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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

JasmeetKaur

Fluids and Transfusion

SpR in Anaesthesia, RNOH

topics
Topics
  • Why?
  • When?
  • Who?
  • Risks
  • Massive Haemmorrhage
example 1
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
Example 2
  • A 70yr old woman with a history of angina and a pre-op Hb of 7.5 g/dl should be transfused?
slide6
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
slide7
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

slide8
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
transfusion triggers
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)
example 112
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
example 113
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 ✔
example 214
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
example 215
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
summary
Summary
  • Think before you transfuse!
  • Does your patient really need blood?
  • Weigh up the benefits vs risks of transfusion.
massive transfusion
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
massive transfusion19
Massive Transfusion
  • Settings
    • Trauma
    • Obstetric
    • Surgical
    • “Medical”
the perfect clot
The Perfect Clot!
  • Red blood Cells
  • Platelets
  • Clotting factors
  • Fibrinogen
the massively bleeding patient
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
get some help
Get some Help….
  • Contact Key Personnel
  • Senior anaesthetist/ surgeon/

obstetrician

  • Blood Bank
  • Haematologist
  • Get someone to coordinate to communicate and document
request lab investigations
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
request prc
Request PRC
  • Uncrossmatched Group O Rh neg
  • Uncrossmatched ABO group specific
  • Fully X match
  • Use a blood warmer/ rapid infusion device
  • Consider cell salvage
request platelets
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
request ffp
Request FFP
  • Aim for PT/ APTT < 1.5 x control
  • Allow for thawing time
request cryopreciptate
Request Cryopreciptate
  • Contains fibrinogen and factor VIII
  • Aim for fibrinogen >1g/L
summary31
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
slide32

IV Fluids

Other IV Fluids

normal adult fluid composition
Normal Adult Fluid Composition

60% composed of water

70 kg person= 42 L

2/3 ICF = 28L

1/3 ECF = 14L

TBW= ECF + ICF

daily requirements
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
daily requirements35
Daily Requirements
  • The normal electrolyte requirements are:
  • Na+ 1-2 mmol/kg/24 h
  • K+ 0.5-1 mmol/kg/24 h.
fluid therapy
Fluid therapy

Maintenance

Resuscitation

pre operatively
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
intra operatively
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
post operatively
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.
elective well patient
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?
slide43

Starved 6 hrs

  • 220ml- 660ml
  • Intra op losses
  • (minimal blood loss, loss dependent on duration)
  • Surgery< 1hr, loss< 150ml
does this patient need intra op fluid
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
emergency laparotomy pt
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?
slide46

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
slide47
What?
  • Crystalloids
  • Colloids
colloids
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
crystalloids
Crystalloids
  • Contain water and dissolved electrolytes
  • Pass freely through a semipermeable membrane
  • Many are isotonic with extracellular fluid
  • Need larger volumes
  • Cheap
questions
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
questions53
Questions
  • What are the H2O and Na+ ions for a 65 Kg patient to replace normal daily losses?
questions54
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
summary55
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