HEMOSTASIS/BLEEDING/

BLOOD TRANSFUSION
HEMOSTASIS
• complex process • 4 major physiologic
• function: events
– to limit blood loss from –vascular constriction
an injured vessels –platelet plug
formation
–fibrin formation
–fibrinolysis
BIOLOGY OF HEMOSTASIS
VASCULAR CONSTRICTION
• initial response to vessel injury • other potent
(medial smooth muscles) vasoconstrictor
• dependent on local contraction of – endothelin
smooth muscles
– serotonin tryptamine
• TXA2( thromboxaneA2)
– bradykinin
– produced locally at the site of
– fibrinopeptides
injury via the release of
arachidonic acid
– potent constrictor of smooth
muscle
PLATELET FUNCTION

• 150,000-400,000: normal • von Willebrand's factor

circulating platelet
• 30% are sequestered by
the spleen
• average life span: 7-10
days
• adenosine
• function: hemostatic plug
& by contributing to
thrombin formation
play a role in platelet
adherence which recruits
more platelet to seal the
disrupted vessels (primary
hemostasis)
diphosphate(ADP) &
serotonin- principal
mediators in platelet
aggregation
ARACHIDONIC ACID PATHWAY
COAGULATION SYSTEM PATHWAY
CONVENTION COAGULATION TEST

• Activated Partial • Prothrombin Time (PT)

Thromboplastin (aPTT) – associated with the extrinsic
– detects abnormality in the arm
intrinsic arm – II,VII,X
– II,IX, X,XI,XII
VIT. K DEFICIENCY/
INR=(measured PT/normal WARFARIN USE
PT) > affects factors IX, X VII,II
FIBRINOLYSIS

• means fibrin clot plasminogen

breakdown tPA → ↓
• allows restoration of blood plasmin
flow during the healing ↓
process following injury
fibrin degradation
• fibrin polymers is
degraded by plasmin
TRANSFUSION

• human blood transfusion

therapy was accepted in
the late nineteeth century
• Landsteiner introduced
blood grouping
• Lavine & Stetson in 1939
followed the concept of Rh
grouping
TYPING & CROSSMATCHING

• crossmatching between • Type O(-) RBC and Type AB

the donor's RBC and plasma, low anti-B titer type
recipient's sera is A: universal donor
performed prior to BT • type specific & O (-) is
equally safe for “E” BT
• Rh(-) should be only
• in the absence of Rh(-)
transfused with Rh(-) RBC, Rh (+) is acceptable
RBC – Rh(+) RBC should not
transfused to Rh(-) females
who are childbearing age
• Banked Whole Blood
– ideal therapy for acute
traumatic hemorrhage
shock
– successful use in military &
civilian trauma patients
• Red Blood Cells & Frozen
RBC
– traditional product of choice
for most clinical situations
requiring resuscitation
– supernatant plasma after
centrifugation is removed
• Leukocyte-Reduced &
Leukocyte-
Reduced/Washed RBC
– about 99.9% of WBC and
most of the platelets are
removed
• Platelet Concentrates
– life span: 5 days
– increased chance of
bacterial overgrowth
– therapeutic level: 50,000 -
100,000/ul
INDICATIONS FOR PLATELET TRANSFUSION

• thrombocytopenia casued
by massive blood loss &
inadequate production
• replacement with platelet-
poor products
• qualitative platelet
disorders
• Plasma
– usual source of Vit. K-
dependent factors
– the only source of FACTOR
V
• Plasma Products
– fresh frozen plasma (FFP)
– fresh dried plasma( FDP)
INDICATIONS FOR REPLACEMENT OF BLOOD

• IMPROVEMENT OF O2-CARRYING CAPACITY

• TREATMENT OF ANEMIA
• VOLUME REPLACEMENT
• PREHOSPITAL TRANSFUSION
• WHOLE BLOOD RESUSCITATION
• FIBRINOGEN REPLACEMENT
DAMAGE CONTROL RESUSCITATION (DCR)

• become the standard for treatment of substantial

traumatic hemorrhage
• emphasizes rapid maneuvers that promote hemostasis (
balanced resuscitation with early delivery of plasma and
platelets)
• limiting iatrogenic insults that exacerbate bleeding
(minimization of crystalloid & artificial colloid, permissive
hypotension)
• MASSIVE TRANSFUSION (MT)
– ≥10 units of RBC in 24 hours or ≥3 units of RBC within
any hour of admission

• CRITICAL ADMINISTRATION THRESHOLD (CAT)

– a positive status is defined by transfusion of 3 units of RBC
within 60- minute period and this is associated with two-fold
increase in risk of mortality
–
COMPLICATIONS OF TRANSFUSION

• Non-hemolytic Transfusion Reaction (NHTR)

• Tranfusion-associated circulatory overload (TACO)
• Transfusion-related Acute Lung Injury (TRALI)

*read table 4-9. transfusion-related complication