Surgery

1) Preoperative assessment of hemostasis.
Tests of hemostasis and blood coagulation: The most valuable part of this assessment is a careful history and physical examination. Specific questions should be asked to determine if there was a prior history of transfusion, untoward bleeding during a major surgical procedure, any bleeding after a minor operation, any spontaneous bleeding, or any family history of bleeding difficulties. The history should include a list of medications and underlying medical disorders (e.g., malignancy, liver or kidney disease) that may affect normal hemostasis. Laboratory studies also provide important clues of hemostatic ability. Platelet Count Spontaneous bleeding rarely occurs with a platelet count of greater than 50,000/mm3. Platelet counts in this range are usually adequate to provide hemostasis following trauma or surgical procedures if other hemostatic factors are normal. Bleeding Time This assesses the interaction between platelets and a damaged blood vessel and the formation of a platelet plug. Deficiencies in platelet number, platelet function, or some coagulation factors will yield a prolonged bleeding time. Prothrombin Time (PT) This test measures the extrinsic pathway of blood coagulation. Thromboplastin, a procoagulant, is added with calcium to an aliquot of citrated plasma, and the clotting time is determined. Partial Thromboplastin Time (PTT) A screen of the intrinsic clotting pathway. This test has a high sensitivity; only extremely PTT, used in conjunction with the PT, can help place a clotting defect in the first or second stage of the clotting process. Thrombin Time (TT) This screen detects abnormalities in fibrinogen and will detect circulating anticoagulants and inhibitors of anticoagulation. Tests of Fibrinolysis Fibrin degradation products (FDPs) can be measured immunologically. Preoperative Evaluation of Hemostasis There are four levels of concern (given the patient’s history and the proposed operation) that should dictate the extent of preoperative testing. Level I: The history is negative, and the procedure is relatively minor (e.g., breast biopsy or hernia repair). No screening tests are recommended. Level II: The history is negative and a major operation is planned, but significant bleeding is not expected. A platelet count, blood smear, and PTT are recommended to detect thrombocytopenia, circulating anticoagulant, or intravascular coagulation.

and a hematologist should be consulted. The body attempts to compensate with peripheral vasoconstriction. Class III Haemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops. Class IV Haemorrhage involves loss of >40% of circulating blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. with minimal derangements in vital signs. Care must be taken in the assessment of these patients. There is typically no change in vital signs and fluid resuscitation is not usually necessary. Local hemostasis. while having poor peripheral perfusion. • • Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. 2. less ability to compensate. such as operations using pump oxygenation or cell savers. In case of an emergency. Bleeding: types and causes. Fluid resuscitation with crystalloid and blood transfusion are usually necessary. retinal or cerebral associated with fatality . The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death. or malignancy should have the platelet count. Skin may start to look pale and be cool to the touch. and the fibrin clot should be checked to screen for abnormal fibrinolysis. The patient may exhibit slight changes in behavior. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss.Grade 1 petechial bleeding. conservative treatment. A PT and PTT should be used to evaluate coagulation. Grade 2 mild blood loss (clinically significant). and may take medications such as betablockers that can potentially blunt the cardiovascular response. This level also applies to situations where minimal postoperative bleeding could be detrimental. such as capillary refill worsens. PT. such as intracranial operations. Level IV: These patients have a known hemostatic defect or a highly suggestive history. and PTT checked preoperatively. Patients with liver disease. obstructive jaundice. the heart rate increases. peripheral perfusion (shock). and the patient is to undergo a procedure in which hemostasis may be impaired. According to WHO:Grade 0 no bleeding . Class II Haemorrhage involves 15-30% of total blood volume. assessment of platelet aggregation and a TT are indicated to detect dysfibrinogenemia or a circulating anticoagulant. These patients may look deceptively stable. A platelet count and bleeding time should be done to assess platelet function.Level III: The history is suggestive of defective hemostasis. requires transfusion (severe). and the mental status worsens. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Types of bleeding: four classes by the American College of Surgeons' • • Class I Haemorrhage involves up to 15% of blood volume. kidney failure. Blood transfusion is not typically required. Grade 4 debilitating blood loss. The same tests suggested for level III should be checked. Grade 3 gross blood loss.

