FLUID AND BLOOD TRANSFUSION Mariana Voigt 2013 COMPONENTS

FLUID AND BLOOD TRANSFUSION Mariana Voigt 2013

COMPONENTS OF ANESTHESIOLOGY Hypnosis Muscle Relaxation Analgesia

COMPONENTS OF ANESTHESIOLOGY Perioperative evaluation and correction of fluid disturbance Hypnosis Fluid management Muscle Relaxation Analgesia

OVERVIEW Patient evaluation Oxygen flux Types of fluid Blood products and guidelines Changes in stored blood Transfusion reactions

PERIOPERATIVE FLUID STATUS 1. 2. 3. Components of fluid status Volume: lost or gained Composition: elec; glu; colloids; ph Concentration: Hyper, Iso or Hypotonic

PATIENT EVALUATION FLUID AND ELECTROLYTE STATUS 1. 2. 3. History: Intake/Output Bleeding Exposure 1. 2. 3. 4. 5. Examination: Blood pressure, pulse –rate, character Skin turgor; capillary refill Mucous membranes, pallor Urine excretion Level of consciousness

PATIENT EVALUATION FLUID AND ELECTROLYTE STATUS 1. 2. 3. Invasive monitoring: CVP- fluid challenge Pulmonary artery catheter Non-invasive cardiac output- arterial pulse contour analysis: SPV, PPV, SVV 1. 2. 3. 4. Special investigations: Na Other electrolytes and p. H Hemoglobin Serum osmolarity= 2(Na +K) + urea + glucose

COMPONENTS OF FLUID REPLACEMENT Maintenance Fluid deficit/replacement Intra-operative blood loss Third space loss Compensation - spinal

COMPONENTS OF FLUID REPLACEMENT Maintenance Fluid deficit NPO Bloodloss

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

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

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

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

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

REPLACEMENT

THIRD SPACE LOSS 1960 Shires describes a 3 rd 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

THIRD SPACE LOSS ic iv ic HAGIE is is

BLOODLOSS

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

OXYGEN FLUX(DO 2 ) DO 2 = CO x Ca. O 2 = CO x (Hb x 1. 34 x Sa. O 2 + 0. 031 x Pa. O 2) = 1000 ml/min; 600 ml/min/mxm Ca. O 2 = Oxygen content in arterial blood = 200 ml/l 1. 34 = Hb’s oxygen binding (ml/g) 0. 031 = Solubility of oxygen in blood

DO 2 PAO 2 VO 2 Hb CO=SV*HR

OXYGEN FLUX(DO 2 ) CO = SV x HR VO 2 = 3. 5 ml/kg/min = 250 ml/kg ERO 2 = VO 2/DO 2 = 250/1000 = 25% ERO 2>= 50% (Trigger for blood transfusion)

TRIGGERS FOR TRANSFUSION Tachycardia; hypotension in normovolemia BE; p. H ; lactate Sv. O 2 < 50% ERO 2 > 50% New RWMA New ST segment changes VO 2 ↓ 10 %

END POINTS OF RESUS MAP > 65 mm Hg Urine output of > 0. 5 ml/kg/h SVO 2> 70% CVP = 8 -12 cm. H 2 O Transfuse to a Hct of 30 Look at improvement of the p. H, lactate

MABL = blood volume x(hct 1 – hct 2) mean haematocrit Hct 1 = initial haematocrit Hct 2 = minimally acceptable hct Bloodvolumes: Prem = 95 ml/kg Fullterm = 90 ml/kg Infant = 80 ml/kg > 1 year = 70 ml/kg

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

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

COLLOIDS 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: 1 Intravascular T 1/2 3 -6 h Bolus dose of 10 -20 ml/kg Volufen most in favor – 70 ml/kg/24 h

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

FLUID ADMINISTRATION Start with crystalloid After 2 l of crystalloid – give colloid

BLOOD PRODUCTS

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 = 7 g/dl Acute coronary syndrome Hb = 8 g/dl

BLOOD CONSERVATION Cell saver Autologous blood transfusion Haemodilution Anti-fibrinolitics Desmopressin Novoseven Hemopure(bovine Hb protein)

CELL SAVER

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

FFP

BLOOD PRODUCTS Blood component therapy PT; platelets; fibrinigen TEG After the loss of 1 bloodvolume platelets should be given

TROMBO ELASTOGRAM R = clotting factors MA = platelet function α = speed of clot formation

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

METABOLIC DEVIATIONS K↑, Mg↑, Ca ↓ p. H↓ 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

TRANSMISSION OF DISEASE Hepatitis B, C HIV 1: 800 000 Ebstein-Barr CMV Malaria, Brucella, Syphilis Bacterial contamination

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

DIVERSE REACTIONS Hypothermia Citrate toxicity with ↓Ca Fluid overload Air embolism Bacterial contamination Bleeding tendencies : dilutional thrombocytopenia

ELECTROLYTE DISTURBANCES Sodium Potassium Calcium Magnesium

HYPONATRAEMIA (< 135 MMOL/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% Na. Cl

HYPONATRAEMIA (< 135 MMOL/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 s-Na < 130 m. M – postpone elective surgery : increase risk for cerebral oedema; delayed awakening s-Na < 120 m. M – high mortality Correct slowly- can cause pontine demyelinization

HYPERNATREMIA>145 MM 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

HYPOKALAEMIA<3. 5 MM Redistribution from extra to intracellular: alkalosis; Ins; B- agonist Decreased intake Increased losses ECG changes: Large p, prolonged pr, st depression, t wave flattening, large u wave, dysrhythmias Rx: 20 mmol – 40 mmol KCl + 1 g- 2 g Mg. SO 2

HYPERKALAEMIA>5 MM Redistribution from intra to extracellular Increased intake Decreased excretion ECG changes: flattened p wave, prolonged qrs and pr, tall T waves,

HYPERKALAEMIA Treatment: § Kayexelate § Glu/Insulin § Lasix to promote excretion § Ca. Cl 2 - Na. HCO 3 - Dialysis

HYPERCALCAEMIA Ca = 2. 2 m. M- 2. 6 m. M Stones, moans, groans, bones, severe dehydration, reduces QT interval Rx. ( 3. 2 mmol) Rehydration and forced diuresis Bisphonates Glucocorticoids Intravenous phosphate

HYPOCALCAEMIA Anxiety, prolonged QT interval, convulsions, hyperreflexia, (Chvostek’s and Trousseau’s sign) Life-threating hypocalcaemia due to massive blood transfusion Can be observed after thyroidectomy Rx. Ca. Cl 2 or Ca gluconate

MAGNESIUM Hypomagnesaemia Torsades de pointes