+

Case Presentation
Cristina Marides Quijano, MD

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Jump Off Case

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Patient Profile

N.N

45 yrs old

Female

Filipino

Roman Catholic

CC: body malaise and abdominal pain

+
Past Medical History
Hypertensive
Diabetic
Asthmatic

No known food or drug allergies

+
OB- Gynecologic History

Menarche 13 yrs old

Menstrual Cycles : regular lasting 3 -4 days, without

associated dysmenorrhea

Coitarche 18 yrs old x 1 sexual partner

LMP: 01/12/16

G5 P5 (5005)

G1 G4 delivered full term, NSD without complications

G5 delivered via Low Segment Transverse Cesarean Section

sec to Non- reassuring Fetal Heart Rate Pattern +
Postpartum Bilateral Tubal Ligation

+
Social History
Cigarette smoker
Alcoholic Beverage Drinker
Illicit Drug Use

+
History of Present Illness

5 months PTA

Onset of intermittent lower back pain (PS 3/10)

Condition tolerated

4 months PTA

Persistence of back pain now of increased severity (PS 5/10)

with radiation to hypogastric area, associated with
abdominal bloatedness and increased abdominal girth

Condition tolerated

3 months PTA

Low back pain persisted now associated with urinary

frequwncy, constipation and early satiety

Consult done

TVS : Anteverted uterus 3 x 6.5 x 5cm with secretory

phase endometrium; Unilocular cystic mass 14 x 12 x 10
cm within the abdominopelvic cavity, inferior pole is
composed of a solid component which on color flow
revealed hypervascularity, suggestive of an ovarian new
growth with malignant sonographic features

Advised surgery Enrolled under Charity service

Morning PTA,

Noted vague abdominal pain (PS 8/10) associated with

body malaise

TVS : Complex, solid cystic mass 15 x 12 x 13 cm at right of

uterus which exhibits moderate color flow on color flow
mapping; irregular solid component is 9.6 cm in widest
diameter suggestive of Right Ovarian New Growth with
Non-benign features.

CA 125 : 798

Advised Admission and scheduled for surgery

+
Physical Examination

Awake , conscious, coherent, not in respiratory distress

but with occasional grimacing

Vital Signs:

BP 100/80 mmHg

HR 100 bpm

RR 20 cpm

T 36.0 oC

O2 sat 99% at room air

Skin: pale, cool to touch, good turgor

HEENT: normocephalic; anicteric sclerae, pale palpebral

conjunctivae; (-) alar flaring; pale, but moist lips,
tongue and mucous membranes

Neck: supple, trachea at midline, thyroid gland not

enlarged

C/L : Equal Chest expansion, clear breath sounds, (-)

rales, (-) wheeze

CVS: Adynamic precordium, distinct S1 and S2,

tachycardic, regular rhythm, (-) murmurs appreciated

Abdomen: globular, distended (AG 85 cm), (+)

pelvoabdominal mass approx 20 cm, firm slightly mobile
and tender on palpation

Speculum Exam: closed cervix, no lesions, minimal mucoid

discharge

Bimanual Pelvic Exam:

Introitus: parous

Cervix: closed, posterior, smooth, non-tender

Uterus: (+) pelvoabdominal mass, 20 cm in size, firm, slightly

movable

Adnexae: as above

Discharges: minimal, mucoid

Extremitites: symmetrical, non-edematous, strong and

palpable pulses, CRT <2 sec

CNS: Within normal limits

+
Admitting Impression

Gravida 5 Para 5 (5005)

Right Ovarian New Growth T/C Malignancy

S/P Primary Cesearean section + Bilateral Tubal

Ligation (2000)

+
On Admission (ER)

Pt conscious, oriented but with occasional facial

grimacing, reported pain score 8/10 on arrival

Vital sigs within normal range

Laboratories taken as outpatient were reviewed and

consistent with Anemia.

IVF started PNSS 1L at 120 ml/hr

To transfuse 2 units of PRBC properly screened and

crossmatched to run in 4 hours with 2 hrs interval

Scheduled for Exploratory Laparotomy, Peritoneal Fluid

Cytology, Right Salpingo-oophorectomy with Frozen Section,
Total Abdominal Hysterectomy Left Salpingo-oophorectomy
possible Bilateral Lymph Node Dissection, Omentectomy

Diet: Clear liquids; NPO postmidnight

Medications:

Cefoxitin (B-braun) 2 grams IVTT ANST prior to induction of

anesthesia

Lansoprazole (Prevacid) 30 mg IVTT at 7AM

Metoclopramide (Vitamet) 10 mg IVTT at 7AM

Referred to Dept of Internal Medicine for comanagement and

CP Clearance

+
Outpatient Labs
Patients
Results

Normal Value

CBC
Hemoglobin

6.8

12.0 16.0

Hematocrit

22.8

37.0 47.0

17.67

4.8 10.8

199

130 - 400

Bleeding Time

1630

2.3 9.5 mins

Clotting Time

615

Up to 15 mins

Activity

77 %

>70%

INR

1.19

<= 1.21

31.3

26.4 36.7 sec

1.2

0.6 1.5 mg/dl

135

134 148 mmol/L

WBC
Platelet

Prothrombin Time

aPTT
Creatinine
Electrolytes
Sodium

+
Outpatient Labs
Patients
Results
SGPT

Normal Value

13

5.0 - 50.0 U/L

CA 125

798.6

0-35 U/ml

HbsAg

NR

Blood Type

A+

+
Outpatient Labs

Minimal subsegmental
atelectasis in the peripheral
aspect of the left lung base;
otherwise clear lung fields

Focal eventration of the

right hemidiaphragm

IM Orders:

O2 inhalation via nasal cannula at 2LPM

Repeat CBC after 2nd unit of PRBC, Serum K

HGT now 115 mg/dl

For 2D Echo with Doppler

Suggest 2 more units PRBC for OR use

Medications:

KCl (K lyte ) 600 mg/tab, 3 tablets orally now then

another 3 tablets orally at bedtime

Laboratories (On Day of Admission)

Patients
Results

Previous Results
(Outpatient)

CBC
Hemoglobin

7.3

6.8

Hematocrit

23.7

22.8

14.26

17.67

160

199

WBC
Platelet

+ st
1 Hospital Day

Pt alert, still with complaints of abdominal pain (PS

6/10), had 1 febrile episode (T 38.8oC)

Laboratories: (S/P 2 units PRBC)

Patients
Results

Previous Results

CBC
Hemoglobin

8.5

7.3

Hematocrit

26.6

23.7

13.14

14.2

Platelet

162

160

Potassium

3.9

3.4

WBC

Transfuse 1 more unit PRBC

2DED Result:

EF 74%

Normal LV geometry with adequate wall motion and

contractility

Normal right atrium, main pulmonary artery and aortic root

dimensions

Medications:

Paracetamol (Aeknil) 300 mg IV now

Defer OR until medically cleared

Diet: Soft

+ nd
2 Hospital Day

Patient with same complaints, no recurrence of febrile

episodes however tachypneic even on 02
supplementation.

PE: pale palpebral conjunctivae; Clear breath sounds,

(-) rales (-) wheeze

Laboratories: (S/P 3 units

PRBC)
Patients

Previous Results

Results
CBC
Hemoglobin

8.7

8.5

Hematocrit

27.6

26.6

WBC

11.33

13.1

Platelet

143

162

Transfuse another 2 units of PRBC of patients blood type

properly screened and crossmatched

Secure another 2 units PRBC of patients blood type properly

screened and crossmatched

Labs: Repeat CBC postBT, include Crea, SGPT, ProTime

Medications:

Cefoxitin (B-braun) 2 grams IVTT ANST now then 1 gram IVTT

every 8 hours thereafter

Ranitidine 50 mg IVTT every 8 hrs

Ketorolac 30 mg IVTT every 6 hrs

Referred to Dept of Anesthesia for Pain Relief

+ Laboratories: (S/P 5 units PRBC)

Patients
Results

Previous Results

CBC
Hemoglobin

10.0

8.7

Hematocrit

32.1

27.6

WBC

9.48

11.33

138

143

71

77

INR

1.26

1.19

Creatinine

1.1

1.2

SGPT

12

13

Platelet
Prothrombin Time
Activity

Secure 2 units FFP of patients blood type; transfuse 1

unit of FFP to run for 30 minutes

Medications:

Vitamin K 1 ampule IVTT every 6 hrs x 4 doses

+ rd
3 Hospital Day

Patient comfortable, with persistence of abdominal pain

but now of decreased severity (PS 2/10), no recurrence
of fever.

Laboratories : (S/P 5units PRBC, 1 unit FFP)

Patients
Results

Previous Results

CBC
Hemoglobin

10.9

10.0

Hematocrit

34.1

32.1

WBC

6.55

9.48

Platelet

148

138

77

71

1.19

1.26

Prothrombin Time
Activity
INR

Transfuse 2 units FFP of patients blood type to run for

30 minutes each unit with 30 minute intervals

Laboratories:
Patients
Results
D - Dimer
Fibrin Split Products

Normal Value

24.370

< 0.5 ugFEU/ml

(+)

negative

7.354

7.35 7.45

33.2

35 - 45

166.1

>80

ABG
pH
pCO2
pO2
HCO3

18.1

SpO2

99.3

fIO2
BE

28
-6.6

95-98

IM Clearance

No absolute cardiopulmonary contraindication to procedure

per clearance protocol nor does [patient have high risk
comorbidities

High risk for perioperative morbidity and risk for adverse

events inherent to underlying condition necessitating
surgical intervention (ongoing Internal Hemorrhage from
probable ruptured cyst)