Caused by a great or extreme amount of force applied over a period of time. and usually does not penetrate below the epidermis Excoriation . One of the most common causes of warfarin-related bleeding is taking antibiotics. such as "ibuprofen" (Motrin) and related drugs. Puncture Wound . Blunt trauma causes injury via a shock effect.Caused by an object that penetrated the skin and underlying layers. For instance.Caused by damage to a blood vessel that in turn causes blood to collect under the skin. the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). classic Hemophilia A . evaluation and treatment will vary with the mechanism of the injury. These include: • • • • • • • • • Abrasion . Vitamin K is required for the production of the clotting factors in the liver. such as a nail.  non-steroidal anti-inflammatory drugs (or "NSAIDs"). Incision . Penetrating trauma follows the . although it usually has an underlying medical cause Hematoma .  Deficiencies of coagulation factors are associated with clinical bleeding. are reversible and therefore. von Willebrand disease  warfarin . ulcerations. the effect on platelets is not as long-lived. Treatment The pattern of injury. Ballistic Trauma . In some instances.Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. or infection may lead to bleeding. this may include two external wounds (entry and exit) and a contiguous wound between the two Due to underlying medical conditions  underlying anatomic deformities. and thereby increase the risk of bleeding.Causes of bleeding Traumatic Traumatic bleeding is caused by some type of injury. This decreases vitamin K levels and therefore the production of these clotting factors. such as weaknesses in blood vessels (aneurysm or dissection). Warfarin acts by inhibiting the production of Vitamin K in the gut. arteriovenous malformation.Also called a graze.This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. delivering energy over an area.Christmas disease(hemophilia B). such as by a scalpel. made during surgery.Also known as a bruise. Wounds are often not straight and unbroken skin may hide significant injury.tissue death. The effect of aspirin is irreversible. which inhibits the production of thromboxane. needle or knife Contusion . Other NSAIDs. The gut bacteria make vitamin K and are killed by antibiotics. this is caused by mechanical destruction of the skin. Laceration . There are different types of wounds which may cause traumatic bleeding. NSAIDs inhibit the activation of platelets.A cut into a body tissue or organ. The prototype for these drugs is aspirin. this is caused by transverse action of a foreign object against the skin. therefore.In common with Abrasion. cancer. this can also be used to describe an incision. The extent of a crushing injury may not immediately present itself. this is a blunt trauma damaging tissue under the surface of the skin Crushing Injuries .Caused by a projectile weapon.

