Hypovolemic shock and blood transfusion intervention - Essay Example

Number School Analysis of Hypovolaemic shock, blood transfusion intervention This paper will analyse the administration of packed red cells transfusion in a patient with hypovolaemic shock arising from severe haemetemesis. The identity of the patient has been changed to Mr. Z to ensure anonymity and confidentiality (NMC, 2008). Haemetemesis is a condition in which the patient rapidly loses fluids from the plasma due to the excessive upper GI haemorrhage leading to inadequate circulating volume, followed by inadequate perfusion and ultimately leading to multiple organ failure. The hypovolaemic shock has arisen from secondary blood loss from upper GI bleeding (Kolecki, 2010). Mr. Z, 46 years male, presented with typical features of hypovolaemic shock, primarily developing from chronic alcoholism. The patient earlier episodes of epigastric pain and upper GI bleeds and was treated for the same by antiemetic drugs and antacids. Following that episode he was advised against drinking and smoking. In this event, Mr. Z developed nausea 48 hours before the haemetemesis. During the haemetemesis episode he vomited blood 5 times, containing blood coffee brown in colour and from the upper GI. Mr. Z has developed internal bleeding arising from gastric erosion and has developed several features typical of the same mentioned in Appendix 4. Mr. Z was prescribed packed red cells as his haemoglobin count was low and he had to be administered the same to restore the haemoglobin and the clotting factors (look at criteria in Appendix 5). In this case, the rationale for giving blood was that the patient’s haemoglobin levels were only slightly above normal, the blood loss was severe, and the patient’s condition was perceived to be serious. The physicians in this case had to make a close decision, as if the symptoms and the vital sign (especially blood pressure) could be managed effectively, blood transfusion was not needed. The criteria for blood transfusion are made based on general criteria and not the management or care setting for the particular patient. For example, if the patient is managed in the ICU, there is oxygen and respiration is taken care of and hence, anaemia may not be a serious issue that the patient has to cope with. Hence, the care settings have an important role to play. The most important criteria for transfusing blood for an ICU patient are whether the patient is hemodynamically stable or not. If the patient cannot be maintained properly in a hemodynamic state (even though the blood loss was minimum), then blood transfusion is needed. Haemoglobin is critical in ensuring oxygen supply to the vital organs and the tissues of the body. However, if the patient can be maintained hemodynamically stable (even though the blood loss was severe) and the haemoglobin levels is below 7 g/dl, the vital signs are seriously affected, then the patient has to be suggested for blood transfusion. In this case, it would be likely that blood transfusion was given as a precautionary measure although in the current care settings, stability of the vital signs and haemoglobin level it would not be necessary. Besides, the fact that the patient was currently in the ICU was not taken into consideration, and it is important that this fact be taken into consideration. The blood pack has been administered slowly over 3 hour duration (as per the mentioned in the case), and any risk of adverse effects were monitored. Though no urticaria and erythema were noticed, there has been a slight improvement in the patient’s blood pressure levels, APTT, Haemoglobin levels, heart rate and respiratory rate. However, there is not much improvement in other important components such as blood pressure, pulse, breathes rate and haemoglobin (Veenema, 2007). Ethically and legally, consent was obtained orally and carefully documented. The patient should be competent to give consent and only if the patient’s condition is such he is in a position to give consent, should consent be taken. There was also a need to ensure that greater autonomy is provided to the patient in choosing blood transfusion as an option as there should be clear indication of the same, and