Transcript Fluid and Blood Administration

Perioperative Fluid and
Blood Administration
Jeffrey Groom, PhD, CRNA
Associate Professor, Anesthesiology Nursing
Florida International University
Fluid and Blood
Administration
Primary objective of
perioperative fluid
management is maintenance
of adequate tissue perfusion
and oxygen transport.
Clinical Indicators
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Mental status
Urine output
Capillary refill
Skin color & texture
Pulse rate
Blood pressure
Temperature
Frank Starling Curve
Acid-base status
BP, CVP, PA pressures
Oxygen consumption
Mixed Venous Oxygen Saturation
Surgical patient who exhibits signs of low perfusion, such as oliguria or hypotension,
the most common etiology is insufficient intravascular volume.
Quantitative
Assessment
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Calculate fluid deficit
Calculate fluid needs
Calculate fluid losses
“The amount of fluid to be
administered is best quantitated by
continuous evaluation of the
response to that which is infused.”
Physiologic Response to
Hemodilution & Anemia
• Increased cardiac output
• Increased heart rate, stroke volume,
contractility
• Decreased peripheral vascular
resistance
• Increased release of oxygen by
erythrocyte
• Decreased blood viscosity
• Increased O2 consumption/demand
Hemostatic
Mechanisms
• Primary Hemostasis
• Coagulation
• Fibrinolysis
Hemostatic
Mechanisms
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Primary Hemostasis
Platelet adhesion
(Factor VIII aka vWF)
Platelet activation
(Thrombin aka IIa)
Platelet aggregation
(ADP, thromboxane A2)
Fibrin production
(ex- in- trinsic & common pathways)
Hemostatic
Mechanisms
ASA & NSAIDS
Thrombin
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Phospholipid
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Arachidonic acid
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Cyclo-oxygenase
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Prostaglandins
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Thromboxane A2
(platelet aggregation)
platelet aggregation
inhibited
ASA- 8-12 days
NSAID – 24-48 hrs
Clotting Cascade
Heparin
PTT and ACT
Coumadin
PT and INR
Coagulation
Studies
• History – ask about bleeding
disorders or bleeding symptoms
• Partial Prothrombin Time (PTT)
• Prothrombin Time (PT)
• Bleeding Time
• Activated Clotting Time (ACT)
Coagulation
Studies
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• Partial Prothrombin Time (PTT)
Evaluates the INTRINSIC pathway of
the clotting cascade system
Normal range – 25 to 35 seconds
Assumes normal clotting factors,
will be elevated with heparin
Not all abnormal PTT values equal
Bleeding
Coagulation
Studies
• Prothrombin Time (PT)
• Evaluates the EXTRINSIC pathway
of the clotting cascade system
• Normal range – 12 – 14 sec
• May be normal in the presence of
certain factor deficiencies (VIII, IX,
XI, XII) and very sensitive to VII
deficiency
Coagulation
Studies
• Thrombin Time (TT)
• Evaluates the final common
pathway which is conversion of
fibrinogen to fibrin
• Normal range – 12 – 20 sec
• Patients with low/abnormal
fibrinogen may have normal or
slightly elevated PT & PTT but
prolonged TT
Coagulation
Studies
• Bleeding Time (3-10 minutes)
• Evaluates interaction of platelets with
vessel endothelium
• Prolonged BT can be caused by
dysfunctional or low platelets,
vonWillebrand’s deficiency (adhesion),
or fibrinogen (fiber) deficiency
• Normal range – results vary with many
factors (technique, tech, pathology)
Coagulation
Studies
Anticoagulant
Factors
Inhibited
PT
PTT
Heparin
II, IX, X, XI,
XII
Normal
Prolonged
Prolonged
Normal
Coumadin II, VII, IX, X
Coagulation Studies
ACTIVATED CLOTTING TIME
• Activated Clotting Time (ACT)-most commonly
used test to evaluate adequacy of anticoagulation
prior to vascular clamp or bypass.
• ACT measures the time required for thrombus
formation when blood is mixed in a tube with a
clotting accelerator such as diatomaceous earth.
• Normal ACT is 80 - 150 seconds.
BEFORE heparinization obtain a baseline ACT.
