Perioperative Fluid and Blood Administration - PowerPoint PPT Presentation

1 / 62
About This Presentation
Title:

Perioperative Fluid and Blood Administration

Description:

0 Perioperative Fluid and Blood Administration Jeffrey Groom, PhD, CRNA Director and Clinical Associate Professor Nurse Anesthetist Program Florida International ... – PowerPoint PPT presentation

Number of Views:534
Avg rating:3.0/5.0
Slides: 63
Provided by: JeffreyGr8
Category:

less

Transcript and Presenter's Notes

Title: Perioperative Fluid and Blood Administration


1
Perioperative Fluid and Blood Administration
0
Jeffrey Groom, PhD, CRNADirector and Clinical
Associate ProfessorNurse Anesthetist
ProgramFlorida International University
2
Fluid and Blood Administration
  • Primary objective of perioperative fluid
    management is maintenance of adequate tissue
    perfusion and oxygen transport.

3
Clinical Indicators
  • 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

Surgical patient who exhibits signs of low
perfusion, such as oliguria or hypotension, the
most common etiology is insufficient
intravascular volume.
4
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.

5
Physiologic Response to Hemodilution Anemia
  • 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

6
Hemostatic Mechanisms
  • Primary Hemostasis
  • Coagulation
  • Fibrinolysis

7
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)

8
Hemostatic Mechanisms
9
ASA NSAIDS
  • Thrombin
  • È
  • Phospholipid
  • È
  • Arachidonic acid
  • È
  • Cyclo-oxygenase
  • È
  • Prostaglandins
  • È
  • Thromboxane A2(platelet aggregation)

platelet aggregation inhibited ASA- 8-12
days NSAID 24-48 hrs
10
Clotting Cascade
Coumadin PT and INR
Heparin PTT and ACT
11
Coagulation Studies
  • History ask about bleeding disorders or
    bleeding symptoms
  • Partial Prothrombin Time (PTT)
  • Prothrombin Time (PT)
  • Bleeding Time
  • Activated Clotting Time (ACT)

12
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

13
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

14
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

15
Coagulation Studies
  • Bleeding Time (3-10 minutes)
  • Evaluates interaction of platelets with vessel
    endothelium
  • Prolonged BT can be caused by dysfunctional or
    low platelets, vonWillebrands deficiency
    (adhesion),or fibrinogen (fiber) deficiency
  • Normal range results vary with many factors
    (technique, tech, pathology)

16
Coagulation Studies
Anticoagulant Factors Inhibited PT PTT
Heparin II, IX, X, XI, XII Normal Prolonged
Coumadin II, VII, IX, X Prolonged Normal
17
Coagulation Studies
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 gt
    400-480 seconds.
  • If ACT lt 400 seconds, additional heparin 100u/kg
    is given.

18
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

19
Indications for Transfusion
  • 1. ANEMIA loss of RBCs
  • Xfuse at Hematocrit
  • CAD 25-30
  • Healthy 20-25
  • No choice (?) 15-20

20
Indications for Transfusion
Hemoglobin Level Mortality
lt 6 g/dL 62
6 8 g/dL 33
8 10 g/dL 0
gt 10 g/dL 5
21
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
22
Indications for Transfusion
  • Estimating Blood Volumes
  • Estimated Blood Loss add all sources of loss
  • EBLSuction sponges drapes floor etc.
  • Allowable Blood Loss calculated estimate
  • ABL Hct(s) Hct(a) X BloodVol / Hct(a)
  • Volume to Transfuse calculated replacement
  • VtTHct(d) Hct(p) X BloodVol / Hct(blood)
  • Avg adult BloodVol 7 of lean mass or 70ml/kg

23
Indications for Transfusion
  • 2. THROMBOCYTOPENIA
  • Spontaneous bleeding occurs withlt 20,000
    platelets
  • Surgical hemostasis may requiregt 50,000
    platelets
  • Platelet transfusion _at_ lt 50,000
  • Causes- decreased production, increased
    utilization, destruction, drug effect, massive
    transfusion

24
Indications for Transfusion
  • 3. COAGULOPATHY bleeding associated with Factor
    losses or prolonged clotting times (PT, PTT, BT,
    ACT)

25
Guidelines for Transfusion
  • Transfusion need should be assessed on a
    case-by-case basis.
  • Blood should be transfused one unit at a time,
    followed by an assessment of benefit and further
    need.
  • Exposure to allogeneic blood should be limited to
    appropriate need.
  • Does this pt need to be transfused?
  • Appropriate transfusion trigger for this pt (HH)
  • Donor-directed transfusion (?)

26
Guidelines for Transfusion
  • 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

27
Guidelines for Transfusion
  • 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

28
Guidelines for Transfusion
  1. Efforts should be made to maximize oxygen
    delivery in the surgical patient.
  2. RBC mass should be increased or restored by means
    other than RBC transfusion.
  3. The patient should be involved in the transfusion
    decision.
  4. The reasons for and results of the transfusion
    decision should be documented contemporaneously
    in the patient's record.
  5. 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.
  6. ASA Guidelines know professional standards

29
Blood Typing Cross-Matching
  • ABO Blood Groups
  • 1.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

30
Blood Typing Cross-Matching
  • ABO Blood Groups in the Population

31
Blood Typing Cross-Matching
  • 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.

32
Blood Typing Cross-Matching
ABO Blood Groups Rh Type in the Population
33
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)

