Bleeding and Blood Transfusion

Lugyanti Sukrisman, MD, PhD

Division of Hematology-Medical Oncology
Dept. of Internal Medicine, Faculty of Medicine
Universitas Indonesia/Cipto Mangunkusumo Hospital

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 HEMOSTASIS:THE CONTROL OF BLEEDING

1. The interaction of the blood vessel & supporting structures

2. The circulating platelet & its interaction with the disrupted
vessel
3. The formation of fibrin by the coagulation system
4. The regulation of the extension of the blood clot by
inhibitors & fibrinolytic system
5. The remodelling &repair of the injury site after the arrest of
bleeding

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Goodnight, Mechanisms of hemostasis & thrombosis, 2001 D edikasi
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 SUBCUTANEOUS BLEEDING
1. Petechiae: 2. Ecchymosis:
• Pinpoint (<1 mm) • a flat subcutaneous
hemorrhages that do not extravasation of blood,
blanch with pressure relatively non specific
• Results from capillary • easy bruising/purpura
bleeding simplex
• Platelet defects: the
main cause of petechiae

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Vermylen, Clinical approach to the bleeding patients, 2008 P eduli
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 SUBCUTANEOUS BLEEDING
3. Hematoma:
• due to a continuous oozing of blood from an
injured vessels
• Often as results of a disturbances of the clotting
systems rather than of platelet

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Vermylen, Clinical approach to the bleeding patients, 2008
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CLINICAL APPROACH

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 INITIAL URGENT MEASURES
• Estimate the extent of blood loss
• Acute phase: hypotension, tachycardia
• Any suspicion of an important hemostatic defect: AVOID
PUNCTURE OF A NECK VEIN/ARTERY
• Initial blood samples:
– Blood grouping & crossmatching
– Blood cell counting (FBC/CBC)
– PT, APTT, fibrinogen
– Limited biochemical screening
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 1. Is this really hemostasis disorder?

Bleeding from single site: • Simultaneous bleeding from

• Isolated epistaxis several sites
• Hematemesis • Simultanoeus presence of
• Hematuria purpura
• Menorrhagia • Oozing form puncture sites

LOCAL VASCULAR DEFECT UNDERLYING HEMORRHAGIC

DIATHESIS
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2. Is the bleeding serious/trivial? appropriate for the
injury?
3. bleeding tendency developed recently/ always been
present?
4. Is there a past history of bleeding?
5. What medications have been given?
6. Is there a family history of bleeding?

• Vermylen, Clinical approach to the bleeding patients, 2008 P rofesional

• Goodnight, Evaluation of bleeding in the hospitalized patient, 2001 A manah
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7. Is there any known underlying medical
condition?
– Hematologic disorders: APL, DIC, etc
– Liver diseases
– Immune disorders, etc.
8. Relationship to medical/surgical problem/
management?

• Vermylen, Clinical approach to the bleeding patients, 2008 P rofesional

• Goodnight, Evaluation of bleeding in the hospitalized patient, 2001 A manah
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 TREATMENT STRATEGIES
FOR ACUTE BLEEDING

• Peripheral venous line à fluid replacement;

A-B-C step of rescuscitation
• Blood grouping & crossmatching à transfusion of blood
component:
– Packed red cells (PRC)
– Platelets
– Fresh frozen plasma (FFP)
– Cryoprecipitate
• Surgical/medical problem?

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 Blood Transfusion
• Lifesaving procedure; one of the
most common medical procedures
performed in hospital.
• Benefit vs. risk: should be justified by
immediate or long-term benefits.
• Things taken into account before
transfusion: the rate & amount of
haemorrhage, patient’s age, co-
morbidities, severity of illness.

Sharma S, Sharma P. Transfusion of blood and blood products: Indications and complications. Am Fam Physician 2011;83(6):719-24; Lotterman S, Sharma S.
Blood transfusion. StatPearls. 2019 Feb 16; Szczepiorkowski Z, Dunbar NM. Transfusion guidelines: When to transfuse. ASH Education Book 2013;1:638-44.
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 Blood Components

Dayyal Dg. Preparation of blood components from whole blood for transfusion. 2019 Jan 31. BioScience.
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 Blood Components

Dayyal Dg. Preparation of blood components from whole blood for transfusion. 2019
Jan 31. BioScience.
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 TRANSFUSION:
BLOOD COMPONENT

• Patients only received blood component he/she needs

• Reduced the volume transfused
• Reduced the transfusion reaction
• Maximized utilization of blood source
• Optimal temperature & storage method of each blood component

SAFE and APPROPRIATE USE

in blood transfusion service
(rational useà appropriate use)
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 FRESH WHOLE BLOOD

• High capacity to carry oxygen

• Low plasma potassium level
• Definition: vary; USA : storage time 3-7 days
Indonesia: 48 hours
• Only for certain patients:
– Premature babies
– Neonates – exchange transfusion
– Shock patients
– Massive bleeding/transfusion
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 TRANSFUSION OF RED CELLS

