Medical Stabilization a bleeding patient Mohammad FaranoushMD Associate Professor Rasool Akram Medical Center 1242014 2 FaranoushGyn seminar Preparation Women with known or suspected medical problems should be identified and evaluated ID: 933814
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Slide2Medical Stabilization a bleeding patient
Mohammad Faranoush,MD
Associate ProfessorRasool Akram Medical Center
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Slide3Preparation
Women with known or suspected medical problems should be identified and evaluated. Plans for care and monitoring in the immediate postoperative period should be made in conjunction with an anesthesiologist, the woman's primary care provider, and medical specialists, as indicated.
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Slide4Preparation
Arrangements may also be necessary for home health care nursing services and rehabilitation centers for care of frail patients or those with complications that require more intensive management.
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Slide5PREOPERATIVE EVALUATION
Preoperative evaluation with a focus on preventing and preparing for perioperative hemorrhage
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Slide6Hematologic
Hematologic assessment may lead to the identification of disorders such as anemia, inherited or acquired coagulopathy, or a
hypercoagulable state. Substantial morbidity may derive from failure to identify these abnormalities preoperatively.
The need for perioperative prophylaxis for venous
thromboembolism
must be carefully reviewed in every surgical patient.
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Slide7Anemia
Anemia is the most common laboratory abnormality encountered in preoperative patients.
It is often asymptomatic and can require further investigation to understand its cause. The history and physical examination may uncover subjective complaints of energy loss, dyspnea, or palpitations, and pallor or cyanosis may be evident
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Slide8Anemia
Patients are evaluated for lymphadenopathy, hepatomegaly, or splenomegaly, and pelvic and rectal examinations are performed.
A CBC, reticulocyte count, and serum iron, total iron-binding capacity, ferritin, vitamin B12, and
folate
levels are obtained to investigate the cause of anemia.
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Slide9Transfusion
The decision to transfuse a patient perioperatively
is made with consideration of the patient's underlying risk factors for ischemic heart disease and the estimated magnitude of blood loss during surgery.
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Slide10Anemia
Generally, patients with
normovolemic anemia without significant cardiac risk or anticipated blood loss can be managed safely without transfusion, with most healthy patients tolerating hemoglobin
levels of 6 or 7 g/dL
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Slide11Guidelines for Red Blood Cell Transfusion for Acute Blood Loss
Evaluate the risk for ischemia
Estimate/anticipate the degree of blood loss.
Less than 30% rapid volume loss probably does not require transfusion in a previously healthy individual
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Slide12Transfusion
Measure the hemoglobin concentration: <6 g/dL, transfusion usually required;
6-10 g/dL, transfusion dictated by clinical circumstance; >10 g/dL, transfusion rarely required
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Slide13Transfusion
Measure vital signs/tissue oxygenation when hemoglobin
is 6-10 g/dL and the extent of blood loss is unknown. Tachycardia and hypotension refractory to volume suggest the need for transfusion; O2 extraction ratio >50%, decreased Vo2, suggest that transfusion is usually needed
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Slide14Assessment
All patients undergoing surgery are questioned to assess their bleeding risk.
Coagulopathy may result from inherited or acquired platelet or factor disorders or may be associated with organ dysfunction or medications
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Slide15History
The inquiry begins with direct questioning about a personal or family history of abnormal bleeding.
Supporting information includes a history of easy bruising or abnormal bleeding associated with minor procedures or injury.
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Slide16History
A history of liver or kidney dysfunction or recent common bile duct obstruction needs to be elicited, as well as an assessment of nutritional status.
Medications are carefully reviewed, and the use of anticoagulants,
salicylates
,
nonsteroidal
anti-inflammatory drugs (NSAIDs), and antiplatelet drugs are noted
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Slide21Physical examination
Physical examination may reveal bruising, petechiae, or signs of liver dysfunction.
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Slide22thrombocytopenia
Patients with thrombocytopenia may have qualitative or quantitative defects as a result of immune-related disease, infection, drugs, or liver or kidney dysfunction.
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Slide23Platelets
Qualitative defects may respond to medical management of the underlying disease process, whereas quantitative defects may require platelet transfusion when counts are less than 50,000 in a patient at risk for bleeding
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Slide24coagulation studies
Although are not routinely ordered, patients with a history suggestive of coagulopathy undergo coagulation studies before surgery.
