Kelly Shinkaruk, MD FRCPC
HLT 123
October 17, 2009
1
Fluid Therapy Objectives
 Body Fluid Compartments
 Fluid Requirements
 Maintenance and Insensible Losses
 Fluid Deficit
 Third Space
 Blood Loss
 Types of Fluid and Resuscitation
 Crystalloids
 Colloids
2
Fluid Therapy Objectives
 Intravenous Access
 Sites for Line Insertion
 Advantages and Disadvantages
 Complication Risks
 Insertion Techniques
3
Fluid Therapy Objectives
 Body Fluid Compartments
 Fluid Requirements
 Maintenance and Insensible Losses
 Fluid Deficit
 Third Space
 Blood Loss
 Types of Fluid and Resuscitation
 Crystalloids
 Colloids
4
The Human Body
 Water composition
 1 – Males 55-60%
 2 – Females 50-55%
 3 – Infants 75-80%
5
Fluid Compartments
 60% water by weight
 Intracellular 2/3
Intracellular
 Extracellular 1/3


Interstitial ¾
Intravascular 1/4
Interstitial
Intravascular
6
Differences in Body Fluids
 Age and Gender:
 Prems – 90mL/kg
 Children – 80mL/kg
 Adult Male – 70 75mL/kg
 Adult Female – 60 65mL/kg
 Obesity:
 Water volume based on
ideal body weight (IBW)
 IBW = 50kg + 2.3kg per
inch over 5ft
7
Fluid Therapy Objectives
 Body Fluid Compartments
 Fluid Requirements
 Maintenance and Insensible Losses
 Fluid Deficit
 Third Space
 Blood Loss
 Types of Fluid and Resuscitation
 Crystalloids
 Colloids
8
Operative Fluid Requirements
 Deficits



Overnight fasting
Bowel preps: Liters of losses potentially
Diuretics
 Maintenance



GI losses:
100-200 ml/day
Insensible:
500-1000 ml/day
Urinary:variable, >1000 ml/day
 Ongoing Losses


Blood loss
Third space losses
9
Maintenance Fluids
 First 10 kg of body weight = 4 ml/kg/hr
 Second 10 kg = 2 ml/kg/hr
 Every kg over 20 = 1 ml/kg/hr
 80 kg person = 40 + 20 + 60 = 120 cc/hr
10
Fluid Requirements for Surgery
 Calculated per hour during OR:
 Fluid deficit (NPO for 6+ hours): 4/2/1
 Ongoing fluid requirements: 4/2/1
 Replacement of blood loss

Crystalloid 3:1, Colloid 1:1
 “Third-space” loss

4/6/8 rule:



4 ml/kg/h for minor surgery (hernias, wrist ORIF, breast)
6 for moderate surgery (gyne, ortho, thoracics)
8 for major procedures (major bowel, vascular, trauma)
11
Clinical example
 29 yo 70 kg male with
femur fracture for ORIF

NPO 12 hours
 Calculate deficit


½ over first hour
½ over the rest of the case
 Provide maintenance

4 - 2 - 1 Rule
 Replace losses


3 to 1 for bleeding
Third space (4-7 cc/kg/hr)
12
Calculation
 Deficit



Maintenance X hours NPO
110 cc/hr X 12 hours = 1320 cc
660 cc in first hour – the rest over the case
 Maintenance

