General Surgery Sheet #4 By Muna Waheed

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General Surgery Sheet #4 By Muna Waheed

Post by Sura on 13/3/2012, 12:02 am

http://www.mediafire.com/?eycc0y7e1b4xoo4

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http://www.4shared.com/file/7PLOJPsf/General_surgery_4.html
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عدد المساهمات : 484
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تاريخ التسجيل : 2010-09-29

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Re: General Surgery Sheet #4 By Muna Waheed

Post by Shadi Jarrar on 30/3/2012, 4:22 pm

General surgery
Blood transfusion
Today we want to talk about blood transfusion. We are going to concentrate on its complications, when it is going to happened, which patient of higher risk, and how to manage it. And at the end every hospital have its policy and guidelines about managements.
We have 4 major groups of blood :
Group A: red blood cells contains A agglutinogen/antibodies beta agglutinin (anti-B antibodies) in plasma so can receive blood from (type A & O)
Group B: red blood cells contains B agglutinogen/antibodies alpha agglutinin (anti-A antibodies) in plasma so can receive blood from (type B&O)
Group O: no agglutinogen in red blood cells /both beta & alpha agglutinin (anti A & anti-B antibodies) in plasma so can receive blood from (O only)
Group AB: red blood cells contains A agglutinogen & B agglutinogen / no agglutinin in plasma so can receive blood from (all types)
Most common type is O (45%)-A (42%)-B(10%)-AB(3%)
In surgeries if there is a need for blood transfusion the blood Bank may cover that need but in catastrophist and emergencies that cause major trauma patient might need for donation so this why we encourage donation. When there is a donor the blood bank ask him: medical history physical health history about transmissible diseases like AIDS or IV abusers or if he travels to some areas where there is endemic disease like malaria. It is important to know if he is taking drugs or not. In blood bank do rapid tests for the donor like CBC which is rapid assessment of the hemoglobin if patient blood hemoglobin doesn’t meets the established standard then we may considered anemic and he might need some work up ..nutritional assessment and anemia work up. The donor can give blood every 2 months/one blood unit (around 400-450ml= 10% of donor blood volume.
You are not eligible to donate blood if you:
• Have ever used self-injected drugs (non-prescription)
• Had hepatitis
• Are in a high-risk group for AIDS

We collect blood in the blood bank and there is usually they weight the blood and maximum they can take 500cc from the patient.
An "homologous" donation occurs when a person donates his or her own blood for someone else like relatives or one ongoing major surgery

An "autologous" donation occurs when a person donates his or her own blood for personal use (when he is going to have surgery soon…. They start planning 2 months before …giving blood enhancing agent like erythropoietin , ferriten and iron. This is the best but it is not applicable that much in older patient. Patient with units positive for infectious agents (cant receive others blood) and units with irregular blood group antibodies against other minor groups of blood are encouraged for autologous donation.
In heart surgery they do autologous donation as following: -donate blood one month before surgery -during surgery another unit of blood taken from the patient after GA -we do him fluids (hemodilution: the patient's blood is collected prior to surgery and replaced with a plasma expander) like normal saline to expand his IV volume. What's the aim of taking his blood during surgery and give it to him again?? Why not to leave it inside?? Answer: during heart surgery the patient might have bleeding so to replace it with his own blood that collected before surgery before (blood changes during surgery so blood before is better)…. That’s during open heart surgeries only..
In major surgeries like heart or liver or bone marrow or vertebral column which might lead to profuse bleeding we use cell saver (This device is used to collect blood in the operative field during surgery by suction, wash it with special kinds of filters, and return it with heparinised saline (not to coagulate) to the patient).. by doing this blood that collected inside cavities (used in clean type of surgeries not contaminated with feces or pus or bacteria or malignant cells= clean surgeries only not clean contaminated or dirty one)
The main aim is trying to minimize "homologous" transfusion = receive own personal blood and not others blood.
we should be very cautious and very hesitant in case of blood transfusion.
The doctor mention Wound drainage (from slides: blood is collected from cavities (such as a joint space into which bleeding has occurred) and returned through a filter (which removes big items like thrombi and tissue fragments, but does not remove inflammatory chemical mediators or cytokines).

