CHAPTER

HAÆMORRHAGE, HAEMOSTASIS

4 AND BLOODTRANSFUSION

HAEMORRHAGE
haemorrhage can be classified in t
According to the SOURCE OF HAEMORRHAGE,
ways
A. Haemorrhage may be 1. External or 2. Internal.
outside or seen externally,
1. External haemorrhage is one that is revealed from outside or it is conceal
seen
2. Internal haemorrhage is ore that is not
haemorrhage. This type of haemorrhage is seen in bleeding peptic ulcer, ruptured ectopic gestation
Sometimes concealed haemorrhage may &
racture of major bones, ruptures of spleen or liver. haematemesis or melaena from bleeding
revealed or external haemorrhage. Examples of these are
peptic ulcer, haematuria from ruptured kidney etc. Capillary.
B. Haemorrhage may be 1. Arterial, 2. Venous or 3.
comes from an artery, it is called an
1. Arterial hacmorrhage.- When haemorrhageby bright red colour and it is ejected in
arterial haemorrhage. Such haemorrhage is recognized
spurts with each systole of the heart.
from a vein. It is characterized by dark
2. Venous haemnorrhage is one which comes loss is also copious in case of
red colour and it flows out steadily instead of spurts. Blood Venous haemorrhage may
venous haemorhage, particularly when large veins are damaged. due to less oxygen given to the
become darker, when the patient is in the state of anoxia, eithersudden cardiac arrest. In case of
anaesthetized patient or there is airway obstruction or there is
oxygen in the
the latter the blood becomes even more darker due to excessive desaturation of
blood. veins
It is not very easy to stop venous haemorrhage. Penetrating wounds involving main
in the thigh may become fatal if t is not controlled properly. Similarly venous haemorrhage
from varicose vein is also difficult to cont:ol. As a first aid measure a compression bandage and
elevation of the limb is a good method to control bleeding for the time being. But such
haemorthage is best controlled by opening the wound and ligating the vein in the operation
theatre.
3. Capillary haemorrhage, is one in which haemorrhage comes from capillaries. In such
haemorrhage blood is bright red and oozes rather than flows out.
According to the TIME OF APPEARANCE haemorrhage can be classified into 1. Primary
haemorrhage, 2. Reactionary haemorrhage and 3. Secondary haemorrhage.
1. Primary haemorrhage is one which occurs at the time of injury or operation.
2. Reactionary haemorrhage is one which occurs within 24 hours of injury or operation.
In majority of cases reactionary haemorrhage occurs within 4 to 6 hours. Such haemorrhage
takes place due to dislodgement of blood clots or slipping of ligatures. This mostly occurs due
 HAEMORRHAGE
HAEMOSTASIS AND BLOOD TRANSFUSION 43

risealso
may of blood
occurpressure when the patient
due to restlessness, is recovering
coughing from which
or vomiting anaesthesia or shock.
raises the Such
venous bleeding
pressure.

3. Secondary
operation. haemorrhage.
This is usually due to infectionThis
and occurs usually
sloughing afterof the
of part 7 toarterial
14 dayswall.of Sometimes
injury or
followed
is preceded by warning haemorrhage, which stains the dressings with blood. This is
it secondary
by the actual may
haemorrhage
haemorrhage which is often moderate to severe. Such type of
occur externally or internally. The examples of latter are haemorrhage from
anastomotic site revealed in the form
thehaematemesis, following peptic ulcer operation, in which bleeding is operation site of
of Similarly secondary haemorrhage may occur at the
haemorrhoidectomy in the form of anorectal bleeding.
Clinical features of haemorrhage. In case of external haemorrhage the bleeding is seen
om outside and the diagnosis of haemorrhage is confirmed. In case of internal haemorrhage
bleeding is concealed and is not seen from outside. Afew symptoms and signs usually
accomparny heavy blood loss, be it internal or external. In case of internal haemorrhage these
helpful to come to the diagnosis. Increased pulse rate, low blood pressure, increasing pallor,
acute blood
restlessness and deep sighing respiration (air hunger) are the typical features of
whern the bleeding
Cold and clammy extremities, empty veins are also characteristically seen
is continuing.
1/2 hourly intervals when the
Pulse rate and blo0d pressure should be measured l/4th or
patientis losing blood during his stay in the emergency
department. Though fall of blood
pressure is often noticed in case of
haemorrhage, yet a normal blood pressure cannot exclude
diagnosis of haemorrhage. Oftern the blood pressure is maintained at normal level by
he when the patient is still bleeding. Suddenly
neripheral vasoconstriction due to adrenergic release evern death of the patient. Pulse rate is a
collapse and
the blood pressure may fall abruptly with Usually with haemorrhage the pulse rate
hetter indicator of haemorrhage than blood pressure. the pulse becomes of low volume, which
been excessive
is increased. When the blood loss has
pulse'.
is classically known as thready obligatory in patients who is losing blood. Urine output becomes
Measuring of urine output is shock.
haemorrhage and
low in patients suffering from important to measure how much the patient
Measurement of blood loss. It is often to
This amount should always be replaced. Whatever methods are adopted methods
has lost blood. actual figure. The blood loss detected
by the
loss, they do not give the the
measure blood
actual loss, because a considerable amount of plasma is lost into
is usually less than the and by
considerable amount of water is lost via lungs, from the wound
interstitial tissuesand a plasma and water constitutes
approximately
from the skin. This loss of
evaporation of sweat
by various methods.
