Transcript BLOOD AND BLOOD PRODUCTS TRANSFUSION IN OBSTETRICS

COMPONENT THERAPY IN
MASSIVE OBSTETRIC
HAEMORRHAGE
Dr. Mona Shroff, M.D.(O&G)
Dr Mona Shroff
www.obgyntoday.info
1
MASSIVE OBSTETRIC HAEMORRHAGE

DEFINITION
Any blood loss
occurring in the
peripartum period,
revealed or concealed,
that is likely to
endanger life
N.B.
Physiological & hematological
changes induced by pregnancy can
hide signs of hypovolemic shock &
patient can collapse suddenly.
Dr Mona Shroff
www.obgyntoday.info
2
Massive transfusion
Massive blood loss may be defined as:
Loss of one blood volume within a 24
hour period.
(7% of lean body weight (5 litres in an
adult)
 Loss of 50% of blood volume within 3
hours.
 Loss of blood at a rate in excess of
150 ml. per minute.

Dr Mona Shroff
www.obgyntoday.info
3
Purpose of Blood transfusion
 Maintenance
of oxygencarrying capacity of the blood
 Replacement of clotting
factors
 Replacement of vascular
volume
Dr Mona Shroff
www.obgyntoday.info
4
Three primary reasons driving the quest
for a substitute for Blood:
Quantity
Chronic shortages
Purity
h/o “ooze for booze” leading to tainted
blood products
infections
Storage
blood is perishable
long and short term storage is an expensive
problem
Dr Mona Shroff
www.obgyntoday.info
5
REMEMBER…
THE DECISION FOR BLOOD
TRANSFUSION SHOULD
ALWAYS BE A BALANCE
BETWEEN
6
SYMPTOMS & SIGNS
Blood loss Systolic BP Signs & Symptoms
(% B Vol)
( mm of Hg)
10-15
Normal
postural hypotension
15-30
slight fall
30-40
60-80
40+
40-60
PR, thirst,
weakness
pallor,oliguria,
confusion
anuria, air hunger,
coma, death
Dr Mona Shroff
www.obgyntoday.info
7
8
1-Every obstetric unit should have a
current protocol for major obstetric
haemorrhage and all staff should be
trained to follow it.
2-Initial resuscitation with
replacement fluids (crystalloid (RL)3ml / ml of blood loss) is a priority to
restore blood volume
Dr Mona Shroff
www.obgyntoday.info
9
DIC is a consequence of
delayed or inadequate
resuscitation
Dr Mona Shroff
www.obgyntoday.info
10
3-Obtain and send 2 blood samples:
*To
blood bank for grouping and
crossmatching
(crossmatch is not required after replacement of
1 blood volume (8 Units in adults) as the cells by
then are unrepresentative.)
*To lab to obtain baseline for Hb, Htc, PT, PTT
,platelet count & fibrinogen levels
4- Inform blood bank that it is an emergency
Dr Mona Shroff
www.obgyntoday.info
11
Give Packed Red Cell
5- Initial packed red cell infusion to restore O2
delivery to tissues


Fully matched blood
Group O Rh –ve cells
should be available in 5 minutes

Group specific uncrossmatched
blood (1/3 of the patient’s estimated blood
volume has been lost.)
Dr Mona Shroff
www.obgyntoday.info
12
6-Component replacement therapy
according to coagulation screen
7- Continuous lab & clinical monitoring
to guide treatment.
( REPEAT AS SERIAL ESTIMATIONS every 4
hours or more often, as necessary after
component therapy.)
Dr Mona Shroff
www.obgyntoday.info
13
Base treatment on need to:–
Maintain fibrinogen level above
1 g/l.
 – Maintain PT and APPT less than
1.5 times control value
 – Stop persistent active bleeding

–
Dr Mona Shroff
www.obgyntoday.info
14
Whole
blood
-Fresh
-old
DIVC
Massive
haemorrha
ge
Blood components
Packed
red
cells
platelets
Fresh
Frozrn
Plasma
Cryopreci
pitate
or when
massive
replacement
when PT
& PTT
are
higher
than 1.5
times
control
levels
when
fibrinogen
level is
less than
80100mg/dl
Platelet
concentrate
(1
pack/10kg)
dose :
6units RDP
or 1 unit
normal
dose: 12
- 15ml/
kg
(45packs)
when pl
Washed count <
50000/cmm
RBC’s
Pts with
allergic
reactions to
plasma proteins
Leukopoor
RBC’s
Pts with
febrile, nonhemolytic
reactions to
plasma WBC’s
Plasma
fractions
dose: 11.5 -2
packs/ 10
kg
(8-10
packs)
Immunoglobuli
n preparations
Saline albumin
solution
Clotting factor
concentrates
Salt-poor
albumin
Clotting disorders
Haemophilia
Liver disease
15