providing/mentioning all the benefits, risks and options to the procedure, before the patient gives consent for the same. Mr. Z was able to make an informed decision before providing consent. In this case, there seems to be a lag in explanation of the procedure and providing the options available to Mr. Z. Hypoperfusion is the reduced blood flow through an organ and it may be related or caused by a hypovolaemic shock, and it can result in cell dysfunction and cell death of the organ. A hypovolaemic shock occurs when blood is lost and the remaining blood present in the body is not sufficient in spite of the constriction of the blood vessels. Hypovolaemic shock can result in Hypoperfusion, as reduced quantity of blood would be supplied to the vital organs of the body. Hypovolaemic shock can develop when the patient has an internal bleeding or an external bleeding, or from diarrhoea, excessive fluid loss from vomiting or even in malignant peritonitis where there is sequestration of the body fluids (Wien, 2011). Both Hypoperfusion and hypovolaemic have the same symptomology including tachycardia, hypotension, loss of skin turgor and colour, mental state changes and sweating, reduction in the pulse pressure, cold extremities, increased respiration rate, etc (Marx, 2009). Further details between differences of hypovolaemic shock and Hypoperfusion is mentioned in Appendix 2. The SHOTS (2011) reporting involves reporting various adverse events that are associated with blood transfusion so that sharing of data and experiences would be enabled between hospitals, and lessons learnt from other mistakes, including greater responsibility with ensuring limitation of the adverse event. Example of adverse events that are reported include transfusion of wrong blood or components that did not meet his requirements, administering inappropriate or unnecessary blood transfusion, handling and storage errors, missing out on standard protocols regarding transfusion, reactions following transfusion, etc. In Mr. Z, the transfusion may have been necessary or was unnecessary as in cardiac patients who are admitted in the ICU, blood transfusion is not needed as long as the patient is hemodynamically stable. Mr. Z haemoglobin was above 8 mg/dl of blood and hence transfusion risk may be at a benefit. The blood is also transfused at a very slow rate which reduces risk of adverse reactions. Before doing the blood transfusion, the patient should give consent for doing the transfusion, and in case the patient is unconscious, the consent should be obtained from the relative or family member. Mr. Z was deemed to be competent in making a decision for transfusion. The vital signs of the patient need to be recorded before the transfusion, frequently during transfusion and after doing the transfusion. Haemoglobin threshold is the optimum haemoglobin level at which high-risk non-cardiac patients can be administered transfusion, and above this level the chances of myocardial infarction or myocardial ischemia would be lesser. Usually a level of less than 7 mg/dl of Haemoglobin is considered as the threshold, and levels above this did not show increased morbidity or mortality in the ICU unit. However, evidence suggests that in patients with ischemic heart disease, the morbidity was higher at 7 mg/dl haemoglobin, and hence a haemoglobin threshold of 9 mg/dl has been suggested for cardiac patients (Bonow, 2011). However, Bracey and Vaughn (1999) found that a lower haemoglobin threshold in cardiac patients following cardiac bypass surgery to 8 mg/dl did not negatively affect the patient’s outcomes, and the RBC resources can be used more effectively in other cases without causing significant risks to the patient. This was reviewed using the patient self-assessment study. Hence, there is a greater need to evaluate the transfusion requirements of the patient. Koch and Sessler (2008) compared the results of transfusing new and old blood, in patients who received blood undergoing heart surgery. According to this study, the new blood included those that were stored for less than 14 days, and old blood was that stored for longer periods. They found that the mortality rates in the hospital were 2.8% for old blood and 1.7 % for new