1. Hemostasis, BLOOD PRODUCTS & TRANSFUSION M K Alam MS;FRCS Professor of Surgery

2. ILOs 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 & adverse effects of blood transfusion.  Describe the autologous transfusion  Describe methods to reduce the need for blood transfusion

3. Hemostasis A complex process that prevents or terminates blood loss from a disrupted intravascular space. Four major physiologic events occur in that general order : 1. Vascular constriction. 2. Platelet plug formation. 3. Fibrin formation. 4. Fibrinolysis occur.

4. Components of hemostasis Vessel (integrity, endothelium, subendothelium) Platelets & red blood cells Pro-coagulant factors (fibrinogen (I), prothrombin (II), factors VII,IX, and X) Anti-coagulant factors (plasminogen, protein C, protein S & antithrombin III) Calcium Blood flow, Temperature pH

5. Hemostasis Primary hemostasis: Vasoconstriction. Platelets aggregation in response to vascular injury. Secondary hemostasis: Generation of thrombin. Fibrin clot formation at the site of vascular injury.

6. Normal hemostasis Vasoconstriction- initial response to injury. Platelets: Endothelial injury→ exposes collagen, which activates them. Von Willebrand factor (vWF)→ platelet adhesion, platelet aggregation and thrombus formation. The extrinsic pathway- activated factor VIIa + tissue factor→ IX, X. The intrinsic pathway- initiated by factor XI to XIa by factor XIIa. The common path- Xa+ Va→ prothromb. to thrombin→ fibrinogen to fibrin.

7. Anticoagulant 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.

8. Defects of hemostasis Congenital or acquired abnormalities of:  Platelets - Von Willebrand’s disease, thrombocytopenia, aspirin  Pro-coagulant factors- Vitamin K dependent factors- II, VII, IX, and X  Anticoagulant factors deficiencies: Protein C and S

9. Platelet disorders Thrombocytopenia: < 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.

10. Platelet disorders Thrombocytosis: >600,000/μL. Myeloproliferative disease, Post-splenectomy. Increased risk of thrombotic episodes. Aspirin reduces the risk. Platelet dysfunction: Hereditary - von Willebrand's, Glanzmann. Acquired - aspirin (inhibiting platelet synthesis of thromboxane A2), uremia, liver disease.

11. Factors deficiencies- acquired 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. 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 vessel → formation of fibrin thrombi, consumption of coagulation factors, particularly fibrinogen, & activation of fibrinolysis.

12. Factors deficiencies- Inherited Hemophilia : Deficiency of factor VIII - hemophilia A Deficiency of factor IX - hemophilia B, Christmas disease. Diagnosis: History, elevated PTT, normal PT, & normal bleeding time. Treatment: Cryoprecipitate (factor VIII, vWF, and fibrinogen) : hemophilia A. Purified factor IX- hemophilia B.

13. Hypercoagulable 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 coagulation Factor 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

14. Preoperative Evaluation of Hemostasis History: Excessive bleeding - tooth extraction, child birth, surgery. Nose bleeds Medications: Aspirin, NSAID (platelet function), Warfarin ( Vit. K inhibitor). Liver disease - ↓production of coagulant factors & clearance of activated anticoagulation factors Renal failure diminishes platelets function Vit. C deficiency (diet)- lead to defect of subendothelium Physical examination : Mucosal bleeding, petechiae, or purpura, splenomegaly

15. Laboratory Tests for evaluation of hemostasis Minor operations - laboratory testing is unlikely to provide additional information over that obtained with a properly performed history and physical examination. Useful for patients undergoing major procedures, or for patients with an abnormal history or physical examination findings. Laboratory tests : Prothrombin time (PT), activated partial thromboplastin time (aPTT), a CBC, platelet count, and occasionally, a bleeding time.

16. Laboratory tests for evaluation of hemostasis PT- (11-14 sec.) M easures factor VII, factor X, prothrombin/thrombin, fibrinogen, and fibrin. Warfarin and vitamin K deficiency (deplete prothrombin, factors VII, IX, X, Protein C and S) prolong the PT. aPTT (partial thromboplastin time) 26-36 sec. Measures factors XII, XI, IX, and VIII, fibrinogen, prothrombin, and factors V and X. H eparin causes prolongation of the aPTT. Used for monitoring patients on heparin. INR (International normalized ratio )- measures function of I, II,V,VII, & X. - Monitoring patients on warfarin

17. Laboratory tests for evaluation of hemostasis Normal PT & ↑ aPTT- deficiency of the intrinsic pathway factors. ↑PT & normal aPTT- abnormalities of the vitamin K–dependent factors. Platelets deficiency- prolongs bleeding time. Count > 50,000/μL is adequate for hemostasis. Bleeding time - 2.5-9 min. Hematology consultation -more specialized investigations.

18. PT aPTT VII XII X V II (prothrombin) XI Fibrinogen IX VIII X V II Fibrinogen

19. Blood 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 35-40 days

20. RBC 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 & 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.

21. Blood Components Packed red blood cells (PRBC) Platelets Fresh frozen plasma (FFP) Cryoprecipitate

22. Packed red blood cells (PRBC) Symptomatic anemia-fatigue, tachycardia, mental sluggishness. (Hb. ˂ 7 g/dl or 7-9 g/dl in cardiovascular 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.

23. Platelets Normal platelet count 150-400 x10⁹/ L Indications for transfusion: Thrombocytopenia Platelet-function abnormalities (aspirin) 1 unit platelet concentrate: increase count by about 10,000/L in 70-kg person. Pediatrics: 1 unit/ 10kg patient weight

24. Fresh frozen plasma (FFP)- Indications Multiple/specific coagulation factor deficiency- specific factor not available. Reversal of warfarin effect. Large volume (10 units) blood transfusion within few hours. Before any invasive procedures if INR >1.5 Deficiency of antithrombin III before surgery. Replacement of deficient factor to 25% of normal - adequate for hemostasis. Dose of FFP: 10-15 ml/kg body weight (2-4 units/ patient).

25. Cryoprecipitate Derived from plasma that has been frozen and then thawed Rich source of fibrinogen and factor VIII Infused rapidly (10 ml/ min.) in adults Indications for use Bleeding due to fibrinogen deficiency Factor VIII deficiency, if specific factor not available Glue to patch dura mater or lacerated liver

26. Albumin Chief plasma protein Treatment of shock Replace fluid loss in burn Oedema due to hypoproteinemia Persists in intravascular space for >24 hours Free from danger of transmitting diseases (unlike RBC, platelets and plasma)

27. Recombinant Factor VIIa Treatment of bleeding in hemophiliacs Excessive bleeding due to trauma or thrombocytopenia Profuse postoperative bleeding due ulcer or inflammatory bowel disease. Complications: thromboembolic, myocardial infarction, cerebrovascular accidents

28. Massive blood transfusion Definition: “one blood volume” replaced within 24 hours. Dilutional coagulopathy- prompt clinical/ lab. assessment. Hematocrit maintained above 25% until bleeding stops. (RBC assist in flow of platelets along vessel wall) Platelets maintained >50,000/ml, preferably 100,000/ml. FFP at 2-4 hours interval - maintain normal INR & PTT. Cryoprecipitate for low fibrinogen. If bleeding persists- DIC screen.

29. Adverse 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.

30. Blood 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.

31. Thank you!