Fluid and Blood Transfusion
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Transcript of Fluid and Blood Transfusion
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Mariana Voigt
2013
FLUID AND BLOOD
TRANSFUSION
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COMPONENTS OF ANESTHESIOLOGY
Hypnosis
AnalgesiaMuscle Relaxation
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Perioperative evaluation and correction of fluid disturbance
COMPONENTS OF ANESTHESIOLOGY
Hypnosis
AnalgesiaMuscle Relaxation
Fluid Fluid managememanageme
ntnt
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Patient evaluationOxygen flux Types of fluidBlood products and guidelinesChanges in stored bloodTransfusion reactions
OVERVIEW
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Components of fluid status1. Volume: lost or gained2. Composition: elec;glu;colloids;ph3. Concentration: Hyper, Iso or
Hypotonic
PERIOPERATIVE FLUID STATUS
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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
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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
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MaintenanceFluid deficit/replacementIntra-operative blood lossThird space lossCompensation - spinal
COMPONENTS OF FLUID REPLACEMENT
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COMPONENTS OF FLUID REPLACEMENT
MaintenanceMaintenance
Fluid deficitFluid deficitNPONPO
BloodlossBloodloss
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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
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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
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High in Osmol( Hypertonic)Low in sodiumGlucose to provide energyIntra operative replacement is done with isotonic fluids
(stress response - glucose↑)
MAINTENANCE
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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
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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
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REPLACEMENT
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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
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THIRD SPACE LOSS
ic
iciv
is
is
HAGIE
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BLOODLOSS
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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
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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)
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DO2
O2
CO=SV*CO=SV*HRHR
PAO2PAO2
HbHb
VO2VO2
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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)
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Tachycardia; hypotension in normovolemia
BE; pH ; lactateSvO2 < 50%ERO2 > 50%New RWMANew ST segment changesVO2 ↓ 10 %
TRIGGERS FOR TRANSFUSION
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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
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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
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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
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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
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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
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Replace blood loss 1:1Intravascular T1/2 3-6 hBolus dose of 10-20ml/kgVolufen most in favor – 70 ml/kg/24h
COLLOIDS
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Fluid overloadAllergic reactions – GelatinsInhibition of clotting – DextransDilutional thrombocytopeniaProlonged in renal failurePruritus Increase incidence of renal failure in septic patients
SIDE EFFECTS OF COLLOIDS
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Start with crystalloidAfter 2l of crystalloid – give colloid
FLUID ADMINISTRATION
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BLOOD PRODUCTS
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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
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Cell saverAutologous blood transfusionHaemodilutionAnti-fibrinoliticsDesmopressinNovosevenHemopure(bovine Hb protein)
BLOOD CONSERVATION
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CELL SAVER
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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
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FFP
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Blood component therapyPT; platelets; fibrinigenTEGAfter the loss of 1 bloodvolume platelets should be given
BLOOD PRODUCTS
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TROMBO ELASTOGRAM
R = clotting R = clotting factorsfactorsMA = platelet MA = platelet functionfunctionα = speed of clot α = speed of clot formationformation
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Acute Haemolytic reactions - ABO incompatibility
Delayed haemolytic reactions-RhAllergic reactions-incompatible proteins
Graft versus Host reactionFebrile, non haemolytic reactionsPost transfusion purpera
TRANSFUSION REACTIONS
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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
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Hepatitis B, CHIV 1:800 000Ebstein-BarrCMVMalaria, Brucella, SyphilisBacterial contamination
TRANSMISSION OF DISEASE
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Occurs 1-6h of TransfusionPt becomes hypoxic, no signs of pulm oedema
FFP most important cause of TraliLeucocytes : leucocyte reduction
TRALI
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HypothermiaCitrate toxicity with ↓CaFluid overloadAir embolismBacterial contaminationBleeding tendencies : dilutional thrombocytopenia
DIVERSE REACTIONS
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SodiumPotassiumCalciumMagnesium
ELECTROLYTE DISTURBANCES
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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)
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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)
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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
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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
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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
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Redistribution from intra to extracellular
Increased intakeDecreased excretionECG changes: flattened p wave, prolonged qrs and pr, tall T waves,
HYPERKALAEMIA>5MM
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Treatment:KayexelateGlu/InsulinLasix to promote excretionCaCl2-NaHCO3-Dialysis
HYPERKALAEMIA
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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
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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
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Hypomagnesaemia Torsades de pointes
MAGNESIUM