fluid and blood transfusion
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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
ic
iciv
is
is
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