4 – 2 – 1 Rule = 110 cc/hr
 Third spacing and bleeding

6 cc/kg/hr = 420 cc/hr
 1190 cc of crystalloid in the first hour alone
13
Fluid Therapy Objectives
 Body Fluid Compartments
 Fluid Requirements
 Maintenance and Insensible Losses
 Fluid Deficit
 Third Space
 Blood Loss
 Types of Fluid and Resuscitation
 Crystalloids
 Colloids
14
What is osmolarity?
15
What is osmolarity?
 Osmolarity: a measure of how many dissolved
particles are in the blood
 Equilibrium: dissolved particles “pull” water across
membranes so that total concentration of dissolved
particles (osmolarity) is equal on each side (give or
take, with some electrochemistry involved)
16
What is normal serum osmolarity?
17
What is normal serum osmolarity?
18
Osmolarity
 Hypertonic: more concentrated than plasma
 Hypotonic: less concentrated than plasma
 Isotonic: the same concentration as plasma
19
Osmolarity
 If you give too much hypotonic fluid, cells can swell
and burst
 If you give too much hypertonic fluid, cells can shrink
 Fast correction of electrolyte imbalances is BAD
 Where is this most important?
 The brain! WHY?
20
Types of Fluids
 Classification: based on their behaviour once given
 Mostly go to ICF: free water
 Stay in ECF: crystalloid
 Stay in plasma: colloid
21
Free Water
 Dextrose
5% or D5W
10 % or D10W
50% or D50W (low
volume packages)
IMPORTANT NOTE:
Pure water is NEVER given IV! It is very hypotonic and
will burst RBCs and cause electrolyte imbalances!
22
Free Water
 D5W: most commonly used
 D10W and D50W usually used for low blood glucose
levels, not free water deficit
 Stats:
 Dextrose 5gm/dL
 pH 5.0
 Osmolarity 253
 IV infusion: little stays intravascular
 Dextrose is actively transported into cells and water
follows it (equilibrium)
23
D5W
 Pros:
Treats hypoglycemia
Often used preop for
diabetic patients who are
NPO
Body needs sugar for
long-term NPO
 Cons:
No good for
resuscitation
Can cause hypoosmolarity and water
intoxication
May worsen brain
trauma
24
Crystalloids
 Used for fluid deficit, third space losses,
maintenance
 Equilibrates in ECF (plasma/interstitial)
 When infused: about 1/3 stays in intravascular
space, and after ~ 10 minutes, the other 2/3 has
diffused out of the plasma
 When administering for blood loss, must use 3-5L
for every 1L of blood
 Ex: 3L blood loss = 9-15L of RL!!

So we use other fluids for LARGE replacement!
25
Crystalloids
 Normal Saline
 Hyperosmolar 308 mosm/l


Sodium 154
Chloride 154
 Acidic relative to the plasma

pH 5.0
 Excessive administration results in:

Hyperchloremic metabolic acidosis
 1000 ml NS – redistributed along [Na]

Extracellular - ISF 750 ml, only 250 ml
stays intravascular
26
Crystalloids
Normal Saline
 Pros:
 Good for initial resuscitation
 Cheap
 Readily available, multiple
sizes
 Widely used for OR
maintenance fluid Compatible
with all drugs and blood
products
 Cons:
 Hyperchloremic,
hypernatremic
metabolic acidosis (Use
3L or less)
 Large sodium load
 Use care with heart
failure, renal failure,
brain injury, old age
27
Crystalloids
 Ringer’s Lactate
 Osmolality 279 mOsm/L






Na+
130 mmol/L
Cl110 mmol/L
Lactate 27 mmol/L
K+
4 mmol/L
Ca++ 3 mmol/L
pH
6.5
 Closer to physiologic pH and Osmo
28
Crystalloids
Ringer’s Lactate
 Pros:
 Good for resuscitation
 More “physiologic”
 Contains K
 Less hyperosmolar
than saline
 No hyperchloremia
 Cons:
 More expensive
 Not compatible with
some drugs or blood
 May worsen brain
swelling (not as bad as
NS)
 Use caution with
elevated K, renal failure
29
Colloids
 NS based fluids
 Contain osmotically active particles
 Large molecules unable to cross endothelium
 Provide colloid oncotic pressure
 Theoretically replenish intravascular volume and stay in
this compartment much longer than crystalloids
30
Colloids
Pentaspan ($70 per 500cc)
○
○
○
○
Normal Saline plus 10
g/100ml pentastarch
250 kDa Protein
pH 5.0
High Na load just as with
NS
Voluven






○
○
○
Renal excretion
70% cleared in 24 hours in
patients with normal GFR
Max dose 28 mL/kg over 24
hours (2 L)

Normal Saline plus 6g/100mL
hydroxyethyl starch
130 kDa Protein
pH 5.0
High Na load just as with NS
Renal excretion
70% cleared in 72 hours in
patients with normal GFR
Max dose 50 mL/kg over 24
hours (3.5L)
31
Colloids
 Pros:




 Cons:
Smaller infused volume
 No O2 carrying capacity
Replace blood loss 1:1
 Expensive
Prolonged ↑ Intravasc vol  Dilutional
coagulopathy
Less edema
 Pulmonary, peripheral
 Leaky capillaries =
interstitial edema
 Increased
anaphylactoid
reactions
32
Colloids
 Albumin
 Human blood product




Purified protein from human blood
Large osmotically active protein increases oncotic pressure
Available as 5% and 25% solutions
Similar risks to other blood products
 Half-life


1.6 hours in plasma = 8 hours plasma elimination
20 days in the body
 Increased morbidity compared to other colloids
33
Hypertonic solutions
 Hypertonic Saline



Available as 1.8%, 3%, 7.5%, 10% solutions
Increases extracellular osmolality
Promotes fluid shift from ICF to ECF
 Rare indications:


Trauma
Symptomatic acute hyponatremia (TURP syndrome)
 Unclear benefits – risk acute hypernatremia
34
Fluid Therapy Objectives
 Intravenous Access
 Sites for Line Insertion
 Advantages and Disadvantages
 Complication Risks
 Insertion Techniques
35
Sites for Line Insertion
 Peripheral Intravenous Access
 Central Intravenous Access
 Internal Jugular (IJ)
 Subclavian
 Femoral
 Intraosseous Access
36
Peripheral IV Access
37
Peripheral IV Access
 Advantages
 Easy to place
 Many points of access
 If unsuccessful,
compressible site
 Fewer complications
than central access
 Large bore access allows
rapid infusion of large
volumes
 Disadvantages
 Vein may be difficult to
access
 Not used for prolonged
administration of
vasoactive drugs
 Cannot be placed distal
to site of surgery or
injury
38
Central Venous Access
39
Central Venous Access
 Advantages
 Reliable IV access when
peripheral sites not
available
 Long term IV and
vasopressor therapy
 Large volume
resuscitation
 Disadvantages
 Special equipment
required
 Longer time to place
 Higher complication
rate
 Need for special skill
40
Complications
 Mechanical
 Arterial puncture (femoral > IJ > subclavian)
 Hematoma (femoral > SC > IJ)
 Hemothorax (only seen in SC)
 Pneumothorax (SC >> IJ)
 Cardiac Tamponade (SC = IJ)
 Infectious
 Embolic
 Wire/catheter embolism
41
Intraosseous Access
42
Intraosseous Access
 Advantages
 Venous access when
no other sites can be found
 Useful if difficult, delayed,
or impossible IV access
 Used in burns or other injuries
preventing alternate access
 Disadvantages
 Need for special
equipment and skill
 Requires pressure
bag to provide
reasonable flow of
fluids
 Osteomyelitis if
long term
43
Whaddya do now???
44
Kelly Shinkaruk, MD FRCPC
HLT 123
October 17, 2009
45
Blood Therapy Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
46
Blood
Therapy
Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
47
Blood Components
 Cells:
 Red blood cells: carry oxygen
 Platelets: imperative for clotting
 White blood cells: removed
 Fluid:
 Plasma: Fluid with proteins (albumin), clotting factors
 Proteins:
 Clotting factors II-XII
48
Blood Transfusion
 Autologous blood
 Recovered blood
 Pooled blood products
 No “whole blood” anymore
 RBCs
 platelets
 Plasma
 Cryoprecipitate, factor VII
49
Autologous Blood
 Pros:
 Person’s own bloodlow risk of transfusion
reactions
 Can donate up to 4
units
 Whole blood:
coagulation factors, etc.
 Cons:
 Anemic, heart disease,
transmissible diseases
not eligible
 Whole blood only
 Anemia from donation
 Expensive
50
Recovered Blood (Cell Saver)
 Pros:
 Person’s own RBCs,
washed
 No transfusion
reaction
 Can be used for some
Jehovah’s Witnesses
 Cons:
 Expensive
 Surgical
contamination
 Bone
 Infection
 Cancer?
 Not 100% recovery
51
Cell Saver
 When?
 Major vascular procedures
 Major ortho procedures
 Major trauma
 Sometimes used in neurosurgery/backs
 Scoliosis surgery
52
Cell Saver
53
Packed RBCs
 Pros:
 1 unit = Hb by 10 g/l
 Best replacement for
excessive blood loss
 Stays in vascular
compartment
 Mix with saline for
faster infusion
 Cons:
 Transfusion reactions
 Expensive
 Freshness
 Risk/benefit ratio
 Cold
54
Frozen Plasma
 Pros:
 Contains all
coagulation factors (V
and VIII unstable)
 Use for high
volume/ongoing
transfusion or bleeding
with coagulopathy
 used to be given for
elevated INR