• Acceptable anticoagulation for CPB is
ACT of > 400-480 seconds.
• If ACT < 400 seconds, additional
heparin 100u/kg is given.
Coagulation
Studies
Platelets
• Normal range
150,000 to 400,000 cells/ml
• Life span 8 to 12 days
• Approximately 1/3 of platelets are
sequestered in the spleen
Indications for
Transfusion
1. ANEMIA – loss of RBCs
Xfuse at Hematocrit –
– CAD 25-30%
– Healthy 20-25%
– No choice (?) 15-20%
Indications for
Transfusion
Hemoglobin Level
Mortality
< 6 g/dL
62%
6 – 8 g/dL
33%
8 – 10 g/dL
0%
> 10 g/dL
5%
Conditions where a
higher Hb is needed
(keep Hb over 10 g/dL )
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Coronary artery disease
Congestive heart failure
Chronic obstructive pulmonary disease
Peripheral vascular disease
Stroke
Use of beta blockers
Blood loss expected
Elderly
From Carson JL Mordidity Risk Assessment in the Surgically Anemic Patient Am J Surg Dec 1995 vol 170, no 6A (Suppl) pp. 32S-36S
Indications for
Transfusion
Estimating Blood Volumes
 Estimated Blood Loss – add all sources of loss
EBL=Suction + sponges + drapes + floor + etc.
 Allowable Blood Loss – calculated estimate
ABL= [Hct(s) – Hct(a)] X [BloodVol / Hct(a)]
 Volume to Transfuse – calculated replacement
VtT=[Hct(d) – Hct(p) X [BloodVol / Hct(blood)]
*Avg adult BloodVol = 7% of lean mass or 70ml/kg
Indications for
Transfusion
2. THROMBOCYTOPENIA
• Spontaneous bleeding occurs with
< 20,000 platelets
• Surgical hemostasis may require
> 50,000 platelets
• Platelet transfusion @ < 50,000
• Causes- decreased production,
increased utilization, destruction,
drug effect, massive transfusion
Indications for
Transfusion
3. COAGULOPATHY –
bleeding associated with
Factor losses or prolonged
clotting times
(PT, PTT, BT, ACT)
Guidelines for
Transfusion
1. Transfusion need should be assessed on a
case-by-case basis.
2. Blood should be transfused one unit at a
time, followed by an assessment of
benefit and further need.
3. Exposure to allogeneic blood should be
limited to appropriate need.
• Does this pt need to be transfused?
• Appropriate transfusion trigger for this pt
• Donor-directed transfusion (?)
(H&H)
Guidelines for
Transfusion
4. Perioperative blood loss should be
prevented or controlled.
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Stop anticoagulant meds preop
Assess/manage preop coagulopathy
Restrict perioperative phlebotomy
Consider regional anesthesia
Consider hypotensive anesthesia
Surgical technique options
Antifibrinolytic drugs
Guidelines for
Transfusion
5. Autologous blood should be
considered for use as an alternative
to allogeneic transfusion.
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preoperative autologous blood
intraoperative acute normovolemic
hemodilution
intraoperative autologous blood
salvage and autotransfusion
postoperative autologous blood
salvage and autotransfusion
Guidelines for
Transfusion
6. Efforts should be made to maximize oxygen
delivery in the surgical patient.
7. RBC mass should be increased or restored by
means other than RBC transfusion.
8. The patient should be involved in the
transfusion decision.
9. The reasons for and results of the transfusion
decision should be documented
contemporaneously in the patient's record.
10.Hospital transfusion policies and procedures
should be developed as a cooperative effort
that includes input from all those involved in the
transfusion decision and reviewed annually.
11.ASA Guidelines – know professional standards
Blood Typing &
Cross-Matching
• ABO Blood Groups
1.Type A with A antigens on the red cells and
anti B antibodies in the plasma
2.Type B with B antigens on the red cells and
anti A antibodies in the plasma
3.Type AB with both A and B antigens on the
red cells and no type antibodies in the
plasma
4.Type O with no type antigens on the red
cells and both anti A and anti B antibodies
in the plasma
Blood Typing &
Cross-Matching
ABO Blood Groups in the Population
Blood Typing &
Cross-Matching
• Rh blood typing – test the presence
(+) or absence (-) of the Rh antigen.
