Fluid 2021

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FLUID MANAGEMENT AND

BLOOD TRANSFUSION

Prof. Mahmoud Almustafa,


M.D FACHARZT.

Edited by Majdoleen Hamed


Body Fluid Compartments
Total body water

• TBW: 55-60% of the BW in men and 45-50% inWomen


young women
Body Fluid Composition in Age
AGE Groups
TBW AS % OF
TOTAL BODY WEIGHT
Neonate Highest 80

6 months 70

1 year 60

Young adult 60

Elderly Lowest 50
Age and TBW inversely correlated to each other
Composition of Body Fluid Compartments
Intravascular

• Ion Plasma (mmol/L) ICF


(mmol/L)
• Na+ Extra cellular >>>> 135-145 9
• K+ Intracellular >>>> 3.5-5 135
• Ca2+ 1.3 <0.8
• Mg2+ 0.9 25
• Cl- Extracellular>>>> 103 9
• HCO3- 24 9
• HPO42- 0.4 74
• Sulphate- 0.4 19
• Proteinate- 1.14 64
ESSENTIAL PRINCIPLES
Osmolarity and Osmolality
• These are ways of quantifying how much of a solute
is dissolved in a solution.
• Osmola(R)ity No. of osmoles of solute particles
per unit VOLUME of solution and has units
osmoles/litre. In the body we use milliosmole

• Osmola(L)ity No. of osmoles of solute particles


per unit WEIGHT of solvent and has units
osmoles/kilogram.
Plasma Osmolality
Plasma osmolality = 2 (Na + K) + glucose +
urea
= 2 (137 + 4.0) + 5.0 + 4
= 291 mosmol/kg H20

• Range 275-299
Tonicity
• A way of describing the relative solute
concentrations of two solutions which are
separated by a selectively-permeable
membrane (often called a semi-permeable
membrane).
Inside Outside
movement movement
WHAT IS THE ‘NORMAL’
DAILY INTAKE AND
OUTPUT OF FLUID AND
ELECTROLYTES?
OUTPUT, INTAKE
Normally should the output =input

• Input: Oral, Enteral, Intravenous

• Output: ‘Sensible’: that it is easily seen and


measured e.g. urine output and loses from the
gastrointestinal tract.

‘Insensible’: not seen and not easy to


quantify e.g. sweat, and water vapor in exhaled
gases.
OUTPUT
1500 ml Urine
200 ml Gastrointestinal(faeces)
400 ml Skin(sweat)
400 ml Respiratory
2500 Total
INTAKE
1500 ml Drinking
750 ml Eating
250 ml Metabolism
2500 Total
• The above volumes do not contain just water
but also electrolytes….
75 Kg PERSON DAILY LOSS / ELECTROLYTE
PER REQUIREME NT
DAY

75 - 112.5 mmol 1-1.5 mmol/kg Sodium

75 – 112.5 mmol 1-1.5 mmol/kg Potassium

7.5 – 15 mmol 0.1-0.2 mmol/kg Magnesium

7.5 – 15 mmol 0.1-0.2 mmol/kg Calcium

5.25 – 16.5 mmol 0.07-0.22 mmol/kg Chloride

1500 – 3000 mmol 20-40 mmol/kg Phosphate


Maintenance and Deficit
Surgery requirement. Before surgery requirement from fasting to prevent aspiration
• Maintenance Vs deficit

• Rule of 4 /2/ 1 In maintenance calculation

• Ex. 70 kg patient
For patient
Above 20kg
1st 10 kg: 10 kg * 4 ml = 40 ml / hr
You can also
Calculate
2nd 10 kg: 10 kg * 2 ml = 20 ml / hr
maintenance
Using
3rd 10 kg: 50 kg * 1 ml = 50 ml / hr
=Kg+ 40ml/ hr
Total=110ml/hr
De cit calculation
• Ex. Fasting for 10 hr without any intake: 10*110=
INTRAOPERATIVE
FLUID LOSS
1 ml blood loss give 3 ml crystalloid( normal saline)
1:3
1:1 1 ml blood loss give 1 ml colloid(blood product)
Factors determine which one give ?
1) baseline Hb
2)hemodynamic stability
3)high risk patients
4)surgery time
5) availability of blood
6)bleeding tendency
Allowable Blood Loss (ABL)
Amount of blood that can lost without need to compensated

• EBV = weight (kg) * Average blood volume


• Allowable Blood Loss = [EBV*(Hi-Hf)]/Hi
• Where:
• EBV=Estimated Blood Volume
• Hi= initial hemoglobin (Hct) The patient current HcT

