION What Prevents Haemorrhage NATURAL BARRIERS AGAINST HAEMORRHAGEIntegrity of vascular wallCoagulation system
10INTRODUCTION Body’s response to haemorrhage/injury Attempts to repair the loss & restore normalityThere are several interrelated stagesLocal response / Gen responseAims at:wall repairRestoration of volume loss
11INTRODUCTION Body’s response to haemorrhage/injury Virchow 1856 famous triad:1. Stasis2. Endothelial damage3. Hypercoaguable stateslocalVasoconstriction• Platelet aggregation and plug formation• Coagulation leading to Fibrin formation –Intrinsic & Extrinsic PathsGeneralCompartmental Volume movement
12PATHOLOGICAL BASIS OF HAEMORRHAGE BLEEDING CAN RESULT DUE TO:LOSS OF INTEGRITY OF WALLTRAUMA/OERATIONSCOAGULATION DEFECTSCONGENITAL - H.PHAQUIRED DIC
13ETIOLOGY OF HAEMORRHAGE CAUSES OF HAEMORRHAGE INJURY /TRAUMA [+ operations]-It commonly results intearing or cutting of a blood-vessel-integrity ofwall breached Trivial OR MajorDISEASES that alter coagulationCongenital –platelet defectsCoagulation factor defectsAcquiredscurvySepsisDIC
14TYPES OF HAEMORRHAGE AMOUNT OF LOSS --MINOR/MAJOR ACUTE/CHRONIC ARTERIAL/VENOUS/CAPILLARY/MIXEDLOCALIZED/DIFFUSEEXTERNAL/ INTERNALOVERT/OCCULT
15TYPES OF HAEMORRHAGEBleeding from an artery is of a bright red colour, and escapes from the end of the vessel nearest the heart in jets synchronous with the heart's beatBleeding from a vein is of a darker colour; the flow is steady, the bleeding is from the distal end of the vessel .Capillary bleeding is a general oozing from a raw surface .
16TYPES OF HAEMORRHAGE SPECIFIC TYPES Bruise or ecchymosis . Extravasation of blood /pouring out of bloodinto the areolar tissues, which become boggyHaematemesis and melenaHaemoptysis .HaematuriaEpistaxis
17TYPES OF HAEMORRHAGE CLASSIFICATION OF SURGICAL HAEMORRHAGE Haemorrhage has been classified as—1-Primary, occurring at the time of the injury2-Reactionary, or within twenty-four hours of the accident, during the stage of reaction3-Secondary, occurring at a later period and caused by faulty application of a ligature or septic condition of the wound . In severe haemorrhage, as from the division of a large artery, the patient may collapse and death ensue from syncope .
18Hemorrhage -four classes American College of Surgeons' Advanced Trauma Life Support (ATLS) Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required.
19Hemorrhage -four classes American College of Surgeons' Advanced Trauma Life Support (ATLS Class III Hemorrhageinvolves loss of 30-40% of circulating blood volume.blood pressure drops, the heart rate increases, peripheral perfusion (shock), such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
20NBFit Individuals may have more effective compensatory mechanisms before experiencing cardiovascular collapse.These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion.Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment of these patients.
21EFFECTS OF HAEMORRHAGE Depend upon following:Acute loss vs Chronic lossThe amount of lossThe compensatory mechanismsGeneral state of health
22EFFECTS OF HAEMORRHAGE Depends upon the amount of blood lossStages of HypovolemiaStage 1Up to 15% blood volume loss (750mls)Compensated by constriction of vascular bedBlood pressure maintainedNormal respiratory ratePallor of the skinSlight anxiety
23EFFECTS OF HAEMORRHAGE Stage 215-30% blood volume loss ( mls)Cardiac output cannot be maintained by arterial constrictionTachycardia >100bpmIncreased respiratory rateBlood pressure maintainedIncreased diastolic pressureNarrow pulse pressureSweating from sympathetic stimulationMildly anxious/Restless
24EFFECTS OF HAEMORRHAGE Stage 330-40% blood volume loss ( mls)Systolic BP falls to 100mmHg or lessClassic signs of hypovolemic shockMarked tachycardia >120 bpmMarked tachypnoea >30 bpmDecreased systolic pressureAlteration in mental status (Anxiety, Agitation)Sweating with cool, pale skin
25EFFECTS OF HAEMORRHAGE Stage ShockLoss greater than 40% (>2000mls)Extreme tachycardia with weak pulsePronounced tachypnoeaSignificantly decreased systolic blood pressure of 70 mmHg or lessDecreased level of consciousnessSkin is sweaty, cool, and extremely pale (moribund)
26MANAGEMENT OF HAEMORRHAGE PreventionPrecautions during surgeryOperative method of control ofhaemorrhageBlood Transfusion
27SURGICAL HAEMOSTASISNATURAL OR ARTIFICIALNatural CONTROLE/arrest of haemorrhage arises from ;(1) the coagulation of the blood itself,(2) the diminution of the heart's action as in fainting,(3) changes taking place in the cut vessel causing its retraction and contraction .