20% more than the blood loss detected is by weighing swabs. The other methods are
of detecting blood loss
The best method from fractures and measurement of blood clot ir
bleeding
easurement of swelling in case of
haemorrhage . course is the best method of measuring blood loss durins
) Weighing of swab. This of they are used and they are weighed again after the-
operation. The swabs are weighed before into a collecting basket. The difference of weigh
individually
is ked with blood and thrown blood loss. As mentioned earlier it cannot give th
ml of modera
achalunt of blood loss. 1gm = 1 multiplied by a factor of1½ in case of
actual amount of blood loss and it should be operations li
mastectomy. In case of longer
operations like partial gastrectomy or radical
 HAEMORRHAGE, HAEMOSTASIS AND BLOOD TRANSFUSION 43

of blood pressure when the patient is recovering from anaesthesia or shock. Such bleeding
torise
also occur due to restlessness, coughing or vomiting which raises the venous pressure.
may a Secondary haemorrhage. This occurs usually after 7to 14 days of injury or
Sometimes
operation. This is usually due to infection and sloughing of part of the arterial wall. is followed
preceded by warning haemorrhage, which stains the dressings with blood. This
is
it the actual haemorrhage which is often moderate to severe. Such type of secondary
by
haemorrhage may occur externally or internally. The examples of latter arerevealed haemorrhage from
nenastomotic site following peptic ulcer operation, in which bleeding is in the form
haematenmesis. Similarly secondary haemorrhage may occur at the operation site of
haemorrhoidectomy in the form of anorectal bleeding.
the bleeding is seen
clinical features of haemorrhage.- In case of external haemorrhage case of internal haemorrhage
outside and the diagnosis of haemorrhage is confirmed.fewIn symptoms and signs usually
bleedingis concealed and is not internal seen from outside. A
heavy blood loss, be it or external. In case of internal haemorrhage these
accompany low blood pressure, increasing pallor,
helpful tocome to the diagnosis. Increased pulse rate,are the typical features of acute blood
resilessness and deep sighing respirationveins (air hurnger) bleeding
Cold and clammy extremities, empty are also characteristically seen when the
lnss.
is continuing. the
measured 1/4th or 1/2 hourly intervals when
Pulse rate and blood pressure should be Though fall of blood
natient is losing blood during his stay in the emergency department.pressure cannot exclude
noticed in case of haemorrhage, yet a normal blood by
pressure is often
haemorrhage. Often the blood pressure is maintained at normal level
the diagnosis of Suddenly
vasoconstriction due to adrenergic release when the patient is still bleeding.
neripheral
fall abruptly with collapse and even death of the patient. Pulse rate is a
the blood pressure may blood pressure. Usually with haemorrhage the pulsewhich rate
better indicator of haemorrhage than volume,
has been excessive the pulse becomes of low
is increased. When the blood loss
pulse'.
is classically known as thready obligatory in patients who is losing blood. Urine output becomes
Measuring of urine output ishaemorrhage and shock.
low in patients suffering from important to measure how much the
patient
Measurement of blood loss. It is often to
amount should always be replaced. Whatever methods are adopted
methods
has lost blood. This by the
actual figure. The blood loss detected lost into the
loss, they do not give the
measure blood is
usually less than the actual loss, because a considerable amount of plasma wound and by
is the
amount of water is lost via lungs, from
interstitial tissues and a considerable water constitutes approximately
evaporation of sweat from the skin. This loss of plasma and
various methods.
20% more than the blood loss detected by weighing swabs. The other methods are
detecting blood loss is by
The best method of bleeding from fractures and measurenment of blood clot in
Measurement of swelling in case of
haemorrhage.
) Weighing of swab.
measuring blood loss during
This of course is the best method of weighed again after they
before they are used and they are The difference of weight
Faon. The swabs are weighed individually
Oakedwith blood and thrown into a collecting basket.
Is the nentioned earlier it cannot give the
blood loss. As
of blood loss. 1gm = 1 ml of multiplied by a factor of 12 in case of moderate
actual amnount
amount of blood loss and it should be mastectomy. In case of longer operations like
S ke partial gastrectomy or radical
 A CONCISE
TEXTBOOK OF
abdominoperineal operations the swab weighing total should be multiplied by a factor
SURGER
(ii) Measurement of swelling in closed fractures.-- In case of moderate of
fractures of the tibia, the blood loss is estimated at 1,000 to 1,500 ml. In Swelling in
case of fractured shaft of femur, the estimated moderate clo sed
(iüi) Measurement of blood clot.-- blood loss is about 1,000 to 2,000 ml.
When the collected blood clots are kept in a pot swelling in
measured against a clenched fist of the patient, total blood clot of the an3
equal to 500 ml. of blood. size of the clenched
Blood olume determinations. Blood fist is
volume
haematocrit reading gives ratio of plasma to red cells. = red cell volume +
plasma volume. The
cells volume is measuredthe Firstly the plasma
the total bloodvolume
and from the or the red
determined. The normal blood volume haematocrit value volume can he
means in case of an adult of normal is about 80 ml of whole blood per Kg body
certain pathological conditions this structure the normal blood volume is about 5 toweight. 6
That
arteriovenous fistula. blood volume is increased e.g. in litres. In
chronic anaemia and
Haemoglobin level is often considered as a good
not so. In the initial stage
hours by haemnodilution causedthe haemoglobin level indication of haemorrhage. But it is practically
due to natural attempt to by movement remains
of
normal. It is only lowered after a few
12 to 16 g per 100 ml. restore blood volume. The extracellular fluid into the vascular Space
normal value of haemoglobin is about
Measurement of C.V.P. or Central Venous Pressure is a
volume in haemorrhage. good method to detect loss of
blood
Treatmnent of
haemorrhage.