Advise that surgical interventions that may correct the

underlying condition be weighed against perioperative risks

Bleed available donors for additional 2 units FWB

Type and screen 2 units FFP

Scheduled for Exploratory Laparotomy, Peritoneal Fluid

Cytology, Right Salpingooophorectomy with Frozen
Section, Total Abdominal Hysterectomy Left
Salpingoophorectomy possible Bilateral Lymph Node
Dissection, Omentectomy

+
Pre-op Assessment

Airway Examination

Mouth opening > 4cm

Thyromental distance > 6cm

Mallampati 1

No missing or loose teeth or dentures

ASA 1

Anesthetic Plan: GA ETT

Anesthesia Orders:

NPO postmidnight

Lansoprazole 30 mg IV at 7AM

+ th
4 Hospital Day (OR)

Pt alert, conversant, with reports of abdominal pain (PS

2/10) and occasional dyspnea despite O2 inhalation via
nasal prong.

Wheeled to OR with ff vital signs prior to transport:

BP: 120/60 mmHg

HR: 102 bpm

RR: 20 cpm

T :36.4 oC

02 sat: 99 % on O2 via nasal prong at 2LPM

On arrival at the OR theatre, patient was awake,

coheremt, conversant, not in respiratory distress and
with the ff vital signs:

BP: 115/75 mmHg

HR 65 bpm

RR 20 cpm

O2 sat 100%

Patient positioned supine and standard ASA monitors

attached.

Peripheral IV line started with PNSS 500 ml on

contralateral arm using IV cath G18.

Induction Agents:

Midazolam 1mg

Fentanyl 100 mcg

Lidocaine 40 mg

Propofol 40 mg

Attached to Mechanical
Ventilator with ff settings:

Rocuronium 40 mg

TV 350 ml

Sevoflurane 2%MAC

RR 10 cpm

PEEP 5 cmH20

Mode: VCV

Atraumatically intubated with

ETT 7.0 , lip level 20 on 1st
attempt, with equal and clear
bibasal breath sounds on
auscultation and a positive
waveform on capnography

Twenty mins from Induction, Procedure started

Vital signs:

BP: 90/50 mmHg

HR 68 bpm

RR 20 cpm

O2 sat 100%

Fentanyl 50 mcg IV given and supplemented with 25 mcg IV bolus every 45 mins

Rocuronium 10 mg IV given and top up done with 10 mg boluses every 30 mins

therafter

45 mins from Induction

Stable vital signs

EBL: 500 ml

1st unit of PRBC transfused

2 hrs and 30 mins from Induction

EBL 2000 ml

Infrequwnt hypotensive episodes as low as 80/40 mmHg

2nd unit PRBC transfused

2 addtl units PRBC secured for transfusion

3 hrs 15 mins from Induction

Stable vital signs

2 units FFP transfused in succession

1 unit FWB transfused on contralateral arm

5 hrs from Induction

2nd unit FWB transfused

6 hrs from Induction

Procedure completed

Patient extubated

Admitted to INT for close monitoring

Summary of Medications:

Midazolam 1 mg

Fentanyl 275 mcg

Propofol 40 mg

Lidocaine 40 mg

Rocuronium 140 mg

Tranexamic Acid 1 gram

Paracetamol 600 mg

Parecoxib 40 mg

Ondansetron 4 mg

Sugammadex 120 mg

Summary

Estimated Blood Loss 3500 mg

Peritoneal Fluid 1200 ml

Total Fluids administered 4850 ml

Total Blood Products Transfused 1460 ml

2 units PRBC

2 units FFP

2 units FWB

Total Urine Output 1280 ml

Postop Medications:

Cefoxitin (Cefoxitin Bag RTU) 1 gram IV q8 hrs

Lansoprazole (Prevacid 30 mg IVTT q12 hrs

Tranexamic Acid (Hemostan) 1 gram IVTT q8 hrs x 3 doses

Tramadol drip: Tramadol 250 mg in 250 ml D5W at 10 ml/hr x 2

cycles

Tramadol 50 mg IVTT q8 hrs PRN for PS>4/10

Paracetamol 600 mg IVTT q4 hrs x 12 doses

Parecoxib (Dynastat) 40 mg IVTT q12 hrs x 3 doses

Ondansetron (Zofran) 4 mg IVTT q8 hrs PRN for nausea and

vomiting

Calcium Gluconate 10 ml amp, 10 ml slow IV over 15 mins x 1

dose

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Immediate Post-op Period (INT)

Patient awake, not in respiratory on continuous 02 via

nasal cannula at 2LPM.

