Jasmeet Kaur

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Jasmeet Kaur

• Fluids and Transfusion
• SpR in Anaesthesia, RNOH

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Blood Transfusion

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Topics

• Why?
• When?
• Who?
• Risks
• Massive Haemmorrhage

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Example 1

• A fit patient with a compound fracture of the
  tibia and a post operative Hb of 7.5 g/dl should
  be transfused?

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Example 2

• A 70yr old woman with a history of angina and a
  pre-op Hb of 7.5 g/dl should be transfused?

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Why?

• The body at rest uses approx 250ml O2/L blood
• O2 delivery can fall with a reduction in any of
• Cardiac Output
• Hb concentration
• O2 saturation
• Organs most sensitive to hypoxia are Heart and
  Brain

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Why?

• The purpose of a red cell transfusion is to
  improve the oxygen carrying capacity of the
  blood.
• Oxygen delivery to tissues (O2 Flux)
• Cardiac Output x Oxygen content of
  blood
  
• Hb x
  Sa02

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When?

• Consider the context
• Cause and severity of anaemia
• Patients ability to compensate for anaemia (
  cardiorespiratory disease)
• Rate of ongoing blood loss
• Likliehood of further blood loss
• Balance of risks vs benefits of transfusion

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Transfusion Triggers

• RBC transfusion not indicated when Hbgt10g/dl
• Hb lt 7g/dl- strong indication for transfusion
• RBC Transfusion less clear when Hb between 7-10
  g/dl
• Cardiopulmonary reserve needs to be assessed.
• Symptomatic patients should be transfused.
  (fatigue, dizziness, shortness of breath, new or
  worsening angina)

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Risks
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Example 1

• A fit patient with a compound fracture of the
  tibia and a post operative Hb of 7.5 g/dl should
  be transfused?
• T
• F

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Example 1

• A fit patient with a compound fracture of the
  tibia and a post operative Hb of 7.5 g/dl should
  be transfused?
• T
• F ?

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Example 2

• A 70yr old woman with a history of angina and a
  pre-op Hb of 7.5 g/dl should be transfused?
• T
• F

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Example 2

• A 70yr old woman with a history of angina and a
  pre-op Hb of 7.5 g/dl should be transfused?
• T ?
• F

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Summary

• Think before you transfuse!
• Does your patient really need blood?
• Weigh up the benefits vs risks of transfusion.

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Massive Transfusion
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Massive Transfusion

• Definitions
• Replacement of one blood volume in a 24 hour
  period
• Transfusion of gt10 units RCC in 24 hours
• Transfusion of 4 or more RCC within 1 hour when
  ongoing need is foreseeable
• Replacement of gt50 of the total blood volume
  within 3 hours

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Massive Transfusion

• Settings
• Trauma
• Obstetric
• Surgical
• Medical

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The Perfect Clot!

• Red blood Cells
• Platelets
• Clotting factors
• Fibrinogen

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Bloody Vicious Cycle
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The Massively Bleeding Patient

• Restore Circulating Volume
• X 2 14G IV cannulae
• Resuscitate with warmed crystalloid/colloid
• Warm patient
• Consider invasive monitoring arterial line
  central venous access

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Effect of Hypothermia on coagulation factor
activity
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Get some Help.

• Contact Key Personnel
• Senior anaesthetist/ surgeon/
• obstetrician
• Blood Bank
• Haematologist
• Get someone to coordinate to communicate and
  document

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Arrest the Bleeding.
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Request Lab investigations

• Ensure correct sample identity
• FBC, ABG
• Full coagulation screen
• X- match
• Repeat after products/4hourly
• May need to give blood products before results
  are available

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Request PRC

• Uncrossmatched Group O Rh neg
• Uncrossmatched ABO group specific
• Fully X match
• Use a blood warmer/ rapid infusion device
• Consider cell salvage

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Request Platelets

• Allow for delivery time.
• Anticipate plt countlt50 x109/l after x2 blood vol
  replacement
• Target plt countgt100 x109/l for multiple/CNS
  trauma, gt 50 in other situations