• Over the years, trigger for transfusion has become

more conservative or restrictive.
• Transfusion is rarely indicated when the hemoglobin
level is above 10 g/dL and is almost always indicated
inpatients when the hemoglobin level is below 6 g/dL;
• The determination of transfusion in patients whose
hemoglobin level is 6-10 g/dL should be based on:
– the rate and magnitude of any potential or actual
bleeding,
– the patient’s intravascular volume status
– any ongoing indication of organ ischemia or risk of
complications due to inadequate oxygenation.
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 Indications of Blood Transfusion

Yaddanapudi S, Yaddanapudi LN. Indications for blood and blood product transfusion. Indian J Anaesth. 2014;58(5):538-42

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WARMING BLOOD
•No evidence that warming blood is beneficial to the patient
when infusion is slow
•Most commonly required in :
• Large volume rapid transfusions :
- Adults : greater than 50 ml/kg/hour
- Children : greater than 15 ml/kg/hour
• Exchange transfusion in infants
• Patients with clinically significant cold agglutinins.
Blood should only be warmed in a blood warmer
Blood warmers should have a visible thermometer and an
warning alarm and should be properly maintained. P rofesional
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 RBC Transfusion

• Prepared from whole blood by removing approximately 250

mL of plasma.
• Each unit of RBCs with a volume of 300 mL transfused
contains approximately 200 mL RBCs.
• One unit of packed RBCs should increase levels of Hb 1 g/dL
and Hct 3%.
• ABO group of RBC products must be compatible with ABO
group of recipient.
• Rate of transfusion:
– Transfuse slowly for first 15 minutes.
– Complete transfusion within 4 hours (per FDA).
P rofesional
A manah
Schrijvers D. Management of anemia in cancer patients: Transfusions. The Oncologist 2011;16(suppl 3):12-8; NCCN Clinical Practice P eduli
Guidelines in Oncology. Hematopoietic growth factors. Version 2.2019; Calabrich A, Katz A. Management of anemia in cancer patients. D edikasi
Future Oncol. 2011;7(4):507-17.
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 Platelets
Platelet transfusion may be indicated
to prevent haemorrhage in patients
with thrombocytopenia or platelet
function defects.

Contraindications:
thrombotic thrombocytopenic
purpura, heparin-induced
thrombocytopenia,
à further thrombosis.

Sharma S, Sharma P. Transfusion of blood and blood products: Indications and complications. Am Fam Physician 2011;83(6):719-24
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What is an adequate platelet count for
procedures ?

• No clinical studies have been established

• The British Committee for Standards in Hematology
has recommended the following:
- dental extraction: 30,000 / uL
- regional dental block: 30,000 / uL
- minor surgery: 50,000/ uL
- major surgery: 80,000/ uL

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 Plasma (FFP)

• Plasma contains all of the

coagulation factors.
• Plasma products include: fresh
frozen plasma and thawed
plasma.
• Fresh frozen plasma can be used
for reversal of anticoagulant
effects.
• Thawed plasma à lower levels
of factors V & VIII, is not
indicated for DIC.
Sharma S, Sharma P. Transfusion of blood and blood products: Indications and complications. Am Fam Physician 2011;83(6):719-24 P rofesional
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 Cryoprecipitate

• Prepared by thawing fresh frozen

plasma and collecting the
precipitate.
• Contains high concentrations of
factor VIII and fibrinogen.
• Used in cases of hypofibrinogenemia
à massive haemorrhage or
consumption coagulopathy.
• Each unit à raising fibrinogen level
by 5-10 mg per dL.

Sharma S, Sharma P. Transfusion of blood and blood products: Indications and complications. Am Fam Physician 2011;83(6):719-24 P rofesional
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 Kasus
• Tn. S, 56 tahun, KU: cepat lelah sejak 1 bulan yang lalu.
• Pasien dirawat karena muntah berwarna hitam 1 hari
sebelum masuk RS. Tidak ada demam, tetapi perut
membesar dan kaki bengkak sejak 1 minggu yang lalu.
• PF: compos mentis, TD 100/60, N 92/menit, konjungtiva
pucat, sklera ikterik, abdomen membuncit, edema di
kedua tungkai.
• Lab: Hb 8 g%, leukosit 5.200/mm3, trombosit
80.000/mm3, albumin 2,8/globulin 3,5 gr/dL.
• Pasien dengan sirosis hati. P rofesional
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 Pertanyaan
• Apakah pasien perlu transfusi darah?
• Jika ya, komponen darah apa yang diperlukan untuk
pasien ini?
• Jika pasien mengalami hematemesis terus-menerus,
pemeriksaan laboratorium apa yang anda
rencanakan dan transfusi apa yang perlu
dipertimbangkan?

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 Take Home Message
• Blood transfusion is lifesaving procedure and one
of the most common medical procedures
performed in hospital.
• Benefit vs. risk: should be justified by immediate
or long-term benefits.
• Transfusion of blood components: the patient
only received blood component needed à safe
and appropriate use in blood transfusion service.

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