fluids and blood transfusion
TRANSCRIPT
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Fluidsy Crystalloids
y RLy NSy Glucose solutionsy DNSy Hypertonic saline
y Colloidsy Dextransy Albuminy Gelatiny HESy blood
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cry stalloidsR inger lactate {Hartmann s solution}y Lactate bicarbonate in livery Slightly hypotonicy Blood should not be given through the same drip sety Fluid of choice for blood lossy Contains Na+,k+, Cl-,ca2+,lactate
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N ormal saline :y Isotonicy Contains Na+,K+y Indications
y Hypochloremic metabolic alkalosisy Brain injury y hyponatremia
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G lucose solutions :y Isotonic hypotonicy Blood cannot be given through the same drip
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D extrose normal saline:y Isotonicy Best used as maintainence fluids intraopH ypertonic saline:y Used for
y Hyponatremiay Cerebral and pulmonary oedema
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c olloidsD extrans:y Dextran 70,40,150y Polysaccharidesy T ½ is 2 to 8 hoursy Low M.Wt improves circulationy Interferes with blood grouping and cross
matchingy Interferes with platelet aggregationy Severe anaphylaxis
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A lbumins:y 5% and 25%y Expensivey t ½ 10-15 daysy Used in
y Cirrhosisy
Protein losing enteropathiesy burns
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H emaccel(gelatin):y Contains gelatin,sodium,potassium,chloride and
calciumy Expand plasma effectively for 2 hoursy D o not interfere with blood grouping and cross
matching,platelet function and anaphylaxis
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H etastarchy 4 hoursy Improve microcirculationy Improves oxygen delivery to the tissues
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C rystalloids colloids
Isotonic or hypertonic hypertonic
T ½ 30 min 2-4 hours
Cheap Expensive
3 times of lost fluid is to be given Replaced in 1 :1 ratio
Can precipitate oedema Decreases cerebral oedema andpulmonary oedema
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In t r a Ope r ative Fluid
Ma n ageme n tHourly requirement formula 4-2-1
y Upto 10 kg-4 ml/kg/hry 10-20 kg-2 ml/kg/hry >20 kg-1 ml/kg/hr
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Routes of admi n ist r atio ny Intra venous :y subcutaneous :outer side of the thighy Intraosseous :
y children < 6 yrs of agey Medullary cavity of upper tibia.
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B lood t r a n sfusio nIndications
y Blood loss more than 20 %y In children > 10 %
y minimal acceptable Hb for elective surgery is 10 g%y O ne unit of blood -0.8 g% will increasey Should not be infused with dextrose solutions and RL ,
hemaccel
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B lood g r oupi n g a n d c ompatibilit yy RBC membrane antigen >20 blood group antigens
y ABO grouping
y Individual who lacks particular antigen will haveantibodies against that antigen
y eg
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Compatibilit y tests ABO-Rh typing :
y Patients red cells are tested with serum known to
contain antibodies against A or By red cells are also tested with anti D antibodies to
determine Rh +ve or -ve
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C ross matching :y Patients (recipient) serum is mixed with donor cells
Three phases1.ABO incompatibility 2.Rh typing3.indirect antiglobulin test determines incomplete
antibodies of other system like Kell,Duffy etc
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B lood group Red cells Plasma C an donateblood to
C an receiveblood from
A Antigen A Anti B A,AB A,O
B Antigen B Anti A B,AB B,O
AB Both Nil AB A,B,O,AB
O nil Bothantibodies
A,B,AB,O O
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Eme r ge n cy t r an sfusio n y No time to determine ABO groupy Transfuse O-ve red cells
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S to r age of bloody Blood is stored at 4 deg Cy Stored for 21 days ( acid citrate dextrose)y 35 days (CD PA )
y Citrate-anticoagulanty Dextrose-energy y Phosphate-buffery Adenine-increase the red cell survival
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45 daysy A DSOL
y Adenine glucose mannitol sodium chloridey NUT RICE
y adenine glucose citrate phosphate Na Cl
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Ch a n ges i n sto r ed bloody pH - decreasesy Hb - decreases(70%)y
K+ - increasesy 2,3 DPGlevel - decreases
y Platelets - decreasesy
Clotting factorsy Factor V only 15% at 21 daysy Factor V III only 50% at 21 daysy Rest stable in stored blood
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Compli c atio n sy Transfusion reactionsy Febrile reactionsy Infectious complications
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Tr a n sfusio n s r ea c tio n sy Allergicy Hemolytic
y Acutey delayed
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A c ute Hemol y tic r ea c tio n sy Due to ABO incompatibility (mismatch rxn)y Clerical errory Intravascular hemolysisy As low as 10 ml of blood can produce rxn