28SURGICAL HAEMOSTASIS EXTERNAL HAEMORRHAGE /WOUNDS The surgical procedure for the treatment of an open wound is-(1) arrest of haemorrhage;(2) cleansing of the wound and removal of any foreign bodies;(3) careful apposition of its edges and surfaces— sutures of aseptic silk or catgut, the surfaces by carefully applied pressure;(4) free drainage, if necessary, to prevent accumulation either of blood or serous effusion;(S) avoidance of sepsis;(6) perfect rest of the part .
29SURGICAL HAEMOSTASIS Surgical treatment of haemorrhage minor means of arresting bleeding are:cold, which is most valuable in general oozing and local extravasations;very hot water, 130° to 16o F., a powerful haemostatic; position, such as elevation of the limb, valuable in bleeding from the extremities;styptics or astringents, applied locally, as perchloride of iron, tannic acid and others, the most valuable being suprarenal extract .
30SURGICAL HAEMOSTASIS Surgical treatment of haemorrhage DIRECT PRESSURE In small blood-vessels pressure will be sufficient to arrest. haemorrhage permanently .LIGATUREIn large vessels with a reef-knotmain artery of the limb exposed by dissection at the most accessible point .
32TRANSFUSION MANAGEMENT Early recognition of significant blood lossit is commoner to see patients who have been under-transfused than over-transfused. It is essential to pay attention to and act on recordings of pulse rate and blood pressure.In a fit patient without cardiac disease, persistent tachycardia − even if blood pressure is maintained − is likely to indicate continuing blood loss.
33SURGICAL HAEMOSTASIS INTERNAL HAEMORRHAGE /WOUNDS CausesPenetrating woundschest,abdomen,neck,limbsUpper GI haemorrhageBleedingUlcersLower GI haemorrhageDiverticulosisHaemorrhoidsCarcinomas
34SURGICAL HAEMOSTASIS INTERNAL HAEMORRHAGE /WOUNDS Principles of managementTeat the primary causeAvoid irrevercible shockFlid electrolytesBlood and blood produvts
35Types of bleedingA subconjunctival hemorrhage is a common and relatively minor post-LASIK complication.The endoscopic image of linitis plastica, a type of stomach cancer leading to a leather bottle-like appearance with blood coming out of it.
36RESPONSE IN INJURYVasoconstriction is mediated through intrinsic mechanisms and various vasoactive agents (thromboxane A2 and serotonin) released during platelet aggregation.COAGULATION SYSTEMVirchow in 1856 described the famous triad:1. Stasis2. Endothelial damage3. Hypercoaguable statesThe coagulation system is based on the coagulation cascade. The end points of this cascade include the formation of thrombin and fibrin.Throughout this system there can be defects in the multiple enzymes or extrinsic factors contributing to its dysfunction.FibrinolysisThere is a delicate balance between formation and lysis of clot.Lysis of fibrindeposits is mediated by antithrombin III, protein C and S and plasmin. Antithrombin II as the name suggests blocks thrombin. When combined with heparin it also blocks factors XII, XI, IX and X (intrinsic pathway).Tests used to measure fibrinolysis include fibrin degradation products (FDB),fibrinogen, d-dimerIn DIC –the FDP’s are raisedI FibrinogenII ProthrombinIII Tissue thromboplastinIV CalciumV ProaccelerinVIVII ProconnectinVIII Antihemophilic factorIX Christmas factorX Stuart-Prower factorXI Plasma thromboplastinXII Hageman factorXIII Fibrin stabilizing factor
37Transfusion management All patients require large-bore intravenous cannulas. Central venous pressure monitoring is valuable in major haemorrhage or if there is cardio-respiratory disease.Haemoglobin concentration − interpretationThe haemoglobin can underestimate the extent of blood loss in cases of acute haemorrhage before haemodilution has occurred, or can overestimate it if the patient is already anaemic from chronic blood loss.