blood. Besides, the morbidity rates from old blood were higher than compared with newer blood. The 1 year mortality from new blood was 7.4%, whereas from old blood it was about 11%. Today a protocol of using stored blood within 42 days is being followed. There is strong evidence that in older blood the harmful effects would be brought about by pro-inflammatory responses that can be related to higher levels of circulating iron levels and tissue iron. Besides, older blood has a pro-oxidation effect (Liumbruno & AuBuchon, 2010). Hence, as per this patient Mr. Z, the chances of morbidities and mortalities could be higher basically due to the presence of pro-inflammatory substances, higher iron content, and higher pro-oxidation effect of older blood and RBC’s. An alternative strategy would be to use tranexamic acid. It is a substance that is derived from the amino acid lysine and can be used as a substitute to blood transfusion in certain circumstances in order to reduce excessive blood loss. It is an antifibrinolytic agent and can prevent the activation of plasminogen to plasmin by binding to certain sites and preventing the degradation of the formed fibrin present in the blood clot. It is said to be 8 times more effective than epsilon-amino-caproic acid (EACA) and can be used in the ICU to reduce the blood loss from severe injuries or medical conditions. In children who undergoing craniosynostosis, it has been found that Tranexamic acid significantly reduces the intra-operative bleeding and hence reduce the transfusion requirement in those patients. However, it was found that the use of tranexamic acid had to be planned and also erythropoietin had to be administered preoperatively. The amount of RBC pack transfused was significantly reduced by 85% intra-operatively. Besides, the adverse events were lesser (Dadure, 2011). Previous studies demonstrate that tranexamic acid can potentially help to arrest the bleeding and is very effective for upper GI bleeding. However, tranexamic acid is not useful to replace lost body fluids or replace the haemoglobin levels present in the blood. To determine the need for blood transfusion or RBC packed cell transfusion, the haemoglobin levels is a good indication (Bergqist, 1980). Level of Evidence - to compare 2 UK Studies Walsh (2010) is a study to demonstrate that ICU patients with anaemia can tolerate the same provides that they are hemodynamically stable, and blood transfusions can increase their risk to develop negative outcomes. The transfusion triggers was 8.2 mg/dl and in about 30% cases was above 9 mg/dl. A significant indication for transfusion was uncontrolled bleeding. According to the TRICC trial, the rate of mortality was higher in those who were young (below 55 years) and those with an APACHE score less than 20, when blood transfusions were used liberally. Hence, blood should not be used liberally and in cases where the patient is hemodynamically stable and has Haemoglobin above 8 mg/dl, blood transfusion should not be used as it may also have a negative outcome. Sudhindran (1997) demonstrated greater need to develop guidelines in spite of clear evidence that blood transfusion can be avoided if the haemoglobin is above 10 mg/dl, and the patient was hemodynamically stable. Most of the patients were inappropriately managed as per discussed by the author. Hence, as per the author, there was greater need for developing guidelines, as recently demonstrated by the mass media. He reported that more than 53% of the blood or RBC transfusions in the ICU settings were considered as unnecessary. The main reason to provide blood transfusion was to increase the oxygen-carrying capacity of the blood and this was only required if the haemoglobin was lower than 9 mg/dl Evaluation of the Patient In this particular patient, Mr. Z, the patient had haemoglobin of 8 mg/dl of blood. The bleeding for the same should be controlled and the vital signs should be maintained. The patient can be given IV tranexamic acid so as to control the bleeding and reduce the need for blood transfusion. The fluid levels could be maintained through IV solutions and blood transfusion would be unnecessary if the patient’s haemoglobin level is 8 or above and is hemodynamically