including bone and brain. Cooling also has been applied to control bleeding and acts by increasing the local intravascular hematocrit and decreasing the blood flow by vasoconstriction. Any body organ. Thermal Cautery effects hemostasis by denaturation of proteins. Local hemostasis The goal of local hemostasis is to prevent the flow of blood from incised or transected blood vessels.) at physiological concentrations. CaCl2 etc. Blood products Blood for transfusion is obtained from human donors by blood donation and stored in a blood bank. can be injured and bleed. Bleeding may not be readily apparent. and the Rhesus blood group system being the most important. which results in coagulation of large areas of tissue. ears may signal internal bleeding. As the energy is applied in a more focused fashion. blood plasma. so crossmatching is done to ensure that a compatible blood product is transfused. The finger has the advantage of being the least traumatic means of hemostasis. the ABO blood group system. generically known as plasma expanders. kidney and spleen may bleed into the abdominal cavity. such as the rectum. Bleeding from a medical procedure also falls into this category. KCl. complications. can be given intravenously. There are many different blood types in humans. or chemical. Cryogenic surgery uses temperatures between 20 and 180°C. Chemical . human serum albumin. and specific coagulation factor concentrates. such as dextrans. a plasma expander is a more effective life-saving procedure than a blood transfusion. either solutions of salts (NaCl. liquid preparations.. Intravenous administration Many forms of medication (from antibiotics to chemotherapy) are administered intravenously. cryoprecipitate. Ligature replaces a hemostat as a permanent method of hemostasis of a single vessel. because the metabolism of transfused red blood cells does not restart immediately after a transfusion. internal organs such as the liver. or fresh frozen plasma. including direct pressure over the bleeding area. Direct pressure is preferable and is not attended by the danger of tissue necrosis associated with a tourniquet. it requires less energy to cause significant injury. The only apparent signs may come with blood loss. but cannot be relied upon. The hemostat represents a temporary mechanical device to stem bleeding. The techniques may be classified as mechanical.After severe acute blood loss. Diffuse bleeding from multiple transected vessels may be controlled by mechanical techniques. Mechanical The oldest mechanical device to effect closure of a bleeding point or to prevent blood from entering an area of disruption is digital pressure. Gravitational suits have been used to create generalized pressure. often fatal.course of the injurious device. Transfusion of blood of an incompatible blood group may cause severe. or generalized pressure. or colloidal solutions. thermal. nose. pressure at a distance. Other blood products administered intravenously are platelets.. as they are not readily or adequately absorbed by the digestive tract. Bleeding from a bodily orifice. In these emergency situations.

and arterial vasoconstriction. One advantage to this is the patient receives his/her own blood instead of donor blood.  recovery of shed blood. and micronized collagen. To respond to hypovolemia is a task for the body fluid balance systems as well as osmotic balance systems.Following an acute response.Some chemicals act as vasoconstrictors. which tends to increase blood pressure.  Oxygentransporting artificial hemoglobin  perflurocarbon solutions can also reduce dependence on transfusion. this function is accomplished by two sets of receptors.  various pharmacology agents can also reduce blood loss. Decreased requirements for bank blood mitigate the scarcity of this vital resource. Epinephrine is a vasoconstrictor. and filters blood so it can be given back to the patient's body instead of being thrown away. the intraoperative cell salvage machine suctions. reductions of blood loss. but because of its considerable absorption and systemic effects.  Anesthetic and/or surgical techniques can be chosen to reduce bleeding. and artificial oxygen transporters. . These include less transfusion reactions and decreased transmission of infections. Local hemostatic materials include gelatin foam. 4. Because the blood is recirculated.  normovolemic hemodilution. others are procoagulants. cellulose. Pathogenesis of blood loss. 3. there is no limit to the amount of blood that can be given back to the patient. the most promising are marrow stimulation. heart rate. where a lack of activation of baroreceptors results in elevation of total peripheral resistance and cardiac output via increased contractility of the heart. Of the above techniques. one in the kidneys and the other in the heart. washes. it is generally used only on areas of mucosal oozing.  Cell Saver (Intraoperative Cell Salvage Machine)Commonly known as a "cell saver". The cell saver is also a viable alternative for patients with religious objections to receiving blood transfusions this is one way of donation on autologous blood. Blood-loss reduction strategies have numerous benefits for the patient. so there is no risk of contracting outside diseases. and others have hygroscopic properties that aid in plugging disrupted blood vessels. Possibilities of blood saving during the operation. Acute response: The first response to hypovolemia is an inversed baroreflex. The techniques for blood "savings" include  lowering the transfusion trigger  stimulation of the marrow with erythropoietin  pre-donation.

