Fluid Management and Transfusion

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Fluid Management and Transfusion

• Franklin L. Scamman, MD

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Evaluation of Intravascular Volume

• Clinical signs
• Laboratory values
• Cardiovascular parameters
• Shock intravascular volume is less than
  intravascular space.

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Signs of Fluid Loss as of Total Body Water
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Laboratory Evaluation

• Rising HCT
• Urinary SPG gt 1.010
• Urinary Sodium lt 20 meq/l
• Urinary Osmolality gt 450 mosm/l
• BUN to Creatinine ratio gt 101

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Hemodynamic Evaluation

• CVP
• PCWP
• Delta Down gt 15 mmHg
• From an arterial line, measure the depression in
  systolic pressure with each ventilator cycle.

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IV Fluids-Crystalloids

• Lactated Ringers (LR)
• Balanced salt solution that maintains bicarb
• Normal Saline (NS)
• Hypertonic and dilutes plasma bicarb, causes a
  metabolic acidosis
• Plasmalite
• Balanced salt solution that lacks calcium so can
  be used to dilute packed cells

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IV Fluids-Colloids

• Dextran 40 and 70
• Tend to coat red cells and platelets helps out
  with blood flow but may cause poor clotting
• Starches-Hespan
• 6 in NS, dilutes bicarb
• Albumin 5 and 25
• Infection free but cannot use in JW patients
• FFP
• To replace clotting factors

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Maintenance Fluids

• 4 ml/kg/hr for the first 10 kg
• 2 ml/kg/hr for the next 10 kg
• 1 ml/kg/hr for the next 10 kg
• ½ ml/kg/hr thereafter

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Replacing Deficit

• ½ the deficit during the 1st hour
• ¼ of the deficit during the 2nd hour
• Clinical evaluation from thereon

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Surgical Fluid Losses

• Blood Loss Replacement
• With crystalloid - 3-4 X the EBL
• With colloid - 1 X the EBL
• Can let the HCT drift down towards high 20s
• Replace RBC for RBC thereafter
• Watch coags after 50 EBV replacement for FFP and
  platelets (keep above 50K)
• Watch calcium levels with massive transfusion

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Surgical Fluid Losses

• Third Space
• Evaporation
• Weeping surfaces
• Edema
• Abdominal - 10ml/kg/hr for 1st 3 hours
• ENT - almost none

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Fluid Replacement for Head and Neck Cancer Surgery

• We suspect that ADH levels are very high during
  the dissection portion that usually finishes by 2
  p.m.
• We should not force urine output until then but
  replace deficit and continue maintenance.
• After 2 p.m., would like to see UO be ½ to 1
  ml/kg/hr.

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Massive Transfusion Protocol

• Number of Red Blood Cell units (full units, not
  pediatric or partial units) within 24 hours
•  Adult gt 10 units
• 6-12 year old child gt 5 units
• 4-5 year old child gt 3 units
• 2-3 year old child gt 2 units
• 0-1 year old child gt 1 unit

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Massive Transfusion Protocol

• Call for help Pathology resident will monitor
  coags and authorize dispensing of FFP and
  platelets and other clotting factors.
• Watch potassium, calcium and base excess
• Watch patient temperature
• Talk with surgeon to see if patient is clotting