One of principle of donation is Directed Donations that you’ve designates certain persons to donate specifically for his or her use (you father for example) and usually we from the families we find that type very strong and matching.
Most common type of blood transfusion is homologous..but the direction is toward autologuos BT.
In developed world they store blood for 20-30 years with certain material and with temperature -60C
Then he said that in blood bank her blood store at freezer (temperature=4C) for couple of years..
Blood donated contains: plasma, WBCs, platelets, coagulation factors and mainly RBCs.
Transfusion is most likely to be done with RBCs. Not preferable to give with BT WBCs because it may some problems. So they are going to use Leukocyte depleted RBC's : they will wash the RBCs.
Frozen RBCs: which stored for many years under temperature of -60C
Indications for BT:
Anemia is the common indication ( hemoglobin normally in males 14-16/ in females 12-15)
“” No recent travel to places where malaria might be a risk, or to places in Europe that might be a risk for variant Creutzfeldt-Jakob disease.””
Acute bleeding ( bleeding during surgeries, bleeding after trauma /fracture, burn, accidents-internal or external bleeding accompanied with them.
The rule at our hospital trying not to give blood unless the patient hemoglobin reaches around 7,5 to 8 .. it is not preferable to give blood transfusion if hemoglobin reaches 9,10,11 even after surgeries.
According to patient condition we do BT. Patient with heart problems like MI, atherosclerosis doesn't tolerate
So BT if hemoglobin was : anemia <8 heart problrms <10
The doctor said that patient with profuse bleeding Smugكميات خرافية!during surgery we might give him blood
The concept is: 1unit _increases hemoglobin around 1g/dl and increases PCV around 3%
For example to increase hemoglobin from 8 to 11 we give him around 3 unit roughly
Steps for BT:
We take a blood sample..be very careful and write full patient name (الدكتور بحكي انه اذا في مريضة اسمها فاطمة حسن و مريضة ثانية اسمها فاطمة حسين والمقيم اخذ عينة دم لفاطمة حسن وكتب عليها فاطمة حسين وبعتها لبنك الدم انه هذا أهم سبب في اختلاط الوحدات الدموية وهون ببين اذا اللي اخذ العينة صاحي أو لا)
Take that sample to blood bank then they cross matching (we take serum of patient sample and mixed with the same type cells in the unit) for example patient blood serum type A we get a unit with cells of type A and mix with each other
Make sure that there is no reaction between the patients serum and the cells unit
Q: is it better to donate blood? A: from logistic point for blood bank it is better but for you if you blood is good 500cc wouldn’t affect you
For how long we can store blood units under 4C?? he said before that stored for couple of years but I'm not sure..
The bag that used to collect blood contains: cetrate (prevent blood clotting) (phosphate, dextrose) both for energy supply for RBCs adenine (amino acid).
These contents causes problems when the patient receives large amount of blood transfusion (لما يعطوا كميات خرافية )
Blood donated is tested for certain diseases to make sure that the donor is (خالي من الأمراض السارية والمعدية) most important are:
-hepatitis B & C which is very common in our country
-HIV
-syphilis (بالرغم انه انقرض ) VDRL???
The policy for transfer of blood to patient is clear: the most important is the same patient that give the blood sample will receive appropriate type of blood.. we make that everything is matching and in this case no human mistakes allowed