Coagulation studies are also obtained before the procedure if considerable bleeding is anticipated or any significant bleeding would be catastrophic.
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Slide25Consultation
Patients with documented disorders of coagulation may require perioperative management of factor deficiencies, often in consultation with a hematologist
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Slide26INR
Patients receiving anticoagulation therapy usually require preoperative reversal of the anticoagulant effect.
In patients taking warfarin, the drug is withheld for four scheduled doses preoperatively to allow the international normalized ratio (INR) to fall to the range of 1.5 or less (assuming that the patient is maintained at an INR of 2.0-3.0).
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Slide27Risk-benefit analysis
Additional recommendations for specific diagnoses requiring chronic anticoagulation are based on risk-benefit analysis.
Patients with a recent history of venous
thromboembolism
or acute arterial embolism frequently require perioperative IV
heparinization
because of an increased risk for recurrent events in the perioperative period
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Slide28Thromboembolism
Systemic
heparinization can often be stopped within 6 hours of surgery and restarted within 12 hours postoperatively.
When possible, surgery is postponed in the first month after an episode of venous or arterial Thromboembolism.
Patients taking anticoagulants for less than 2 weeks for pulmonary embolism (PE) or proximal DVT are considered for inferior vena cava filter placement before surgery
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Slide29Assessment
All surgical patients are assessed for their risk for venous
thromboembolism and receive adequate prophylaxis according to current guidelines.
Patients are questioned to elicit any personal or family history suggestive of a
hypercoagulable
state.
Levels of protein C, protein S, antithrombin III, and
antiphospholipid antibody can be obtained
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Slide30Risk factor
Risk factor stratification is achieved by considering multiple factors, including age, type of surgical procedure, previous
thromboembolism, cancer, obesity, varicose veins, cardiac dysfunction, indwelling central venous catheters, inflammatory bowel disease,
nephrotic
syndrome, pregnancy, and
estrogen
or tamoxifen use.
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Slide31Prophylaxis
A number of regimens may be appropriate for prophylaxis of venous
thromboembolism, depending on assessed risk.
Such regimens include the use of
unfractionated
heparin, low-molecular-weight heparin, intermittent compression devices, and early ambulation.
Initial prophylactic doses of heparin can be given preoperatively, within 2 hours of surgery.
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Slide32Medical history
Important elements of the history are a personal or family history of prolonged bleeding, transfusion, or persistent anemia
Nongynecologic etiologies of bleeding symptoms may be present.For example, menorrhagia, a common indication for gynecologic surgery, can be a presenting symptom of von Willebrand disease (VWD)Further evaluation by a hematologist is warranted if a bleeding disorder is suspected.
Timely diagnosis allows for preoperative correction of coagulation defects.
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Slide33Medication history
Prescription, over-the-counter, or alternative medications can act as anticoagulants. Deciding whether to discontinue a medication
perioperatively depends upon the risk of bleeding versus the risk of morbidity from a hiatus of medical treatment.
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Slide34Laboratory evaluation
If a patient has abnormal uterine bleeding or another cause for anemia, testing should be performed early in the surgical planning process to allow time for correction of anemia
A blood sample for ABO and Rh typing and antibody screen is typically sent to the blood bank for patients undergoing surgery in which the expected blood loss is greater than minimal; if significant bleeding is anticipated, it is prudent to prepare two to four units of donor blood by crossmatching with the patient's serum with the donor red cells to incompatibility
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Slide35Routine tests
Routine tests of hemostasis (prothrombin time [PT], activated partial thromboplastin time [aPTT], platelet count) are NOT necessary unless the patient has a known bleeding diathesis, an illness associated with bleeding tendency, or takes a medication that may cause anticoagulation
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Slide36Transfusion
Women with blood transfusion incompatibilities or religious beliefs that preclude allogeneic blood transfusion should be identified prior to surgery.
In addition to careful surgical technique, strategies to avoid allogeneic blood product transfusion include correction of anemia, autologous blood donation, cell salvage, and
hemodilution
.
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Slide37Correction of anemia
Women planning gynecologic surgery to treat bleeding issues have typically declined or failed medical therapy.
