DIC & Blood component therapy

Gp Capt G S Sandhu

DIC
DIC is a syndrome characterized by diffuse activation of the coagulation system leading to intravascular fibrin deposition. Thromboplastins endothelial cell activation - Activation of coagulation Massive activation of coagulation - depletion of coagulation factors and platelets (consumptive coagulopathy) - hemorrhagic complications. Microvascular fibrin thrombi - impair tissue circulation multi-organ dysfunction

Obstetric aetiology
Abruptio placentae Severe pre-eclampsia Severe Sepsis Amniotic fluid embolism Prolonged IUFD Molar pregnancy Placenta accreta Intra-amniotic hypertonic saline Acute Fatty Liver of pregnancy Transfusion reactions Large feto-maternal haemmorrhage Severe trauma

Patho-physiology of DIC

Coagulation & Fibrinolytic Systems

Severity of DIC

Management principles
Assess derangement of function Control hemorrhage Replace blood loss, coagulation factors and platelets as indicated Supportive management to correct multiorgan dysfunction Treat underlying cause

Massive blood loss

Loss of one blood volume within a 24 hr period 50% blood volume loss within 3 hrs Rate of blood loss 150 ml /min Massive transfusion 10 units in 24 hrs or > 50 ml / kg / hr in adults

Blood product
Any therapeutic substance prepared from human blood

Blood component
A constituent of blood separated from whole blood Where resources are available use of blood components allows optimal utilization of donated blood

Apheresis
It is a sterile process by which a specific component is mechanically separated and collected while components not required are re-infused back to the donor Platelet pheresis : Collection of donor platelets by apheresis Plasma pheresis : Collection of donor plasma by apheresis

Whole blood
Qty 450 ml donor blood + 63 ml anticoagulant Anticoagulant preservative solution CPD, CPDA(Citrate, Phosphate, Dextrose, Adenine) or ACD Storage time 21 days (ACD, CPD) / 35 days (CPD-A) Start transfusion within 30 mins of issue Complete transfusion within 4 hrs of starting

Effects of storage of blood

pH plasma K+ RBC content of 2, 3 DPG leading to reduced release of oxygen at tissue level Loss of platelets within 48 hrs of donation in Factor VIII to 10 20% of normal within 48 hrs of donation

Indications of whole blood transfusion

RBC replacement in acute blood loss with hypovolemia Exchange transfusions When RBC concentrates are not available (Use of whole blood may sometimes be the safest and most sustainable way of meeting urgent transfusion requirements)

Advantages : Whole blood transfusion

Simple inexpensive collection packs No special processing For patients with haemorrhage, supplies RBC, volume and stable coagulation factors (Factors IX and VII) Disadvantage : Higher volume load

RBC concentrate (Packed RBC)

Quantity 220 340 ml (Generally 250 ml). Contains 150 200ml RBC Prepared by gravity separation / centrifugation of whole blood RBC concentrate also contains WBC Storage time 21 days (ACD, CPD) / 35 days (CPD-A)

Indications of RBC concentrates

Replacement of RBC in anaemic patients Along with crystalloids in acute blood loss

Disadvantages of RBC concentrates

viscosity. Haematocrit 55 75% WBC are cause of febrile non-haemolytic reactions

RBC suspension
150 200 ml RBC + 110 ml Normal saline, Adenine, Glucose and Mannitol solution (SAG-M) as a Red cell nutrient medium. Less viscosity as compared to RBC concentrates Better flow rates during transfusion

Indications of blood transfusion in Obstetrics

Replacement of acute blood loss Pregnancy < 36 weeks
Hb 5.0 gm% or less Hb 5 to 7 gm%
Established or incipient cardiac failure or clinical evidence of hypoxia Pre-existing cardiac disorder Serious infection i.e. pneumonia Malaria

Indications of blood transfusion in Obstetrics

Pregnancy > 36 weeks
Hb 6.0 gm% or less Hb 6 to 8 gm%
Established or incipient cardiac failure or clinical evidence of hypoxia Pre-existing cardiac disorder Serious infection i.e. pneumonia Malaria

Fresh Frozen plasma

Volume 200 300 ml (Generally 250 ml) Separated from whole blood and frozen at -250 C within 6 to 8 hrs of collection in order to preserve labile coagulation factors (Factors V and VIII) Supplies 150 mg fibrinogen / unit + other coagulation factors Can be stored for 1 yr At - 250 C, Factor VIII levels maintained at 70% of normal fresh plasma levels At 2 to 60 C labile clotting factor activity will decline to 10 20% within 48 hrs

Fresh Frozen Plasma : Indications

Replacement of multiple coagulation factor deficiencies
DIC Liver disease Warfarin overdose Dilutional coagulopathy (large volume transfusions)

Fresh Frozen Plasma

Not recommended as replacement fluid
Expensive Risk of transfusion transmitted infections No benefit over use of crystalloids / colloids

Dose : Initial dose 15 ml / kg body wt One unit FFP raises Plasma fibrinogen by 25 mg% Must be thawed between 30 - 370 C before use Should be used within 6 hrs of initiating thawing Infuse within 20 minutes If not used immediately, store between 2 to 60 C for maximum 24 hrs

Cryoprecipitate
Prepared from FFP by collecting precipitate formed during controlled thawing and resuspending it in 10 to 20 ml plasma Rich in Fibrinogen(150 300mg/ pack), Factor VIII (80 100 IU / pack), von Willebrand factor, Fibronectin, Factor XIII Storage at - 250 C for 1 yr Should be infused within 6 hrs of thawing Infuse over 20 minutes

Cryoprecipitate
Indications
Von Willebrands disease Factor VIII deficiency (Haemophilia A) DIC (as a source of Fibrinogen)

Platelet concentrate (Prepared from whole blood donation)

Single donor unit
Prepared from one donation Contain 55 x 109 platelets

Pooled donor unit

Prepared from 4 to 6 donor units pooled into one pack Contains 240 x 109 platelets

Volume 50 60 ml Storage at 200 to 240 C (with agitation) for up to 5 days Bacterial contamination (with consequent risk of septicaemia in recipient) occurs in 1% of pooled units

Platelet concentrate (Collected by Plateletpheresis)

Platelet content 150 500 x 109 platelets Storage at 200 to 240 C (with agitation) for up to 24 hrs ABO compatibility important to prevent haemolysis of recipient RBC

Platelet concentrate
Indications
Thrombocytopenia (< 50,000 / cu mm in a bleeding / surgical patient) Platelet function defects

Dosage
1 unit platelet concentrate / 10 kg body wt

A unit of random (pooled) donor platelets increases platelet count by 5000 to 8000 / cu mm. Infuse within 4 hrs of issue to reduce risk of bacterial contamination Do not refrigerate Infuse within 20 minutes of starting Rh negative recipients should not receive platelet concentrates from Rh positive donors ABO compatible platelet concentrates to be infused whenever possible