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HAPPY NEW YEAR WITH SLOWLY ENTERING INTO 2013

WELCOME YOU ALL FACULTY MEMBERS AND FRIENDS OF THE DEPTT. WONDERFUL PROCESS STARTED BY OUR DEPARTMENT. HAPPY NEW YEAR WITH SLOWLY ENTERING INTO 2013. ESTIMATION OF BLOOD LOSS. Prof: Anil Ohri DEPARTMENT OF ANAESTHESIA INDIRA GANDHI MEDICAL COLLEGE, SHIMLA-171001. INTRODUCTION.

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HAPPY NEW YEAR WITH SLOWLY ENTERING INTO 2013

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  1. WELCOME YOU ALL FACULTY MEMBERS AND FRIENDS OF THE DEPTT. WONDERFUL PROCESS STARTED BY OUR DEPARTMENT HAPPY NEW YEAR WITH SLOWLY ENTERING INTO 2013

  2. ESTIMATION OF BLOOD LOSS Prof: Anil Ohri DEPARTMENT OF ANAESTHESIA INDIRA GANDHI MEDICAL COLLEGE, SHIMLA-171001

  3. INTRODUCTION WHY ESTIMATION OF BLOOD LOSS ….? • Blood loss Threatening Fatal Problem. Blood losses>20-30%(total blood),Body Unable To Adjust Consequently Causes Failure in Multi-organ Functions. Not Treated in time, Lead Irreversible Functions Losses. • Surgeon Usually Estimate at the End By Seeing Blood-Suction Container and Surgical sponges. Underestimated. • Medical Personnel to EstimateAccurately. Under or Over Estimation-Delayed or Excessive Unnecessary Transfusion.

  4. PROBLEMS WITH MEASUREMENTS • Common Reason Cited For underestimation loss is blood loss looked upon unfavourably. *Many Techniques Devised –Estimate Accurately, Includes –Mathematical Model, Photometric Method,Cell Counts on blood loss. Methods Time consuming, Impractical,& Expensive.

  5. IMPACT OF WRONG ESTIMATION • Inaccurate Estimates Adversely Affects Well Being - intra- and postoperative care. • Decision –Transfusion After Considering - complications,symptoms, HB Level ,Hematocrit Level, & Amount of Surgical Loss as well

  6. COMPONENT IMPORTANT FOR OXYGEN DELIVERY TO TISSUES • Four Components viz. Hb%, SpO2, Cardiac output and Hb-O2 affinity, also Hematochrit determines Quantity of O2, Available for Bodily Functions. • Hb% (only component can be augmented easily) Pre-operatively for Enhancing Availability of O2 and is basis for Pre-operative Hb% Estimation.

  7. DETERMINANTS OF OXYGEN DELIVERY 1.Pulmonary Gas Exchange 2.Cardiac Output 3.Blood Oxygen Contents 4.Hb-Oxygen afiinity 5. Oxygen consumption Oxygen Extraction Ratio=Art O2 -Mix VO2/A O2

  8. IMPOTANCE OF HAEMOBLOBIN • BEST EVIDENCE ANAESTHESIA REPORTS (BEARs) IS IT NECESSARY TO ESTIMATE HAEMOGLOBIN LEVEL ROUTINELY PRIOR TO SURGERY ?(Dr. Kotur. P. F.)(IJA,April,2006) • Ott and cooley ,1977 reported study of 542 cases in Texas without transfusion cardiac surgeries and reported that 51 patients died out of which 12 were related to pre or post operative anemia,3,died due to blood loss.

  9. PRE-REQUISITS FOR ESTIMATING BLOOD LOSS • Measurement Of Haemoblobin • Measurement of PCV and Or Hct(F=39-40%&M=39-49%) • Measurement of Blood Volume • EBV(Lt)=0.0248xH0.725xW0.425-1.954(Female or 55-65ml/kg) • EBV(Lt)=0.236xH0.725xw0.425-1.229 or Males 60-75ml/kg

  10. METHODS OF ESTIMATING BLOOD LOSS 1.Measurement of HB% 2. Measurement Of PCV &or HCT% 3.Subjective Method 4.Gravimetric Method 5. Calorimetric method

  11. 1. Measurement of Hb% 7-10 gm%. Simple can give us rough estimates pre & or postoperatively. Mortality related with Hb<6gm%-mortality 61.5%;7.1% if 10 gm% or more.by CARSEN JL etal,1988 reported in severity of Anaemia &operative mortality morbidity,TEXAS.