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Request FFP

• Aim for PT/ APTT lt 1.5 x control
• Allow for thawing time

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Request Cryopreciptate

• Contains fibrinogen and factor VIII
• Aim for fibrinogen gt1g/L

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Summary

• Recognise the situation early!
• Get some help.
• Aggressive management of hypothermia/acidosis
• Avoid haemodilution and use appropriate volumes
  of blood components
• Inadequately treated coagulopathy is associated
  with worse outcome

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IV Fluids
Other IV Fluids
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Normal Adult Fluid Composition

• 60 composed of water
• 70 kg person 42 L
• 2/3 ICF 28L
• 1/3 ECF 14L
• TBW ECF ICF

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Daily Requirements

• Maintenance Fluid formula
• 4 ml/kg/h for the first 10 kg
• 2 ml/kg/h for the next 10 kg
• 1 ml/kg/h for every kg over 20 kg
• Therefore a 70 kg patient using the calculation
• 402050110
• will require 110 ml/h

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Daily Requirements

• The normal electrolyte requirements are
• Na 1-2 mmol/kg/24 h
• K 0.5-1 mmol/kg/24 h.

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Fluid therapy

• Maintenance
• Resuscitation

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Pre-operatively

• Should consider
• History, examination
• Deficit (measured insensible)
• Intravascular vs cellular dehydration
• Electrolyte levels
• Speed of fluid loss (days/hours/minutes)
• Vasodilated / ill patients may need several
  litres of fluid before surgery

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Signs and symptoms of dehydration
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Intra-operatively

• Should use CO monitor for emergency or major
  surgery
• Serial 200ml colloid boluses
• Ongoing Hartmanns soln with colloid
• Warm fluid to reduce hypothermia

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Post- operatively

• Fluids are used to continue fluid replacement
• To provide daily water and electrolyte
  requirements, until the patient is able to drink
  an adequate daily volume.

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Elective, well patient

• Q Fit , young pt having elective surgery not
  involving the abdomen what fluid losses do you
  expect before and during surgery of less than an
  hour?

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• Starved 6 hrs
• 220ml- 660ml
• Intra op losses
• (minimal blood loss, loss dependent on duration)
• Surgerylt 1hr, losslt 150ml

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Does this patient need intra op Fluid?

• Not necessarily
• But if hot weather, insensible losses may
  increase, pt may feel better post op if 500ml
  given

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Emergency Laparotomy Pt

• Q Patient needing urgent laparotomy, history of
  vomiting for several days.
• What fluid loss do you expect this patient to
  have had before surgery?

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• Pt may be severely water and electrolyte depleted
• Large volumes fluid may be needed to resuscitate
  this patient
• Vomiting leads to loss of hydrogen and chloride
  ions, NaCl solution will help to replace these
• K ions may be lost in bowel, so may need
  replacing
• Check serum electrolytes before and after fluid
  resuscitation

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What?

• Crystalloids
• Colloids

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Colloids

• Contain Proteins/large molecules suspended in a
  carrier solution
• Large molecules stay in the plasma, keeping
  infused fluid in largely in circulation.
• Smaller volumes needed
• Small risk of anaphylaxis

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Colloids
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Crystalloids

• Contain water and dissolved electrolytes
• Pass freely through a semipermeable membrane
• Many are isotonic with extracellular fluid
• Need larger volumes
• Cheap

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Crystalloids
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Questions

• Acute haemorrhage of 15 blood volume should be
  treated with 5 glucose.
• F
• Major sepsis should be treated with 5 glucose.
• F
• Acute haemorrhage of 40 blood volume should be
  treated with blood.
• T

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Questions

• What are the H2O and Na ions for a 65 Kg patient
  to replace normal daily losses?

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Questions

• Requirements H2O 105 ml/hr 2520 ml/day
• 
  Na 65-130mmol/day
• A. 2.5L 0.18 NaCl 4 dextrose?
• F
• B. 1L Hartmanns soln 1.5L 5 dextrose?
• T
• C. 2.5L Hartmanns soln?
• T
• D. 2.5L of 5 dextrose?
• F

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Summary

• Think about why you are giving fluids
• Work out how much fluid to give
• Select which type of fluid to give
• Correct fluid management is essential to every
  patients care

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Questions?