Transcript File
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.
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Components of fluid status Volume: lost or gained Composition: elec;glu;colloids;ph Concentration: Hyper, Iso or Hypotonic
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PATIENT EVALUATION FLUID AND ELECTROLYTE STATUS History: Intake/Output Bleeding Exposure 1.
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Examination: Blood pressure, pulse –rate, character Skin turgor; capillary refill Mucous membranes, pallor Urine excretion Level of consciousness
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PATIENT EVALUATION FLUID AND ELECTROLYTE STATUS Invasive monitoring: CVP- fluid challenge Pulmonary artery catheter Non-invasive cardiac output- arterial pulse contour analysis: SPV, PPV, SVV 1.
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Special investigations: Na Other electrolytes and pH 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 Fluid deficit NPO Maintenance Bloodloss
MAINTENANCE 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 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) = 4ml/% burns/kg/24h 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 to the intracellular space rd space – movement of fluid from the interstitial 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 ic is is iv HAGIE
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 ) 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
DO2 PAO2 O 2 Hb CO=SV*HR VO2
OXYGEN FLUX(DO 2 ) CO = SV x HR VO2 = 3.5 ml/kg/min = 250 ml/kg ERO2 = VO2/DO2 = 250/1000 = 25% ERO2>= 50% (Trigger for blood transfusion)
TRIGGERS FOR TRANSFUSION Tachycardia; hypotension in normovolemia BE; pH ; lactate SvO 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 SVO2> 70% CVP = 8-12 cmH2O Transfuse to a Hct of 30 Look at improvement of the pH, lactate
MABL MABL = blood volume x(hct1 – hct2) mean haematocrit Hct1 = initial haematocrit Hct2 = 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 T1/2 3-6 h Bolus dose of 10-20ml/kg Volufen most in favor – 70 ml/kg/24h
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 2l 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 = 7g/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 Leucocyte depleted blood Irradiated blood Platelets; stored at 22 o u/10kg C C for 5 days; give 1 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 ↓ pH↓ 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 1-6h 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 (< 135MMOL/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% 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 s-Na < 130 mM – postpone elective surgery : increase risk for cerebral oedema; delayed awakening s-Na < 120 mM – high mortality Correct slowly- can cause pontine demyelinization
HYPERNATREMIA>145MM 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<3.5MM
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: 20mmol – 40mmol KCl + 1g- 2g MgSO 2
HYPERKALAEMIA>5MM 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 CaCl2 NaHCO3 Dialysis
HYPERCALCAEMIA Ca = 2.2 mM- 2.6 mM Stones, moans, groans, bones, severe dehydration, reduces QT interval Rx.( 3.2mmol) Rehydration and forced diuresis Bisphosphonates 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.
CaCl2 or Ca gluconate
MAGNESIUM
Hypomagnesaemia