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Fluid and Blood Transfusion

Fluid and Blood Transfusion. Mariana Voigt 2013. Components of Anesthesiology. Components of Anesthesiology. Perioperative evaluation and correction of fluid disturbance. Fluid management. Overview. Patient evaluation Oxygen flux Types of fluid Blood products and guidelines

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Fluid and Blood Transfusion

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  1. Fluid and BloodTransfusion Mariana Voigt 2013

  2. Components of Anesthesiology

  3. Components of Anesthesiology • Perioperative evaluation and correction of fluid disturbance Fluid management

  4. Overview • Patient evaluation • Oxygen flux • Types of fluid • Blood products and guidelines • Changes in stored blood • Transfusion reactions

  5. Perioperative fluid status • Components of fluid status • Volume: lost or gained • Composition: elec;glu;colloids;ph • Concentration: Hyper, Iso or Hypotonic

  6. Patient evaluationFluid and Electrolyte status • History: • Intake/Output • Bleeding • Exposure • Examination: • Blood pressure, pulse –rate, character • Skin turgor; capillary refill • Mucous membranes, pallor • Urine excretion • Level of consciousness

  7. Patient evaluationFluid and Electrolyte status • Invasive monitoring: • CVP- fluid challenge • Pulmonary artery catheter • Non-invasive cardiac output- arterial pulse contour analysis: SPV, PPV, SVV • Special investigations: • Na • Other electrolytes and pH • Hemoglobin • Serum osmolarity= 2(Na +K) + urea + glucose

  8. Components of fluid replacement • Maintenance • Fluid deficit/replacement • Intra-operative blood loss • Third space loss • Compensation - spinal

  9. Components of fluid replacement Maintenance Fluid deficit NPO Bloodloss

  10. Maintenance • To compensate for respiration; skin; urine and bowel losses • Adult loss = 1-2 ml/kg/h • children: 1-10kg 4ml/kg/h 10-20kg 2ml/kg/h >20 kg 1ml/kg/h

  11. Maintenance • 26 kg child: • 1-10 kg = 4ml/kg = 40ml • + 11-20 kg = 2ml/kg = 20ml • + 21-26 kg = 1ml/kg = 6ml • Maintenance= 40+20+6= 66ml/h

  12. Maintenance • High in Osmol( Hypertonic) • Low in sodium • Glucose to provide energy • Intra operative replacement is done with isotonic fluids • (stress response - glucose↑)

  13. Replacement • High up GIT losses rich in chloride, hydrogen and potassium – should be replaced with normal saline and potassium • Lower GIT losses rich in bicarbonate – should be replaced with normal saline, potassium and bicarbonate

  14. Replacement • Burns (Parkland formula) = 4ml/% burns/kg/24h • ½ of the replacement in 8 h • ½ of the replacement in 16 h • NPO period = Maintenance x hours NPO ( 50% during the first hour)

  15. Replacement

  16. Third space loss • 1960 Shires describes a 3rd space – movement of fluid from the interstitial space to the intracellular space • Should be replaced with crystalloids • Minimal 1-2 ml/kg/hr Moderate 3-6 ml/kg/hr Large 7-10 ml/kg/hr • Not applicable

  17. Third space loss iv ic HAGIE ic is is

  18. Bloodloss

  19. Resuscitation • Restoration of circulatory volume with plasma volume expanders • Choice of fluid is controversial • Debate of colloids versus crystalloids • Blood transfusion >= 20% blood loss • Criteria for blood administration not so rigid any more

  20. Oxygen Flux(DO2) • DO2= CO x CaO2 = CO x (Hb x 1.34 x SaO2 + 0.031 x PaO2) = 1000ml/min; 600ml/min/mxm • CaO2 = Oxygen content in arterial blood = 200 ml/l • 1.34 = Hb’s oxygen binding (ml/g) • 0.031 = Solubility of oxygen in blood

  21. DO2 PAO2 VO2 O2 Hb CO=SV*HR

  22. Oxygen Flux(DO2) • CO = SV x HR • VO2 = 3.5 ml/kg/min = 250 ml/kg • ERO2 = VO2/DO2 = 250/1000 = 25% • ERO2>= 50% (Trigger for blood transfusion)

  23. Triggers for Transfusion • Tachycardia; hypotension in normovolemia • BE; pH ; lactate • SvO2 < 50% • ERO2 > 50% • New RWMA • New ST segment changes • VO2↓ 10 %

  24. End points of Resus • MAP > 65 mm Hg • Urine output of > 0.5 ml/kg/h • SVO2> 70% • CVP = 8-12 cmH2O • Transfuse to a Hct of 30 • Look at improvement of the pH, lactate

  25. MABL • MABL = blood volume x(hct1 – hct2) mean haematocrit • Hct1 = initial haematocrit • Hct2 = minimally acceptable hct • Bloodvolumes: Prem = 95 ml/kg Fullterm = 90 ml/kg Infant = 80 ml/kg > 1 year = 70 ml/kg