initiates the conversion of a protein called angiotensinogen to angiotensin. as intravascular fluid decreases. contribute to elicit thirst. Physiologically. These cells secrete a hormone called renin when there is a decrease in the flow of blood to the kidneys. In order to exert its effects on the body. leading to the reabsorption of water. Fluid is passively transferred from all of the fluid compartments in the body. when the volume of blood being transported back to the heart is decreased. angiotensin II stimulates the release of hormones by the posterior pituitary gland (ADH. Naturally.. by affecting the subfornical organ. Aldosterone causes the kidneys to reabsorb sodium.Kidney:The kidneys have a specialized set of cells called granular cells that enable the recognition of changes in blood flow to the kidneys. ADH (vasopressin) also causes the kidneys to reabsorb water. including intracellular.1500mls) Cardiac output cannot be maintained by arterial constriction Tachycardia . these receptors detect the change in the amount of blood thereby reducing the release of atrial natriuretic peptide. these atrial baroreceptors detect the amount of blood that is being pumped back into the heart from the veins. these cells detect the presence of hypovolemia and react accordingly to the loss of blood volume. Stages of Hypovolemic Shock Stage 1 Up to 15% blood volume loss (750mls) Compensated by constriction of vascular bed Blood pressure maintained Normal respiratory rate Pallor of the skin Slight anxiety Stage 2 15-30% blood volume loss (750 . Thirst Both the activation of the renin angiotensin system and the decrease in atrial natriuretic peptide. Commonly referred to as stretch receptors. blood pressure is reduced and some compensation occurs as fluid from other cellular compartments moves into the vasculature. Other responses Furthermore. The body constantly returns blood to the heart through veins. also known as vasopressin) and the adrenal cortex (aldosterone). Heart: The next set of receptors responsible for detecting volumetric insufficiency are located in the heart atria. angiotensin II. along with their other functions. Angiotensin II increases blood pressure by contracting arterial muscles. interstitial and other extravascular compartments. Renin flows into the blood and there. angiotensin I must be converted by enzymes into its active form.. Therefore.

conduct a secondary survey and . diminished blood pressure. Hypovolemia can be recognized by elevated pulse. Note that in children. and extremely pale (moribund) 6. lips and nail beds.Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating from sympathetic stimulation Mildly anxious/Restless Stage 3 30-40% blood volume loss (1500 . or very thirsty. These signs are also characteristic of most types of shock. Also consider possible mechanisms of injury (especially the steering wheel and/or use/non-use of seat belt in motor vehicle accidents) that may have caused internal bleeding such as ruptured or bruised Landon internal organs. classes of blood loss. The patient may feel dizzy. Diagnosis Clinical symptoms may not be present until 10-20% of total whole-blood volume is lost. nauseated. This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should always be treated aggressively. Also look for obvious signs of external bleeding while remembering that people can bleed to death internally without any external blood loss.2000mls) Systolic BP falls to 100mmHg or less Classic signs of hypovolemic shock Marked tachycardia >120 bpm Marked tachypnoea >30 bpm Decreased systolic pressure Alteration in mental status (Anxiety. If trained to do so and the situation permits. and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead. Signs and diagnosis of blood loss. faint. Agitation) Sweating with cool. cool. pale skin Stage 4 Loss greater than 40% (>2000mls) Extreme tachycardia with weak pulse Pronounced tachypnoea Significantly decreased systolic blood pressure of 70 mmHg or less Decreased level of consciousness Skin is sweaty. compensation can result in an artificially high blood pressure despite hypovolemia.

