perioperative fluid and blood administration jeffrey groom, phd, crna associate professor,...
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Perioperative Fluid and Blood Administration
Perioperative Fluid and Blood Administration
Jeffrey Groom, PhD, CRNAAssociate Professor, Anesthesiology Nursing
Florida International University
Primary objective of perioperative fluid
management is maintenance of adequate tissue perfusion and
oxygen transport.
Fluid and Blood Administration
• Mental status • Urine output • Capillary refill • Skin color & texture• Pulse rate • Blood pressure• Temperature • Frank Starling Curve • Acid-base status • BP, CVP, PA pressures • Oxygen consumption • Mixed Venous Oxygen Saturation
Clinical Indicators
Surgical patient who exhibits signs of low perfusion, such as oliguria or hypotension, the most common etiology is insufficient intravascular volume.
Quantitative Assessment
• Calculate fluid deficit• Calculate fluid needs• Calculate fluid losses• “The amount of fluid to be
administered is best quantitated by continuous evaluation of the response to that which is infused.”
• Increased cardiac output • Increased heart rate, stroke volume,
contractility • Decreased peripheral vascular
resistance • Increased release of oxygen by
erythrocyte • Decreased blood viscosity• Increased O2 consumption/demand
Physiologic Response to Hemodilution & Anemia
Primary Hemostasis• Platelet adhesion
(Factor VIII aka vWF)• Platelet activation
(Thrombin aka IIa)• Platelet aggregation
(ADP, thromboxane A2)• Fibrin production
(ex- in- trinsic & common pathways)
Hemostatic Mechanisms
ASA & NSAIDSThrombin
Phospholipid
Arachidonic acid
Cyclo-oxygenase
Prostaglandins
Thromboxane A2
(platelet aggregation)
platelet aggregation inhibited
ASA- 8-12 days
NSAID – 24-48 hrs
• History – ask about bleeding disorders or bleeding symptoms
• Partial Prothrombin Time (PTT)• Prothrombin Time (PT)• Bleeding Time• Activated Clotting Time (ACT)
Coagulation Studies
• Partial Prothrombin Time (PTT)• Evaluates the INTRINSIC pathway of the
clotting cascade system• Normal range – 25 to 35 seconds• Assumes normal clotting factors, will be
elevated with heparin• Not all abnormal PTT values equal
Bleeding
Coagulation Studies
• Prothrombin Time (PT)• Evaluates the EXTRINSIC pathway of
the clotting cascade system• Normal range – 12 – 14 sec• May be normal in the presence of
certain factor deficiencies (VIII, IX, XI, XII) and very sensitive to VII deficiency
Coagulation Studies
• Thrombin Time (TT)• Evaluates the final common pathway
which is conversion of fibrinogen to fibrin
• Normal range – 12 – 20 sec• Patients with low/abnormal fibrinogen
may have normal or slightly elevated PT & PTT but prolonged TT
Coagulation Studies
• Bleeding Time (3-10 minutes)• Evaluates interaction of platelets with
vessel endothelium• Prolonged BT can be caused by
dysfunctional or low platelets, vonWillebrand’s deficiency (adhesion),or fibrinogen (fiber) deficiency
• Normal range – results vary with many factors (technique, tech, pathology)
Coagulation Studies
Coagulation Studies
AnticoagulantFactors
Inhibited PT PTT
HeparinII, IX, X, XI,
XIINormal Prolonged
Coumadin II, VII, IX, X Prolonged Normal
ACTIVATED CLOTTING TIME
• Activated Clotting Time (ACT)-most commonly used test to evaluate adequacy of anticoagulation prior to vascular clamp or bypass.
• ACT measures the time required for thrombus formation when blood is mixed in a tube with a clotting accelerator such as diatomaceous earth.
• Normal ACT is 80 - 150 seconds. BEFORE heparinization obtain a baseline ACT.