  26. Types of fluids • Crystalloid solutions : a) Isotonic solutions b) Hypertonic saline • Colloids: ( Starling equation) a) Natural colloids – albumin, ffp b) Synthetic colloids – Dextrans, Gelatins, Hydroxy-ethyl starches

  27. Crystalloids • After 2 hours only 1/4 →IV due to extra vascular extravasation • Blood loss → 3 x Volume • Ringer’s lactate remains the most popular fluid for resuscitation

  28. Colloids • Dextrans: polymers produced from sucrose by fermentation, by the bacteria leuconostrocmesenteroides. • Gelatins: hydrolysed animal collagen; bovine protein: Haemaccel; Gelofusin • Hydroxy-ethyl starches: maize; potatoes:Haesteril; Volufen, Venafunden

  29. Colloids • Replace blood loss 1:1 • Intravascular T1/2 3-6 h • Bolus dose of 10-20ml/kg • Volufen most in favor – 70 ml/kg/24h

  30. Side effects of Colloids • Fluid overload • Allergic reactions – Gelatins • Inhibition of clotting – Dextrans • Dilutional thrombocytopenia • Prolonged in renal failure • Pruritus • Increase incidence of renal failure in septic patients

  31. Fluid administration • Start with crystalloid • After 2l of crystalloid – give colloid

  32. Blood products

  33. Blood products • Lethal triad: acidosis; hypothermia; coagulopathy • Blood component therapy • Restrictive transfusion strategy versus the 10:30 rule • Healthy patient Hb = 6 g/dl • Associated disease Hb = 7g/dl • Acute coronary syndrome Hb = 8 g/dl

  34. Blood conservation • Cell saver • Autologous blood transfusion • Haemodilution • Anti-fibrinolitics • Desmopressin • Novoseven • Hemopure(bovine Hb protein)

  35. Cell SAVER

  36. Blood products • Whole blood • Packed cells – Hct 60; stored at 4o C • Leucocyte depleted blood • Irradiated blood • Platelets; stored at 22o C for 5 days; give 1 u/10kg • FFP; give 15-20 ml/kg • Cryoprecipitate : fibrinogen; factor 8

  37. ffp

  38. Blood products • Blood component therapy • PT; platelets; fibrinigen • TEG • After the loss of 1 bloodvolume platelets should be given

  39. Tromboelastogram R = clotting factors MA = platelet function α = speed of clot formation

  40. Transfusion reactions • Acute Haemolytic reactions - ABO incompatibility • Delayed haemolytic reactions-Rh • Allergic reactions-incompatible proteins • Graft versus Host reaction • Febrile, non haemolytic reactions • Post transfusion purpera

  41. Metabolic deviations • K↑, Mg↑,Ca ↓ • pH↓ • 2,3 DPG ↓(L shift oxy-Hb curve) • ATP depletion • ↑ release of pro-inflammatory substances • ↓in platelets and clotting factors v and viii • AGE of blood is a predictor of post-op infection

  42. Transmission of disease • Hepatitis B, C • HIV 1:800 000 • Ebstein-Barr • CMV • Malaria, Brucella, Syphilis • Bacterial contamination

  43. TRALI • Occurs 1-6h of Transfusion • Pt becomes hypoxic, no signs of pulm oedema • FFP most important cause of Trali • Leucocytes : leucocyte reduction

  44. Diverse reactions • Hypothermia • Citrate toxicity with ↓Ca • Fluid overload • Air embolism • Bacterial contamination • Bleeding tendencies : dilutional thrombocytopenia

  45. Electrolyte disturbances • Sodium • Potassium • Calcium • Magnesium

  46. Hyponatraemia(< 135mmol/l) • Clinical picture: ( acute onset) lethargy; confusion; seizures; coma • Hypovolaemia: electrolyte rich fluid loss; N&V; diarrhoea; fistulae; diuretics; cerebral salt wasting syndrome – Rx 0.9% NaCl

  47. Hyponatraemia(< 135mmol/l) • Hypervolaemia: TURP-syndrome; cardiac failure(sec hyperaldosteronism); renal failure, cirrhosis – Rx fluid restriction and diuretics • Normovolaemia: SIADH, hypothyroidism, Addisons – Rx hormone replacement and fluid restriction

  48. Hyponatraemia • s-Na < 130 mM – postpone elective surgery : increase risk for cerebral oedema; delayed awakening • s-Na < 120 mM – high mortality • Correct slowly- can cause pontinedemyelinization

  49. Hypernatremia>145mM • Hypervolaemic: Hypertonic saline- Rx loop diuretics + Dextrose water • Normovolemia: Diabetes Insipidus- Rx desmopressien + Dextrose water • Hypovolemia: renal losses due to osmotic diuretics, D&V, sweating – Rx Dextrose water

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