A. To stop blood loss It consists of twO
and B. To restore parts
crystalloid solution and infusion of plasma or blood volume by blood transfusion, infusion of
A.. The blood loss is plasma substitutes.
from outside and 3. By stopped mainly 3mathods- 1. Rest, 2.
by
1. REST
operative methods. Pressure and packing
Absolute rest is vital so far as the
Restlessness
rest to
causes more blood loss. Some
sedatives and
treatmnent of haemorrhage is concerned.
the patient. If the patient
Morphine is a good sedative and is becomes restless dueanalgesics
to pain,
may be prescribed to provide
intravenously or even intramuscularly often used intravenously in the haemorrhage
dose of
will be more.
but not 1/4th gr. It is given
subcutaneous vessels
effect of the drug is following
subcutaneously. Due to
haemorrhage absorption of the drug willvasoconstriction of the
not properly be minimal. As the
subcutaneously. When the blood achieved,
volume is
the surgeon may push
some more amount
vasoconstriction diminishes and excessive amount ofrestored and the circulation improves,
disastrous effect. Morphine however is morphine will be absorbed. This mnay induce
head injuries, where
chloralhydrate contraindicated when there is respiratory
old individuals. Inj. pethidine is a is more preferred. is also avoided in childrendepression
It
and in very
in
alongwith morphine to induce sleep. better drug than morphine. Some
In this respect short acting sedative maybe prescribed
may be used. temazepam or benzodiazepam
Position of the patient is sometimes helpful to reduce
from thyroidectomy wound, the head end of the
bed
haermorrhage. In case of haemorrhage
should
position). In case of haemorrhage from varicose vein, the be raised (arnti-Trendelenburg
(Trendelenburg position), in this case gravity reduces bleeding. footend of the bed is raised
Trendelenburg position is also
helpful as it increases blood supply to the brain and helps to restore
blood pressure.
 BLOOD TRANSFUSION
ORRHAGE, HAEMOSTASIS AND
HAEMO

PIESSIURE AND PACKING FROM OUISIDE.

treatment.
This is mainly a first-aid
2. and bandage may be used as pressure bandage to reduce bleeding from
piecesof gauze are not available clean linen cloth may be used
Sterile wound. If sterile gauzes and barndages
external bleeding from the wound. The gauze pieces are used as package.
bandageto reduce to stop haemorrhage has been obsolete. This in fact cannot stop arterial
tourniquet
as Use of causes venous congestion and increases venous bleeding.
the contrary
on of tourniquet is only restricted in the operation theatre for use in
modern surgery place
bleeding,
Its uses are
In operations as prophylactic measure to control haemorrhage.
certain Inamputations except for atherosclerotic gangrene. menisectomy
() blood-less field for orthopaedic and soft tissue operations (e.g. in
get a
(i) To remove ganglion from tendon sheath etc.).
operations,to
control haemorrhage temporarily while exploration and repair are being carried
(ii) To
out. application, The limb is elevated and an Esmarch bandage is applied spirally to
Method oflimb from toes towards the thigh. The bandage is wound upto the groin and the
elevated
the
the tourniquet is inflated. The distal spirals of the Esmarch bandage are now unwound
quff operation.
expose thhe site for The time of application of the tourniquet must be written on the
to Removal of tourniquet.
theatre. The tourniquet should not be used for more than 1 hour.
blackboardin the operation
finished before that period. Before deflating the cuff a firm bandage is
operation must be
The wound, so that haemorrhage from minute vessels are stopped by the
appliedon the operating
pressure bandage.
RY OPERATIVE METHODS.- During operation haemorrhage is usually stopped by
bleeding vessels. Now the bleeding vessel
artery forceps (haemostats) and clips applied to the vessel. Smaller vessels can be
aifher ligated with catgut or silk according to the size of the
coagulated with diathermy.
n case of big vessels like renal artery and vein transfixion suture may be used with silk.
used to
When haemorrhage is in the form of oozing, Oxycel or gelatine sponge may be platelets
stop such bleeding. This type of material provides a network upon which fibrin and
are deposited to stop bleeding. Such bleeding can also be stopped by gauze soaked in adrenalin
solution (1 : 1000). 'Stypven' or Russell Viper Venom may be applied. In case of oozing from
bone, bone wax may be used.
When the actual bleeding vessel cannot be detected, it is customary to use rolls of gauze
for packing the wound for sometime. After 5 minutes the gauze pack is removed and slight
Dieeding from the spurting vessel can be identified. This is held by long curved artery forceps
and then ligated to stop bleeding.
asolid viscus is ruptured and bleeds heavily, the whole or part of such viscus should be
excised e.g-
splenectomy, partial hepatectomy, nephrectomy etc.