• Acceptable anticoagulation for CPB is ACT of > 400-480 seconds.
• If ACT < 400 seconds, additional heparin 100u/kg is given.
Coagulation Studies
Platelets• Normal range
150,000 to 400,000 cells/ml• Life span 8 to 12 days• Approximately 1/3 of platelets are
sequestered in the spleen
Coagulation Studies
1. ANEMIA – loss of RBCsXfuse at Hematocrit –
–CAD 25-30%–Healthy 20-25%–No choice (?) 15-20%
Indications for Transfusion
Hemoglobin Level Mortality
< 6 g/dL 62%
6 – 8 g/dL 33%
8 – 10 g/dL 0%
> 10 g/dL 5%
Indications for Transfusion
Conditions where a higher Hb is needed (keep Hb
over 10 g/dL )• Coronary artery disease • Congestive heart failure • Chronic obstructive pulmonary disease • Peripheral vascular disease • Stroke • Use of beta blockers • Blood loss expected • Elderly
From Carson JL Mordidity Risk Assessment in the Surgically Anemic Patient Am J Surg Dec 1995 vol 170, no 6A (Suppl) pp. 32S-36S
Indications for TransfusionEstimating Blood Volumes
Estimated Blood Loss – add all sources of lossEBL=Suction + sponges + drapes + floor + etc.
Allowable Blood Loss – calculated estimateABL= [Hct(s) – Hct(a)] X [BloodVol / Hct(a)]
Volume to Transfuse – calculated replacementVtT=[Hct(d) – Hct(p) X [BloodVol / Hct(blood)]
*Avg adult BloodVol = 7% of lean mass or 70ml/kg
2. THROMBOCYTOPENIA• Spontaneous bleeding occurs with
< 20,000 platelets• Surgical hemostasis may require
> 50,000 platelets• Platelet transfusion @ < 50,000• Causes- decreased production,
increased utilization, destruction, drug effect, massive transfusion
Indications for Transfusion
3. COAGULOPATHY – bleeding associated with Factor losses or prolonged clotting times (PT, PTT, BT, ACT)
Indications for Transfusion
1. Transfusion need should be assessed on a case-by-case basis.
2. Blood should be transfused one unit at a time, followed by an assessment of benefit and further need.
3. Exposure to allogeneic blood should be limited to appropriate need. • Does this pt need to be transfused?• Appropriate transfusion trigger for this pt (H&H)
• Donor-directed transfusion (?)
Guidelines for Transfusion
4. Perioperative blood loss should be prevented or controlled.
• Stop anticoagulant meds preop• Assess/manage preop coagulopathy• Restrict perioperative phlebotomy• Consider regional anesthesia• Consider hypotensive anesthesia• Surgical technique options• Antifibrinolytic drugs
Guidelines for Transfusion
5. Autologous blood should be considered for use as an alternative to allogeneic transfusion.
• preoperative autologous blood • intraoperative acute normovolemic
hemodilution• intraoperative autologous blood salvage
and autotransfusion• postoperative autologous blood salvage
and autotransfusion
Guidelines for Transfusion
6. Efforts should be made to maximize oxygen delivery in the surgical patient.
7. RBC mass should be increased or restored by means other than RBC transfusion.
8. The patient should be involved in the transfusion decision.
9. The reasons for and results of the transfusion decision should be documented contemporaneously in the patient's record.
10. Hospital transfusion policies and procedures should be developed as a cooperative effort that includes input from all those involved in the transfusion decision and reviewed annually.
11. ASA Guidelines – know professional standards
Guidelines for Transfusion
Blood Typing & Cross-Matching
• ABO Blood Groups1.Type A with A antigens on the red cells and anti
B antibodies in the plasma 2.Type B with B antigens on the red cells and anti
A antibodies in the plasma 3.Type AB with both A and B antigens on the red
cells and no type antibodies in the plasma 4.Type O with no type antigens on the red cells
and both anti A and anti B antibodies in the plasma
• Rh blood typing – test the presence (+) or absence (-) of the Rh antigen.