Vital signs stable without episodes of hypotension or

desaturation.

Diet : NPO

Additional 3 units of PRBC secured and transfused over

4 hours per unit with 1 hour interval in between

ABG
Patients
Results

Normal Value

ABG
pH

7.39

7.35 7.45

pCO2

34.9

35 - 45

pO2

173

>80

HCO3

21.0

SpO2

99.5

fIO2

28.0

BE

-3.7

95-98

Laboratories
Patients
Results

Previous Results

CBC
Hemoglobin

9.9

10.9

Hematocrit

31.9

34.1

WBC

5.6

6.55

Platelet

126

148

78

77

1.18

1.19

Prothrombin Time
Activity
INR
Electrolytes
Sodium

136

Potassium

3.4

+ th
5 Hospital Day

Patient comfortable with tolerable pain over post-op

site, (+) complaints of dizziness, (-) burp and flatus; no
overt bleeding

Diet: Sips of water

May turn to sides

Laboratories:

Patients
Results

Previous Results

CBC
Hemoglobin

13.7

9.9

Hematocrit

40.3

31.9

WBC

11.7

5.6

Platelet

117

126

80

78

Prothrombin Time
Activity

+ th
6 Hospital Day

Pt without subjective complaints, (+) burp and flatus

Diet: General liquids with crackers

Transout to Regular Room

+ th
7 Hospital Day

Patient without subjective complaints

Diet: Soft

FBC removed and O2 inhalation discontinued

Venoclysis shifted to Heplock

Mefenamic Acid PO started

Laboratories:
Patients
Results

Previous Results

CBC
Hemoglobin

12.0

13.7

Hematocrit

35.9

40.3

WBC

9.02

11.7

Platelet

201

117

+ th
9 Hospital Day

Discharged Improved

+
Blood Products Transfused

Pre-op:

5 units PRBC

1 unit FFP

Intra-op:

2 units PRBC

Total:

2 units FFP

10 units PRBC

2 units FWB

3 units FFP

2 units FWB

Post-op:

3 units PRBC

+Case Discussion
Transfusion Therapy

+
Indications: Allogeneic Blood

To increase oxygen carrying capacity and intravascular

volume

ASA Recommendations
1.

Transfusion is rarely indicated when Hgb > 10 g/dl and is

almost always indicated when it is <6 g/dl, especially
when anemia is acute

2.

The determination of whether intermediate Hgb

concentrations (6 to 10 g/dl) justify or require RBC
transfusion should be based on the patients risk for
complications of inadequate oxygenation

3.

Use of a single Hgb trigger for all patients and other

other approaches that fail to consider all important
physiologic and surgical factors affecting oxygenation is
not recommended

4.

When appropriate, preoperative autologous blood

donation, intraoperative and postoperative blood recovery,
acute normovolemic hemodilution, and measures to
decrease blood loss (i.e. deliberate hypotension and
pharmacologic agents) may be beneficial

5.

The indications for transfusion of autologous RBCs may

still be liberal for allogeneic RBCs because of less frequent
(but still significant) risks associated with the former.

Rule of Thumb:

Administration of 1 unit PRBCs will increase Hct value by

3% to 5%:
1.

Blood loss greater than 20% of blood volume when more

than 100 ml

2.

Hgb level <8g/dl

3.

Hgb level <10 g/dl with major disease (i.e emphysema,

ischemic heart disease)

4.

Hgb level <10 g/dl with autologous blood

5.

Hgb level <12 g/dl and ventilator dependent

* Anesthesia 6th ed

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WHAT IS
MASSIVE
TRANSFUSION?

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Definition

Traditional:

>20 units RBCs in 24 hours (Approximately 1 blood volume

in a 70 kg patient)

Trauma : > 10 units RBCs in 24 hours

Others:

Loss of 0.5 blood volume within 3 hours

use of 50 units of blood components in 24 hours

use of 6 units RBCs in 12 hours.

Practical standpoint

Requirement for > 4 RBC units in 1 hour with ongoing need

for transfusion

Blood loss > 150 ml/min with hemodynamic instability and

need for transfusion

+
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COMPATIILITY TESTING

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Compatibility Testing

Include:

ABO-Rh type

Crossmatch

Antibody Screen

Designed to demonstrate harmful antigen antibody

interactions in vitro so that harmful in vivo antigenantibody reactions could be prevented

+
Compatibility Testing

ABO Rh typing

Most serious and tragic

reactions are caused by
accidental transfusion of
ABO incompatible blood

Result from naturally

occurring antibodies
which activate
complement and lead
to rapid intravenous
hemolysis

Antigen D most likely to

cause immunization

+
Compatibility Testing

Crossmatching

A trial transfusion within a test tube in which donor RBC are mixed with
recipient serum to detect a potential for serious transfusion reaction

Phases:
1.