If your red blood cells:
• Contain the Rh antigen,
your blood is Rh-positive.
• Do not contain the Rh antigen,
your blood is Rh-negative.
Blood Typing &
Cross-Matching
ABO Blood Groups & Rh Type in the Population
Blood Typing &
Cross-Matching
Screening Tests Performed on Donated Blood
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Hepatitis B surface antigen (HBsAg)
Hepatitis B core antibody (anti-HBc)
Hepatitis C virus antibody (anti-HCV)
HIV-1 and HIV-2 antibody (anti-HIV-1 & anti-HIV-2)
HIV p24 antigen
HTLV-I & HTLV-II antibody (anti-HTLV-I & antiHTLV-II)
• Serologic test for syphilis
• Nucleic Acid Amplification Testing (NAT)
Blood Typing &
Cross-Matching
• Donor & Recipient blood is typed on ABO
antigen group and Rh factor. Screening
tests for other antigen/antibodies.
• Cross-matching tests patient’s plasma
with donor’s RBCs to test for hemolysis.
• Emergency – transfuse type specific OR
O-negative and type specific ASAP
Blood Typing &
Cross-Matching
Blood Component
Therapy
Whole Blood – 500 ml
Contains:
RBCs, WBCs, Platelets, Plasma
Indications:
Replace plasma volume and RBCs
WBCs & platelets nonfunctional > 72 hr.
Deficient in Factors V, VII
Blood Component
Therapy
Packed RBC’s 250 ml
Contains:
RBCs, WBCs, platelets, minimal
plasma
Indications:
Increase RBCs & increase O2 xport
WBCs & platelets nonfunctional > 72 hr.
Deficient in Factors V, VII
Blood Component
Therapy
Packed RBC’s 250 ml
One unit of PRBCs – 70% Hct
One unit will raise patient’s Hct
approximately 3% or HgB 1 gm/dL
Volume to Transfuse –
calculated replacement
VtT=[Hct(d) – Hct(p) X [BloodVol / Hct(blood)]
Emergency
Transfusion
• If pt ABO is known, use an abbreviated
cross-match to check ABO compatibility
• If not known, give O neg packed RBCs
• O neg whole blood contains
anti-A & anti-B antibodies
– May react with patient’s A or B
antigens
– May react with subsequent A or B blood
– If O neg whole blood used, continue
until anti-A and anti-B titers are done
Massive Transfusion Risks
o Coagulopathy
o Citrate Toxicity
o Hypothermia
o Acid-Base Imbalance
o Hyperkalemia
o Increased opportunity for error
o Increased opportunity for infection
o Increased risk to providers
Blood Component
Therapy
Platelet Concentrate 50 ml
Contains:
> 5 x 1010 platelets, RBCs, WBCs,
platelets, minimal plasma
Indications:
Bleeding from thrombocytopenia or
thrombocytopathy
Blood Component
Therapy
Platelet Concentrate 50 ml
One unit of PC increases platelet
count 5000 – 10,000 cells/mm
Blood Component
Therapy
Fresh Frozen Plasma 220 ml
Contains:
Contains plasma with coagulation
factors but no platelets
Indications:
Correction of coagulopathy
Blood Component
Therapy
Fresh Frozen Plasma 220 ml
Dose of 10-15 ml/kg increases
coagulation factors by 30%
Fibrinogen increases 1mg/ml of FFP
Rapid reversal of warfarin usually
requires 5 – 10 ml/kg of FFP
Blood Component
Therapy
Cryoprecipitate 15 - 25 ml
Contains:
Fibrinogen, Factors VIII, XIII, von
Willebrand’s
Indications:
Correction of coagulopathy where
Fibrinogen, Factors VIII, XIII, or von
Willebrand’s are deficient
Blood Component
Therapy
Cryoprecipitate 15 - 25 ml
Dose of 1 unit per 10 kg raises
fibrinogen level 50 mg/dL
Blood Administration
Check and double check IDs &
Labels.