If your red blood cells:
• Contain the Rh antigen, your blood is Rh-positive.
• Do not contain the Rh antigen, your blood is Rh-negative.
Blood Typing & Cross-Matching
Screening Tests Performed on Donated Blood• Hepatitis B surface antigen (HBsAg) • Hepatitis B core antibody (anti-HBc) • Hepatitis C virus antibody (anti-HCV) • HIV-1 and HIV-2 antibody (anti-HIV-1 & anti-HIV-2) • HIV p24 antigen • HTLV-I & HTLV-II antibody (anti-HTLV-I & anti-HTLV-II) • Serologic test for syphilis • Nucleic Acid Amplification Testing (NAT)
Blood Typing & Cross-Matching
• Donor & Recipient blood is typed on ABO antigen group and Rh factor. Screening tests for other antigen/antibodies.
• Cross-matching tests patient’s plasma with donor’s RBCs to test for hemolysis.
• Emergency – transfuse type specific ORO-negative and type specific ASAP
Blood Typing & Cross-Matching
Whole Blood – 500 mlContains:
RBCs, WBCs, Platelets, PlasmaIndications:
Replace plasma volume and RBCsWBCs & platelets nonfunctional > 72 hr.
Deficient in Factors V, VII
Blood Component Therapy
Packed RBC’s 250 mlContains:
RBCs, WBCs, platelets, minimal plasmaIndications:
Increase RBCs & increase O2 xportWBCs & platelets nonfunctional > 72 hr.
Deficient in Factors V, VII
Blood Component Therapy
Packed RBC’s 250 mlOne unit of PRBCs – 70% HctOne unit will raise patient’s Hct
approximately 3% or HgB 1 gm/dL Volume to Transfuse –
calculated replacementVtT=[Hct(d) – Hct(p) X [BloodVol / Hct(blood)]
Blood Component Therapy
• If pt ABO is known, use an abbreviated cross-match to check ABO compatibility
• If not known, give O neg packed RBCs• O neg whole blood contains
anti-A & anti-B antibodies– May react with patient’s A or B antigens– May react with subsequent A or B blood– If O neg whole blood used, continue until
anti-A and anti-B titers are done
Emergency Transfusion
Massive Transfusion Risks
o Coagulopathyo Citrate Toxicityo Hypothermiao Acid-Base Imbalanceo Hyperkalemiao Increased opportunity for erroro Increased opportunity for infectiono Increased risk to providers
Blood Component Therapy
Platelet Concentrate 50 mlContains:
> 5 x 1010 platelets, RBCs, WBCs, platelets, minimal plasma
Indications:Bleeding from thrombocytopenia or thrombocytopathy
Platelet Concentrate 50 ml
One unit of PC increases platelet count 5000 – 10,000 cells/mm
Blood Component Therapy
Fresh Frozen Plasma 220 mlContains:
Contains plasma with coagulation factors but no platelets
Indications:Correction of coagulopathy
Blood Component Therapy
Fresh Frozen Plasma 220 ml
Dose of 10-15 ml/kg increases coagulation factors by 30%
Fibrinogen increases 1mg/ml of FFPRapid reversal of warfarin usually
requires 5 – 10 ml/kg of FFP
Blood Component Therapy
Blood Component Therapy
Cryoprecipitate 15 - 25 mlContains:
Fibrinogen, Factors VIII, XIII, von Willebrand’s
Indications:Correction of coagulopathy where Fibrinogen, Factors VIII, XIII, or von Willebrand’s are deficient
Cryoprecipitate 15 - 25 ml
Dose of 1 unit per 10 kg raises fibrinogen level 50 mg/dL
Blood Component Therapy
Check and double check IDs & Labels.Blood should not be infused with D5W
hemolysisBlood should not be infused with LR
Ca++ in LR may induce clot formation
RBCs are compatible with:Normal saline, 5% albumin, FFP
Blood Administration
