Mariana Voigt

2013

FLUID AND BLOOD

TRANSFUSION

COMPONENTS OF ANESTHESIOLOGY

Hypnosis

AnalgesiaMuscle Relaxation

Perioperative evaluation and correction of fluid disturbance

COMPONENTS OF ANESTHESIOLOGY

Hypnosis

AnalgesiaMuscle Relaxation

Fluid Fluid managememanageme

ntnt

Patient evaluationOxygen flux Types of fluidBlood products and guidelinesChanges in stored bloodTransfusion reactions

OVERVIEW

Components of fluid status1. Volume: lost or gained2. Composition: elec;glu;colloids;ph3. Concentration: Hyper, Iso or

Hypotonic

PERIOPERATIVE FLUID STATUS

History:1. Intake/Output2. Bleeding3. Exposure

Examination:1. Blood pressure, pulse –rate, character 2. Skin turgor; capillary refill3. Mucous membranes, pallor 4. Urine excretion5. Level of consciousness

PATIENT EVALUATIONFLUID AND ELECTROLYTE

STATUS

Invasive monitoring:1. CVP- fluid challenge2. Pulmonary artery catheter3. Non-invasive cardiac output- arterial pulse

contour analysis: SPV, PPV, SVV

Special investigations:1. Na2. Other electrolytes and pH 3. Hemoglobin4. Serum osmolarity= 2(Na +K) + urea + glucose

PATIENT EVALUATIONFLUID AND ELECTROLYTE

STATUS

MaintenanceFluid deficit/replacementIntra-operative blood lossThird space lossCompensation - spinal

COMPONENTS OF FLUID REPLACEMENT

COMPONENTS OF FLUID REPLACEMENT

MaintenanceMaintenance

Fluid deficitFluid deficitNPONPO

BloodlossBloodloss

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

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

MAINTENANCE

High in Osmol( Hypertonic)Low in sodiumGlucose to provide energyIntra operative replacement is done with isotonic fluids

(stress response - glucose↑)

MAINTENANCE

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

REPLACEMENT

Burns (Parkland formula) = 4ml/% burns/kg/24h

½ of the replacement in 8 h½ of the replacement in 16 h

NPO period= Maintenance x hours NPO( 50% during the first hour)

REPLACEMENT

REPLACEMENT

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/hrNot applicable

THIRD SPACE LOSS

THIRD SPACE LOSS

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HAGIE

BLOODLOSS

Restoration of circulatory volume with plasma volume expanders

Choice of fluid is controversialDebate of colloids versus crystalloidsBlood transfusion >= 20% blood lossCriteria for blood administration not so rigid

any more

RESUSCITATION

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

OXYGEN FLUX(DO2)

DO2

O2

CO=SV*CO=SV*HRHR

PAO2PAO2

HbHb

VO2VO2

CO = SV x HRVO2 = 3.5 ml/kg/min = 250 ml/kg

ERO2 = VO2/DO2 = 250/1000 = 25%

ERO2>= 50% (Trigger for blood transfusion)

OXYGEN FLUX(DO2)

Tachycardia; hypotension in normovolemia

BE; pH ; lactateSvO2 < 50%ERO2 > 50%New RWMANew ST segment changesVO2 ↓ 10 %

TRIGGERS FOR TRANSFUSION

MAP > 65 mm HgUrine output of > 0.5 ml/kg/hSVO2> 70%CVP = 8-12 cmH2OTransfuse to a Hct of 30Look at improvement of the pH, lactate

END POINTS OF RESUS

MABL = blood volume x(hct1 – hct2)mean haematocrit

Hct1 = initial haematocritHct2 = minimally acceptable hct

Bloodvolumes:Prem = 95 ml/kgFullterm = 90 ml/kgInfant = 80 ml/kg> 1 year = 70 ml/kg

MABL

Crystalloid solutions : a) Isotonic solutions

b) Hypertonic saline

Colloids: ( Starling equation)a) Natural colloids – albumin,

ffpb) Synthetic colloids –

Dextrans, Gelatins, Hydroxy-ethyl starches

TYPES OF FLUIDS

After 2 hours only 1/4 →IV due to extra vascular extravasation

Blood loss → 3 x VolumeRinger’s lactate remains the most popular fluid for resuscitation

CRYSTALLOIDS

Dextrans: polymers produced from sucrose by fermentation, by the bacteria leuconostroc mesenteroides.