The complication of BT: (the most common cause is mismatch)
The complication appears during the 1st 15-30minute after BT
Taking about Jordan university policy : the order is clear .. the doctor and the nurses stays around him for 15 minute after BT then a visit/30mintue then a visit/1 hour until the patient receive all the unit
The most important is blood matching as we said in the beginning .. patient with blood type A receives blood from type A or O if you give him other blood groups he will have Hemolytic Reactions
¡ Hemolytic reactions occur when the recipient's serum contains antibodies directed against the corresponding antigen found on donor red blood cells.
This can be an ABO incompatibility or an incompatibility related to a different blood group antigen and if that doesn’t discovered during 1st 5 minute the patient will die
The most common cause of this is human mistakes(أخطاء بشرية) by mixing blood samples …the form that you write on is in 3 copies (one in a file, one to blood bank and one if reaction happened to recheck).. the process is obvious but it needs (ناس صاحيين)
So BT not an easy process, it is very complicated process and it needs to be very cautious to avoid errors (clerical) error is the most common and important cause
Human mistake may lead to hemolytic reaction (تحلل الدم الفجائي) which cause:
DIC (Disseminated intravascular coagulation)
(acute) Renal failure (mortality rate 60-70%)
Acute anaphylactic shock ..allergy, bronchospasm , tachycardia
The most common cause for a major hemolytic transfusion reaction is a clerical error, such as a mislabeled specimen sent to the blood bank (مش عينته بس اسمه صح), or not properly identifying the patient to whom you are giving the blood. Or error in crossmatching.
Do not assume it is someone else's responsibility to check ..you've ask for blood sample then it is your responsibility
If the patient receives wrong type of blood the first symptom pain at the site of transfusion with first drop of blood enters then goes into hemolytic reaction..anaphylaxis..bronchospasm..tachycardia..dyspnea (shortness of breath) and he might end with sudden cardiac arrest
Patient with anaphylaxis have itching , bronchospasm , noisy breathing and shortness of breath..this is the most common one of complications
The complication is becoming less because of improvement in health services level.
The second complication that when the donor has URT infection and blood bank doesn’t discover that then blood contain certain inflammatory cells causes White blood cell reactions (febrile reactions) (are caused by patient antibodies directed against antigens present on transfused lymphocytes or granulocytes)
In general others blood causes some sort of harm but if the temperature of the patient doesn’t increase more than 1C then we continue BT …if the temperature 73,8-38 this considered as minor febrile reaction which is routine complication so continuous recheck for temperature during transfusion is done
If temperature increases more than 1C we should stop BT and recheck again blood type and make sure than no mixed samples , or there is minor groups wasn’t seen so they do cross matching again. They may wash the unit from WBC.
Another kind of minor allergic reaction ..the patient starts etching if it wasn’t severe we continue BT and give him antihistamine
Most threatening complication is hemolytic reactions ,that causes acute lung injury(most common cause of morbidity) : it related to certain antigen in blood that cause reaction with certain antibodies inside the lungs then the patient gets lung injury ..the patient enter in picture of Adult Respiratory Distress Syndrome (ARDS) in this case the patient needs artificial ventilation for a while and this kind of complication happened in all types of blood and can't be predicted unless careful monitoring and observation of the patient (when he has certain respiratory symptoms we stop BT)….. this happened commonly in patient who receives big amount of others blood and variety of blood products (trauma patient, major surgeries)
Last complication is contamination of the blood by bacteria (Bacterial contamination) : it mostly related to Blood Banks (but her this doesn’t occur because blood donation occurs under aseptic technique). During storage this doesn’t happened because most bacteria can't grow at 4C.
But there is platelets that don’t enter the freezer they store them at room temperature and connected to device to keep it moving
By the way Blood Bank is in the (الطابق الثالث\مبنى العيادات الخارجية)
Patient of cardiac problems can't tolerate 500cc load on their heart if it indicated give them slowly then we give them diuretics to decrease the load on the heart and avoid heart failure..we see it in elderly patient (circulatory overload)
Hypothermia
RBCs are stored at 4°C. Rapid transfusion at this temperature will quickly lower the recipient's core temperature and further impair haemostasis.
Hyperkalemia may happened in patient who receive a lot of blood units (when some of blood cells disintegrate and release K)
Also patient who receive a lot of blood unit may have hypocalcemia (because citrate binds calcium)
Graft Versus Host Disease (GVHD) : very rare complication.. antibodies against the patient own tissues ..this patient will be labeled that he can't receive any strange blood which is very serious issue.
Incidence of Transfusion Reactions
The most common is allergic acute hemolytic reaction then delayed hemolytic rxn… then febrile hemolytic reactions then hemolytic which is rare 1:250000
Acute hemolytic reaction shouldn’t happened it is illegal issue because it is personal error (عدم صحيان) and serious condition
Other complications like infections ..when the donor have Hepatitis C at endoral (not sure) phase that antigen can't be detected in serum
Infecions:
HIV
HCV
Most commonly happened for viruses not tested like Cytomegaovirous
And bacterial infection very rare
Massive Transfusion :the patient receive massive amount of blood in short period for example patient take 5000cc(20 unit)/day that means that receive all his blood volume in less than 24hours
Another definition : the patient receives half of his blood volume (2500cc=10 units) in 5-6 hours this happened after major surgeries (major artery affected) this blood is cross matched
In some cases when patient loses massive amount and come to emergency they give him uncrossed matched blood which is (O-)
Patient with multiple fracture and he is pale he can't wait we give him uncross matched blood because cross matching take 30-45minute or more.
The patient take massive amount we give him RBC only without coagulation factors or platelets.. so they have complication
1-Coagulopathy (bleeding tendencies
2-Hypothermia
3-Citrate toxicity …..hypocalcemia
4-Metabolic(hyperkalemia ,Acidosis/acid base abnormality generated by citric acid)
acute lung injury
the patient may receive platelets ….thrombocytopenia patient to prevent spontaneous bleeding
when we dental extraction (minor surgery) we can't do if platelets count <50000/dl
at major surgery <100000/dl we can't do it
the patient with normal count but abnormal function (throbasthenia)
single donor: one donor platelets only this is better
random donor: 4-5 donors platelets ….the patient receive these the possibility of reaction increase
dose of platelets is : 1 unit/10Kg…100Kg patient needs 10 units platelets
every unit of platelets increase platelets count by 5,000 –10,000
How can we manage MT?
the patient may receive (1)fresh frozen plasma given in cases of liver failure , massive transfusion ,vitamin K deficiency ,DIC and patient receive warfarin therapy(patient with hypercoagulative state (deep vein thrombosis or artificial valves or atrial fibrillation
Aspirin : antiplateletes
Warfarin : anticoagulant
Patient with INR>2,5-3,5 you should be very careful before doing surgery we give them fresh frozen plasma that contains coagulation factors.
(2)Platletes
(3)Cryo precipitate : it contain high concentration of fibrinogen
(4)Albumin : to expand volume, it is protein not related to blood product … increase IV volume , advantage: doesn’t transmit disease it is prepared by genetic engineering by factories
There is a Q that I didn’t hear but answer was sometime crystalloids will not elevate blood pressure to the needed desire …there is something called damage control management (the recording finished)


General surgery/ Dr. Mahmoud ABU-ABEELEH
6-3-2012
Done by : Mona Waheed Yanis



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Shadi Jarrar
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عدد المساهمات : 997
النشاط : 12
تاريخ التسجيل : 2009-08-28
العمر : 26
الموقع : Amman-Jordan

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