Blood Filters80 mcm filters should be used for all
blood components 170 mcm filters should be used to
administer plateletsLeukocyte filters for patients with febrile
rxn history, maybe for all to prevent alloimmunization to foreign leukocyte antigens
Blood Administration
Albumin• Isotonic Albumin 5%• Hypertonic Albumin 20 & 25%• Intravascular half-life = 10 to 15 days
Plasma Substitutes
Dextran• Dextran 70 – Macrodex and
Dextran 40 – Rheomacrodex• Intravascular half life = 2 to 8 hours• Decreases platelet adhesion and VIII• Coag changes > 1.5g/kg• 1% incidence of anaphylactoid reactions• Give 20 ml Promit to inhibit dextran binding
antibodies
Plasma Substitutes
Hespan ( Hydroxyethyl starch )- small molecules broken down by
kidneys, large molecules by amylase
- Nonantigenic, anaphylactoid reactions are rare
- Coag studies not impaired- Half-life – 24-36 hours
Plasma Substitutes
Autologous Donation• Donation 5 weeks pre-op, must have
HgB > 11 g/dL, can donate Q 3 days, last donation > 72 hr pre-op
• Not all patients tolerate donation• Transfusion reaction risk is reduced but
human error component is still present – transfuse with same criteria & precautions
Blood Conservation Techniques
Hemodilution Techniques (?)• Remove 1 to 2 units of whole blood (Hct
25-30%)• Replace volume with LR or colloids• Intraop loss then is greater plasma loss
and less RBC loss• Reinfuse fresh autologous blood (Hct will
be the same as pre-op, not PRBC)
Blood Conservation Techniques
Cell Saver• Intraop autotransfusion• Double lumen suction aspirates
blood from clean field (heparin + saline + blood)
• Collected blood is filtered and washed prior to reinfusion
• RBC’s in saline Hct ~ 50%• No plasma, clotting factors or
platelets
Blood Conservation Techniques
Acute Hemolytic Reactions• ABO-incompatiability• Occur ~ 1 in 33,000 most due to human
error, fatal in 1:300k to 700k• Symptoms may be masked by
anesthesia (agitation, chest or flank pain, headache, dyspnea, chills)
• Signs include: fever, tachycardia, hypotension, DIC, hemoglobinuria
Complications of Transfusion
Complications of Transfusion
Acute Hemolytic Reactions• STOP the infusion• Establish a noncontaminated IV• Send unused donor blood to lab with blood sample from
patient for rematch• Send blood for: Hgb, haptoglobin, Coomb’s and DIC screening• Rx hypotension – fluids & vasopressors prn• May give corticosteroids• Preserve renal function – fluids, dopamine, diuertic – maintain
UO 1-2ml/kg/hr• R/O DIC
Non-Hemolytic Reactions• Allergic or febrile rxn to antibodies to
donor WBCs or platelets• Transfused allergens in plasma interact
with the patient's tissue mast cells, causing them to degranulate and release inflammatory mediators (histamine, tryines, etc.)
Complications of Transfusion
Non-Hemolytic Reactions• STOP the transfusion, establish clean IV
and send labs• Mild rxn – diphenhydramine 25-50 mg
IV & hydrocortisone 50-100 mg IV, acetaminophen 650 mg
• May resume transfusion slowly (?)• Rx other symptoms prn
Complications of Transfusion
Complications of Transfusion
Hepatitis B 1 : 200 1 : 2,000 1 : 200,000
Hepatitis C1 : 70 to 1 : 500
1 : 4001 : 4,000 to 1 : 100,000
HIV1 : 125 to 1 : 250
1 : 12,500 1 : 550,000
HTLV ? 1 : 10,000 1 : 100,000
Population Donor Screen Blood Units