(Injuries to the pelvis and bleeding into the thigh from the femoral artery can also be life-threatening. 60 days after transfusion. Packed Red Cells and Frozen Red Cells Packed cells have approximately 70 percent of the volume of whole blood. A decrease in circulating blood volume also results in tachycardia in response to decreased stroke volume from inadequate preload. and ammonia and a decrease in pH. Fresh Whole Blood This term refers to blood given within 24 h of its collection. Rh-negative recipients should be transfused only with Rh negative blood. Care must be taken in the assessment of these patients. and Rh groups. Principles of treatment of blood loss. Orthostatic testing may unmask cardiovascular instability 7. The hematocrit can be used to estimate blood loss. including increases in lactate. and XI are stable in banked blood. reflex mechanisms allow the body to accommodate up to moderate-size blood losses. These patients may look deceptively stable. IX. less ability to compensate. potassium.) Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. Replacement Therapy Banked whole blood is stored at 4°C and has a storage life of up to 35 days. VII. Typing and Crossmatching Serologic compatibility is routinely established for donor and recipient A. Loss of blood during operation may be estimated by weighing the sponges (representing about 70 percent of the true loss). red cell metabolism and plasma protein degradation result in chemical changes in the plasma. guarding or swelling. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss. Factor VIII rapidly deteriorates during storage.check the chest and abdominal cavities for pain. and may take medications such as betablockers that can potentially blunt the cardiovascular response. Up to 70 percent of transfused erythrocytes remain in the circulation 24 h after transfusion. Banked blood is a poor source of platelets. In the normal person. deformity. B. O. but up to 72 h is required to establish a new equilibrium after a significant blood loss. If it is known that the prospective recipient is group AB. In the patient receiving repeated transfusions. while having poor peripheral perfusion. Signs: The pale. Approximately 14 percent of all inpatient operations include blood transfusions. approximately 50 percent of the cells will survive. Emergency transfusion can be performed with group O blood. group A blood is preferable. Blood provides transportation of oxygen to meet the body’s metabolic demands and removes carbon dioxide. Banked blood is rarely indicated. Factors II. cool skin noted on examination and the blanching of the bowel with decreased pulses in the mesentery are gross signs seen at the bedside and at laparotomy. During the storage of whole blood. Significant hypotension develops only after about a 40 percent loss of blood volume. serum drawn less than 48 h before cross-matching should be used. Use of frozen cells markedly reduces the risk of infusing antigens to which the . with minimal derangements in vital signs. As a rule. Volume Replacement The most common indication for blood transfusion in the surgical patient is the restoration of circulating blood volume.

Fresh Frozen Plasma and Volume Expanders Factors V and VIII require plasma to be fresh or freshly frozen to maintain activity. VIII. and 80 percent after more than 100 transfusions. Albumin also may be used as a concentrate (25 g has the osmotic equivalent of 500 mL). and XI. raising hemoglobin levels above 7–8 g/dL provides little additional benefit. Fresh frozen plasma is used in the treatment of a coagulopathy in patients with liver disease. Isoantibodies are demonstrated in about 5 percent of patients after 1–10 transfusions. 20 percent after 10–20 transfusions. Replacement of Clotting Factors Supplemental platelets or clotting factors may be required in the treatment of certain hemorrhagic conditions. deficiency in factors V.patients have previously been sensitized. impaired platelet function.3-DPG) concentrations are maintained. thrombocytopenia due to inadequate production. a plasma level greater than 100 mg/dL should be maintained. The simplest factor VIII concentrate is plasma cryoprecipitate. If fibrinogen is required. and the increased acid load of stored blood products. The rigid use of PT and PTT to anticipate the effect of fresh frozen plasma is not justified. Improvement in Oxygen-Carrying Capacity Transfusion should be performed only if treatment of the underlying anemia does not provide adequate blood counts for the patient’s clinical condition. Fluosol-DA. including thrombocytopenia. In general. provides oxygen-carrying capacity in the absence of blood products. A number of problems may accompany the use of massive transfusion. and qualitative platelet disorders.3diphosphoglycerate (2. HLA-compatible platelets minimize this problem. and the ATP and 2. Platelet Concentrates Platelet transfusions should be used for thrombocytopenia due to massive blood loss replaced with stored blood. . The risk of hepatitis is the same as that of whole blood or packed red cells. lactated Ringer’s solution can be administered in amounts two to three times the estimated blood loss. In emergency situations. Concentrates Antihemophilic concentrates are prepared from plasma with a potency of 20–30 times that of fresh frozen plasma. Dextran or lactated Ringer’s solution with albumincan be used for rapid plasma expansion. Massive Transfusion This term refers to a single transfusion of greater than 2500 or 5000 mL over a 24h period. but its efficacy is very low. A whole blood substitute. The red cell viability is improved. with the advantage of being hepatitis-free.