• Hf= final hemoglobin (Hct) The lowest acceptable HcT

• Normal Hct Values


• Men 42-52% HcT=Hg*3

• Women 37-47%
ALLOWABLE BLOOD
LOSS
Hb 7 mg/dl ??????
Availability of test and blood
ALLOWABLE BLOOD
LOSS
Pediatric
Adult
20% of total blood in the body (adults)
10-15% of total blood in the body (pediatrics)
Estimated Blood Volume (EBV)
• Men 75 ml / kg
• Women 65 ml / kg

• Infants 80 ml / kg

• Neonates 85 ml / kg

• Premature Neonates 95 ml / kg
INTRAVENOUS FLUIDS
Types
• types

• Crystalloids 1:3 increase hydrostatic pressure —> stay in interstitial

• Colloids 1:1 increase molecular weight (oncotic pressure) —> keep


inside vessels
• Solutions that contain a combination of water
and electrolytes.

• Divided into "balanced" salt solutions (e.g.


Ringer's lactate) and hypotonic solutions (e.g.
D5W).
Ringer’s Lactate (Hartman’s)
Balanced isotonic

• Na+ = 131 mmol/L


• Cl- = 111 mmol/L
• Lactate = 29 mmol/L
• K+ = 5 mmol/L
• Ca++ = 2 mmol/L
• PH = 6.5
• Osmolality = 279 mosm/L
• Potential problem = potassium may accumulate,
Hyperkalemia
Normal saline (0.9% saline solution)
Unbalanced

• 9 g of NaCl/L water
• 154 mmol/L sodium
• 154 mmol/L chloride
• Osmolality = 308 mosm/L Hypertonic but consider isotonic
• PH = 5.0
• Potential problem = hyperchloraemic metabolic
acidosis, more likely with renal insufficiency
Special Solutions
• Hypertonic (3%) saline....
Ph
hyponatremia
Osmo
• 30 gm NaCl, 1027, 4.5 to 7.0

• Half normal saline.... hypernatremia Contraindication


Nacl In cerebral edema
• 77 meq/L Hypotinic
Osmo=154

• 8.4% Bicarbonate solution... acidosis

• Mannitol 20%....brain oedema, pulmonary


oedema
Albumin
Dextran
Gelatins
Starches
Colloids
Plasma expanders
(polymers)
• Colloid: a large molecule that does not diffuse
across semipermeable membranes (capillary)
Harmful if there is capillary leakage (sepsis, ARDS) Bcz will
accumulate extra vascular
• Exerts an osmotic pressure in the blood,
causing fluid to remain within the vascular
system. The result is an increase in
intravascular volume.
• Two categories of colloid may be defined:
• Natural (e.g. human albumin)

• Artificial (e.g. gelatins, dextran and


hydroxyethyl starches [HES]).
Albumin Available

• Half-life (t½) = 1.6 hours in plasma


• Stays within the intravascular space unless the
capillary permeability is abnormal
• 5% solution - isotonic; 20% solutions -
hypertonic
• Expands volume 5x its own volume in 30
minutes Preserve renal function
• Side effects - volume overload, fever (pyrogens
in albumin), defects of haemostasis
Dextran
• High MW polysaccharide
• Dextran 40 - MW 40,000
• Dextran 70 - MW 70,000
• 10% solution in NS or D5W Hypotonic solution

• Side effects: anaphylaxis, coagulopathy, renal


vWS+ VIII
failure
• Dose: limit to 20 ml/kg/day
• Used as antiaggregant in patients undergoing
vascular and microvascular surgical
procedures
PERIOPERATIVE BLOOD
TRANSFUSION
Purpose of Infusion of Fluids and
Blood Products

• Maintain organ transfusion

• Normal blood pressure and heart rate, normal


mental status (in non-comatose patients),
normal oxygen saturation, normal urine output,
well perfused extremities
Blood Products
• Whole blood

• Packed Red Blood Cells

• Platelets
• Cryprecipitate

• Human albumin

• Fresh Frozen Plasma


BLOOD BANK PRACTICES
Preparation of Blood Components
• Blood donors:
• Approximately 17 million units of blood are donated in Europe each year.
• Each donor is interviewed for medical history of known infectious
diseases
• Each unit is screened for antibodies to:
• Syphilis
• Hepatitis B and C
• HIV 1 and 2
• +/- CMV
Centrifugation
• Collect 500 mL whole blood
• Divert the first 40 mL to reduce risk of bacterial contamination
from donor skin
• The 40 mL are used for
donor unit testing
• Blood is centrifuged and
separated into 3 parts:
• Red Blood Cells
• Plasma
• Buffy coat
• The Buffy coat units from four donors are further processed
to separate the platelets
• The red blood cell and platelet components are leukoreduced
• Separated of blood components by 1 unit of Whole blood:

• PRBCS(hematocrit 70%):
• 250 mL+saline preservative=350 mL.
• 1–6°C.
• May be frozen in a hypertonic glycerol solution for up to
10 years(rare phenotypes)
• Platelet:
• 50–70 mL.
• 20–24°C for 5 days.