  12. Constitution OF Blood (B) • Hematocrit • 45 ± 7 (38–52%) for males42 ± 5 (37–47%) for females • pH • 7.35–7.45 • base excess • −3 to +3 • PO2 • 10–13 kPa (80–100 mm Hg) • PCO2 • 4.8–5.8 kPa (35–45 mm Hg) • HCO3− • 21–27 mM • Oxygen saturation • Oxygenated: 98–99%Deoxygenated: 75%

  13. Gas Exchange In The BODY(C)

  14. HB-O2 Dissociation Curve(D)

  15. 2.Measurement OF PCV & or Hct % (A) Allowable Blood Loss (ABL)* EBV x (Hi - Hf)Hi  = ABL Blood volume Hi = initial Hct Blood volume Normal Hct Values*** Men 42-52% Women 37-47% Hf = final lowest acceptable Hct Estimated Blood Volume (EBV) • EBV = weight (kg) x average blood volume • Average blood volumes** • Age

  16. (B)PCV & or HCT% constitutes the important factor in maintaining the viscosity • With loss of RBC the viscosity decreases and proteins are also lost then it decreases further. • In animal studies-1% loss of blood associated with 1.8% decrease in cardiac output.(POVEK&CARY IN 1974) Mortality and morbidity associated with blood loss(500ml or less-8% and 42% if>2000ml). • If previous formula applied to a standard person the allowable blood loss comes to about 1083ml

  17. Allowable Blood Loss(C)

  18. Normal Blood Vol.&HCT(D) • Premature Neonates 95 mL/kg • Full Term Neonates 85 mL/kg • Infants 80 mL/kg • Adult Men 75 mL/kg • Adult Women 65 mL/kg • Normal Hct Values*** • Men 42-52% • Women 37-47%

  19. 3. Subjective Measurement Of Blood Loss • Cheap,Continuous &Unreliable • Difficult to Assess Loss 500ml to 1500 ml as under,Don’t use in Cardiac, Trauma or pediatric surgery as loss of blood in tissues One should know allowable blood loss. MORTALITY RATES ARE HIGHER IF BLOOD NOT REPLACED. • Blood Loss measured by Surgeon is usually inaccurate (Comparison of Subjective Estimates by Surgeons and Anaesthetists of Operative Blood Loss By AEDelikan Concluded :That it is Mutual decision by the anaesthetist &Surgeon STUDIED 100 CASES)

  20. 4.GRAVIMETRIC METHOD A) WEIGHING OF PATIENT: Operation Table Available To Measure Pre and post Surgery Weight Accuracy +- 10 G. Inaccurate. Good Check On other Methods. B) WEIGHING SWABS: Simple & Commonly Used. Bloss Measured in GAIN Of Weight Of Swab &Towels Together with Contents of Bottle1ml of Blood=1Gm of swab ;Underestimation of 25%. Source of Error SP GR RBC-1.0293 ;Sp Gr Plasma-1.0270, • Neither Precise Nor Accurate Assessing Gravimetric Estimation of Intraoperative Blood Loss RAVI S. JOHAR and ROGER P. SMITH. Journal of Gynecologic Surgery. Fall 1993, 9(3 C)Modified BY Bonica & Lyter 1951 Using saline for comparison

  21. 5.COLORIMETRIC METHOD • Towels,Swab mixed with large known Vol of Fluid(Added Ammonium Hydroxide1:1000+defoaming Agent) Which is then estimated colorimitrically. • Error: Contamination Or Bile Mixed • Prerequisite: Preoperative HB%;Weighing Of Patient if Complex ExChanges expected inBlood • Blood Loss(ML)=Colorimetric Reading(Hb%)xVol Of sol ----------------------------------------------------- 200(Dilution Factor)XPatients Hb% (ESTIMATION OF BLOOD LOSS DURING SURGERY J. A. Thornton Ann R Coll Surg Engl. 1963 )

  22. 6.RADIOACTIVITY OF BLOOD) • Measuring the activity on blood in swabs • Inject known ammount of Radioactive dye • Time cosuming,Costly Apparatus and leakage are the problem.If albumins are tagged then Leak in Non vascular Compartment.If RBCs then has to be tagged preopratively. • Advantage : No over Previous Methods.

  23. 7. MEASUREMENT OF LOSS BY SUCTION • Meaured Jars Can be used IN The Operation Theatre • Using Defoaming Agent In The Jar. 8.VISUAL COMPARATIVE COLORIMETRY: • Simple to use in OT • Does not require preoperative HB/Hct • Color of two solutions are compared. • does not depend on Laboratory • We Prepare two Solutions ------------------------------------CONTD.