Chronic haemorrhage. Bleeding from haemorrhoids, carcinoma of caecum and peptic
ulcer are
for quite examples
a
of chronic
haemorrhage. These bleedings are small in quantity and continue
never long time till effective treatnment is performed. In these cases the blood volume is
however diminished as plasma replacement occurs as bleeding continues. Red cell replacement
lagsAs thebehind, which results in microcytic hypochromic anaemia. The patient becomes
anaemiopc.
devel blood
volume is normal or slightly more than normal, these patients often
high-output cardiac failure. This high-output is due to increased cardiac output which
 A CONCISE TEXTBOOK
OF
sequied to reverse the state of anaemic hypoxia. If acute haemorrhage occurs in these SURGEW
is more dangerous tharn normal individuals as oxygen carriage is already depleted due tocases
R.B.C. ount.
When these cases are treated, packed cells should be used instead of whole blood lom
extra burden on the heart. What these patients require is not the plasma but only the to
cells. red redue
bloo
Natural restoration of blood volume after haemorrhage.--As soon as
or bleeding takes place
required to maintain blood
the vasular space. This
nature almost immediately starts to replenish the blood
haemorrhage
volume.
flow to the vital organs. First of all interstitial fluid is absorbedThis i
causes
short time. However red cell haemodilution. Plasma proteins are replaced by the
in a liver
should be sufficient to maintainrecovery
takes more timne, about 5 to 6 weeks.
this period. Iron absorption
B. As soon as haemorrhage takes
place, every effort should be made to
by blood transfusion. Blood sample should be sent for grouping and restore blood volume
time the report is received, infusion of
crystalloid should be given. Only crOSS-matching. By the
when blood is not
available for the time being plasma or plasma substitutes may be used.
HAEMOSTASIS
Natural attempt of
bleeding. The first step haemostasis
or stoppage of bleeding starts
in immediately at the site of
known as thromboxane. Thisachieving haemostasis is due to local release
agent is a powerful constrictor of of a humoral agent.
aggregation of platelets. This causes constriction of the small smooth muscle and promotes
off. It is probably released by the arteries and spontaneous sealing
is a product of platelets at the site of disruption of the endothelial surface. It
prostaglandin metabolism.
sized arteries also constrict, after they It must be understood that larger
have been transected in response tovessels and medium
innervation and to circulating humoral agent like direct sympathetic
norepinephrine.
atherosclerotic arteries cannot contract. Larger veins are less efficient at Only diseased arteries and
Incomplete transection of arteries paradoxically contracts less as
spontaneous sealing off.
humoral agent. they are less respondent to
Platelets are one of the essential components of
which is known as thrombosthenin allows the haemostasis. A contractile protein in platelets,
platelet plug to contract, thus reinforces the
contraction of the vessels. Platelet factor III, a thrombogenic
which promotes coagulation. phospholipid is also released locally
The next mechanism in haemostasis is the
known as coagulation. The coagulation sequenceformation leads to
of a fibrin clot, the process of which is
the
fibrinogen to form insoluble fibrin which is acted upon by formation a factor
of thrombin, which splits
The detail process of coagulation and XIII to form a tough clot.
involvement
book and the students are instructed to follow any of various factors is beyond the scope of this
purpose.
standard TextBook on Physiology for this
Another important aspect of coagulation is the fibrinolytic process,
of intravascular fibrin. Formation of
such fibrin and which prevents formation
excess fibrin in areas where it is not necessary
will be disastrous. For this a strong proteolytic enzyme
soluble fragment is formed which is known as plasminthat breaks down fibrin into much smaller
(also
from plasminogen, a circulating precursor that converts to called fibrinolysin). This is formed
which are found in the blood, many tissues and plasmin by the action of activators
especially in vascular endothelium. It is no
 AND BLOODTRANSFUSION
HAEMORRHAGEHAEMOSTASIS

effects of plasmin are limited to

the areas of need. Plasminogen and circulating
howthe are selectively adsorbed on fresh fibrin. By
this the beneficial clots are
cear
activators
plasminogen harmful clots are lysed.
whereas
preserved
CONGENITAL ABNORMALITIES OF HAEMOSTASIS
congenital abnormality of haemostasis is
haemophilia. Christmas disease
most
common
carried by a
The
A).- It is a sex linked inherited disorder and is
i sthenext. (Haemophilia. transmitted through
Haemophilia
that it manifests only in
males and asymptomatically
so total lack of factor VIIl activity. The level of coagulation
gene, involves an almost
individual.
recessive
carriers. It
may be less than 1% of normnal Bleeding after slight trauma is
blood manifestations vary considerably.
female
VII inthe from repeated
features.- Clinical problems are mainly orthopaedic resulting be manifested
factor will
Clinicalproblem. Surgical retroperitoneal bleeding may occur and noticed. Death in
Spontaneous Sometimes haematuria is
main joints.:
haemorrhagesinto pain,tenderness
the and ileus.
nervous system.
abdominal results from bleeding into the central haemorrhage with mild trauma
severe problem. Recurrent haemophilia but is
haemophiliacs usually is an orthopaedic haemarthrosis is not only seen inresult in permanent
by
Haemophilicjoints Such recurrent recurrent haemarthrosis may
condition. Such disorganization of the joints.
characterizesthis Christnas disease. will cause heading
across in articular surfaces and VIiI and is discussed under theincrease
also
comne aarticular cartilages, a rich source of factor
infusions of this ryoprecipitate
will
infusion.
damageto
the Cryoprecipitate is Periodic performed after each
Treatment.- later in this chapter.
level should be after raising the level of
Substitutes Vl performed only fresh blood or fresh
Blood Monitoring of factor be
of alof factor VII. contenmplate, this should
of therapy include
Alternative torms
operation has to level. congenitaldisorder
#any almost normal common
Lr VI fo most
This is thesecond offactor IX.
frozenplasma. (HaemophiliaB).- congenital
deficiency almost same as those.IX
are
Christmas diseasecondition there is a than haemophilia A and definite substitue of factor
this milder no also.
ofcoagulation.
