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Jasmeet K aur Fluids and Transfusion SpR in Anaesthesia, RNOH Blood Transfusion Topics Why? When? Who? Risks Massive Haemmorrhage Example 1 A fit patient with a compound fracture of the tibia and a post operative Hb of 7.5 g/dl should be transfused? Example 2

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Jasmeet k aur l.jpg

JasmeetKaur

Fluids and Transfusion

SpR in Anaesthesia, RNOH



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Topics

  • Why?

  • When?

  • Who?

  • Risks

  • Massive Haemmorrhage


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Example 1

  • A fit patient with a compound fracture of the tibia and a post operative Hb of 7.5 g/dl should be transfused?


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Example 2

  • A 70yr old woman with a history of angina and a pre-op Hb of 7.5 g/dl should be transfused?


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Why?

  • The body at rest uses approx 250ml O2/L blood

  • O2 delivery can fall with a reduction in any of:

    • Cardiac Output

    • Hb concentration

    • O2 saturation

  • Organs most sensitive to hypoxia are Heart and Brain


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Why?

  • The purpose of a red cell transfusion is to improve the oxygen carrying capacity of the blood.

  • Oxygen delivery to tissues (O2 Flux)

    = Cardiac Output x Oxygen content of blood

    Hb x Sa02


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When?

  • Consider the context:

  • Cause and severity of anaemia

  • Patients ability to compensate for anaemia ( cardiorespiratory disease)

  • Rate of ongoing blood loss

  • Likliehood of further blood loss

  • Balance of risks vs benefits of transfusion


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Transfusion Triggers

  • RBC transfusion not indicated when Hb>10g/dl

  • Hb < 7g/dl- strong indication for transfusion

  • RBC Transfusion less clear when Hb between 7-10 g/dl

  • Cardiopulmonary reserve needs to be assessed.

  • Symptomatic patients should be transfused. (fatigue, dizziness, shortness of breath, new or worsening angina)



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Example 1

  • A fit patient with a compound fracture of the tibia and a post operative Hb of 7.5 g/dl should be transfused?

  • T

  • F


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Example 1

  • A fit patient with a compound fracture of the tibia and a post operative Hb of 7.5 g/dl should be transfused?

  • T

  • F ✔


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Example 2

  • A 70yr old woman with a history of angina and a pre-op Hb of 7.5 g/dl should be transfused?

  • T

  • F


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Example 2

  • A 70yr old woman with a history of angina and a pre-op Hb of 7.5 g/dl should be transfused?

  • T ✔

  • F


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Summary

  • Think before you transfuse!

  • Does your patient really need blood?

  • Weigh up the benefits vs risks of transfusion.



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Massive Transfusion

Definitions

  • Replacement of one blood volume in a 24 hour period

  • Transfusion of >10 units RCC in 24 hours

  • Transfusion of 4 or more RCC within 1 hour when ongoing need is foreseeable

  • Replacement of >50% of the total blood volume within 3 hours


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Massive Transfusion

  • Settings

    • Trauma

    • Obstetric

    • Surgical

    • “Medical”


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The Perfect Clot!

  • Red blood Cells

  • Platelets

  • Clotting factors

  • Fibrinogen



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The Massively Bleeding Patient…

  • Restore Circulating Volume:

  • X 2 14G IV cannulae

  • Resuscitate with warmed crystalloid/colloid

  • Warm patient

  • Consider invasive monitoring: arterial line + central venous access



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Get some Help….

  • Contact Key Personnel

  • Senior anaesthetist/ surgeon/

    obstetrician

  • Blood Bank

  • Haematologist

  • Get someone to coordinate to communicate and document



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Request Lab investigations

  • Ensure correct sample identity

  • FBC, ABG

  • Full coagulation screen

  • X- match

  • Repeat after products/4hourly

  • May need to give blood products before results are available


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Request PRC

  • Uncrossmatched Group O Rh neg

  • Uncrossmatched ABO group specific

  • Fully X match

  • Use a blood warmer/ rapid infusion device

  • Consider cell salvage


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Request Platelets

  • Allow for delivery time.