  24. 8.VCC(A) • Sol.-A- 5ml pt blood in HEPARINISED Syringe Make it 1% in Water(1%=0.15%Hb) • Sol.-B-Washing OF All type Blood and Prepare a Sol. Till its Color match with A.Take it in 10ml Syringe. • Sol.C-This syringe contain 9ml of water • From Original patient Sample 10% solution made and filled in Insulin Syringe and drop wise added in Sample tube-B-Compare both Sol for color Match in X-ray view box.Ammount of blood requiered to bring match Noted(Vb): Vol Of Sample(10 ml);Vol of Diluent(Vd) • OBL=Vb/VcxVd=Ml • Similar sample to Lab for blinding and Color in Spectrometry Error1-2%

  25. 9.Plastic Bag Collection • Use of a transparent plastic collector bag for estimation of blood loss in the third stage of labour: a cluster randomised trial (This protocol follows the recommendations for reporting randomised controlled trials described withinEUPHRATES-Protocol-C-RCT-11-2005-approved by Collaborators meeting

  26. 8. USE OF iPAD CAMERAS AND ALGORITHM TO ESTIMATE BLOOD LOSS • “Gauss Surgical Inc.’s mobile medical platform uses the iPad to scan surgical surfaces that are covered in blood — namely, pieces of gauze that soak up blood during surgery. Through an iPad app, those scanned images are sent to the cloud, where Gauss’ algorithms go to work, ‘almost like facial recognition software,’ to determine and deliver an estimate of how much blood is present in that sample, said co-founder and chief technology officer SiddarthSatish.” • The iMedical Apps team has discussed the myriad of ways the iPad may be a game changer in the OR, and this is another tool to add to the list. If you combine this with the disposable sterile iPad sleeve for use in the operating room exclusive we brought to you first, you would further the utility of the platform. • Furthermore, if this new methodology is shown to be superior, it may be incorporated into the routine of the OR.

  27. COMPARISON AND BEST REPLACEMENT METOD • Baronofsky et al 1946,said gravimiteric and Colorimetric Methods are Comparable and One should Adopt Swab Method For Measuring Blood Loss.Add persipiration,Drapes loss,Loss of water and 25% of Loss is equal to true operative loss.But blood lost in operative site and tissues can not be measured. • BEST METHOD Of REPLACEMENT is replace blood as lost. Replace Whole blood,540ml (Stored Bl) has 440ml of Whole blood. Use Of Labels While Trasfusing The blood.

  28. BEST METHOD OF REPLACEMENT(A)

  29. BEST METHOD OF ADMINISTRATION(B) • Perioperative complications (on the 'Y' axis) decreasing with increasing volume load (on the 'X' axis) up to a critical point (optimal level).  • Hypovolaemialeads to tissue underperfusion, suboptimal organ function, organ failure, and death. (Perioperative fluid therapy: How much is not too much?CL Gurudatt-2012) • FUNCTIONS cardiac function, pulmonary function, tissue oxygenation, wound healing, postoperative ileus, renal function, and coagulation may all be influenced by perioperative fluid administration.  • Goal-directed fluid managementguided by flow-based haemodynamic monitors decreases postoperative complications in major surgeries.

  30. FUTURE IMPORTANCE • To EDUCATE THE WHOLE STAFF IN THEATRE ABOUT ASSESSING BLOOD LOSS. • Training Schedule for the Medical students to learn about Blood loss and its Importance • Review and Clinical Material For Teaching About Blood loss by the article below REF.BLOOD LOSS: CLINICAL TECHNIQUES FOR ONGOING QUANTITATIVE MEASUREMENT(Audrey Lyndon, PhD, CNS, RNC, Department of Family Health Care Nursing, University of California, San Francisco; Suellen Miller, PhD, CNM, MHA, Department of Obstetrics;Gynecology and Reproductive Sciences, University of California, San Francisco; Valerie Huwe;RN, BSN, El Camino Hospital; Mark Rosen, MD, Department of Anesthesia, University of California, San Francisco; David Lagrew, MD, Saddleback Memorial Medical Center; Patricia Dailey, MD; Anesthesiology, Mills Peninsula Health Services; Elliott Main, MD, Department of OB/GYN, California Pacific Medical Center, Sutter Health)

  31. Thankyou

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