Inmanifestations are frozen plasmna. There is used in this conditiondisorder of
Theclinical transfusion of fresh Cryoprecipitatemay be common inherited
Treatment is effective. most
treatment isless This is the 3rd from mucous
henceWillebrand's disease.
andVon to be more
bleeding tends there are loW plasma
severity, but the condition some platelet
peculiar also
coagulation. manifestations vary in system. In this antigen. There is
Cinical musculo-skeletal related
than from the and factor VII manifestations.
embrane complenent
levels of factor VIII episodic bleeding
abnormalities. to bizarre
All these combine to
give rise
BLOOD TRANSFUSION
haemorrhage be it
during acute
transfusion is blood loss is
Indications, of blood amount of
indication good
1. The commonest a
operations, where
external or internal. certain major
2. It is indicated during
 A CONCISE
TEXTBOOK OF
inevitahle eg. radical mastectomy, abdominoperineal resection etc.
1 in case of deep burms blood transfusion is
administration, as there is considerable haemolysis andindicated besides initial fluid
SURGERY
4. Preoperatively blood transfusion is
there is no adequate time for iron required whendestruction
the
of RBCs. and plasma
replacement therapy patient is already
needed before operations for malignant
5. In postoperative cases blood diseases.
before operation. This is anaemic and
considerable anaemic and debilitated, either
result of infection or septicaemia.
transfusion
due to
is required
when the patient has
excessive
particularty
6. In anaemic
patients, bleeding during
operation, become or
bloodtransfusion is often particularly when the as a
anaemia, it
is indicated to treat anaemia.haemoglobin
It must be level is below 10 g/100
the already better to transfuse packed cells rather
7. In burdened heart due to than whole bloodremembered that in ml.
severe
any type of surgery. malnutrition hypervolaemia.
and
to chronic reduce more burden to
coagulation hypoproteinaemia, transfusion
8. n certain blood is
purpura etc., blood disorders like indicated before
transfusions
diseases9. e.g. Hodgkin's disease, blood fraction
or haemophilia, Christmas are disease,
transfusion
In treating
cases leukaemia,
of transfusions
aplastic anaemia thrombocyt
whole openi crequired. In a few blood
is
10. During often performed erythroblastosis
through foetalis due to Rhblood
transfusion
for umbilical vein of the new born baby.
is require.
the routine
blood chemotherapy
examination shows malignant diseases blood incompatability, exchange
Collection
or donor, of blood for
one has to make blood
considerable diminution transfusion
of RBC 1evel.is often indicated if
transmitted
hepatitis through
or AIDS the blood. Particular transfusion,-Before
sure that the donor is
not suffering collecting
from
blood from an
any individual
The donor lies(which is transmitted byattention is made that
the disease which may be
is inflated to a down on a bed. A HIV I and II viruses). donor is not suffering from
in the
antecubital
vein. The needle is fossa sphygmomanometer
pressure of 80 mm Hg. 0.5 ml local
throughto which 15 gauge anaesthetic
cuff is applied to the
solution is injected upper arm and
subcutaneously
close sterile unit. connected a plastic tube needle is
introduced into median
which already contains Blood from the donor is which is attached to a plasticthe cubital
mixed with the 75 ml of allowed to come out bag which form a
grouping anticoagulant
and anticoagulant solution.
solution to prevent clotting. During
and run into the
collection, blood sterile bag
crOSS-matching.
Two types of
anticoagulant
solution contains
About 410 ml of blood is taken inspecimen A
a
is
of blood isconstantly
sent for
solutions are usually used to single
trisodiumandcitrate (dihydrate), citric acid mix with the donor blood. (i) bag
phosphate
(monohydrate) CPD
above-mentioned solution
Blood storage. Alladenosine
dextrose mixed
is added with
(CPDA-I)
water
to
(monohydrate),
to sodium
make the soluion. (ii)dihydrogen
special bloods that are collected increase the storage life of With the
to comerefrigerator at
in contact controlled termperature of 4°C from donor are stored in the blood.
During storagewith higher temperature, there (ranging
of blood, is
the red blood cells or danger of
from 6°C to 2°C). Ifblood blood bank in
is allowed
component, lose their
when a patient requiresability to release oxygen to the erythrocytes, transmitting
which infection.
which are less than 7 days massive tissues theof
old. transfusion, it is advisable to use atrecepient
constitute
within
the major
7 days.
least 1 or 2 units of So
blo00
 .HAEMOSTASIS AND BLOOD TRANSFUSION
HAEMORRHAGE. 49

White blood cells or WBC are rapidly destroyed in the stored blood.
also destroyed considerably at 4°C. But afew are still functionally useful after
Platelets are
hours. Clotting factors e.g. factor V, VIl and platelets are also destroyed quickly.
24 Shelf-life of.stored blood in CPD solution is about 3 weeks. When blood is stored in CPDA-
life is increased to 5 weeks.
solution, the storage
I transfusion,-
Types of blood
of whole blood transfusion may be used
Five typestypical stored CPD blood from blood bank is most commonly used.
