HEMORRHAGE

& BLOOD PRODUCTS

 Learning objectives
 To define hemorrhage and classify it.
 To enumerate the various types of hemorrhage
and their clinical features.
 To describe the clinical effects of hemorrhage
and outline the management principles.
 To know about the various blood products
available , their uses in surgical practice and
common complications of transfusion.
 What is hemorrhage ?
 Hemorrhage is the medical term for bleeding
( loss of blood from the body)
 Commonly, hemorrhage indicates particularly
severe bleeding ; but technically, it means
escape of blood to extravascular space.
 The complete loss of blood is referred to as
exsanguination.
 Definition of Hemorrhage
Hemorrhage:
Extravasation of blood from living blood
vessel
OR
Leakage of blood from a living blood vessel
 Causes of hemorrhage
 Trauma – blunt injury or penetrating injury or
iatrogenic trauma, surgical procedures.
 Underlying pathology – peptic ulcers,
aneurysms, AV malformations, malignancy,
uremia, etc.
 Coagulation disorders – e.g. hemophilia, DIC,
Von- Willebrand disease etc.
 Drugs – NSAIDs, warfarin, etc.
 Classification
According to visibility
 Internal Hemorrhage (concealed )

 External Hemorrhage ( revealed)

According to Timing of Bleeding

 Primary Hemorrhage

 Delayed Primary Hemorrhage

 Secondary Hemorrhage
Internal Vs External
 Classification
According to source of bleeding
 Arterial Hemorrhage

 Venous Hemorrhage

 Capillary Hemorrhage
 Arterial hemorrhage

 Bright red in color (oxygenated blood)

 Spurting jet which rises and falls in time with
the pulse ( from high pressure artery)
 Can become watery in appearance if excess of
intravenous fluids are given
 Venous hemorrhage
 Dark red in color
 Steady and copious flow
 Can be rapid if large veins are opened like
common femoral or jugular vein
 Can be from veins under increased pressure
e.g. ruptured varicose veins, esophageal
varices
 Capillary hemorrhage

 Bright red in color

 Hemorrhage is often rapid and oozing
 Can be serious if prolonged for many hours
e.g. in hemophilia
 Primary hemorrhage
 Occurs at the time of injury or operation
 Can be arterial, venous or capillary
 If due to injury, can be revealed or concealed
 If during surgery, usually revealed and hence
can be controlled with proper care
 Reactionary hemorrhage
 Occurs within 24hours (usually 4-6 hrs) after
injury / surgery.
 Mainly due to ‘slipping’ of ligature or
dislodgment of clot or cessation of reflex
vasospasm.
 Can be arterial or venous
 Precipitating factors – rise in B.P ,
restlessness, vomiting, coughing.
 Secondary hemorrhage
 Occurs 7-14 days after the insult.
 Due to infection and sloughing of part of the
wall of a vessel.
 Predisposing factors – presence of drainage
tube, presence of a fragment of bone, ligature
in an infected area, cancer.
 External hemorrhage
 Bleeding which is visible.
 Also called revealed hemorrhage.
 Easy to assess the blood loss and to control the
hemorrhage.
 E.g. hemorrhage due to cut wounds, ruptured
varicose veins, hematemesis etc.
 Internal hemorrhage
 Invisible bleeding.
 Also called concealed hemorrhage.
 E.g. ruptured spleen or liver, cerebral
hemorrhage, etc.
 May become ‘revealed’ e.g. hematemesis or
melena in a case of peptic ulcer bleed,
hematuria from a injured kidney, etc.
 Quantifying blood loss
 Blood clot – a clot the size of a clenched fist is
roughly equal to 500 ml
 Swelling – moderate swelling in a closed
fracture of tibia equals 500-1000 ml of blood
loss, whereas in fracture shaft of femur, it
amounts to about 1000-2000 ml.
 Swab weighing- useful in operating theatres.
1gm= 1 ml. For lengthy surgery, it is
multiplied by 1.5 and for prolonged surgery
like APR, by 2.
 Effects of blood loss
 Relates to the pre-existing circulating blood
volume.
(Adults: 65-75ml/kg ;Infants:80-85ml/kg )
 Hb level – No immediate change in acute
hemorrhage but, levels fall after some hours
due to influx of interstitial fluid into vascular
compartment or due to i.v. fluids.
 Blood volume starts to recover immediately.
 Effects of blood loss…
 Plasma proteins are replaced by the liver.
 Red cell recovery takes about 5-6 weeks.
 The clinical features of hemorrhage depends
on the amount of blood loss and the rapidity of
loss of blood.
 Classified into 4 classes ( ATLS classification)
according to the amount of blood lost.
 Classes of hemorrhage
 Class I – upto 15% blood loss
- usually, no change in BP, pulse pressure or
respiratory rate.
- minimal tachycardia may be there
- CRT > 3 seconds ≈ volume loss of 10%