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Awake-y fever with chills and rigors,y nausea and vomiting,y flushing ,y Chest pain, flank painy dyspnoea
Anesthetized-y tachycardiay hypotensiony oozing from surgical site
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y Confirmed by hemoglobinuriay Hb cystals block the renal tubules leading to ARF
M anagement:y Stop infusiony Recheck details of blood slipy Send the remaining blood back to blood banky Maintain urine output 1-2 ml/kg/hr by mannitol and
fluid administration
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A lle r gic r ea c tio n sMildy Urticaria due to plasma proteinsy Rx is antihistamines
Anaphylaxis (1 in 1.5 lakhs)y Immediately stop the transfusiony Adrenaline and steroids
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Feb r ile r ea c tio n sy Due to infusion of white cell microaggregatesy Minimised by the use of microdrip set with pore size of
20- 40 micro m instead of conventional drip set of 170micro my Mildy Require no treatment
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In fe c tious c ompli c atio n s Viral
y Hepatitisy 90% are non A non B virus
y A IDSy HI V -1
y CMV y EBV y HTLV-1y Parvovirus
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Bacterialy Pseudomonasy Staphy Syphilisy Brucellosisy Salmonellay Yersiniay rickettsial
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Fluid overloading and pulmonary oedemay Seen in cardiac compromised individuals
Metabolicy Hyperkalemiay Hypocalcemia
y Citrate chelates calciumy If rate of transfusion is high
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Indications for calcium replacement duringtransfusion
y
Blood given at a very fast ratey Liver diseasesy Massive blood transfusiony Severe hypothermia
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Acid base abnormalitiesy Massive transfusion alkalosis because of citrate
metabolismCoagulation abnormalities :y Dilutional coagulopathy y Dilutional thrombocytopeniay Rx: fresh blood , FFP, platelets, specific blood
component therapy
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H ypothermiaImmunosuppression
y
Graft vs host reactionT issue hypoxia
--Decreased 2,3 DPGEndotoxemia and septicemia
y Due to pseudomonas ,staph,citrobacter,yersinia
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A dult respiratory distress syndromey High mortality y Mismatched transfusiony Anaphylaxisy Pulmonary vasculature obstruction by
microaggregates
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D isseminated intravascular coagulation:y Mismatched transfusiony Dilutional coagulopathiesy Rx : FFP
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Massive blood t r a n sfusio ny Defined as transfusion of blood more than patients blood
volume (5 litres) in less than 24 hrsy Transfusion of >10% of the blood volume in less in 10 miny
Complicationsy Hyperkalemiay Hypocalcemiay Hyperammonemiay Hypothermiay Metabolic alkalosisy Dilutional coagulopathiesy DICy ARDS
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B lood c ompo n e n t t h e r ap yP acked cell :y Anemic patientsy Volume is 250 mly One unit raises Hb by 1.5 to 2 g%y T ½ 60 daysy Infectious and allergic prob related to plasma avoidedy Cardiac overload can be avoided
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F rozen RB C y Can be stored for yearsy Intra cellular 2,3 DPG can be retained for yearsy Fresh frozen plasma :y Plasma is frozen within 6 hrs of collectiony Vol 225mly Contains all coagulation factors and proteins
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Indications :y Coagulopathies asso with liver diseases,blood
transfusiony Reversal of warfarin therapy y Antithrombin III deficiency y Plasma protein deficiency (poor man s albumin)
y
ABO compatibility with FFP may not be necessary y Each unit increases clotting factor by 2 to 3%
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P latelet concentratey Vol 50 mly Stored at room temperature 4-5 daysy 1 unit increases the count by 5000 -10000y Count <50000 increased blood loss during surgery y Preop increase the platelet count to 1 lakhy ABO compatibility is desirable but not necessary
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Cryoprecipitatey Vol 10 mly Factor V III and fibrinogeny Factor X III and von willebrand s factory Pooled from many donorsy Max chances of disease transmission
G ranulocyte precipitate :y neutropenic pts
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A utologous blood t r a n sfusio n y 3-4 units of pts own blood are taken 4-6 weeks before
surgery y
Patients blood is transfused back intraoperatively y Risk of infections and hemolytic reactions can be
avoided
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B lood salvage a n d r ei n fusio ny Patients lost blood is saved in container ,processed
and transfused backy
Should not be done if blood is infected or containsmalignant cells
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Sy n th eti c ox y ge n c a rr ie r sy Perflurocarbon emulsion called as flusol-DA y Recombinant Hby
Recombinant erythropoietin