2.

3.

Immediate Phase

Conducted at room temperature

Check against errors in ABO typing

Detects ABO incompatibilities and those caused by naturally

occurring antibodies in the MN, P and Lewis systems

1 5 mins to complete

Incubation Phase

First phase reactions are incubated at 37 oC in albumin or low-ionic

strength salt solution

Primarily detects antibodies in the Rh system

Incubation: 30 to 45 mins (Albumin) 10 to 20 mins ( Salt soltn)

Antiglobulin Phase (Indirect Antiglobulin Test)

Addition of antiglobulin sera to incubated test tubes

Detects most incomplete a ntibodies in the blood group systems

including Rh, Kell, Kidd and Duffy blood group systems

Antibody Screening

Carried out in 3 phases

A trial transfusion between the recipients serum and

commercially supplied RBCs that are specifically selected to
contain optimal numbers of RBC antigens or those antigens
that will react with antibodies that are commonly
implicated in hemolytic transfusion recations

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Component Use

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+
Schema for Separation of
Whole Blood for Component
Therapy

+
Packed RBC

Contain same amount of

Hgb as FWB but much of
the plasma has been
removed

Administration is facilitated
y reconstituting them with a
crystalloid or colloid,
however not all crystalloids
are suitable

If Calcium containing
soltn, clotting occurs.

Impt factor is whether

diluent is hypotonic with
respect to plasma; if so
RBCs swell and lyse

+
Platelet Concentrate

Great demand for hemato-oncology patients

Types:

Apheresis

Leukocyte-depleted

Ultraviolet B-irradiated

High risk of bacterial contamination (1 in 12 000) in platelets

stored for 3 days or more:

Bacteria can enter pack from donor skin at the time of collection

Platelets are stored in oxygen permeable bag kept at 22 oC to help

preserve platelet function but also encourage bacterial growth

High incidence of Transfusion Related Acute Lung Injury (TRALI)

Interaction between leukocyte antibodies and in donor plasma and

corresponding antigen in the patient

+
Platelet Concentrate

Preparation:

Prepared by differential centrifugation from freshly drawn units

of blood or from donors who specifically donate large amounts
of platelets by plateletpheresis techniques

From pooled buffy coats of the whole blood donated by four

donors to make one adult pack

Individual donor apheresis (from a previously tested donor) can

yield up to three adult packs

Storage:

Stored for up to 5 days on an agitator at 22 oC

Volume: 250-350 ml

Platelet count in pack: >2.4 x 1011 per adult dose

+
Platelet Concentrate

Dose

1 Platelet Concentrate produces an increase of

approximately 7000 to 10000 platelets/mm3 at 1 hour after
transfusion to ave 70 kg adult

10 units Plt Concentrate required to increase platelet count

by 100 000 cells/mm3

+
Platelet Concentrate

ASA Recommendations:
1.

Prophylactic platelet transfusion is ineffective and rarely

indicated when thrombocytopenia is due to increased
platelet destruction (e.g. Idiopathic Thrombocytopenic
Purpura)

2.

Prophylactic platelet transfusion is rarely indicated in

surgical patients with thrombocytopenia because of
decreased platelet production when the platelet count is
greater than 100 x 109/L and is usually indicated when the
platelet count is less than 50 x 109/L. The determination of
whether patients with intermediate platelet counts ( 50100 x 109/L) require therapy should be based on the
patients risk for bleeding.

3.

Surgical and Obstetric patients with microvascular

bleeding usually require platelet transfusion if the platelet
count is less than 50 x 109/L and rarely require therapy if it
is greater than 100 x 109/L. With intermediate platelet
counts ( 50-100 x 109/L) the determination should be
based on the patients risk for more significant bleeding.

+
Platelet Concentrate
4.

Vaginal Deliveries or operative procedures ordinarily

associated with insignificant blood loss may be undertaken
in patients with platelet counts less than 50 x 109/L.

5.

Platelet transfusion may be indicated despite an

apparently adequate platelet count if there is known
platelet dysfunction and microvascular bleeding.

+
Fresh Frozen Plasma

Most frequently used plasma product

Contains all the plasma proteins particularly factors V

and VIII which gradually decline during the storage of
blood

Frequently used in cases of excessive bleeding or to

prevent bleeding in those patients with abnormal
coagulation

NO documentation exists that FFP has a beneficial effect

when used as part of transfusion management of
patients with massive hemorrhage.

Preparation

Centrifugation of whole blood from previously tested donor

and frozen to achieve Factor VIII concentration >0.7 iu.ml

+
Fresh Frozen Plasma

Storage:

Collected plasma from donated packs or plasmapheresis

and frozen to -30oC

Thawed using a dry oven (10 mins), microwave (2-3 mins)

or in a waterbath (20 mins)

Once thawed is best used immediately but may be stored

at 4oC and infused within 24 hours

Dose: 12 15 ml/kg

+
Fresh Frozen Plasma

ASA Recommendations :
1.