34
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 patients plasma with
    donors RBCs to test for hemolysis.
  • Emergency transfuse type specific ORO-negative
    and type specific ASAP

35
Blood Typing Cross-Matching
36
Blood Component Therapy
  • Whole Blood 500 ml
  • Contains
  • RBCs, WBCs, Platelets, Plasma
  • Indications
  • Replace plasma volume and RBCs
  • WBCs platelets nonfunctional gt 72 hr.
  • Deficient in Factors V, VII

37
Blood Component Therapy
  • Packed RBCs 250 ml
  • Contains
  • RBCs, WBCs, platelets, minimal plasma
  • Indications
  • Increase RBCs increase O2 xport
  • WBCs platelets nonfunctional gt 72 hr.
  • Deficient in Factors V, VII

38
Blood Component Therapy
  • Packed RBCs 250 ml
  • One unit of PRBCs 70 Hct
  • One unit will raise patients Hct approximately
    3 or HgB 1 gm/dL
  • Volume to Transfuse
  • calculated replacement
  • VtTHct(d) Hct(p) X BloodVol / Hct(blood)

39
Emergency Transfusion
  • 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 patients 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

40
Massive Transfusion Risks
  • Coagulopathy
  • Citrate Toxicity
  • Hypothermia
  • Acid-Base Imbalance
  • Hyperkalemia
  • Increased opportunity for error
  • Increased opportunity for infection
  • Increased risk to providers

41
Blood Component Therapy
  • Platelet Concentrate 50 ml
  • Contains
  • gt 5 x 1010 platelets, RBCs, WBCs, platelets,
    minimal plasma
  • Indications
  • Bleeding from thrombocytopenia or
    thrombocytopathy

42
Blood Component Therapy
  • Platelet Concentrate 50 ml
  • One unit of PC increases platelet count 5000
    10,000 cells/mm

43
Blood Component Therapy
  • Fresh Frozen Plasma 220 ml
  • Contains
  • Contains plasma with coagulation factors but no
    platelets
  • Indications
  • Correction of coagulopathy

44
Blood Component Therapy
  • Fresh Frozen Plasma 220 ml
  • Dose of 10-15 ml/kg increases coagulation factors
    by 30
  • Fibrinogen increases 1mg/ml of FFP
  • Rapid reversal of warfarin usually requires 5
    10 ml/kg of FFP

45
Blood Component Therapy
  • Cryoprecipitate 15 - 25 ml
  • Contains
  • Fibrinogen, Factors VIII, XIII, von Willebrands
  • Indications
  • Correction of coagulopathy where Fibrinogen,
    Factors VIII, XIII, or von Willebrands are
    deficient

46
Blood Component Therapy
  • Cryoprecipitate 15 - 25 ml
  • Dose of 1 unit per 10 kg raises fibrinogen level
    50 mg/dL

47
Blood Administration
  • Check and double check IDs Labels.
  • Blood should not be infused with D5W ?hemolysis
  • Blood should not be infused with LR ?Ca in LR
    may induce clot formation
  • RBCs are compatible withNormal saline, 5
    albumin, FFP

48
Blood Administration
  • Blood Filters
  • 80 mcm filters should be used for all blood
    components
  • 170 mcm filters should be used to administer
    platelets
  • Leukocyte filters for patients with febrile rxn
    history, maybe for all to prevent
    alloimmunization to foreign leukocyte antigens

49
Blood Administration
  • Future Blood Substitutes
  • Fluosol-DA 20
  • Free hemoglobin solutions

50
Plasma Substitutes
  • Albumin
  • Isotonic Albumin 5
  • Hypertonic Albumin 20 25
  • Intravascular half-life 10 to 15 days

51
Plasma Substitutes
  • Dextran
  • Dextran 70 Macrodex and Dextran 40
    Rheomacrodex
  • Intravascular half life 2 to 8 hours
  • Decreases platelet adhesion and VIII
  • Coag changes gt 1.5g/kg
  • 1 incidence of anaphylactoid reactions
  • Give 20 ml Promit to inhibit dextran binding
    antibodies

52
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

53
Blood Conservation Techniques
  • Autologous Donation
  • Donation 5 weeks pre-op, must have HgB gt 11 g/dL,
    can donate Q 3 days, last donation gt 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

54
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)

55
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
  • RBCs in saline Hct 50
  • No plasma, clotting factors or platelets

56
Complications of Transfusion
  • Acute Hemolytic Reactions
  • ABO-incompatiability
  • Occur 1 in 33,000 most due to human error,
    fatal in 1300k to 700k
  • Symptoms may be masked by anesthesia (agitation,
    chest or flank pain, headache, dyspnea, chills)
  • Signs include fever, tachycardia, hypotension,
    DIC, hemoglobinuria

57
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, Coombs 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

58
Complications of Transfusion
  • 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.)

59
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

60
Complications of Transfusion
  • Infection Risk

61
Complications of Transfusion
Population
Donor Screen
Blood Units
Hepatitis B 1 200 1 2,000 1 200,000
Hepatitis C 1 70 to 1 500 1 400 1 4,000 to 1 100,000
HIV 1 125 to 1 250 1 12,500 1 550,000
HTLV ? 1 10,000 1 100,000
62
SUMMARY
  • Blood components
  • Coagulation system and tests
  • Blood and fluid administration
Write a Comment
User Comments (0)
About PowerShow.com