Most women will accept a short course of preoperative therapy with the goal of increasing Hct and, thereby, avoiding the need for blood transfusion. Iron deficiency anemia associated with menorrhagia or dietary deficiency is the most common cause of anemia in the gynecologic population
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Slide38Strategies to correct anemia preoperatively are listed below:
Iron supplementation
Medical treatment of abnormal uterine bleedingErythropoiesis-stimulating agents (recombinant human erythropoietin [rHuEPO] and darbepoetin Alfa)Preoperative rHuEPO reduces risk of allogeneic transfusion
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Slide39Attention
Erythropoiesis-stimulating agents are associated with serious cardio- and thrombovascular events and more rapid tumor progression and increased mortality in cancer patients (including cervical cancer)
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Slide40Autologous transfusion methods
Autologous blood donation — A patient scheduled for surgery and are not anemic may bank one or more units of her own blood.
Intraoperative and postoperative blood salvage — Blood that is shed during or after surgery is retrieved, processed, and returned to the patient.
Acute
normovolemic
(
isovolemic) hemodilution
— Blood is removed from a patient, either immediately before or shortly after induction of anesthesia, with isovolemia is maintained using crystalloid and/or colloid replacement. The blood withdrawn is
anticoagulated
and is
reinfused
into the patient as needed during, or after, the surgical procedure
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Slide41Hemodynamic monitoring
Fluid losses lead to depletion of the extracellular fluid. This problem, if severe, can cause a potentially fatal decrease in tissue perfusion.
Early diagnosis and treatment can restore normovolemia in almost all cases
.
Volume depletion primarily results from sodium and/or water loss
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Slide42Volume Depletion
True volume depletion occurs when fluid is lost from the extracellular fluid at a rate exceeding net intakeThe urine volume is typically, but not always, low (
oliguria) in hypovolemic patients due to the combination of sodium and water avidity
If, however, concentrating ability is impaired as noted above,
oliguria
may not be present.
Acid-base balance
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Slide43Fluid and electrolyte management
Suspicion of postoperative hemorrhage, fluid resuscitation Preparation made for possible surgical re-exploration
Large-bore intravenous accessIsotonic fluids given (normal saline or Ringers lactate)Foley catheter reinsertedCrystalloid fluids should be replaced in a 3:1 ratio of
fluid:blood
loss.
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Slide44Fluid Replacement
Saline solutions are generally preferred for the management of patients with severe volume depletion not due to bleeding.
Saline solutions seem to be as safe and as effective as colloid-containing solutions, and are much less expensive Hyperoncotic starch solutions should be avoided as they increase the risk of acute kidney injury and mortality
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Slide45BUFFER THERAPY
Patients with marked hypoperfusion may develop lactic acidosis, leading to a reduction in extracellular pH below 7.10.
Sodium bicarbonate can be added to the replacement fluid in this setting, in an attempt to correct both the acidemia
and the volume deficit.
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Slide46Therapy
Rapid volume repletion is indicated in patients with severe hypovolemia or
hypovolemic shock.Delayed therapy can lead to ischemic injury and possibly to irreversible shock and multiorgan
system failure.
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Slide47Fluid and electrolyte management
Patients who are stable but anemic may be managed conservativelyTransfusion is given, if appropriate, and hemodynamic status, urine output, and
Hct are monitored.Further evaluation and more aggressive management are indicated if there is suspicion of ongoing blood loss.
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Slide48Intraoperative hemorrhage
Intraoperative hemorrhage is generally defined as blood loss exceeding 1000 mL or requires a blood transfusion
Massive hemorrhage refers to acute blood loss of more than 25 percent of a patient's blood volume or bleeding that requires emergency intervention to save the patient's lifeSevere postoperative anemia impacts perioperative morbidity and mortality
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Slide49Associated abnormalities
A variety of electrolyte and acid-base disorders may also occur, depending upon the composition of the fluid that is lost.
