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8/12/2019 Anaesthesia Blood
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Fluids and Transfusion
SpR in Anaesthesia, RNOH
the centre for
Anaesthesia
L
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L
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TopicsWhy?
When?
Who? Risks
Massive Haemmorrhage
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Example 1A 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 2A 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 areduction 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 ofblood
Hbx 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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Risks
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Example 1A 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 1A 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 2A 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 2A 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
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Massive TransfusionDefinitions 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 whenongoing need is foreseeable
Replacement of >50% of the total blood volume within3 hours
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Massive Transfusion Settings
TraumaObstetric
Surgical
Medical
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The Perfect Clot! Red blood Cells
Platelets Clotting factors
Fibrinogen
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Bloody Vicious Cycle
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The Massively Bleeding Patient Restore Circulating
Volume:
X 2 14G IV cannulae
Resuscitate with warmedcrystalloid/colloid
Warm patient
Consider invasivemonitoring: arterial line+ central venous access
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Effect of Hypothermia on
coagulation factor activity
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Get some Help. Contact Key Personnel
Senior anaesthetist/ surgeon/
obstetrician Blood Bank
Haematologist
Get someone to coordinate to communicate anddocument
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Arrest the Bleeding.
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Request Lab investigations Ensure correct sample identity
FBC, ABG
Full coagulation screenX- match
Repeat after products/4hourly
May need to give blood products before resultsare available
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Request PRC Uncrossmatched Group
O Rh neg
Uncrossmatched ABOgroup specific
Fully X match
Use a blood warmer/
rapid infusion device Consider cell salvage
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Request PlateletsAllow for delivery time.
Anticipate plt count100x109/l for multiple/CNStrauma, > 50 in othersituations
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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/acidosisAvoid haemodilution and use appropriate volumes of
blood components
Inadequately treated coagulopathy is associated with
worse outcome
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Other IV FluidsIV 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 therapyMaintenance
Resuscitation
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History
Vomiting/ diarrhoea
Intestinal obstruction
Fluid intakeThirst
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Signs/ Symptoms
Dry mucous membranes
Low urine output
TachycardiaIncreased capillary refill time
Postural hypotension (late sign)
Low CVP
Decreased concious level
Signs and symptoms of dehydration
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Intra-operatively Should use CO monitor for emergency or major
surgery
Serial 200ml colloid boluses
Ongoing Hartmanns 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 dailyvolume.
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Elective, well patient Q: Fit , young pt having elective surgery not involving
the abdomen what fluid losses do you expect beforeand 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, ptmay 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 hadbefore 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 fluidresuscitation
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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 f luid in largely incirculation.
Smaller volumes needed
Small risk of anaphylaxis
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ColloidsNa Cl K Lactate Ca Mg Other
GelofusinElohaes,
VoluvenVolplexHaesterilAlbumin
150 120-150
Haemacell 145 145 5 6
Geloplasma 150 100 5 30 1-1.5Volulyte 137 4 110 1.5 Acetate
34
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Crystalloids Contain water and dissolved
electrolytes
Pass freely through asemipermeable membrane
Many are isotonic withextracellular fluid
Need larger volumes Cheap
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CrystalloidsNa+ Cl- K+ Lactate Ca Mg OtherHartmannsSolution (CSL)
131 111 5 29 2
0.9% Saline 154 154
5% glucose Glucose 50g/l
4% glucose saline 30 30 Glucose 40g/l
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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 normaldaily losses?
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Questions Requirements: H2O 105 ml/hr = 2520 ml/dayNa = 65-130mmol/day
A. 2.5L 0.18% NaCl + 4% dextrose?
F
B. 1L Hartmanns soln + 1.5L 5% dextrose?
T
C. 2.5L Hartmanns soln?
T
D. 2.5L of 5% dextrose?
F
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Summary Think about why you are giving f luids
Work out how much fluid to give
Select which type of fluid to give Correct fluid management is essential to every
patients care
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Questions?