Gelatins: hydrolysed animal collagen; bovine protein: Haemaccel; Gelofusin

Hydroxy-ethyl starches: maize; potatoes:Haesteril; Volufen, Venafunden

COLLOIDS

Replace blood loss 1:1Intravascular T1/2 3-6 hBolus dose of 10-20ml/kgVolufen most in favor – 70 ml/kg/24h

COLLOIDS

Fluid overloadAllergic reactions – GelatinsInhibition of clotting – DextransDilutional thrombocytopeniaProlonged in renal failurePruritus Increase incidence of renal failure in septic patients

SIDE EFFECTS OF COLLOIDS

Start with crystalloidAfter 2l of crystalloid – give colloid

FLUID ADMINISTRATION

BLOOD PRODUCTS

Lethal triad: acidosis; hypothermia; coagulopathy

Blood component therapyRestrictive transfusion strategy versus the 10:30 rule

Healthy patient Hb = 6 g/dlAssociated disease Hb = 7g/dlAcute coronary syndrome Hb = 8 g/dl

BLOOD PRODUCTS

Cell saverAutologous blood transfusionHaemodilutionAnti-fibrinoliticsDesmopressinNovosevenHemopure(bovine Hb protein)

BLOOD CONSERVATION

CELL SAVER

Whole bloodPacked cells – Hct 60; stored at 4o CLeucocyte depleted bloodIrradiated bloodPlatelets; stored at 22o C for 5 days; give 1 u/10kg

FFP; give 15-20 ml/kgCryoprecipitate : fibrinogen; factor 8

BLOOD PRODUCTS

FFP

Blood component therapyPT; platelets; fibrinigenTEGAfter the loss of 1 bloodvolume platelets should be given

BLOOD PRODUCTS

TROMBO ELASTOGRAM

R = clotting R = clotting factorsfactorsMA = platelet MA = platelet functionfunctionα = speed of clot α = speed of clot formationformation

Acute Haemolytic reactions - ABO incompatibility

Delayed haemolytic reactions-RhAllergic reactions-incompatible proteins

Graft versus Host reactionFebrile, non haemolytic reactionsPost transfusion purpera

TRANSFUSION REACTIONS

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 viiiAGE of blood is a predictor of post-op infection

METABOLIC DEVIATIONS

Hepatitis B, CHIV 1:800 000Ebstein-BarrCMVMalaria, Brucella, SyphilisBacterial contamination

TRANSMISSION OF DISEASE

Occurs 1-6h of TransfusionPt becomes hypoxic, no signs of pulm oedema

FFP most important cause of TraliLeucocytes : leucocyte reduction

TRALI

HypothermiaCitrate toxicity with ↓CaFluid overloadAir embolismBacterial contaminationBleeding tendencies : dilutional thrombocytopenia

DIVERSE REACTIONS

SodiumPotassiumCalciumMagnesium

ELECTROLYTE DISTURBANCES

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

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

HYPONATRAEMIA(< 135MMOL/L)

s-Na < 130 mM – postpone elective surgery : increase risk for cerebral oedema; delayed awakening

s-Na < 120 mM – high mortalityCorrect slowly- can cause pontine demyelinization

HYPONATRAEMIA

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

HYPERNATREMIA>145MM

Redistribution from extra to intracellular: alkalosis; Ins; B- agonist

Decreased intake Increased lossesECG changes: Large p,prolonged pr, st depression, t wave flattening, large u wave, dysrhythmias

Rx: 20mmol – 40mmol KCl + 1g- 2g MgSO2

HYPOKALAEMIA<3.5MM

Redistribution from intra to extracellular

Increased intakeDecreased excretionECG changes: flattened p wave, prolonged qrs and pr, tall T waves,

HYPERKALAEMIA>5MM

Treatment:KayexelateGlu/InsulinLasix to promote excretionCaCl2-NaHCO3-Dialysis

HYPERKALAEMIA

Ca = 2.2 mM- 2.6 mM

Stones, moans, groans, bones, severe dehydration, reduces QT interval

Rx.( 3.2mmol)Rehydration and forced diuresisBisphosphonatesGlucocorticoidsIntravenous phosphate

HYPERCALCAEMIA

Anxiety, prolonged QT interval, convulsions, hyperreflexia, (Chvostek’s and Trousseau’s sign)

Life-threating hypocalcaemia due to massive blood transfusion

Can be observed after thyroidectomyRx.CaCl2 or Ca gluconate

HYPOCALCAEMIA

Hypomagnesaemia Torsades de pointes

MAGNESIUM