fluids and blood transfusion

8/8/2019 Fluids and Blood Transfusion

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Fluidsy Crystalloids

y RLy NSy Glucose solutionsy DNSy Hypertonic saline

y Colloidsy Dextransy Albuminy Gelatiny HESy blood



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



N ormal saline :y Isotonicy Contains Na+,K+y Indications

y Hypochloremic metabolic alkalosisy Brain injury y hyponatremia



G lucose solutions :y Isotonic hypotonicy Blood cannot be given through the same drip



D extrose normal saline:y Isotonicy Best used as maintainence fluids intraopH ypertonic saline:y Used for

y Hyponatremiay Cerebral and pulmonary oedema



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



A lbumins:y 5% and 25%y Expensivey t ½ 10-15 daysy Used in

y Cirrhosisy

Protein losing enteropathiesy burns



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



H etastarchy 4 hoursy Improve microcirculationy Improves oxygen delivery to the tissues



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



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



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.



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



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



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



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



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



Eme r ge n cy t r an sfusio n y No time to determine ABO groupy Transfuse O-ve red cells



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



45 daysy A DSOL

y Adenine glucose mannitol sodium chloridey NUT RICE

y adenine glucose citrate phosphate Na Cl



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



Compli c atio n sy Transfusion reactionsy Febrile reactionsy Infectious complications



Tr a n sfusio n s r ea c tio n sy Allergicy Hemolytic

y Acutey delayed



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



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



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



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



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



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



Bacterialy Pseudomonasy Staphy Syphilisy Brucellosisy Salmonellay Yersiniay rickettsial



Fluid overloading and pulmonary oedemay Seen in cardiac compromised individuals

Metabolicy Hyperkalemiay Hypocalcemia

y Citrate chelates calciumy If rate of transfusion is high



Indications for calcium replacement duringtransfusion

y

Blood given at a very fast ratey Liver diseasesy Massive blood transfusiony Severe hypothermia



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



H ypothermiaImmunosuppression

y

Graft vs host reactionT issue hypoxia

--Decreased 2,3 DPGEndotoxemia and septicemia

y Due to pseudomonas ,staph,citrobacter,yersinia



A dult respiratory distress syndromey High mortality y Mismatched transfusiony Anaphylaxisy Pulmonary vasculature obstruction by

microaggregates



D isseminated intravascular coagulation:y Mismatched transfusiony Dilutional coagulopathiesy Rx : FFP



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



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



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



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%



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



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



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



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



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

fluids and blood transfusion

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