The
(6) Warm blood.- During cardiopulmonary operations the blood may be warmed by
()
stored blood through a blood warming unit to reduce the risk of cardiac arrest
passingthe caused by transfusion of large volume of cold blood direct from blood bank.
whichmay be
Fltered blood is sometimes used by filtering blood through a membrane with 40um
(iüi) blood
poreso filter
off platelet aggregates and leucocytes in stored
Autotransfusion is an old method of restoring the patiernt's blood volume by
(iv)
transfusinghis or her own blood who is excessively losing blood by injury such as ruptured
or ruptured liver or in ruptured ectopic gestation. The blood is collected .from the
spleen into a sterile container. This blood is now filtrated through a few
peritonealcavity and put
of sterile gauge into a container which already contained anticoagulant CPD solution.
layers
blood is now immediately transfused into the patient.
This method is particularly used
This available.
when stored blood is not infants suffering from
) Exchange. or replacement transfusion is indicated in new born infant with a
hrohlastosis foetalis. The transfusion is given through the umbilical vein of the
adaptor one tothe infant's body, one to the donor, one to the citrated
syringe with four way with the infant's blood5 to 10
aline and the other to the waste. Rh negative blood is exchanged
ml at a time.
Such transfusion is also indicated in çarbon monoxide poisoning to remove
carboxyhaemoglobin in exchange of fresh oxyhaemoglobin. conditions.
Besides whole blood, packed red cells are also transfused in certain
Packed red cells.-This is specially transfused to patients with chronic anaemia, in elderly
individuals, in children and in those patiernts whose cardiac reserve is low andmay suffer from
cardiac failure if whole blood is transfused. If the whole blood is centrifuged at 2,000 to 2,500 g
ior 15 to 20 minutes or if the stored blood is allowed to stay idle so that the supernatant plasma
is taken off and the blood sediment is used for packed cells.
ertan other fractions of blood e.g. plasma, platelet rich plasma etc. are also transfused
various conditions. These are discussed in details in the section of blood substitutes later in this
chapter.
Amount of blood transfusion, It should be kept in mind that approximately 70% of
amount of blood loss should be replaced by trarnsfusion of blood. 500 ml of CPD stored
blood wil generally raise the haemoglobin by 10%.
How to measure the amount of bloodloss in haemorrhage has been discussed inthe section
of
haBlemoorodrhage
earlier in this chapter.
groups and compatibility.-
BLOOD GROUPS.-The red cells contain agglutinogens named Aand Band the serum
Contains agglutinins named anti-A and anti-B. For transfusion, the. red of the donor are
matched against the serum of the recipient. As agglutinins, present in thecells
recipient, are in high-
 ACONCISE TEXTBOOK
OF
titre, can act on the SURGE
and haenmolysis. To agglutinogens in the red cells of the donor's blood to produce
the contrary, the small amount of agglutinins,
not sufficient to cause agglutination of the
the huge blood volume of the
present in donor's
recipient's cells as its titre falls on being Serum, agglutinatic
agglutinogens Aand recipient. According to the presence or ofdiluted
absence
B, there are 4 blood groups : ) Group Ais one, whose the tw
A agglutinogen and the serum contains anti-B agglutinin; (iü) Group B is one, red cells conta
Contain B agglutinogen and the serum contains anti-A whose red cet
red cells contain both Aand B agglutinin; (ii) Group AB is one, who
agglutinin; (iv) Group O is one,agglutinogens
whose
and the serum contains neither anti-A
red cells contain neither A nor B nor anti-
The persons with group agglutinogen
Serum contains both anti-A and anti-B and h
trom arny group (universal recipient).agglutinins. AB can receive blon
anybody as it has got no agglutinogen inThe persons with group O blood can give blood
can use group O blood if the time does the red cells (universal donor). So in
or to wait for the availability of the not permit to do proper grouping and
proper cross-matched blood. Before transfusion, the dono
emergency,
crosS-matchin
one
and the recipient must be grouped and
are matched against the serum of the cross-matched. For transfusion, the red cells of the dono
factor, which is very important to be considered recipient. There is another factor known as Rhesus (Rh
RH RACTOR.- This is an during cross-matching.
antigen found in the red cells. Human beings can be
into Rh positive and Rh negative groups divided
not. Obviously persons with Rh positive accordingly whether the red cells contain Rh factor
Rh positive cells are injected into blood do not posses Rh anti-body in the
serum. When
Rh-negative persons, the anti-body Rh
transfusion may escape to produce any symptom but further transfusion willdevelops. The fist
serious reactions. A similar condition happens when a definitely produce
foetus. The red cells of the foetus whern come in Rh-negative woman carries Rh-positive
anti-Rh. The anti-Rh will pass into foetal circulation contact with the mother's serum, will form
and destroy the red cells of the foetus,
producing haemolytic reaction.
Approximately 85% of population are Rh positive and 15% are Rh negative.