 Cons:
 Can contain infectious
particles
 Fluid overload
Now we have octaplex!
55
Platelets
 Indications:
 Acute
thrombocytopenia
(platelet deficiency)
 Large volume
transfusion + bleeding
 One unit = increase
platelet count by 5-10
 Complications:
 Stored at room
temperature
 High risk of bacterial
contamination/sepsis
56
Cryoprecipitate
 Contains
 Factor VIII
 Factor XIII
 Von Willebrand’s Factor
 Fibrinogen (Factor II)
 Indications



Coagulopathy in massive bleeding and transfusion
Actively bleeding patients with Fibrinogen < 0.8-1.0 g/L
VWD or Hemophilia A (Factor 8 deficiency)
 Only in the absence of specific factor concentrates
 DDAVP is not available or ineffective
57
Blood Therapy Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
58
Indication for Transfusion
 Blood products administered for dangerous
levels of blood loss



Normal Hgb 120-150g/L
Healthy patients tolerate >70g/L
With systemic disease >90g/L
 Start with PRBCs
 Historically, transfuse Plts, FP, cryo only when
“indicated”
 low plts, surgical oozing, etc
 Now moving to PRBCs : FP : Plts (1:1:1)
59
Acceptable Blood Loss
 Depends on:
 Preop Hb
 Volume of blood loss
 Coexisting disease
 Cardiovascular disease
 Normal Hb level can be  by ~25% with little
stress…as long as intravascular VOLUME is
maintained!
60
Acceptable Blood Loss (ABL)
ABL= [ Hgbinitial – Hgbfinal / Hgbfinal ] X EBV
Example:
60 yo female for THR. Preop Hgb 120, Wt 75kg
We will accept Hgb of 75 post-op
EBV = 75kg x 60 cc/kg = 4500cc
ABL = [120-75 / 120] x 4500 = 1688 cc
We will allow her to lose 1700cc blood without transfusing her
61
Blood Volume
 How much blood do we have?
Preemie
Baby
90 ml/kg
80
Adult male
75 (less for obesity)
Adult female
65 (less for obesity)
“Acceptable loss” = ml/kg blood volume x kg body weight x % decrease in
Hb
62
Factors Related to Blood
Administration
 Consent
 Discuss options early therefore alternatives can be
considered
 Ensure all questions answered
 Type and screen
 Jehovah’s Witnesses
 Most will not accept allogenic products
 Must verify what they will/won’t accept
 DOCUMENT IT IN THE CHART!
63
Blood Sparing Techniques
 Procedures with high anticipated blood loss
 Preop techniques
 Erythropoietin + Fe – at least 2wks pre
 Autologous donation – at least 1mth pre
 Intraop techniques
 Antifibrinolytic therapy (tranexamic acid)
 Cell saver
 Controlled hypotension
 Tourniquet
 “damage control” surgery
64
Blood Therapy Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
65
Dangers of Blood
 Transfusion reactions
 Clerical error: most common reason
 Transmission of infectious particles:
 Viruses
 Bacteria
 Prions?


