FLUID AND BLOOD
TRANSFUSION
Mariana Voigt
2013
COMPONENTS OF
ANESTHESIOLOGY
Hypnosis
Muscle Relaxation
Analgesia
COMPONENTS OF ANESTHESIOLOGY
Perioperative evaluation and
correction of fluid disturbance
Hypnosis
Fluid
management
Muscle Relaxation
Analgesia
OVERVIEW
Patient evaluation
Oxygen flux
Types of fluid
Blood products and guidelines
Changes in stored blood
Transfusion reactions
PERIOPERATIVE FLUID STATUS

1.
2.
3.
Components of fluid status
Volume: lost or gained
Composition: elec;glu;colloids;ph
Concentration: Hyper, Iso or
Hypotonic
PATIENT EVALUATION
FLUID AND ELECTROLYTE STATUS

1.
2.
3.
History:
Intake/Output
Bleeding
Exposure

1.
2.
3.
4.
5.
Examination:
Blood pressure, pulse –rate, character
Skin turgor; capillary refill
Mucous membranes, pallor
Urine excretion
Level of consciousness
PATIENT EVALUATION
FLUID AND ELECTROLYTE STATUS

1.
2.
3.
Invasive monitoring:
CVP- fluid challenge
Pulmonary artery catheter
Non-invasive cardiac output- arterial pulse contour
analysis: SPV, PPV, SVV

1.
2.
3.
4.
Special investigations:
Na
Other electrolytes and pH
Hemoglobin
Serum osmolarity= 2(Na +K) + urea + glucose
COMPONENTS OF FLUID REPLACEMENT
Maintenance
Fluid deficit/replacement
Intra-operative blood loss
Third space loss
Compensation - spinal
COMPONENTS OF FLUID REPLACEMENT
Maintenance
Fluid deficit
NPO
Bloodloss
MAINTENANCE
To compensate for respiration; skin; urine and
bowel losses
Adult loss = 1-2 ml/kg/h
children: 1-10kg 4ml/kg/h
10-20kg 2ml/kg/h
>20 kg 1ml/kg/h
MAINTENANCE
26 kg child:
 1-10 kg = 4ml/kg = 40ml
 + 11-20 kg = 2ml/kg = 20ml
 + 21-26 kg = 1ml/kg = 6ml
Maintenance= 40+20+6= 66ml/h
MAINTENANCE
High in Osmol( Hypertonic)
Low in sodium
Glucose to provide energy
Intra operative replacement is done with
isotonic fluids
(stress response - glucose↑)
REPLACEMENT
High up GIT losses rich in chloride, hydrogen
and potassium – should be replaced with
normal saline and potassium
Lower GIT losses rich in bicarbonate – should
be replaced with normal saline, potassium
and bicarbonate
REPLACEMENT
 Burns (Parkland formula)
= 4ml/% burns/kg/24h
 ½ of the replacement in 8 h
 ½ of the replacement in 16 h
 NPO period
= Maintenance x hours NPO
( 50% during the first hour)
REPLACEMENT
THIRD SPACE LOSS
1960 Shires describes a 3 rd space –
movement of fluid from the interstitial space
to the intracellular space
Should be replaced with crystalloids