Muscle weakness due to hypokalemia or hyperkalemia
Polyuria
and
polydipsia
due to hyperglycemia or severe hypokalemiaLethargy, confusion, seizures, and coma due to
hyponatremia, hypernatremia, or hyperglycemia
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Slide50MANAGEMENT OF INTRAOPERATIVE BLEEDING
Surgical techniquesManage diffuse bleeding
Bleeding from all sites indicates a possible bleeding diathesis, and should be treated medicallyTopical hemostatic agents
Gelatin
ORC
Microfibrillar
collagen (MC)
Topical thrombinFibrin sealant
In women undergoing gynecologic surgery with areas of low volume bleeding
, suggest
the use of topical hemostatic agents (
Grade 2C
)
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Slide51Topical Agents
In the absence of high quality data, in general, surgeons should pick the topical agent with which they are most familiar. If the choice is to use a combination of gelatin and thrombin
Recommendation the combined liquid preparation rather than gelatin sponge soaked in thrombin (Grade 1A
).
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Slide52POSTOPERATIVE BLEEDING
Tachycardia, hypotension, oliguria
(urine output <20 mL/hour), confusion, and increasing abdominal pain may all signal postoperative intraabdominal bleeding.Evaluation of a patient with suspected postoperative bleeding includes physical examination and assessment of vital signs and urine output.
A laboratory evaluation should exclude a decreasing
Hct
or bleeding diathesis.
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Slide53POSTOPERATIVE BLEEDING
Patients who are stable but anemic may be managed conservatively. Transfusion is given, if appropriate, and hemodynamic status, urine output, and Hct are monitored.
Further evaluation and more aggressive management are indicated if there is suspicion of ongoing blood loss.
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Slide54Blood product replacement
Transfusion during perioperative hemorrhage often requires replacement of red blood cell and plasma components
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Slide55Guidelines for red cell transfusions and volume replacement in adults
>40 percent loss (>2000 mL):
Rapid volume replacement, including RBC transfusion, is required30 to 40 percent loss (1500 to 2000 mL):
Rapid volume replacement with crystalloids or synthetic colloids is required; RBC transfusion will probably also be required
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Slide56Cont’
15 to 30 percent loss (800 to 1500 mL):
Need to transfuse crystalloids or synthetic colloids; need for RBC transfusion is unlikely unless the patient has pre-existing anemia, continuing blood loss, or reduced cardiovascular reserveLess than 15 percent blood loss (≤750 mL):
No need for transfusion unless volume loss is superimposed on preexisting anemia, or when patient is unable to compensate due to severe cardiac or respiratory disease
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Slide57Need based on hemoglobin concentration:
Hgb <7 g/dL:
RBC transfusion indicated. If the patient is otherwise stable, the patient should receive 2 units of packed RBC, following which the patient's clinical status and circulating
HgB
should be reassessed
Hgb 7 to 10 g/dL:
Correct strategy is unclear
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Slide58Cont’
Hgb >10 g/dL:
RBC transfusion not indicatedHigh risk patients:Patients >65 and/or those with cardiovascular or respiratory disease may tolerate anemia poorly. Such patients may be transfused when Hgb< 8 g/dL.
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Slide59platelets
Treatment with platelets and coagulation factors is justified in patients who have serious bleeding, are at high risk for bleeding (eg
, after surgery), or require invasive procedures. Patients with marked or moderate thrombocytopenia (<50,000/microL) and serious bleeding should be given platelet transfusions (1 to 2 units per 10 kg per day);
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Slide60Component
Composition
Indications and dose*
FFP, thawed plasma, and 24 hour frozen plasma (FP 24) (one unit)
All soluble plasma proteins from one unit of whole blood
Correction of bleeding due to excess warfarin, vitamin K deficiency, or deficiency of multiple coagulation factors (
eg
, DIC, liver disease, dilutional coagulopathy) Initial dose: 15 mL/kg
Massive transfusion protocols
For infusion or plasma exchange in TTP-HUS
Cryo-precipitate (one bag)
10-15 mL of cold insoluble protein from one unit of FFP; Pasteurized; contains vWF, factors VIII, XIII, fibrinogen, fibrinonectin
Source of fibrinogen (200 mg/bag)
For bleeding in vWD: 1 bag/10 kg q 6-12 hr
Factor XIII deficiency: 1 bag/10 kg usually once
Factor VIII deficiency: 100 units/bag. This use is outmoded; recombinant factor VIII should be used
Cryo-poor plasma (one unit)
240 mL of FFP that is depleted of cold insoluble proteins
Suitable for bleeding due to
coumadin
overdose, vitamin K deficiency.
For infusion or plasma exchange in TTP-HUS
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Slide61Thank You
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