39Gastrointestinal haemorrhage: haematemesis and melaena Haematemesis: vomiting fresh red blood.Coffee-ground vomiting: vomiting of altered black blood.Melaena: the passage of black tarry stools.Bleeding may be from oesophageal varices or from other sites (non-variceal bleeding).Acute upper gastrointestinal (GI) bleeding affects 50 to 150 per 100,000 of the population each year and accounts for a substantial proportion of all blood used in UK hospitals. In the UK in 1995, mortality was reported to be 11% in patients admitted to hospital because of bleeding and 33% in those who developed gastrointestinal bleeding while hospitalised for other reasons. In the west of Scotland in 1997, the corresponding figures were 8.2% and 43%. Most deaths are in elderly patients with significant co-morbidity. Mortality is reported to be lower in specialist units where there is close medical/surgical/endoscopic cooperation and adherence to management protocols. This section is intended only to give an overview of transfusion, which is just one part of the overall management of patients with GI haemorrhage (Tables 10 and 11).(PMID )(PMID )(PMID )(PMID )(PMID )Table 10 Use of fluids and transfusion in GI bleeding in chronic liver disease (with variceal bleeding)FeaturesTransfusion managementEnd pointsBleeding is often but not always from oesophageal varices and is often severe. Other causes such as peptic ulcer are not uncommon and must be excluded.Bleeding from varices usually recurs if there is no intervention to control the varices or to reduce portal pressure. The prognosis depends on the severity of the liver disease.Hepatic failure may follow variceal bleeding, but usually recovers if bleeding can be stopped and recurrence prevented.¹Insert one or two large bore cannulas. A central line may be indicated.Ensure red cells are available quickly; use local emergency transfusion protocol: order 4−6 units.Crystalloids should be used carefully. Saline should be avoided as sodium retention is usual and leads to ascites.Systolic pressure> 100 mmHgUrine output > 40 ml/hrCVP 0−5 mmHg(not higher)Haemoglobin up to 90 g/lThrombocytopenia is usual. Provided the platelet count is above 50 x 109/l, bleeding is unlikely to be controlled or prevented by platelet transfusion.Normal (i.e. pre-bleed) systolic blood pressure is often lower than in non-cirrhotic patients.Platelet transfusion is rarely needed. If there is continued bleeding with a platelet count below 50 x 109/l, platelet transfusion may be considered in an effort to control variceal bleeding.Platelet count may show little increment following platelet transfusion in patients with splenomegaly.Deficiency of coagulation factors is frequent (except fibrinogen and factor VIII).Coagulation factor concentrates may be indicated. Seek expert advice as some of the products have a risk of thrombogenicity, especially in patients with liver disease.Fresh frozen plasma is indicated only if there is documented coagulopathy, e.g. INR >2.0.Keep INR < 2.0 if possible. Complete correction is rarely possible with FFP due to the large volume needed.Giving red cells to try to raise Hb towards normal values may raise portal venous pressure, since blood volume is often increased. Over-transfusion may contribute to rebleeding.Provided blood volume is replaced and cardio-respiratory function was previously adequate, haemoglobin of 90 g/l appears to be adequate.Transfuse red cells to approach but not exceed end point of 90 g/l.Note:This table is based on the protocol used by the Gastrointestinal Bleeding Unit, Royal Infirmary, Aberdeen. (PMID )[Table 10 resources: View large format or download as Word™ document]Table 11 Use of fluids and blood components in acute non-variceal gastrointestinal bleedingSeverityClinical featuresIV infusionEnd pointSevereHistory of collapseand/or shock− systolic BP < 100 mmHg− pulse > 100/minReplace fluid rapidlyEnsure red cells are available quickly; use local emergency transfusion protocolTransfuse red cells according to clinical assessment and Hb/HctMaintainurine output > 40 ml/hoursystolic BP > 100 mmHghaemoglobin > 90 g/lSignificantResting pulse > 100/minand/orhaemoglobin < 100 g/lReplacement fluidOrder compatible red cells (four units)TrivialPulse and haemoglobin normalMaintain intravenous access until diagnosis is clearSend patient sample for red cell group and antibody screenRecheck haemoglobin at 24 hours to reassess blood lossNo evidence of bleedingMay have 'coffeegrounds' or altered blood in vomitus. Faecal occult blood negative.[Table 11 resources: View large format or download as Word™ document]Early recognition of significant blood loss is important. In clinical practice, it is commoner to see patients who have been under-transfused than over-transfused. It is essential to pay attention to and act on recordings of pulse rate and blood pressure. In a fit patient without cardiac disease, persistent tachycardia − even if blood pressure is maintained − is likely to indicate continuing blood loss.All patients require large-bore intravenous cannulas. Central venous pressure monitoring is valuable in major haemorrhage or if there is cardio-respiratory disease.Haemoglobin concentration − interpretationThe haemoglobin can underestimate the extent of blood loss in cases of acute haemorrhage before haemodilution has occurred, or can overestimate it if the patient is already anaemic from chronic blood loss.If liver disease is suspected (e.g. oesophageal varices)The platelet count and prothrombin time should be checked and correction with blood components may be indicated. It is not necessary to check clotting screen routinely in every case of GI haemorrhage.Guidelines for management can be found at the BSG website:Management of upper GI bleeding andManagement of bleeding in patients with oesophageal varices