anaesthesia blood

8/12/2019 Anaesthesia Blood

1/56

Fluids and Transfusion

SpR in Anaesthesia, RNOH

the centre for

Anaesthesia

L


2/56

L


3/56

TopicsWhy?

When?

Who? Risks

Massive Haemmorrhage


4/56

Example 1A fit patient with a compound fracture of the tibia and

a post operative Hb of 7.5 g/dl should be transfused?


5/56

Example 2A 70yr old woman with a history of angina and a pre-

op Hb of 7.5 g/dl should be transfused?


6/56

Why? The body at rest uses

approx 250ml O2/L blood

O2 delivery can fall with areduction in any of:

Cardiac Output

Hb concentration

O2 saturation Organs most sensitive to

hypoxia are Heart and Brain


7/56

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 ofblood

Hbx Sa02


8/56

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


9/56


10/56

Transfusion Triggers RBC transfusion not indicated when Hb>10g/dl

Hb < 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)


11/56

Risks


12/56



T F


13/56



T F


14/56



T F


15/56



T

F


16/56

Summary Think before you transfuse!

Does your patient really need blood?

Weigh up the benefits vs risks of transfusion.


17/56

Massive Transfusion


18/56

Massive TransfusionDefinitions Replacement of one blood volume in a 24 hour period

Transfusion of >10 units RCC in 24 hours

Transfusion of 4 or more RCC within 1 hour whenongoing need is foreseeable

Replacement of >50% of the total blood volume within3 hours


19/56

Massive Transfusion Settings

TraumaObstetric

Surgical

Medical


20/56

The Perfect Clot! Red blood Cells

Platelets Clotting factors

Fibrinogen


21/56

Bloody Vicious Cycle


22/56

The Massively Bleeding Patient Restore Circulating

Volume:

X 2 14G IV cannulae

Resuscitate with warmedcrystalloid/colloid

Warm patient

Consider invasivemonitoring: arterial line+ central venous access


23/56

Effect of Hypothermia on

coagulation factor activity


24/56

Get some Help. Contact Key Personnel

Senior anaesthetist/ surgeon/

obstetrician Blood Bank

Haematologist

Get someone to coordinate to communicate anddocument


25/56

Arrest the Bleeding.


26/56

Request Lab investigations Ensure correct sample identity

FBC, ABG

Full coagulation screenX- match

Repeat after products/4hourly

May need to give blood products before resultsare available


27/56

Request PRC Uncrossmatched Group

O Rh neg

Uncrossmatched ABOgroup specific

Fully X match

Use a blood warmer/

rapid infusion device Consider cell salvage


28/56

Request PlateletsAllow for delivery time.

Anticipate plt count100x109/l for multiple/CNStrauma, > 50 in othersituations


29/56


30/56

Request Cryopreciptate Contains fibrinogen and factor VIII

Aim for fibrinogen >1g/L


31/56

Summary Recognise the situation early!

Get some help.

Aggressive management of hypothermia/acidosisAvoid haemodilution and use appropriate volumes of

blood components

Inadequately treated coagulopathy is associated with

worse outcome


32/56

Other IV FluidsIV Fluids


33/56

Normal Adult Fluid Composition

60% composed of water

70 kg person= 42 L

2/3 ICF = 28L

1/3 ECF = 14L

TBW= ECF + ICF


34/56

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: 40+20+50=110

will require 110 ml/h


35/56

Daily Requirements The normal electrolyte requirements are:

Na+

1-2 mmol/kg/24 h K+0.5-1 mmol/kg/24 h.


36/56

Fluid therapyMaintenance

Resuscitation


37/56


38/56

History

Vomiting/ diarrhoea

Intestinal obstruction

Fluid intakeThirst


39/56

Signs/ Symptoms

Dry mucous membranes

Low urine output

TachycardiaIncreased capillary refill time

Postural hypotension (late sign)

Low CVP

Decreased concious level

Signs and symptoms of dehydration


40/56

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


41/56

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 dailyvolume.


42/56

Elective, well patient Q: Fit , young pt having elective surgery not involving

the abdomen what fluid losses do you expect beforeand during surgery of less than an hour?


43/56

Starved 6 hrs

220ml- 660ml

Intra op losses (minimal blood loss, loss dependent on duration)

Surgery< 1hr, loss< 150ml


44/56

Does this patient need intra op

Fluid?

Not necessarily

But if hot weather, insensible losses may increase, ptmay feel better post op if 500ml given


45/56

Emergency Laparotomy Pt Q: Patient needing urgent laparotomy, history of

vomiting for several days.

What fluid loss do you expect this patient to have hadbefore surgery?


46/56

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 fluidresuscitation


47/56

What? Crystalloids

Colloids


48/56

Colloids Contain Proteins/large molecules

suspended in a carrier solution

Large molecules stay in the plasma,keeping infused f luid in largely incirculation.

Smaller volumes needed

Small risk of anaphylaxis


49/56

ColloidsNa Cl K Lactate Ca Mg Other

GelofusinElohaes,

VoluvenVolplexHaesterilAlbumin

150 120-150

Haemacell 145 145 5 6

Geloplasma 150 100 5 30 1-1.5Volulyte 137 4 110 1.5 Acetate

34


50/56

Crystalloids Contain water and dissolved

electrolytes

Pass freely through asemipermeable membrane

Many are isotonic withextracellular fluid

Need larger volumes Cheap


51/56

CrystalloidsNa+ Cl- K+ Lactate Ca Mg OtherHartmannsSolution (CSL)

131 111 5 29 2

0.9% Saline 154 154

5% glucose Glucose 50g/l

4% glucose saline 30 30 Glucose 40g/l


52/56

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


53/56

Questions What are the H2O and Na+ ions for a 65 Kg patient to replace normaldaily losses?


54/56

Questions Requirements: H2O 105 ml/hr = 2520 ml/dayNa = 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


55/56

Summary Think about why you are giving f luids

Work out how much fluid to give

Select which type of fluid to give Correct fluid management is essential to every

patients care


56/56

Questions?

anaesthesia blood

Documents