The red blood cells (together with endothelial vessel cells and other cells) are also . use of blood components. By volume. the circulatory fluid would be too viscous for the cardiovascular system to function effectively.1 million (male). composed of plasma and several kinds of cells these formed elements of the blood are erythrocytes. 4. Blood components. the plasma constitutes about 55%.7 to 6.4 million (female) erythrocytes: In mammals. leukocytes) and thrombocytes . Cells Further information: Complete blood count One microliter of blood contains: • 4. In addition.2 to 5. if all human hemoglobin were free in the plasma rather than being contained in RBCs.8. the red blood cells constitute about 45% of whole blood. The average adult has a blood volume of roughly 5 liters. its flow properties are adapted to flow effectively through tiny capillary blood vessels with less resistance than plasma by itself. mature red blood cells lack a nucleus and organelles. Whole blood exhibits non-Newtonian fluid dynamics. They contain the blood's hemoglobin and distribute oxygen. and white cells constitute a minute amount.

000 thrombocytes: 45 ± 7 (38 – 52%) for males thrombocytes. Plasma also circulates hormones transmitting their messages to various tissues. as well as attack infectious agents (pathogens) and foreign substances.45 is too alkaline. It is essentially an aqueous solution containing 92% water. The combined surface area of all red blood cells of the human body would be roughly 2. Possibilities of use of autologous blood. HCO3 21 mM – 27 mM Oxygenated: 98 – 99% Oxygen saturation Plasma Deoxygenated: 75% About 55% of whole blood is blood plasma. This fibrin creates a mesh onto which red blood base excess -3 to +3 cells collect and clot. such as glucose. Other important components include: • • • • • • Serum albumin Blood-clotting factors (to facilitate coagulation) Immunoglobulins (antibodies) lipoprotein particles Various other proteins Various electrolytes (mainly sodium and chloride) The term serum refers to plasma from which the clotting proteins have been removed.45).7 – 3. also called platelets. partial pressure of oxygen (pO2). carbon dioxide.40 (normal range is 7. a fluid that is the blood's liquid medium. There are actually at least three kinds of autologous procedures: . 9. and lactic acid. urea.000 leukocytes: White blood cells are part of the immune system. and removes waste products.35 – 7.0 litres in an average human. partial pressure of carbon dioxide (pCO2).35 – 7. The normal pH of human arterial blood is approximately 7. and HCO3 are carefully regulated by a number of homeostatic mechanisms. which by itself is straw-yellow in color. Blood pH. The blood plasma volume totals of 2.marked by glycoproteins that define the different blood types. which exert their influence principally through the respiratory system and the urinary system in order to control the acid-base balance and respiration. prior to a scheduled elective surgery. The list of normal reference ranges for various blood electrolytes is extensive. are Hematocrit 42 ± 5 (37 – 47%) for females responsible for blood clotting (coagulation). amino acids.000-500. Plasma circulates dissolved nutrients.35 is too acidic. 8% blood plasma proteins.8 kPa (35 – 45 mm Hg) prevent bacteria from entering the body.8 – 5.000 times as great as the body's exterior surface. whereas blood pH above 7. such as. which then stops more PO2 10 – 13 kPa (80 – 100 mm Hg) blood from leaving the body and also helps to PCO2 4. • 4. and is normally about 45%. they destroy and remove old or aberrant cells and cellular debris. The proportion of blood occupied by red blood cells is referred to as the hematocrit. Parameter Value • 200. and fatty acids (dissolved in the blood or bound to plasma proteins). Autologous blood can be used for donation: when a person donates blood for their own use. Most of the proteins remaining are albumin and immunoglobulins. a weakly alkaline solution. Blood that has a pH below 7. pH 7. The cancer of Constitution of normal blood leukocytes is called leukemia.000-11.45 They change fibrinogen into fibrin. and trace amounts of other materials.