stable. Once the patient has been hemodynamically stabilised and sufficiently maintained above 8 mg/dl, blood transfusion would be unnecessary, as anaemia can be tolerated and managed in the ICU settings. According to Dadure 2011, there were no negative effects of not using blood transfusion intra-operatively or postoperatively in children undergoing craniosynostosis. In this patient, there limited need for blood transfusion and using published evidences the procedure would be considered unnecessary. Blood transfusion would not be needed as anaemia can appropriately be handled in the ICU in patients who are hemodynamically stable (bleeding should be controlled as demonstrated in this patient). The patient’s condition did not improve significantly following the blood transfusion. There was also a need to ensure that greater autonomy is provided to the patient in choosing blood transfusion as an option as there should be clear indication of the same, and providing/mentioning all the benefits, risks and options to the procedure, before the patient gives consent for the same (Veenema, 2007). Total Word Count (Excluding Headings, Headers, In-text Citations, Bibliography, Appendices, etc): 2050 Appendices Appendix 1: Patient Progress (Table 1) No Laboratory / Clinical Parameter Parameters before Transfusion Interpretation Parameters after Transfusion Interpretation Remarks 1 Blood Pressure 84/50 mm hg hypotension, Need to administer IV fluids 110/70 mm hg Within normal range after IV fluid administration Requires only IV fluid administration, blood transfusion not required 2 Pulse 130 bpm Tachycardia, require replacement of body fluids 98 bpm Within normal range following IV fluid administration Requires only IV fluid administration, blood transfusion not required 3 Breathe rate 30 bpm Increased due to fluid loss, require replacement of body fluids 22 bpm Respiratory rate still high, but within control following fluid replacement Requires only IV fluid administration, blood transfusion not required 4 Hemoglobin 8 g/dl Hemoglobin levels low, but not requiring blood/RBC transfusion if managed in an ICU 9.1 g/dl Hemoglobin slightly improved following blood/RBC transfusion As long as patient maintained in the ICU, a Hb% reading of 7 g/dl would be fine 5 Platelet count 77000 cells Platelet count low, but not serious to cause spontaneous bleeding and not requiring blood transfusion 77000 No improvement following RBC/Blood transfusion as platelet components were not transfused. Transfusion not needed as platelet levels are not seriously low 6 WBC Count 5.4 WBC count within normal range 4.8 WBC count within normal range 7 Neutrophils 3.9 Within normal range 3.5 Within normal range 8 APTT 65.7 Prolonged due to loss of clotting factors 63.5 Slight improvement but not significant 9 INR 1.3 Prolonged due to loss of clotting factors 1.2 Slight improvement but not significant 10 PT 14.9 Slightly prolonged due to loss of clotting factors 14.8 Slightly prolonged due to loss of clotting factors 11 Potassium 4.5 mmol/L Within normal range 4.7 mmol/L Within normal range 12 Sodium 138 mmol/L Within normal range 140 mmol/L Within normal range 13 CVP 4 mm hg Within normal range 10 mm hg Within normal range Appendix 2: differences between symptoms of Hypoperfusion and hypovolaemic shock Some of the common symptoms of CNS hypoperfusion include nausea, headache, neck pain, lightheadedness, blurring of vision, palpitations, dizziness, poor cognitive function, vertigo and tremulousness. Hypovolameic shock symptoms are mostly peripheral and include anxiety, cold clammy skin, confusion, lowered urine output, weakness, pallor, rapid shallow breathing, sweating and unconsciousness (Bradley, 2003). In this case, Mr. Z lost significant amounts of blood and was likely to develop hypovolaemic shock. However, the signs of CNS hypoperfusion are not evident, though it cannot be ruled out that the patient was not affected with it. Due to the serious nature of the blood loss, hypoperfusion should be anticipated and managed appropriately. Appendix 3: SHOT Reporting process Identify the event Record the vital signs, laboratory findings, etc Take immediate corrective events Reporting – local and SHOT (Completion of the SHOT