Mad cow
Kreutzfeld-Jacob
66
Dangers of Blood
Event
Risk
HIV transmission
1 : 4.1 million
Hepatitis C
1 : 3.1 million
Hepatitis B
1 : 82,000
Death from sepsis
1 : 500,000
Risk of sepsis is even higher with autologous blood and platelets!
67
Complications of Blood Transfusion
 Volume overload
 heart failure, pulmonary edema
 Temperature
 hypothermia from large amounts of cold blood/fluid
 Air
 if given under pressure, risk of air entering circulation
(air trapping in lung, heart, brain)
 Immune suppression
 non-specific suppression with blood product
administration
68
Complications of Blood Transfusion
 Incompatibility
 red blood cell, white blood cell, plasma antibody
reactions
 Most common reason: clerical error
 Dilutional coagulopathy
 Infection
 blood screened for HIV, Hep C/B, syphilis, others
 Not screened for all viruses!
69
Complications of Blood Transfusion
 Biochemical abnormalities
 Citrate: anticoagulant in pRBCs, binds calcium, may
necessitate calcium replacement
 Potassium: high concentrations in pRBCs, with low pH.
Interreaction of pH and K may mean high or low K after
transfusion
 Microaggregates
 tiny clots in pRBCs may lodge in lungs (TRALI)
70
Symptoms of Blood Reactions
 Pain, rash, hives, edema
 Fever, chills, nausea, vomiting, SOB
 BP, HR, O2 sat, mental status changes
 Pink or brown urine
 Circulatory collapse
TAKE-HOME MESSAGE
Any change in clinical condition after blood transfusion is suspect!! Stop
transfusion and treat aggressively!!
71
Complications: What to Do
 STOP blood product IMMEDIATELY!
 Notify other OR staff, blood bank.
 Send blood and samples from patient to lab.
 O2, drugs as necessary to support vital signs.
 Fluids, drugs to flush kidneys.
 Monitor for coagulation problems, treat as
necessary.
72
Transfusing Blood
 Does patient want blood?
 How much of this anemia is acute?
 Is blood loss more than “acceptable”?
 Will there be more blood loss? Is there a
coagulopathy causing this?
 Is the patient at risk from heart or vascular
disease?
 Have I tried to use other fluids without success?
73
Blood Therapy Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
74
Lab and Point of Care Testing
 Used for intra-op diagnosis
 Rapid assessment of blood measurements
 Helps guide ongoing therapy
 Different equipment
 Hemocue for Hgb
 Hemochron for PTT/INR
 iStat for ABGs, lytes, Hgb
 Traditional lab work also available – but takes far
longer!
75
Lab and Point of Care Testing
 Hemocue
 Used for rapidly
checking Hgb
 Easy to use, no need for
arterial access
 Not as accurate as
sending a CBC
76
Lab and Point of Care Testing
 Hemochron Jr.
 Measures coagulation
parameters
 PTT and INR
 No need for arterial
access
77
Lab and Point of Care Testing
 iStat
 Rapid assessment of
blood gases, Hgb,
electrolytes
 Need arterial sample
 More accurate than
Hemocue
 Same technology as
ABG sampling
machines
78
Lab and Point of Care Testing
 ACT (activated clotting time)
 Used during vascular procedures
 Monitors effectiveness of high dose heparin therapy
 Sample from undiluted site not contaminated by
heparin infusion
 Helps guide further dosing of heparin or reversal of
heparin with protamine
79
Blood Therapy Objectives
 Blood Components
 Blood Transfusion
 Pros and Cons of Blood Products
 Indications for Transfusion
 Acceptable Blood Loss
 Factors Related to Blood Administration
 Complications Related to Transfusion
 Lab and Point of Care Testing
 Administration Techniques
80
Administering Fluids and Blood
Products
 Ensure at least one functional IV
 Normal Procedure
 IV infusion set up
 Fluid warmer - not necessary, often if >2hr procedure or
possibility of blood transfusion
 Procedure with anticipated transfusion
 IV Blood set
 Fluid warmer essential
81
Administering Fluids and Blood
Products
 Some physicians now use infusion pumps
 Occasionally administer meds by infusion pump
 Vancomycin
 Insulin
82
Blood Set
83
Massive Transfusion
 Definition
 the replacement of TBV in less than 24 hours or…
 more than half the EBV per hour.
 TOH has a massive transfusion protocol
 In the binder
 Includes studies/point of care, order of blood products,
factor VIIa, etc.
 Rapid infusion – Pressure bags, Level 1
84
Fluid Warmer and Pressure Bag
85
Compatibility
 Packed RBC
 Frozen Plasma
 Cryoprecipitate
 Platelets
86
Administration Set
 Frozen Plasma
 Packed RBC
 Cryoprecipitate
 Platelets
87
Questions???
88