8- Massive transfusion of stored whole blood
can aggravate coagulopathy due to:
- Dilutional thrombocytopenia
- Coagulation factor depletion
- Acidosis
- Hypothermia
thus




1 unit of fresh blood for every 5 – 10 units of stored blood
IV 10% calcium gluconate 10 mls with every litre of
transfused citrated blood
Warming blood
Microaggregate blood filters
Dr Mona Shroff
www.obgyntoday.info
16
Fresh Frozen Plasma
200-250 ml of plasma containing all
clotting factors, AT III, Protein C & S.
 Compatibility Important
 Can Give: A plasma to A or O patient
B plasma to B or O patient
O plasma to O patient
AB plasma to anyone

Dr Mona Shroff
www.obgyntoday.info
17
Guidelines: FFP Use
 Usual
dosing: 10-15ml/Kg
 15-20% rise in factor levels
 Usually does not correct
laboratory coagulation status
to “normal”
 Evidence
for its use as prophylaxis
in nonbleeding patients, is limited
Dr Mona Shroff
www.obgyntoday.info
18
Cryoprecipitate
 10-15
ml per unit (bag)
 Fibrinogen
250 mg
 Factor VIII
80-120 units
 Von Willebrand Factor 40-70% of
FFP
 Factor XIII 20-30% of FFP
 Fibronectin
20-40 mg
Dr Mona Shroff
www.obgyntoday.info
19
Cryoprecipitate: Dosing
1-2 Units / 10 Kg
 Expect 60-100 mg/dl rise in fibrinogen
 Goal: Fibrinogen 70-100 mg/dl
 Patients on massive transfusion protocol
and receiving greater than 10 units of
FFP generally do not need additional
cryoprecipitate, having received an
adequate bolus of fibrinogen in the large
quantity of FFP.

Dr Mona Shroff
www.obgyntoday.info
20
Platelets: Risk of Spontaneous
Hemorrhage
Count
> 40,000
20-40,000
5-20
< 5
Site
Minimal
GI Mucosa
Skin,Mucus Membranes
CNS, Lung
Dr Mona Shroff
www.obgyntoday.info
21
Prophylactic Platelet TX Guidelines
Platelet Count/μl
0-5,000
5-10,000
11-20,000
>20,000
Recommendation
Always
If Febrile of Minor Bleeding
If coagulopathy / minor
procedure
If Major Bleed / invasive
procedure
Dr Mona Shroff
www.obgyntoday.info
22
Transfused Platelets/Survival
6 units = 1 single donor unit (SDP);
available as ¼, ½ and full SDP
 Dose: adult 1 unit/8-10 kg



Lifespan: 7-10 Days Native
2-3 Days Transfused
Factors shortening Lifespan:




Fever, Sepsis
HLA, Platelet Specific Abs
DIC
Product Age?
Dr Mona Shroff
www.obgyntoday.info
23
rFVIIa





Recombinant activated factor VII (rFVIIa)
is synthesized human factor VII that is
available for reconstitution and infusion in
patients with massive hemorrhage.
Decrease in RBC requirement ,a trend
toward improved survival and reductions in
critical morbidities.
Thrombosis ??
Dosing guidelines for h’ge (general range,
90-120 mcg/kg of body weight) have yet to
be established
Cost of rFVIIa is over $3000 / patient
Dr Mona Shroff
www.obgyntoday.info
24
Types of Replacement Products under
research

Oxygen Carrying Solutions
Hemoglobin Based Oxygen Carrying
Solutions (HBOCS)
 Perflourocarbons


Other
Antigen Camouflage
 Recombinant Plasma Proteins
 Transgenic Therapeutic Proteins
 Platelet Substitutes

Dr Mona Shroff
www.obgyntoday.info
25
Complications of Blood
Transfusion




Febrile reactions
Bacterial
contamination
Immune reactions
Physical
complications
 Circulatory
overload
 Air embolism
 Pulmonary
embolism
 Thrombophlebitis
 ARDS

Metabolic complications





Hyperkalaemia
Citrate toxicity & hypocalcaemia
Release of vasoactive peptides
Release of plasticizers from PVCphthalates
Haemorrhagic reactions
After massive transfusion of
stored blood

Disseminated intravascular
coagulation
Transmission of disease

Hepatitis, CMV. EBV

AIDS (Factor VIII)

Syphilis

Brucellosis

Toxoplasmosis

Malaria

Trypanosomiasis


Dr Mona Shroff
www.obgyntoday.info
26
27
Thank you
Dr Mona Shroff
www.obgyntoday.info
28