The preoperative autologous donation is the most common of the three procedures. When the blood is given back to the patient. and hemoglobin based. which can be collected and returned to the patient via transfusion. white blood cells defend against disease. platelets promote clotting. there is no limit to the amount of blood that can be given back to the patient. During some surgical procedures. and friends are all screened and tested to minimize any risk of transmitting infectious disease. D5W (dextrose 5% in water) or colloid-based (Voluven.  Eliminate the risk of acquiring infectious diseases from blood tranfusions. by using your own blood you don't reduce the community blood supply and you leave it for people who may need it. Utilizes a machine called a cell saver. PolyHeme and Perftoran. Hemopure.  Postoperative cell salvage .  Though blood from strangers. Pre-operative autologous donation . • Oxygen therapeutics are in turn broken into two categories based on transport mechanism: perfluorocarbon based.  Also. Blood substitutes also called artificial blood are used to fill fluid volume and/or carry oxygen and other blood gases in the cardiovascular system. Examples: Perftec. washes.Done usually after the patient leaves the operating room. there can be an accumulation of blood in the body.  Intra-operative salvage . Cell Saver (Intraoperative Cell Salvage Machine) Commonly known as a "cell saver". . Because the blood is recirculated. The cell saver is also a viable alternative for patients with religious objections to receiving blood transfusions. family. Red blood cells transport oxygen. Blood substitutes. Haemaccel. so there is no risk of contracting outside diseases. the intraoperative cell salvage machine suctions. and oxygen therapeutics for oxygen-carrying products. 10. autologous donation remains the only way to eliminate the risks.patient donates his/her own blood prior to surgery. and filters blood so it can be given back to the patient's body instead of being thrown away. Gelofusin). it is called an autologous blood transfusion. Oxygen therapeutics: mimic human blood's oxygen transport ability. normal saline. the term is not accurate since human blood performs many important functions. Oxygent. These may be crystalloid-based (Ringer's lactate. One advantage to this is the patient receives his/her own blood instead of donor blood. Although commonly used. The blood which a patient donates prior to their scheduled elective surgery is stored and saved for their use. Examples of these two "blood substitute" categories: • Volume expanders: inert and merely increase blood volume. use of blood substitutes. and plasma proteins perform various functions.a way of saving blood lost during surgery so it can be returned to the patient. The preferred and more accurate are volume expanders for inert products.

oxygen delivery may still be about 75 percent of normal. In extreme cases. The heart pumps more blood with each beat. When blood is lost. patients have survived with a hemoglobin level of 2 g/dl. A patient at rest uses only 25 percent of the oxygen available in his blood. only used in cases of great physical exertion. Normal human blood has a significant excess oxygen transport capability.Volume expanders are widely available and are used in both hospitals and first response situations by paramedics and emergency medical technicians. . As a result of chemical changes. The body automatically detects the lower hemoglobin level and compensatory mechanisms start up. packed red blood cells. the now diluted blood flows more easily. In these situations the only alternatives are blood transfusions. These adaptations are so effective that if only half of the red blood cells remain. Since the lost blood was replaced with a suitable fluid. the greatest immediate need is to stop blood loss. even if volume expanders maintain circulatory volume. less than 1/3rd of a healthy person. about 1/7th the norm. This way remaining red blood cells can still oxygenate body tissue. However in some circumstances hyperbaric oxygen therapy can maintain adequate tissue oxygenation even if red blood cell levels are below normal life sustaining levels. although levels this low are very dangerous. a quiescent patient can safely tolerate very low hemoglobin levels. Provided blood volume is maintained by volume expanders. With enough blood loss. or oxygen therapeutics (if available). ultimately red blood cell levels drop too low for adequate tissue oxygenation. more oxygen is released to the tissues. even in the small vessels. The second greatest need is replacing the lost volume.

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