 Class II – blood loss 15-30 %

- tachycardia, tachypnea, decreased pulse
pressure, cool clammy skin, delayed capillary
refill, slight anxiety.
 Classes of hemorrhage
 Class III - loss of 30-40%
- marked tachycardia and tachypnea, decreased
systolic BP, oliguria, altered mental status like
confusion or agitation.
- most will require blood transfusion
 Class IV- loss of > 40% blood volume
-marked tachycardia, decreased BP( diastolic may
be unrecordable), markedly decreased or no urinary
output, depressed mental status ( or loss of
consciousness), cold and pale skin.
- immediately life threatening.
Treatment of hemorrhage
 Treatment of hemorrhage
 Urgent treatment required
 Resuscitation -stabilize the patient and assess
ABC ( airway, breathing, circulation) and
follow basic life support protocol if required.
 Minimize further blood loss (Arrest of
Bleeding)
- direct pressure: digital pressure or pressure
dressings or use of balloon catheters.
- packing with rolls of wide gauze with or
without adrenaline(1:1000).
 - elevation of the affected area.
- drugs: vasopressin, adrenaline can be used
in various circumstances
 Operative techniques
- hemostats (artery forceps) , clips, ligatures
- electrocautery
- topical haemostatic agents: gelatin sponge
(oxygel), crushed patch of muscle, adrenaline
soaked gauze, Russell viper venom etc
- removal of bleeding organ may be required
e.g. splenectomy.
 Restoration of intravascular volume
- isotonic i.v fluids.
- plasma expanders.
- blood and blood products.
 Identify the primary cause of bleeding and
treat it. E.g peptic ulcer, hemophilia etc.
BLOOD AND BLOOD PRODUCTS
 Blood in History

- China, 1000 BC
The soul was contained in the blood.

- Egyptians bathed in blood for their health.

- Romans drinking the blood of

fallen gladiators to gain strength and vitality and to cure
epilepsy.

- the practice of bathing in blood as it cascaded from a

sacrificial bull, was practiced by the Romans.
. Animal to animal --- Richard Lower ,1665
 Animal to human --- Jean Denis , 1667

. Human to human --1818, James Blundell

-- 1900 The elucidation of the ABO blood
group system by Landsteiner

-- 1914 Lewisohn - used citrate

-- 1940 Landsteiner and Wiener, in, describe

Rh typing
 Composition of blood
 Red Blood cells + Plasma
 Plasma contains
-white blood cells,
-platelets, fibrinogen,
-all the clotting factors,
-proteins like albumin.
Whole Blood components Plasma fractions
blood
-Fresh Packed platelets Fresh Cryoprec
-old red cells Frozrn ipitate
Plasma
Massive -Washed when platelet. when PT & when Clotting factor
haemorrha
ge RBC’s count less PTT are fibrinogen concentrates
Major liver
Pts with allergic than higher than level is Immunoglobulin
reactions to
trauma 50000/cmm less than
plasma proteins
1.5 times preparations
Bleeding -Leuko- or when 80-
associated control 100mg/dl Saline albumin
poor massive blood
with liver levels Initially a tx for VW
solution
disease RBC’s loss or Dz, Hemophilia
All clotting
factors; no
Now a source of
Pts with febrile, replacement platelets fibrinogen in Salt-poor
non-hemolytic Can supplement obstetric
reactions to has occurred RBC’s when whole
blood not available
emergencies
albumin
plasma WBC’s for exchange
transfusion