questionnaire) Gathering of data Producing of the report Identification of the cause of the adverse event Place corrective measures or preventive actions Have a means of tracking for the same Review the entire mechanism (Haggs, 2009) Appendix 4: Symptoms developed by Mr. Z Lightheadedness Weakness Confusion Lethargy Epigastric pain – diagnostic Vomiting of blood – 3 litre of blood in 5 episodes Vital signs abnormal – Refer to the table on patient progress Hypotension – BP was 84 / 50 mm of hg Tachycardia – 130 beats per minute Tachyopnea – 30 breathes per minute Anaemia – 8 mg/dl Thrombocytopenia – platelet count of 77,000 cells/cu mm History of alcohol abuse – Has been known for alcoholism and drinking heavily History of smoking – about 20 cigarettes per day Prolonged APTT (due to loss of the clotting factors) of 65.7 breathes per minute Prolonged INR (Kolecki, 2010) Appendix 5: Criteria for administering blood to critically ill patient:- Haemoglobin below 7 g/dl in a normal patient Haemoglobin below 10 g/dl in patients with coronary artery disease, CVD or pulmonary disease Acute loss of large quantities of blood, in which the blood pressure and other vital signs become unstable and uncontrollable Severe and unmanageable cardiac symptoms or mental symptoms (Sudhindran, 1997) Bibliography Abeloff, 2008. Abeloff: Abeloff's Clinical Oncology. 4th ed. London: Churchill Livingston. Bergqvist, D., Dahlgren, S., & Hessman, Y. 1980. ‘Local Inhibition of the Fibrinolytic System in Patients with Massive GI Hemorrhage’, Upsala J Med, vol. 85, pp. 173-178. http://ad-teaching.informatik.uni-freiburg.de/zbmed/InformaHealthcare/production/ups/1980/85/2/03009738009179185/03009738009179185.pdf Bonow, R.O., Mann, D.L., Zipes, D. P. et al 2011. Bonow: Braunwald's Heart Disease - A Textbook of Cardiovascular Medicine, 9th ed, Saunders, Philadelphia. Bracey, A.W, Riggs, S.A., Vaughn, W.K. et al 1999. ‘Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome’ Transfusion, vol. 39, pp. 1070-1077. http://themostbeautifullest.com/Articles/CriticalCare/bracey%20-%20transfusion%20in%20CABG.PDF Bradley, J.G., and Davis, K.A. 2003. ‘Orthostatic Hypotension’ Am Fam Physician, vol. 68, no. 12, pp. 2393-2399. http://www.aafp.org/afp/2003/1215/p2393.html Dadure, C., Sauter, M., Brinquier, S. et al 2011. ‘Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study.’ Anesthesiology, vol. 114, no. 4, pp. 856-861. http://www.ncbi.nlm.nih.gov/pubmed/21358317 Haggs, R. 2007. How to effectively report to SABRE and SHOT [Online], Available: http://www.shotuk.org/wp-content/uploads/2010/03/Reporting-Richard-Haggas.pdf [Accessed: 2012, January 31]. Kolecki, P. 2010. ‘Hypovolemic Shock Clinical Presentation’ [Online], Available: http://emedicine.medscape.com/article/760145-clinical#a0217 [Accessed: 2012, January 31]. Liumbruno, G. M., AuBuchon, J. P. 2010. ‘Old Blood, new blood or better stored blood?’ , Blood Transfusion, vol. 8, no. 33, pp. 1-3. http://www.newhealthsciences.com/NewsItems/Blood%20Transfusion%20editorial.pdf Marx, J. A. 2009. Marx: Rosen's Emergency Medicine. 7th ed. St. Louis: Mosby. SHOT UK 2011. Definitions of Current SHOT Categories & What to Report [Online], Available: http://www.shotuk.org/wp-content/uploads/2010/03/SHOT-Categories-2010-v14.pdf [Accessed: 2012, January 31]. Sudhindran, S. 1997. ‘Perioperative blood transfusion: a plea for guidelines’, Ann R Coll Surg Engl, vol. 79, pp. 299-301. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502818/pdf/annrcse01608-0069.pdf Univeristy of North Carolina Hospitals 2009. Criteria for Transfusion [Online], Available: http://labs.unchealthcare.org/forms/critunc.pdf [Accessed: 2012, February 23]. Veenema, T.G. 2007. Disaster nursing and emergency preparedness: for chemical, biological, and radiological terrorism and other hazards. London: Springer. http://books.google.co.in/books?id=EwmhaCmZzMsC&dq=hypovolemic+shock+from+hematemesis&source=gbs_navlinks_s Walsh, T.S. 2010. ‘Red cell transfusion triggers in critically ill patients: time for some new TRICCs?’ Crit Care, vol. 14, no. 3, pp. 170. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911743/?tool=pubmed Wein, A.J. 2011. Wein: Campbell-Walsh Urology. 10th. Ed, Philadelphia: Saunders. Read More