  • Anticipate plt count<50 x109/l after x2 blood vol replacement

  • Target plt count>100 x109/l for multiple/CNS trauma, > 50 in other situations


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Request FFP

  • Aim for PT/ APTT < 1.5 x control

  • Allow for thawing time


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Request Cryopreciptate

  • Contains fibrinogen and factor VIII

  • Aim for fibrinogen >1g/L


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Summary

  • Recognise the situation early!

  • Get some help.

  • Aggressive management of hypothermia/acidosis

  • Avoid haemodilution and use appropriate volumes of blood components

  • Inadequately treated coagulopathy is associated with worse outcome


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IV Fluids

Other IV Fluids


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Normal Adult Fluid Composition

60% composed of water

70 kg person= 42 L

2/3 ICF = 28L

1/3 ECF = 14L

TBW= ECF + ICF


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Daily Requirements

  • Maintenance Fluid formula

  • 4 ml/kg/h for the first 10 kg

  • 2 ml/kg/h for the next 10 kg

  • 1 ml/kg/h for every kg over 20 kg

  • Therefore a 70 kg patient using the calculation:

  • 40+20+50=110

  • will require 110 ml/h


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Daily Requirements

  • The normal electrolyte requirements are:

  • Na+ 1-2 mmol/kg/24 h

  • K+ 0.5-1 mmol/kg/24 h.


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Fluid therapy

Maintenance

Resuscitation


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Pre-operatively

Should consider:

  • History, examination

  • Deficit (measured + insensible)

  • Intravascular vs cellular dehydration

  • Electrolyte levels

  • Speed of fluid loss (days/hours/minutes)

  • Vasodilated / ill patients may need several litres of fluid before surgery



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Intra-operatively

  • Should use CO monitor for emergency or major surgery

  • Serial 200ml colloid boluses

  • Ongoing Hartmann’s soln with colloid

  • Warm fluid to reduce hypothermia


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Post- operatively

  • Fluids are used to continue fluid replacement:

  • To provide daily water and electrolyte requirements, until the patient is able to drink an adequate daily volume.


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Elective, well patient

  • Q: Fit , young pt having elective surgery not involving the abdomen what fluid losses do you expect before and during surgery of less than an hour?


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  • Starved 6 hrs

  • 220ml- 660ml

  • Intra op losses

  • (minimal blood loss, loss dependent on duration)

  • Surgery< 1hr, loss< 150ml


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Does this patient need intra op Fluid?

  • Not necessarily

  • But if hot weather, insensible losses may increase, pt may feel better post op if 500ml given


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Emergency Laparotomy Pt

  • Q: Patient needing urgent laparotomy, history of vomiting for several days.

  • What fluid loss do you expect this patient to have had before surgery?


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  • Pt may be severely water and electrolyte depleted

  • Large volumes fluid may be needed to resuscitate this patient

  • Vomiting leads to loss of hydrogen and chloride ions, NaCl solution will help to replace these

  • K ions may be lost in bowel, so may need replacing

  • Check serum electrolytes before and after fluid resuscitation


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What?

  • Crystalloids

  • Colloids


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Colloids

  • Contain Proteins/large molecules suspended in a carrier solution

  • Large molecules stay in the plasma, keeping infused fluid in largely in circulation.

  • Smaller volumes needed

  • Small risk of anaphylaxis



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Crystalloids

  • Contain water and dissolved electrolytes

  • Pass freely through a semipermeable membrane

  • Many are isotonic with extracellular fluid

  • Need larger volumes

  • Cheap



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Questions

  • Acute haemorrhage of 15% blood volume should be treated with 5% glucose.

  • F

  • Major sepsis should be treated with 5% glucose.

  • F

  • Acute haemorrhage of 40% blood volume should be treated with blood.

  • T


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Questions

  • What are the H2O and Na+ ions for a 65 Kg patient to replace normal daily losses?


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Questions

  • Requirements: H2O 105 ml/hr = 2520 ml/day

    Na = 65-130mmol/day

  • A. 2.5L 0.18% NaCl + 4% dextrose?

  • F

  • B. 1L Hartmann’s soln + 1.5L 5% dextrose?

  • T

  • C. 2.5L Hartmann’s soln?

  • T

  • D. 2.5L of 5% dextrose?

  • F


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Summary

  • Think about why you are giving fluids

  • Work out how much fluid to give

  • Select which type of fluid to give

  • Correct fluid management is essential to every patient’s care



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