Blood should not be infused with
D5W hemolysis
Blood should not be infused with LR
Ca++ in LR may induce clot
formation
RBCs are compatible with:
Normal saline, 5% albumin, FFP
Blood
Administration
Blood Filters
 80 mcm filters should be used for all
blood components
 170 mcm filters should be used to
administer platelets
 Leukocyte filters for patients with
febrile rxn history, maybe for all to
prevent alloimmunization to foreign
leukocyte antigens
Blood
Administration
Future Blood Substitutes
• Fluosol-DA 20%
• Free hemoglobin solutions
Plasma Substitutes
Albumin
• Isotonic Albumin 5%
• Hypertonic Albumin 20 & 25%
• Intravascular half-life = 10 to 15 days
Plasma Substitutes
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Dextran
Dextran 70 – Macrodex and
Dextran 40 – Rheomacrodex
Intravascular half life = 2 to 8 hours
Decreases platelet adhesion and VIII
Coag changes > 1.5g/kg
1% incidence of anaphylactoid reactions
Give 20 ml Promit to inhibit dextran
binding antibodies
Plasma Substitutes
Hespan ( Hydroxyethyl starch )
- small molecules broken down
by kidneys, large molecules by
amylase
- Nonantigenic, anaphylactoid
reactions are rare
- Coag studies not impaired
- Half-life – 24-36 hours
Blood Conservation
Techniques
Autologous Donation
• Donation 5 weeks pre-op, must have
HgB > 11 g/dL, can donate Q 3 days,
last donation > 72 hr pre-op
• Not all patients tolerate donation
• Transfusion reaction risk is reduced
but human error component is still
present – transfuse with same
criteria & precautions
Blood Conservation
Techniques
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Hemodilution Techniques (?)
Remove 1 to 2 units of whole blood
(Hct 25-30%)
Replace volume with LR or colloids
Intraop loss then is greater plasma
loss and less RBC loss
Reinfuse fresh autologous blood (Hct
will be the same as pre-op, not PRBC)
Blood Conservation
Techniques
Cell Saver
• Intraop autotransfusion
• Double lumen suction aspirates
blood from clean field
(heparin + saline + blood)
• Collected blood is filtered and
washed prior to reinfusion
• RBC’s in saline
Hct ~ 50%
• No plasma, clotting factors or
platelets
Complications of
Transfusion
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Acute Hemolytic Reactions
ABO-incompatiability
Occur ~ 1 in 33,000 most due to
human error, fatal in 1:300k to 700k
Symptoms may be masked by
anesthesia (agitation, chest or flank
pain, headache, dyspnea, chills)
Signs include: fever, tachycardia,
hypotension, DIC, hemoglobinuria
Complications of
Transfusion
Acute Hemolytic Reactions
• STOP the infusion
• Establish a noncontaminated IV
• Send unused donor blood to lab with blood
sample from patient for rematch
• Send blood for: Hgb, haptoglobin, Coomb’s
and DIC screening
• Rx hypotension – fluids & vasopressors prn
• May give corticosteroids
• Preserve renal function – fluids, dopamine,
diuertic – maintain UO 1-2ml/kg/hr
• R/O DIC
Complications of
Transfusion
Non-Hemolytic Reactions
• Allergic or febrile rxn to antibodies
to donor WBCs or platelets
• Transfused allergens in plasma
interact with the patient's tissue
mast cells, causing them to
degranulate and release
inflammatory mediators (histamine,
tryines, etc.)
Complications of
Transfusion
Non-Hemolytic Reactions
• STOP the transfusion, establish
clean IV and send labs
• Mild rxn – diphenhydramine 25-50
mg IV & hydrocortisone 50-100 mg
IV, acetaminophen 650 mg
• May resume transfusion slowly (?)
• Rx other symptoms prn
Complications of
Transfusion
Infection Risk
Complications of
Transfusion
Population Donor Screen Blood Units
Hepatitis
B
1 : 200
Hepatitis
C
1 : 2,000
1 : 200,000
1 : 70 to
1 : 500
1 : 400
1 : 4,000 to
1 : 100,000
HIV
1 : 125 to
1 : 250
1 : 12,500
1 : 550,000
HTLV
?
1 : 10,000
1 : 100,000
SUMMARY
• Blood components
• Coagulation system and tests
• Blood and fluid administration