Perioperative Fluid and Blood Administration Jeffrey Groom, PhD, CRNA Associate Professor,...

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• Coagulation• Fibrinolysis

Hemostatic Mechanisms

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)


ASA & NSAIDSThrombin

Phospholipid

Arachidonic acid

Cyclo-oxygenase

Prostaglandins

Thromboxane A2

(platelet aggregation)

platelet aggregation inhibited

ASA- 8-12 days

NSAID – 24-48 hrs

Clotting Cascade

Heparin

PTT and ACT

Coumadin

PT and INR

• 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%


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


3. COAGULOPATHY – bleeding associated with Factor losses or prolonged clotting times (PT, PTT, BT, ACT)


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


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


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


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

ABO Blood Groups in the Population


• 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.



ABO Blood Groups & Rh Type in the Population

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)


• 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


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


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)]


• 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


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


Fresh Frozen Plasma 220 mlContains:

Contains plasma with coagulation factors but no platelets

Indications:Correction of coagulopathy


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



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


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


Future Blood Substitutes• Fluosol-DA 20%• Free hemoglobin solutions


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)


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


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


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.)


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


Infection Risk



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

SUMMARY

• Blood components• Coagulation system and tests• Blood and fluid administration

Perioperative Fluid and Blood Administration Jeffrey Groom, PhD, CRNA Associate Professor,...

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