Fluids and Transfusion

SpR in Anaesthesia, RNOH

the centre for
Anaesthesia
UCL


Topics
Why?
When?
Who?
Risks
Massive Haemmorrhage
Example 1
A fit patient with a compound fracture of the tibia and
a post operative Hb of 7.5 g/dl should be transfused?
Example 2
A 70yr old woman with a history of angina and a pre-
op Hb of 7.5 g/dl should be transfused?

Why?
The body at rest uses
approx 250ml O2/L blood
O2 delivery can fall with a
reduction in any of:
Cardiac Output
Hb concentration
O2 saturation
Organs most sensitive to
hypoxia are Heart and Brain


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 of
blood

Hb x Sa0
2


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
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)
Risks

Example 1
A fit patient with a compound fracture of the tibia and
a post operative Hb of 7.5 g/dl should be transfused?
T
F
Example 1
A fit patient with a compound fracture of the tibia and
a post operative Hb of 7.5 g/dl should be transfused?
T
F
Example 2
A 70yr old woman with a history of angina and a pre-
op Hb of 7.5 g/dl should be transfused?
T
F
Example 2
A 70yr old woman with a history of angina and a pre-
op Hb of 7.5 g/dl should be transfused?
T
F
Summary
Think before you transfuse!

Does your patient really need blood?

Weigh up the benefits vs risks of transfusion.

Massive Transfusion
Massive Transfusion
Definitions
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 when
ongoing need is foreseeable
Replacement of >50% of the total blood volume within
3 hours

Massive Transfusion

Settings
Trauma
Obstetric
Surgical
Medical

The Perfect Clot!

Red blood Cells
Platelets
Clotting factors
Fibrinogen

Bloody Vicious Cycle
The Massively Bleeding Patient
Restore Circulating
Volume:
X 2 14G IV cannulae
Resuscitate with warmed
crystalloid/colloid
Warm patient
Consider invasive
monitoring: arterial line
+ central venous access
Effect of Hypothermia on
coagulation factor activity
Get some Help.
Contact Key Personnel
Senior anaesthetist/ surgeon/
obstetrician
Blood Bank
Haematologist

Get someone to coordinate to communicate and
document
Arrest the Bleeding.
Request Lab investigations
Ensure correct sample identity
FBC, ABG
Full coagulation screen
X- match
Repeat after products/4hourly

May need to give blood products before results
are available



Request PRC
Uncrossmatched Group
O Rh neg
Uncrossmatched ABO
group specific
Fully X match
Use a blood warmer/
rapid infusion device
Consider cell salvage
Request Platelets
Allow for delivery time.

Anticipate plt count<50
x10
9
/l after x2 blood vol
replacement

Target plt count>100
x10
9
/l for multiple/CNS
trauma, > 50 in other
situations
Request FFP
Aim for PT/ APTT < 1.5 x
control

Allow for thawing time
Request Cryopreciptate
Contains fibrinogen and factor VIII

Aim for fibrinogen >1g/L
Summary
Recognise the situation early!
Get some help.
Aggressive management of hypothermia/acidosis
Avoid haemodilution and use appropriate volumes of
blood components
Inadequately treated coagulopathy is associated with
worse outcome

Other IV Fluids
IV Fluids
Normal Adult Fluid Composition

60% composed of water
70 kg person= 42 L
2/3 ICF = 28L
1/3 ECF = 14L

TBW= ECF + ICF

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
Daily Requirements
The normal electrolyte requirements are:

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

Maintenance

Resuscitation
Pre-operatively
Should consider:
History, examination
Deficit (measured + insensible)
Intravascular vs cellular dehydration
Electrolyte levels
Speed of fluid loss (days/hours/minutes)
Vasodilated / ill patients may need several litres of fluid
before surgery

History
Vomiting/ diarrhoea
Intestinal obstruction
Fluid intake
Thirst
Signs/ Symptoms
Dry mucous membranes
Low urine output
Tachycardia
Increased capillary refill time
Postural hypotension (late sign)
Low CVP
Decreased concious level
Signs and symptoms of dehydration
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

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 daily
volume.
Elective, well patient
Q: Fit , young pt having elective surgery not involving
the abdomen what fluid losses do you expect before
and during surgery of less than an hour?
Starved 6 hrs
220ml- 660ml
Intra op losses
(minimal blood loss, loss dependent on duration)
Surgery< 1hr, loss< 150ml
Does this patient need intra op
Fluid?

Not necessarily
But if hot weather, insensible losses may increase, pt
may feel better post op if 500ml given
Emergency Laparotomy Pt

Q: Patient needing urgent laparotomy, history of
vomiting for several days.

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


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 fluid
resuscitation
What?

Crystalloids

Colloids
Colloids
Contain Proteins/large molecules
suspended in a carrier solution
Large molecules stay in the plasma,
keeping infused fluid in largely in
circulation.
Smaller volumes needed
Small risk of anaphylaxis
Colloids
Na Cl K Lactate Ca Mg Other
Gelofusin
Elohaes,
Voluven
Volplex
Haesteril
Albumin
150 120-
150
Haemacell 145 145 5 6
Geloplasma 150 100 5 30 1-1.5
Volulyte 137 4 110 1.5 Acetate
34
Crystalloids
Contain water and dissolved
electrolytes
Pass freely through a
semipermeable membrane
Many are isotonic with
extracellular fluid
Need larger volumes
Cheap
Crystalloids
Na+ Cl- K+ Lactate Ca Mg Other
Hartmanns
Solution (CSL)
131 111 5 29 2
0.9% Saline 154 154
5% glucose Glucose 50g/l
4% glucose saline 30 30 Glucose 40g/l
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
Questions
What are the H2O and Na+ ions for a 65 Kg patient to replace normal
daily losses?


Questions
Requirements: H2O 105 ml/hr = 2520 ml/day
Na = 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

Summary
Think about why you are giving fluids
Work out how much fluid to give
Select which type of fluid to give
Correct fluid management is essential to every
patients care
Questions?