Platelet normal dose: 1- Clotting disorders

concentrates dose: 12 - 1.5 -2 Haemophilia
(1 15ml/ kg packs/ 10 Liver disease
pack/10kg) kg
(4-
dose : 6units 5packs)
(8-10
packs)
Why blood transfusion ? (Indication)
 Severe blood loss following trauma or from any
pathology e.g. GI bleed
 During major operative procedures e.g. APR ,
cardiovascular surgery etc.
 Postoperatively in a patient who has become severely
anemic.
 Following severe burns (hemolysis)
 Preoperatively in pts of chronic anemia who require
urgent surgery.
 Pts with hemorrhagic disease e.g. hemophilia,
thrombocytopenia, liver disease etc.
 Blood products available..
 Whole blood
 Packed cells ( RBCs)
 Platelet concentrate
 Fresh frozen plasma
 Cryoprecipitate
 Factor VIII, factor IX concentrates, fibrinogen
 Others- Granulocytes, washed RBCS,
leukoreduced RBCs, SAG-M blood, human
albumin
 Blood Vs Blood components
 Whole blood is more likely carrier of
transfusion transmitted diseases.
 Most patients require only one particular
component of whole blood.
 Blood products have a better self life than
whole blood.
 Blood products can often be infused regardless
of ABO blood group.
 Hence whole blood is rarely used now a days.
 Whole blood
 Collected from a healthy and fit donor
 410 ml of blood is collected into a bag
containing 75 ml of CPD (anticoagulant)
 Stored at 4°C ± 2°C for up to 3-5 wks
(CPDA – 5 wks)
 Uses – “fresh” blood is used for resuscitation
in a pt severe acute blood loss
 Changes in stored blood
 White blood cells are rapidly destroyed.
 Platelets are functional only up to 24 hours
( due to cold temperature).
 Clotting factors VIII and V are labile and their
levels fall rapidly after 7 days.
 2,3 DPG level is decreased causing reduced
oxygen release into tissues.
 Higher temp can lead to transmission of
infections.
 Blood components Plasma fractions
Packed red cells platelets Fresh Cryoprec
Frozrn ipitate
Plasma
-Washed RBC’s when platelet. when PT & when Clotting factor
Pts with allergic reactions to plasma
proteins
count less PTT are fibrinogen concentrates
than higher than level is Immunoglobulin
-Leuko-poor 50000/cmm less than
RBC’s 1.5 times preparations
or when 80-
Pts with febrile, non-hemolytic control 100mg/dl Saline albumin
reactions to plasma WBC’s massive blood
levels Initially a tx for VW
solution
loss or All clotting Dz, Hemophilia
factors; no Now a source of
replacement platelets fibrinogen in Salt-poor
Can supplement obstetric
has occurred RBC’s when whole
blood not available
emergencies
albumin
for exchange
transfusion

Platelet normal dose: 1- Clotting disorders

concentrates dose: 12 - 1.5 -2 Haemophilia
(1 15ml/ kg packs/ 10 Liver disease
pack/10kg) kg
(4-
dose : 6units 5packs)
(8-10
packs)
 Packed red cells
 Obtained by centrifuging whole blood at 2000-
2300 g for 15-20 minutes and then removing the
plasma.
 Contains about 180 cc of RBCs + 30 cc of
plasma.( Total volume – 200-250 cc).
 Hematocrit – about 70-80 %
 Solutions like AS-1, AS-5, optisol etc is added
 No viable WBCs, platelets or clotting factors.
 Uses- chronic anemia, elderly, children,
deranged cardiac function.
Red blood cells
 Other RBC products..
 Washed red blood cells – Packed Cells are
washed with saline to remove the plasma and
proteins; reduces transfusion reactions.
 Leukoreduced red blood cells- WBCs are
removed using filters; reduces incidence of
non-hemolytic febrile reactions.
 Pediatric/ divided RBC units- smaller units are
prepared, each containing 45-50 cc of RBCs
and 15 cc of plasma.
 Platelet concentrate
 Freshly donated blood is centrifuged at 150-
200 g for 15-20 minutes. The supernatant is
removed and is called platelet rich plasma.
 This is again centrifuged at 1200-1500 g for
15-20 minutes to obtain platelet concentrate.
 Usually 4-6 platelet concentrates are pooled in
a single bag.
 Platelets can also be obtained by “apheresis”.
 Platelet concentrate…
 Stored at room temperature.
 Platelets viable for up to 72 hours.
 Uses- bleeding due to thrombocytopenia,
platelet dysfunction or some combination of
the two conditions. ( avoid platelet transfusion
in ITP with mild symptoms).
Platelet concentrate
 Fresh frozen plasma (FFP)
 Plasma removed from fresh blood (within 4
hrs) is rapidly frozen by immersing into solid
CO2 and ethyl alcohol mixture.
 Stored at -40°C to -50°C.
 A unit is about 200-250 cc in volume.
 Good source of all coagulation factors.
 Uses- severe liver failure, mild form of
individual clotting factor deficiencies e.g.
Christmas disease (IX) , hemophilia (VIII)
Fresh frozen plasma
 Cryoprecipitate
 FFP is allowed to thaw at 4°C and the
supernatant plasma is removed. The glutinous
precipitate is called cryoprecipitate.
 1 unit contains about 10-20 cc.
 Stored at -40°C.
 Very rich source of factor VIII & fibrinogen.
 Used in hemophilia, hypofibrinogenemia
Cryoprecipitate
 Individual factor concentrates
 E.g. factor VIII concentrate, factor IX
concentrate, fibrinogen etc
 Prepared by organic liquid fractionation of
plasma and stored in lyophilized powder form
(freeze-dried form).
 Stored at -50 to -60°C.
 Used for respective factor deficiencies.
Factor VIII concentrate
 SAG - Mannitol blood
 Plasma is removed from donated blood and
replaced by 100 cc of a crystalloid solution
( SAG-M) containing Sodium Chloride,
Adenine, Glucose and Mannitol.
 It increases the shelf life of RBCs (42 days)
and provides more volume to the recipient per
transfusion.
 Mainly used for top-up transfusions for
anemia.
 Complications of Blood
 Febrile reactions
Transfusion
Metabolic complications