Technique of
and one from groupblood grouping. On a glass slide, one
B, are placed side by side. The person, drop of stock serum from group A
his finger tip and a drop of blood is added to who is to be grouped, is pricked in
each of
After 5 minutes, the slide is examined under the these drops of serum placed on the slide.
serum of group A, the person belongs to group B. Ifmicroscope. If agglutination is observed in
B, the person belongs to group A. If agglutination occurs in the serum of group
AB and if agglutination is not seen in agglutination is seen in both, the person belongs to group
Before the blood is sent for either of the two, the person belongs to group O.
the patient's serum is mixed withtransfusion,
one
direct cross-matching is carried out. One drop of
examined under microscope after 5 drop of donorsblood (diluted 1:20 in
minutes. If agglutination does not saline). The slide is
compatible. agglutination occurs the blood is
If occur, the blood is
incompatible.
Incompatibility.-
haemolysis
If incompatible blood has been
of transfused RBCs transfused, agglutination and then
necrosis, renal failure and deathoccur. If haemolysis is severe,
of the individual. So it is it may cause acute renal
tubua
of the donor's blood is extremely essential that
checked. This is done by
() Transfusion of blood of same group as the
compatibiuty
should also be checked that means Rh. status of recipient should be given. (ii) Rh. compatibiiy
Rh. status of the recipient. (iü) the transfused blood should be
Direct cross-matching of the donor's red cells against similar to tne
recipient s
 HAEMORRHAGEHAEMOSTASIS AND BLOOD TIRANSFUSION

shouldbe performed before transfusion.

COMPLICATIONS or BLOOD TRANSFUSION.-There
serum
LBRARY
are variFus complications of
transfusion, though attempt should be made that blood transfusion,
ziven to the patient/
twà gtoupsiare very
blood free of complications. COf the complications of blood transfusion, connpBications
shouldbe are - A. Transfusion reactions and B. Transmission of diseases. Other
important.These
insignificant. The various complications are follows :- reactions which
not Transfusion reactions.- The followings are the various transfusion
of blood transfusion. Of these incompatibility is probably most
are
seen as
complications
maybe andshould be avoided at
all costs.
important INCOMPATIBILITY, There are three causes of incompatibility
()1. Incomnpatible transfusion.
of blood which is already haemolyzed by heating or over freezing or shaking.
Transfusion
(ü) Transfusion of blood after expiry date.
(iü)
causes it is clear that incompatibility is mainly due to human error
()he above and cross-matching.
at theelabel of the bottle of blood and imperfect grouping patient first develops
negiligencein.looking Once the incompatible blood has been transfused, the and vomiting,
Clinical
features.-
anaesthetized, he will complain of headache, nausea characteristic
andfever. If he
is not extremities. Pain in the loin is a very
rigor tingling sensation in the
theloins and means grave consequences.
painin
it indicates blockage of renal tubules, which tightness in the chest and
dyspnoea.
feature and preceded by a filling of The patient
Pain in the loin may be in shock, it becomes pronounced instead of curing it.
already
EFhe patient isconsciousness.
within 2 or 3 hours.
maygraduallylose diminished and haemoglobinuria occurs
Urine output is
gradually
definite of incompatible transfusion and it usually appears
is a sign
Appearance of jaundice pigment.
within 24 to 36 hours. blockage of renal tubules with haematin
due to of venous
Ultimately renal failure sets inshould be stopped immediately. A fresh specimenthe rejected
Treatment.- The transfusion
sernt to the laboratory for checking alongwith
patient are
blood and urine from the of blood. Haematin
bottle of blood. started instead
intravenously should be blood should be done with
Administration of fluids so alkalization of
precipitated in acid medium,simultaneously 10 ml of saturated
solution of
Pigments tend to be
of sodium lactate andFrusemide 80 to 120mg intravenously is given
10 ml of isotonic solution intravenously. upto 30 ml/hour.
Sodium bicarbonate are injectedbe repeated if urine output is not increased
may
Oprovoke diuresis. Thishydrocortisone may be prescribed.
Antihistamine and may be used in extreme cases.
Haemodialysis with artificial kidney accompanied by pyrexia,
Sometimes blood transfusion is
PTREXIAL REACTIONS.- pulse rate, nausea and
vomiting.
hil , tigor, restlessness, headache, increased
are as follows
e causes of such pyrexial reactions
J Improperly sterilized transfusion sets.
(ü) Presence of pyrogens' in the donor apparatus.
due
(m) Transfusion of infected blood.
tubing (this is not used nowadays
(iv) rubber in the
to Presenceof of sulphur compounds
av()ailabilVerityy rapidplastictransfusion
disposable sets).
of blood.
S2
A CONCISE
TEXTBOOK OF
Prevention.- These pyrexial reactions can be largely prevented by the use
SURG
disposable transfusion sets now available in the market. of
Treatment.- The transfusion is plag
with blankets. immediately stopped temporarily. The patient is
Antipyretic and antihistaminic drugs are injected. If the temperature has come Cove
the patient is
at a slow rate. feeling comfortable, transfusion is again started with a fresh plastic down a
disposabl
3. ALLERGIC
REACTIONS. Sometimes after blood transfusion (usually within ak
hours) the patient develops mildtachycardia, urticarial rash, fever and
there may be circulatory collapse, which is known as acute dyspnoea. In acute c
The cause is the allergic reaction to plasma shock.
anaphylactic
product
Treatment.- The transfusion is immediately stopped. in the donor's blood.
chlorpheniramine 10 mg or diphenhydrazine 25 mg should beAntihistaminic drugs #.