Minimal
1-2 ml/kg/hr
Moderate 3-6 ml/kg/hr
Large
7-10 ml/kg/hr
Not applicable
THIRD SPACE LOSS
ic
iv
ic
HAGIE
is
is
BLOODLOSS
RESUSCITATION
Restoration of circulatory volume with plasma
volume expanders
Choice of fluid is controversial
Debate of colloids versus crystalloids
Blood transfusion >= 20% blood loss
Criteria for blood administration not so rigid
any more
OXYGEN FLUX(DO 2 )
DO2 = CO x CaO2
= CO x (Hb x 1.34 x SaO2 +
0.031 x PaO2)
= 1000ml/min; 600ml/min/mxm
CaO2 = Oxygen content in arterial blood
= 200 ml/l
1.34 = Hb’s oxygen binding (ml/g)
0.031 = Solubility of oxygen in blood
DO2
PAO2
VO2
O2
Hb
CO=SV*HR
OXYGEN FLUX(DO 2 )
CO = SV x HR
VO2 = 3.5 ml/kg/min = 250 ml/kg
ERO2 = VO2/DO2 = 250/1000
= 25%
ERO2>= 50% (Trigger for blood
transfusion)
TRIGGERS FOR TRANSFUSION
Tachycardia; hypotension in normovolemia
BE; pH ; lactate
SvO 2 < 50%
ERO 2 > 50%
New RWMA
New ST segment changes
VO 2 ↓ 10 %
END POINTS OF RESUS
MAP > 65 mm Hg
Urine output of > 0.5 ml/kg/h
SVO2> 70%
CVP = 8-12 cmH2O
Transfuse to a Hct of 30
Look at improvement of the pH, lactate
MABL
MABL = blood volume x(hct1 – hct2)
mean haematocrit
Hct1 = initial haematocrit
Hct2 = minimally acceptable hct
Bloodvolumes:
Prem = 95 ml/kg
Fullterm = 90 ml/kg
Infant = 80 ml/kg
> 1 year = 70 ml/kg
T YPES OF FLUIDS
Crystalloid solutions :
a) Isotonic solutions
b) Hypertonic saline
Colloids: ( Starling equation)
a) Natural colloids – albumin,
ffp
b) Synthetic colloids – Dextrans,
Gelatins, Hydroxy-ethyl starches
CRYSTALLOIDS
After 2 hours only 1/4 →IV due to extra
vascular extravasation
Blood loss → 3 x Volume
Ringer’s lactate remains the most
popular fluid for resuscitation
COLLOIDS
Dextrans: polymers produced from sucrose by
fermentation, by the bacteria leuconostroc
mesenteroides.
Gelatins: hydrolysed animal collagen; bovine
protein: Haemaccel; Gelofusin
Hydroxy-ethyl starches: maize;
potatoes:Haesteril; Volufen, Venafunden
COLLOIDS
Replace blood loss 1:1
Intravascular T1/2 3-6 h
Bolus dose of 10-20ml/kg
Volufen most in favor – 70 ml/kg/24h
SIDE EFFECTS OF COLLOIDS
Fluid overload
Allergic reactions – Gelatins
Inhibition of clotting – Dextrans
Dilutional thrombocytopenia
Prolonged in renal failure
Pruritus
Increase incidence of renal failure in
septic patients
FLUID ADMINISTRATION
Start with crystalloid
After 2l of crystalloid – give colloid
BLOOD PRODUCTS
BLOOD PRODUCTS
Lethal triad: acidosis; hypothermia;
coagulopathy
Blood component therapy
Restrictive transfusion strategy versus
the 10:30 rule
Healthy patient Hb = 6 g/dl
Associated disease Hb = 7g/dl
Acute coronary syndrome Hb = 8 g/dl
BLOOD CONSERVATION
Cell saver
Autologous blood transfusion
Haemodilution
Anti-fibrinolitics
Desmopressin
Novoseven
Hemopure(bovine Hb protein)
CELL SAVER
BLOOD PRODUCTS
Whole blood
Packed cells – Hct 60; stored at 4 o C
Leucocyte depleted blood
Irradiated blood
Platelets; stored at 22 o C for 5 days; give 1
u/10kg
FFP; give 15-20 ml/kg
Cryoprecipitate : fibrinogen; factor 8
FFP
BLOOD PRODUCTS
Blood component therapy
PT; platelets; fibrinigen
TEG
After the loss of 1 bloodvolume platelets
should be given
TROMBO ELASTOGRAM
R = clotting factors
MA = platelet function
α = speed of clot
formation
TRANSFUSION REACTIONS
Acute Haemolytic reactions - ABO
incompatibility
Delayed haemolytic reactions-Rh
Allergic reactions-incompatible proteins
Graft versus Host reaction
Febrile, non haemolytic reactions
Post transfusion purpera
METABOLIC DEVIATIONS
K↑, Mg↑,Ca ↓
pH↓
2,3 DPG ↓(L shift oxy -Hb curve)
ATP depletion
↑ release of pro-inflammatory substances
↓in platelets and clotting factors v and viii
AGE of blood is a predictor of post-op infection
TRANSMISSION OF DISEASE
Hepatitis B, C
HIV 1:800 000
Ebstein-Barr
CMV
Malaria, Brucella, Syphilis
Bacterial contamination
TRALI
Occurs 1-6h of Transfusion
Pt becomes hypoxic, no signs of
pulm oedema
FFP most important cause of Trali
Leucocytes : leucocyte reduction
DIVERSE REACTIONS
Hypothermia
Citrate toxicity with ↓Ca
Fluid overload
Air embolism
Bacterial contamination
Bleeding tendencies : dilutional
thrombocytopenia
ELECTROLY TE DISTURBANCES
Sodium
Potassium
Calcium
Magnesium
HYPONATRAEMIA
(< 135MMOL/L)
Clinical picture: ( acute onset) lethargy;
confusion; seizures; coma
Hypovolaemia: electrolyte rich fluid loss;
N&V; diarrhoea; fistulae; diuretics;
cerebral salt wasting syndrome
– Rx 0.9% NaCl
HYPONATRAEMIA
(< 135MMOL/L)
Hypervolaemia: TURP-syndrome; cardiac
failure(sec hyperaldosteronism); renal failure,
cirrhosis – Rx fluid restriction and diuretics
Normovolaemia: SIADH, hypothyroidism,
Addisons – Rx hormone replacement and fluid
restriction
HYPONATRAEMIA
s-Na < 130 mM – postpone elective
surgery : increase risk for cerebral
oedema; delayed awakening
s-Na < 120 mM – high mortality
Correct slowly- can cause pontine
demyelinization
HYPERNATREMIA>145MM
Hypervolaemic: Hypertonic saline- Rx
loop diuretics + Dextrose water
Normovolemia: Diabetes Insipidus- Rx
desmopressien + Dextrose water
Hypovolemia: renal losses due to
osmotic diuretics, D&V, sweating – Rx
Dextrose water
HYPOKALAEMIA<3.5MM
Redistribution from extra to intracellular:
alkalosis; Ins; B- agonist
Decreased intake
Increased losses
ECG changes: Large p,prolonged pr, st
depression, t wave flattening, large u
wave, dysrhythmias
Rx: 20mmol – 40mmol KCl + 1g- 2g
MgSO 2
HYPERKALAEMIA>5MM
Redistribution from intra to extracellular
Increased intake
Decreased excretion
ECG changes: flattened p wave,
prolonged qrs and pr, tall T waves,
HYPERKALAEMIA
Treatment:
Kayexelate
Glu/Insulin
Lasix to promote excretion
CaCl2
- NaHCO3
- Dialysis
HYPERCALCAEMIA
 Ca = 2.2 mM- 2.6 mM
 Stones, moans, groans,
bones, severe dehydration,
reduces QT interval
 Rx.( 3.2mmol)
 Rehydration and forced diuresis
 Bisphosphonates
 Glucocorticoids
 Intravenous phosphate
HYPOCALCAEMIA
Anxiety, prolonged QT interval, convulsions,
hyperreflexia, (Chvostek’s and Trousseau’s
sign)
Life-threating hypocalcaemia due to massive
blood transfusion
Can be observed after thyroidectomy
Rx.
CaCl2 or Ca gluconate
MAGNESIUM
Hypomagnesaemia 
Torsades de pointes