For urgent reversal of warfarin therapy

2.

For correction of known coagulation factor deficiencies for which

specific correlates are unavailable

3.

For correction of microvascular bleeding in the presence of increased

(>1.5x normal) PT and aPTT

4.

For correction of microvascular bleeding secondary to coagulation

factor deficiency in patients transfused with more than 1 blood
volume and when PT and aPTT cannot be obtained in a timely
fashion

5.

FFP should be given in doses calculated to achieve a minimum of

30% of plasma factor concentration (usu. 10 to 15 ml/kg) except for
urgent reversal of warfarin anticoagulation (5 to 5 ml/kg)Four to five
platelet concentrates, 1 unit of single donor apheresis platelets, or 1
unit of whole blood provides a quantity of coagulation factors similar
to that contained in 1 unit of FFP.

6.

FFP is contraindicated for augmentation of plasma volume or

albumin concentration

+
Cryoprecipitate

Is the cryoglobulin fraction of plasma obtained by thawing a

single donation of FFP at 4oC

No virally-inactivated preparation

Are rich in factor VIII, von Willebrand factor (VWF), factor XIII,
fibronectin and fibrinogen

Indications:

In those with acquired coagulopathy related to hemorrhage, trauma

or sepsis, to correct a fibrinogen level <1 g/dl

Frequently administered as ABO compatible

Should be administered through a filter and as rapidly as

possible; rate: 200 ml/hr; completed within 6 hours of thawing

+
Prothrombin Complex

Complex of Factors II, VII, IX and X

Commercial Preparations available:

Konyne

Proplex

Aphanine SD

Indication:

Mainly for treatment of Factor IX deficiency

Acquired Hypothrombinemic bleeding disorders principally

sodium warfarin overdose

+
Fibrinogen Concentrates

Derived from human plasma and does not contain relevant levels of
other coagulation factors

Does not have complications associated with blood transfusions

Reduces the required need for allogeneic blood components

RCTS: may be first line therapy to reduce transfusion requirements

improves hemostasis more rapidly and at lower risk for immunologic
reactions, infection and intravascular volume overload than
conventional allogeneic blood products

Single dose of 4g would achieve a blood level approximately 200 mg/dl

reducing incidence of platelet administration and number of donor
exposures

NOT superior to conventional blood components for treatment of

perioperative coagulopathy in bleeding patients

+
Single Donor Plasma

Plasma that has been removed from stored blood

without any effort being made to preserve coagulation
factors

Very effective as a volume expander

+
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OTHERS

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+
Albumin

Prepared commercially from albumin fractions from

large pools of plasma reconstituted in isotonic
electrolyte solutions

Given without regard to ABO blood type and

crossmatch

Primarily used as volume expanders

Risk: Bacterial Contamination

Administered within 4 hours of initiation of the infusion

Use should be restricted in cases of hypoprotinemia

bec expansion of vascular space occurs for a longer
period than does balanced electrolyte solutions

+
Synthetic Colloid Solutions

Synthetic Hydroxyethyl Starch

Dextrans

Infusion > 20 ml/kg in 24 hrs: interferes with normal blood

clotting causing deficiency with cross matching and a
bleeding diathesis

Major concern: anaphylaxis

Hypertonic Saline

Na conc: 250 to 1200 meq/L

Theoretical advantage: the greater the Na concentration,

the less total volume required for adequate resuscitation

Pharmacologic Management
Options

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+
Antifibrinolytics

Tranexamic Acid

Inhibits plasminogen activation and at high concentration

inhibits plasmin

Loading dose: 1 gram over 10 mins then 1 gram every 8

hrs

Use with CAUTION in patients with renal impairment as the

drug is predominantly excreted unchanged by the kidneys

CONTRAINDICATIONS:

Subarachnoid hemorrhage cerebral edema and

infarction

Aprotinin

Serine protease inhibitor, inhibiting trypsin, chymotrypsin,

plasmin and kallikrein

Reduces blood loss associated with accelerated fibrinolysis

in surgery (cardiothoracic or transplant surgery)

Adverse Effects:

Anaphylaxis 1:200 first time use

Risk of Acute Renal Failure, Myocardial Infarction and

Heart Failure, as well as Stroke and Encephalopathy

Should only be used when benefits outweigh any risks to

individual patients

Desmopressin

Synthetic analogue of antidiuretic hormone vasopressin

Increases the levels of factor VIII and von Willebrand factor

and reduces blood loss and transfusion requirements in
patients with normal preoperative coagulation status who
are undergoing spinal or cardiac surgery

Adverse effects: hypotension, hyponatremia, increased

platelet adhesion

Factor Concentrates

For patients with Inherited bleeding disorders such as

haemophilia or von Willebrand disease

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EMERGENCY TRANSFUSION

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Type Specific Partially Crossmatched Blood

1.

