1.

Discuss the medical history and physical findings, which might identify the presence and etiology of a bleeding disorder. Bleeding disorder ? medical problems that lead to poor blood clotting and continuous Bleeding. result from defects in the blood vessels or from abnormalities

in the blood itself (blood clotting factors or in platelets)

medical history ?

Excessive bleeding and longer than normal bleeding. easy bruising and excessive bruising - purpura Easy bleeding Abnormal menstrual bleeding (female) bleeding gums blood in the urine - hematuria bloody stools -melena frequent nosebleeds usage : NSAIDS, alcohol, iron supplements, warfarin or other anticoagulants.

physical findings ? 1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality. 2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) 3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted. 4. mouth :check for inflammation, pockets around the teeth, swelling, retraction, hypertrophy, discoloration, and gum hyperplasia

2. Name five etiologic factors that may lead to bleeding in the surgical patient. - Drug usage : warfarin or heparin therapy - Disease : liver disease - malabsorption of Vit K - haemorrhagic disease of the newborn - disseminated intravascular coagulation (DIC) 3. Describe the laboratory tests used to assess the hemostatic status of a patient. Test Purpose FBC Platelet number Blood film To confirm genuine thrombocytopenia. Platelet structure,size,colour, other abnormalities (eg: leukaemic cells) PT Tests extrinsic pathway APTT Test intrinsic pathway TT Tests fibrin formation LFT underlying liver disease

Endoscopy Anoscopy

diagnosis and management of GI bleeding identify the source of lower GI bleeding

Nuclear medicine studies Angiography

localizing bleeding sources to the small intestine, right colon, or left colon. dentify the source of lower GI bleeding.

4. Identify the causes which might be responsible for a bleeding disorder in a patient who has received massive transfusions. List the recommended treatments for this situation. 5. Define disseminated intravascular coagulation (DIC) and name surgical conditions that lead to DIC. Definition : is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. Risk factors for DIC include:

Blood transfusion reaction , ABO incompatible Cancer, especially certain types of leukemia Infection in the blood by bacteria or fungus Pregnancy complications (retained placenta after delivery,eclampsia,abratio placenta,Fetal death in utero) Recent surgery or anesthesia Sepsis (an overwhelming infection)

Severe liver disease - The liver plays a major role in haemostasis, as most of the
coagulation factors, anticoagulant proteins and components of the fibrinolytic system are synthesized by hepatic parenchymal cells. Additionally, the reticuloendothelial system of the liver helps to regulate coagulation and fibrinolysis by clearing these coagulation factors from the circulation. Finally, because the liver is a highly vascularized organ with vital venous systems draining through the parenchyma, liver diseases can affect abdominal blood flow and predispose patients to significant bleeding problems.

Severe tissue injury (as in burns and head injury)

6. Outline the process of obtaining and transfusing blood. Describe the symptoms of a transfusion reaction and discuss its diagnosis and management. Transfusion reaction=The allergic reaction to the transfusion of blood products to a person Symptoms of Transfusion Reaction Anxiety Flushing - involuntary skin redness usually of the face Tachycardia - Heart rate greater than 100 beats per minute. Hypotension

Chest pain Back pain Dyspnoea Fever Chills Jaundice

Dx : 1. clinical presentation : Fever Chills Hypotension/Hypertension Pain (along IV infusion line, chest or back) Acute Respiratory Distress/stridor/wheeze Dark urine Bleeding, oozing (DIC) Urticaria (hives)

2. Investigation Requirements

Completed Transfusion Reaction Report Form Blood pack Post reaction blood sample (EDTA) Post reaction urine sample

Additional samples sometimes required (as directed by haematologist-on-call)

Blood cultures HLA or neutrophil antibodies (serum/gel) Anti-IgA antibodies (serum/gel)

HLA typing (ACD)

Febrile Reactions (+chills) Urticarial (Allergic) Reactions If urticaria in isolation (w/o fever and other signs): 1. slow the rate or temporarily stop transfusion. If symptoms are bothersomeSevere Allergic (Anaphylact ic) Reactions 1. Immediately stop transfusion 2. supportive care -airway management -Adrenaline Usually given as Acute Haemolytic Reactions

Management

Symptomatic, -paracetamol

Symptoms : 1. Chills 2. fever 3. pain 4. hypotension, 5. dark urine 6. uncontrolled bleeding due to DIC.

administering an antihistamine before restarting the transfusion. If associated with other symptoms, cease the transfusion and proceed with investigation.

1:1000 solution, 0.01mg/kg s.c./i.m. or 3.slow i.v. Anaphylaxis

1. Immediately stop transfusion. 2. Notify hospital blood bank urgently (another patient may also have been given the wrong blood!). 3. require ICU support and therapy - vigorous treatment of hypotension and maintenance of renal blood flow. proper 1. identification of the patient from sample collection through to blood administration 2. labelling of samples and products 3. Prevention of non-immune haemolysis requires adherence to proper handling, storage and administration of blood products

Investigation

Fever can be the initial sign in more severe transfusion reactions (haemolytic or bacterial sepsis) and should be taken seriously. Follow the steps 'immediate management of an acute transfusion reaction'. For isolated fever or chills in some patients, the medical officer may elect to restart the transfusion. If the fever is accompanied by significant changes in blood pressure or other signs and symptoms, the transfusion should be ceased and investigated Check for HLA antibodies in patients having

In the case of mild urticarial reactions with no other signs or symptoms, it is not necessary to submit blood specimens for investigation. It is also usually possible to restart the transfusion. Such a decision should be made after assessment by the treating doctor.

IgA levels and anti-IgA antibodies.

repeated febrile reactions. 7. Describe the recommended criteria for transfusions (RBC, WBC, platelets), the components utilized for such transfusions, and the potential adverse reactions of such transfusions. 8.Define Massive Blood Transfusion and its complications.

Complication : acidosis, hypothermia, and coagulopathy, electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia, hyperkalemia), citrate toxicity, and transfusion-associated acute lung injury. Circulatory Overload- Volume overload usually due to rapid or massive transfusion of blood in patients with diminished cardiac reserve or chronic anaemia.