hydrocortisone and calcium may be administered in acute anaphylacticadministered. Sometimg
4. SENSITISATION TO reactions.
LEUCOCYTES
where many blood transfusions have been AND PLATELETS. This is
in the recent past. The occasionally
Se
given
antibodies against the white cells or platelets of the donated patient develon
Prevention. Such blood. This causes
many blood transfusionsunusual reaction can be avoided by giving packed red reactions.
are required. cells, wheneve
Treatment.- Antipyretics, antihistamines and steroids may be given to
B. Transmission of combat reactions.
diseases.- The most
attributable to transfusion is the transmission of diseases.common serious complication directh
1. SERUM
the most importantHEPATITIS, While many diseases have been
is by far the serum transmitted by transfusion.
which is the most common form of hepatitis. It is usually called non-A, non-B hepatitis
immunologic transfusion related hepatitis in developed countries, where
is mainly the markers
for different types of hepatitis have
been used.
hepatitis B, the virus of which is transmitted from In Indian subcontinent it
all blood donors the donor to the recipient. So
in the blood priorshould be carefully tested for
But the methodpresence
to of hepatitis Bvirus associated antign
all cases bearing thattransfusion.
virus. About 1% of cases pass
of testing is not
sensitive enough to eliminate
serum hepatitis is'usually revealed within undetected. The symptoms and signs
3 months after
2. It is now clear that ACQUIRED transfusion.
transmitted by transfusion. HIV IMMUNE
is transmittedDEFICIENCY SYNDROME (AIDS) can be
virus
Although AIDS has received considerable from the donor's
death resulting from transfusion. blood to the recipiernt
attention it ranks far behind hepatitis
3.
as a cause of
techunique.BACTERIAL
The donor's INFECTIONS,
blood when left
This is not common and
occurs due to faulty storag
bacteriai infection to the recipient may in a warm room for some hours
of any bacteria may take occur. In fact in this warm room before transfusion
C. Reactions
place. Such bacterial infection is revealed by temperature proliterado
caused by
massive transfusion, which shouldmassive transfusion,-- There
septicaemia in the recipien.
are
be
1. ACID-BASE IMBALANCE kept in mind. These are quite a few hazards O
transfusion is discussed in details below
usually results in reasonably expected in massive transfusion. Extensive
in the
anticoagulant solution significant
is present metabolic alkalosis.
as sodium citrate, This is
which because most of the cua
becomes sodium bicarbonate
 HAEMOSTASIS AND BLOOD TRANSFUSION
ORRHAGE,H
HAEMO
consumed. This alkaline nature of the blood may help the patient who is already
the
citrateis
as
acidotic. HYPERKALAEMIA - is also a theoretical possibility as the potassium level of the
2.blood may reach upto 30 mEq/L. This is due to shift of potassium out of the red cells
stored temperature of storage. But after transfusion, the transfused red cells take back as
loW there should not be
duetopotassium as they had released during storage. So at the end
massive
patients at the end of
much
hyperkalaemia atthe end of transfusion. But all studies show that
Iransfusionare hypokalaemic.
This is probably due to alkalosis induced by massive transfusion.
CITRATE TOXICITY is mainly a theoretical problem rather than practical.
Its main
3. Consume ionized calcium from the patient's body. But the body mobilizes calcium
effectisto required. Only in rare cases when
fronmskeletal stores. So supplemental calcium is notinfusing calcium, which is also not
rapidly hypocalcium is received, one may consider of
reportofharmless.
absolutely
HYPOTHERMIA..- Since massive transfusion usually occurs under most urgent
4 blood usually rushed directly from the refrigerator to
is the patient. If the patient
cicumstances, these patients
operátion theatre, he is paralyzed and unable to shiver, consequently
isinthe experience a drop in body temperature of at least 3 to 4 degrees.
almost always COAGULATION.- Probably the most important danger of factorsmassive
E RAILURE OF
failure of natural process of coagulation. This is mainly caused by two volume
kronsfusion is the
platelets and various clotting factors due to transfusion of large
(a) Dilution of of platelets, fibrinogen and various
coagulating
blood, as stored blood has low content
f stored
VIletc. massive
factors - factor V, coagulation (DIC) has been the complication ofthis
(b) Disseminated intravascular may
an incompatible blood transfusion, but
transfusion. This of course follows obviously
massive blood transfusion.
be noticed in certain cases of transfusion with fresh frozen plasma,
Treatment.Coagulation failure is mainly treated by may be
concentrate or cryoprecipitate. If DIC is considered to be the cause heparin
platelet
Used.
of over-transfusion. This complication is particularly noticed in
D. Complications and in elderly individuals. These cases should be transfused
CSes ot chronic anaemia, in children
cardiac failure is particularly seen if
Wth packed red cells rather than whole blood. Congestive patients and elderly individuals.
Me Dlood transfusion is given to chronic anaemic should be transfused and diuretics should
be
es of chronic anaemia packed red cells
unit in 4 to 6 hours. Transfusion
Ded. Transfusion should be given slowly at the rate of 1 intervals
should not be continuous, instead it should be given on separate occasions giving
Deween consecutive transfusions.
Patients over 60 years of age should also be given packed red cells with diuretics. They
should not be transfused more than 300 ml at atime.
E. CComplication of generalintravenous fluid administration. Afew complications
occur after blood
Susion. T y ntrávenous infusion. These complications may also
On. These are (a)
thrombovhlebitis, (b) air embotisi should be concluded by
Considering
Saying 'the best amount
the of blood to dangers
complications
c
of blood transfusion, it
give is the least amont that is needed'.
and