Patients serum added to donor RBCs at room temp, centrifuged and

read for microscopic agglutination

Duration: 1-5 mins

Eliminates serious hemolytic reactions resulting from errors that

may occur in ABO typing

Only a few unexpected antibodies outside ABO system are

detected, most of which are not clinically significant

2.

Type Specific Uncrossmatched Blood

3.

Type O Rh negative (Universal Donor), Uncrossmatched

Blood

PRBC preferrably as opposed to Whole Blood bec of smaller volume

of plasma

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Equipment to Aid Transfusion

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Infusion Devices

Administration sets should

incorporate an integral
mesh filter (170 -300um)

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Pressure Devices

Exert pressure evenly over

the entire bag

Have a gauge to measure

the pressure

Not exceed 300 mmHg of

pressure

Be monitored at all times

when in use

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Blood Warmers

In all adults undergoing

elective or Emergency
surgery under general or
regional anesthesia,
Intravenous fluids and
blood components should
be warmed to 37oC

Greatest benefit :
controlled warming of red
cells (stored at 4oC) rather
than platelets (stored at
22+/- 2oC) or
FFP/cryoprecipitate (thawed
to 37oC)

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Massive Transfusion

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Principle

Massive Transfusion protocol (MTP) is activated by a

clinician in response to a patient that is experiencing
massive bleeding.

Once a patient is in the protocol, the blood bank is able

to insure rapid and timely availability of blood
components to facilitate resuscitation.

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Rationale

Transfusion of packed red cells (RBCs), plasma, and

platelets in a similar proportion as whole blood may
minimize the effects of dilutional coagulopathy and
hypovolemia

Retrospective studies demonstrate a survival

advantage of increased plasma: red cell ratio on
mortality in massive transfusion after trauma.

optimal ratio of plasma to red cells appears to be in the

range 1:2.4 or higher

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Definition

Traditional:

>20 units RBCs in 24 hours (Approximately 1 blood volume

in a 70 kg patient)

Trauma : > 10 units RBCs in 24 hours

Others:

Loss of 0.5 blood volume within 3 hours

use of 50 units of blood components in 24 hours

use of 6 units RBCs in 12 hours.

Practical standpoint

Requirement for > 4 RBC units in 1 hour with ongoing need

for transfusion

Blood loss > 150 ml/min with hemodynamic instability and

need for transfusion

Practice Guidelines for

Perioperative Blood Management
Updated Report by the American Society of Anesthesiologists Task
Force on Perioperative Blood Management
Anesthesiology Vol V, No 2
February 2015

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Patient Evaluation

Review previous medical records and intervoew the patient

or family to identify :

Previous blood transfusion

History of drug induced coagulopathy (e.g warfarin, clopidogrel,

aspirin and other anticoagulants, as well as vitamins or herbal
supplements that may affect coagulation)

Presence of congenital coagulopathy

History of thrombotic events (e.g. DVT, pulmonary embolism)

Risk factors for organ ischemia (e.g cardiorespiratory disease)

which may influence the ultimate transfusion trigger for red
blood cells (e.g hemoglobin level

Inform patients of the potential rrisks versus benefits of

blood transfusion and elicit their preference

Review available laboratory test results including

hemoglobin, hematocrit, and coagulation profiles

Order additional laboratory tests depending on a

patients medical condition (e.g coagulopathy, anemia)

Conduct a physical examination of the patient (e.g

ecchymosis, petechiae, pallor)

If possible, perform the preoperative evaluation well

wnough in advance to allow for proper patient
preparation

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Preadmission Patient
Preparation
Erythropoeitin with or without Iron may be administered when

possible to reduce the need for allogeneic blood in selected

patient populations (e.g renal insufficiency, anemia of chronic
disease)

Administer Iron to patients with Iron Deficiency Anemia if time

permits

In consultation with an appropriate specialist, discontinue

anticoagulation therapy for elective surgery.

Transition to short acting drugs (LMWH) may be appropriate in

selected patients

If clinically possible, discontinue nonaspirin antiplatelet agents

(thienopyridines) for a sufficient time in advance of surgery,
except for patients with a history of percutaneous coronary
intervention

Aspirin may be continued on a case by case basis

Risk of thrombosis versus the risk of increased bleeding

should be considered when altering anticoagulation
status

Assure that blood and blood components are available

for patients when significant blood loss or transfusion is
expected

When autologous blood is preferred, the patient may

be offered the opportunity to donate blood before
administration only if there is adequate erythropoeitic
reconstitution.

