Transcript Slide 1

Whole Blood
 After transfusion with one unit of whole blood, 1.0g/dL
hemoglobin indications for transfusion with whole blood
are hemorrhagic shock with cogulation factor
abnormalities.
Packed Red Blood Cells
 General indications for use include the replacement of
hemoglobin for oxygen carrying capacity in patients with
reduced hemoglobin, such as patients with major trauma
and bleeding, shock secondary to acute blood loss, intra
operative blood loss > 750mL, and significant anemic
states requiring intervention.
Massive Transfusion
 Replacement of the patient’s blood volume over a 24 h
period defines massive transfusion.
Platelets
 Transfusion
of
platelets
is
indicated
for
thrombocytopenia.
 In a 70 kg adult, one platelet pack may be expected to
increase the platelet count by 5,00 to 10,000/mm3 1h
post transfusion.
Granulocytes
 Granulocyte transfusions are reserved for febiril
neutropenic patients (<500 neutrophils/mm3) who have
a good chance of bone marrow recovery and have
bacterial or fungal infections unresponsive to ntibiotic
therapy.
Granulocyte transfusions may also be
considered for septic, pancytopenic neonates with
decreased bone marrow reserve.
Plasma Products
 Plasma is indicated for patients with coagulation factor
deficiency, hemolytic uremic syndrome, thrombotic
thrombocytopenic purpura, and antithrombin III
deficiency.
 Cryoprecipitate contains von Willebrand factor, factor
VIII, fibrinogen, factor XIII, and fibronectin. It is used
for therapy of von Willebrand’s disease, hemophilia A,
factor XIII deficiency, and firbrinogen deficiency. It must
be ABO matched .
 Factor VIII concentrate is used for severe hemophilia A
and in patients with significant factor VIII inhibitors.
Factor IX concentrate is used to treat hemophilia B,
deficiencies of factors II, VII, or X and factor VIII
inhibitor.
Albumin and Plasma Protein Fraction


These products are derived from plasma, heat treated to
prevent disease transmission, and indicated for patients
who are hypovolemic and hypoproteinemic.
A 5% concentration of either solution has osmotic and
oncotic properties equivalent to plasma.
Shock
Definitions
 Shock is the underprefusion of multiple organ systems.
Initial Management
 The mainstays of shock therapy are to 1. improve
oxygen delivery (by raising hemoglobin concentration,
cardiac output, or arterial saturation); 2. reduce oxygen
consumption, and 3. identify and treat the precipitants of
hypoperfusion.
Urgen resuscitation of the Patient with Shock;
Intravenous Volume and Vasoactive Drug Therapy
1. Hemorrhagic Shock including Truma, Raptured Aneurysms
 Elevate legs, MAST
 Access/infuse emergency blood Group/Match /Administer warmed
blood/ Components
 >3L/20 min warmed saline equal volumes of colloid or substitutes
(albumin, dextran, hetastarch)
 Continue aggressive volume infusion until blood pressure normal.
 Consider early surgical hemostasis
 Awaiting adequate volume repletion, institute multipurpose agent
(dopamine or epinephrine) and increase does from 1 towards 10
(g/kg/min for dopamine; g/min for epinephrine) as needed to
maintain blood pressure.
 If higher doses are needed, add norepinephrine (2-20 g/min ).
 Discontinue these drugs as urgently as volume repletion and
hemostasis allow (see Second column).
2. Nonhemorrhagic Hypovolemia including septic shock
 Elevate legs
 L/20 min warmed saline
 Group/match packed RBCs and plasma re dilutional anemia
 Continue aggressive volume infusion until blood pressure normal or
heart “too full”
 Detect and treat tamponade with pericardiocentesis, thoracostomy,
peritoneal drainage, or reduced PEEP
 Avoid vasoactive drug until heart “too full”
 Except dopamine (2-5 g/kg/min) for renal perfusion early.
 Nitroglycerin and nitroprusside are contraindicated.
 Vasoconstrictors delay adequate volume repletion (see left column).
 In right heart overload with shock norepinephrine (2-20 g/min)
may help by maintaining RV perfusion; in septic shock,
vasoconstrictors may replacement provides inadequate perfusion
pressure (see text ).
3. Cardiogenic Shock due to Myocardial Ischemia
 When heart is “too full” decreasing blood volume (rotating
tourniquets, phlebotomy, nitroglycerin, morphine, diuretics).
 If the heart is not “too full” or blood pressure decreasing with above
interventions, NS 250ml/20 min
 Repeat if blood pressure increasing until heart too full.
 Dobutamin (5-15 g/kg/min) to enhance contractility wihout excess
tachycardia, arrhythmia, or vasconstriction; higher doses dilate
skeletal vascular bed.
 Dopamine (g/kg/min) to preserve renal cortical blood flow; at
higher dose (4-12 g/kg/min) increases heart rate, contractility,
venous tone, and preload, like epinephrine.
 Nitroglycerin (5-250 g/min) for venodilation with minimal arterial
dilation except for the coronary circulation.
 Sodium nitroprusside (0.1-10 g/kg/min)for arterial dilation to
reduce afterload and allow greater ejection from a depressed left
ventricle or regurgitant aortic/mitral valve