 Bacterial contamination
 Hyperkalaemia
 Citrate toxicity & hypocalcaemia
 Immune reactions  Release of vasoactive peptides
 Physical complications  Release of plasticizers from PVC-
 Circulatory overload
phthalates
 Air embolism  Haemorrhagic reactions
 Pulmonary embolism  After massive transfusion of stored blood
 Thrombophlebitis  Disseminated intravascular coagulation
 ARDS  Transmission of disease
 Hepatitis, CMV. EBV
 AIDS (Factor VIII)
 Syphilis
 Brucellosis
 Toxoplasmosis
 Malaria
 Trypanosomiasis
 Haemosiderosis
 After repeated transfusion in patients with
haematological diseases
 PLASMA EXPANDERS

 Used for re-establishment of blood volume in

patients suffering from acute blood loss.
 Several products are available:
- Human albumin
- Dextrans
- Gelatin
- Hydroxyethyl starches
 Volume expanders
When a patient has lost a lot of body fluids but does not need
red blood cells or other specific blood components,
volume expanders may be given to prevent or treat shock
caused by fluid loss.
The most common Other
Crystalloids Colloids
solutions that contain large
solutions that contain sodium molecular weight that do not
readily cross capillary walls
normal lactated albumin hydroxyet dextrans purified
saline Ringer’s hyl starch protein
(HES), fractions
 Human albumin
 Obtained by repeated fractionation of plasma
followed by heat treatment.
 Available as 5% and 20% solutions.
 Can be stored for 1 year at room temperature
and upto 5 years at 2-8 °C.
 5% albumin used for hypovolemia and 20% for
severe hypoalbuminemia.
 Considered as ideal colloid.
 S/E: expensive, may transmit diseases.
 Dextrans
 Synthetic polysaccharide polymers.
 Iso-osmotic to plasma.
 High molecular weight (70,000) is used in
hypovolemia (1.5 gms/kg), whereas low
molecular weight (40,000) is used to increase
microcirculation in various conditions.
 S/E : interferes with platelet function,
increased rouleux formation, deranged
hemostasis, anaphylactic reactions.
 Gelatin
 It is used in a degraded form ( mol. weight
about 30,000) as plasma expander.
 Intermediate duration of action.
 Low rate of anaphylactic reaction.
 Hydroxyethyl starches
 Produced from sorghum or maize.
 Available in various molecular weights and
degree of substitution (tetra, penta or hepta-
starch)
 Susceptible to hydrolysis by non-specific
amylases in the blood.
 Duration of action > 6 hours.
 Less adverse effects – coagulopathy, itching,
anaphylactoid reaction
 Blood transfusion
 The blood must be crossed matched for patient
compatibility ( ABO and Rh factor).
 Warm the blood to avoid hypothermia.
 Filter is used ( 40µm) to filter off platelet
aggregates and leucocyte membranes.
 Usually given at a rate of 40 drops per minute
( 1 unit transfused in 4 hours) ; in emergency,
1-2 units can be given in 30 mins using a
pressure cuff.
 Autotransfusion
 Patient’s own blood is used.
 Particularly useful in elective surgery.
 Reduces the incidence of transfusion reactions
and infection transmission.
 3 techniques :
i) Predeposit transfusion
ii) Intraoperative acute normovolemic
hemodilution
iii) Intraoperative cell salvage