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Preprocedure Preparation

Restrictive red blood cell transfusion strategy may be safely

used to reduce transfusion administration:

The determination of whether Hgb hemoglobin concentrations

between 6 and 10g/dl justify or require red blood cell transfusion
should be based on potential or actual ongoing bleeding (rate
and magnitude), intra- vascular volume status, signs of organ
ischemia, and adequacy of cardiopulmonary reserve.

Red blood cells should be administered unit-by-unit, when

possible, with interval reevaluation

A protocol for avoidance of transfusion may be used as a

strategy to reduce blood loss for patients in whom transfusion is
refused or is not possible.

A massive (i.e., hemorrhagic) transfusion protocol may be used

when available as a strategy to optimize the delivery of blood
products to massively bleeding patients.

Use a maximal surgical blood order schedule, when avail- able

and in accordance with your institutional policy, as a strategy to
improve the efficiency of blood ordering practices

Reversal of Anticoagulants

For urgent reversal of warfarin, administer PCCs in consultationwiththeappropriatespecialist,oradministerFFP.

Administer vitamin K for selected patients for nonurgent reversal

of warfarin, except when rapid restoration of anticoagulation after
surgery is required.

Antifibrinolytics for Prophylaxis of Excessive Blood Loss

Use antifibrinolytic therapy for prophylaxis of the use of

allogeneic blood transfusion in patients undergoing
cardiopulmonary bypass.

Consider using antifibrinolytic therapy for prophylaxis in certain

orthopedic surgery.

Consider using antifibrinolytic therapy for prophylaxis in liver

surgery and other clinical circumstances at high-risk for excessive
bleeding.

Acute Normovolemic Hemodilution (ANH)

Consider ANH to reduce allogeneic blood transfusion in patients

at high-risk for excessive bleeding (e.g., major cardiac,
orthopedic, thoracic, or liver surgery), if possible

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Intraoperative and
Postoperative Management of
Blood
Loss
Allogeneic Red Blood Cell Transfusion

Administer blood without consideration of duration of

storage.

Leukocyte-reduced blood may be used for transfusion for

the purpose of reducing complications associated with
allogeneic blood transfusion.

Reinfusion of Recovered Red Blood Cells

Reinfuse recovered red blood cells as a blood sparing

intervention in the intraoperative period, when appropriate.

Intraoperative and Postoperative Patient Monitoring

Periodically conduct a visual assessment of the surgical

field jointly with the surgeon to assess the presence of
excessive microvascular (i.e., coagulopathy) or surgical
bleeding

Use standard methods for quantitative measurement of

blood loss, including checking suction canisters, surgical
sponges, and surgical drains.

Monitor for perfusion of vital organs using standard ASA

monitors (i.e., blood pressure, heart rate, oxygen
saturation, electrocardiography) in addition to observing
clinical symptoms and physical exam features

Additional monitoring may include echocardiography,

renal monitoring (urine output), cerebral monitoring (i.e.,
cerebral oximetry and NIRS), analysis of arterial blood
gasses, and mixed venous oxygen saturation.

If anemia is suspected, monitor hemoglobin/hematocrit

values based on estimated blood loss and clinical signs.

If coagulopathy is suspected, obtain standard coagulation

tests (e.g., INR, aPTT, fibrinogen concentration) or
viscoelastic assays (e.g., thromboelastography [TEG] and
ROTEM), if available, as well as platelet count.

During and after transfusion, periodically check for signs of

a transfusion reaction including hyperthermia,
hemoglobinuria, microvascular bleeding, hypoxemia,
respiratory distress, increased peak airway pressure,
urticaria, hypotension and signs of hypocalcemia.

If signs of a transfusion reaction are apparent, immediately

stop the transfusion, give supportive therapy, and initiate
supportive care.

Notify the blood bank of the transfusion reaction case.

Treatment of Excessive Bleeding

Obtain a platelet count before transfusion of platelets, if possible

In addition, obtain a test of platelet function, if available, in
patients with suspected or drug- induced (e.g., clopidogrel)
platelet dysfunction.

Obtain coagulation tests (i.e., PT or INR and aPTT) before

transfusion of FFP, if possible

Assess fibrinogen levels before the administration of

cryoprecipitate, if possible

Desmopressin may be used in patients with excessive bleeding

and platelet dysfunction. Consider topical hemostatics such as
fibrin glue or thrombin gel.

Consider the use of antifibrinolytics (i.e., -aminocaproic acid,

tranexamic acid) if fibrinolysis is documented or suspected and if
these agents are not already being used

PCCs may be used in patients with excessive bleeding and

increased INR.

Consider recombinant activated factor VII when traditional

options for treating excessive bleeding due to coagulopathy
have been exhausted.

Fibrinogen concentrate may be used