• Plasma:
• The remaining plasma supernatant is further processed and
frozen to yield fresh frozen plasma; rapid freezing helps prevent
inactivation of labile coagulation factors (V and VIII). Slow
thawing of fresh frozen plasma yields a gelatinous precipitate
(cryoprecipitate) that contains high concentrations of Factor VIII
and fibrinogen.
• 200 mL.
• Once thawed it must be transfused within 24 h.
BUT BEFORE
EVERYTHING THE BLOOD
BANK HAS TESTS TO
COMPARE THE BLOOD OF
THE DONOR TO THE
BLOOD OF THE RECIPIENT
So you must know the blood groups
Blood Groups

• At least 20 separate blood group antigen


systems are known; fortunately, only the ABO
and the Rh systems are important in the majority
of blood transfusions.
The ABO System
• Simply speaking, the chromosomal locus for this
system produces two alleles: A and B. Each
represents an enzyme that modifies a cell
surface protein.
Type Naturally Occurring Incidence
Antibodies in
Serum

A Anti-B 45%
B Anti-A 8%
AB (Universal — 4%
recipient)

O (Universal donor) Anti-A, anti-B 43%


COMPATIBILITY TESTING
Intra-operative Transfusion
Practices
WHAT TO CHECK BEFORE
TRANSFUSION
Check blood groups
Check expire day of unite
Check the name of the patient
Check the medical record number
Check unit number
Packed Red Blood Cells
• Ideal for patients requiring RCs but not volume
replacement (eg, anemia pt in compensated
CHF).
• Hgb 7-8 g/dL (<6, most people require blood;
>10 most people do not)
• Each unit raise Hgb by 1g/dl
• 170-µm filter to trap any clots or debris.
• Warming to 37°C during infusion.
• Hypothermia and low levels of 2,3-diphosphoglycerate (2,3-DPG)
in stored blood can cause a marked leftward shift of the
hemoglobin–oxygen dissociation curve
• ABO-compatible units are mandatory.
Fresh Frozen Plasma
• FFP contains all plasma proteins, including all clotting factors.
• Indications:
• Isolated factor deficiencies.
• Reversal of warfarin therapy.
• Coagulopathy associated with liver disease.
• CABG,bleeding+NL ACT.
• Massive blood transfusions.
• Antithrombin III def.

• The initial therapeutic dose is usually 10–15 mL/kg


• ABO-compatible units are mandatory.
• Coagulation factors INR 1.4-1.6 (INR>1.6, most people require
FFP transfusion for major surgery; INR<1.4, most people do not
require)
Platelets
• Thrombocytopenia or dysfunctional platelets .

• Surgery or invasive procedures: 70,000 x 109/L.

• Vaginal delivery and minor surgical procedures: 50,000 x 109/L.

• Eachunit expected to increase the count by 10,000–20,000 x


109/L.

• ABO-compatible platelet transfusions are desirable but not


necessary
Cryoprecipitate
From thawing FFP slowly
• Each unit (15 ml) contains fibrinogen 150 mg, factor VIII 100
units, von Willebrand factor (vWF) (100 units)

• DIC,hemophilia A, von Willebrand disease, quick reversal of


thrombolytic therapy

• Fibrinogen(most people require


cryoprecipitate for major surgery if
fibrinogen < 1 g/dL)
Machine to give autologous blood transfusion >> we take the patient's blood,
go to reservoir, go to the machine gets cleaned and washed then go to the red
bag, then go back to the patient. (we use when we suspect large blood loss
during surgeries, example: open heart surgery)

CELL SAVER
Never used in cancer patients

CELL SAVER
LEVEL 1 (A) INFUSION
PUMP

Give large volume in short time


using large cannula or central line
Used in trauma / ruptured AAA
Complications of Blood
Transfusion
• Hemolytic reactions
• Acute Vs. Delayed

• Febrile Non hemolytic reactions

• Transfusion Related Acute Lung Injury


(TRALI)

• Infectious complications
TRALI
• ARDS following blood transfusion
Accumulation of uid in the alveoli

• High morbidity … mechanical ventilation

• Lung injury is generally transient with PO2 levels returning to


pretransfusion levels within 48 -96 hours and CXR returning
to normal within 96 hours.

• Mortality rate, often approximated at 5 to 10%

• Treatment as ARDS O2 therapy

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