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&

12

12.1 ............................... 322


12.1.1 A .............................................................................. 322
12.1.2 (DO2) (VO2).................................................. 323
12.1.3 ................................................... 324
12.1.4 ...................................................................... 328
12.2 ..................................................... 333
12.2.1 ..................................................................................... 333
12.2.2 .................................................................. 334
12.2.3 ........................................................................................... 336
12.2.4 : ........... 339
12.3 ................................................................... 341
12.3.1 ................................................................. 341
12.3.2 .................................................... 344
12.3.3 ........................................................ 346
12.4 .......................... 349
12.4.1 ......................................................................... 349
12.4.2 ............................................................................................................. 350
12.4.3 ........................................................................351
12.4.4 ....................................................................... 353
12.5 ........................................................................ 354
12.5.1 .................................................................................................. 354
12.5.2 ............................................................................................ 357
12.5.3 ..................................................................................... 358
12.6 .................................. 362
12.6.1 ............................................................................................. 363
12.6.2 ....................................... 364
12.6.3 .......................................................................... 366
12.7 .............................................................................................................. 367
12.8 H (PBLD) ...................................................................... 368
12.8.1 - ...................................................... 368
12.8.2 ......... 369
12.8.3 .................................................................................. 369

12.1

,
:

(.. , )

.

,
.
:





.
12.1.1 A
,
,
,
.
,

. shock

(SIRS).

" " shock


:

- -
.
[ (1)]
:
(Q)
(Hb)
(Sa2).
, , (Hb)

.
Hb 10g/dl, ,

b . Hb
,
322

12 &

.
10g/dl Hb
.

, .
,
2-3 DPG, 12 36 .
Hb 9 g/dl Hb < 6.5 g/dl.
,
. Hb

. Hb < 9 g/dl.

,
.

,

, .
12.1.2 (DO2) (VO2)

H (DO2)
:
(Hb)
(SaO2)
2 (PaO2)
(Q)
:
DO2 = Q x CaO2
DO2 = Q x [(Hb x 1.31 x SaO2) + (PaO2 x 0.003)]
(1)
: CaO2 2, 1.31
2 Hb ml 2 /dl , 0.003
2 ml 2/dl /mmHg. :
5.000 ml/min, Hb 15 g/dl, SaO2 98 % PaO2 100 mmHg,
2 (DO2) = [19.2 + 0.3] x 5.000 = 19.5 ml/100 ml x 5000 = 975 ml 2
/min.

(VO2)
.
2, , 2,
,
, :
V2 = Q x [CaO2 - CvO2]
V2 = Q x [Hb x 1.31 x (Sa2 - Sv2) + (Pa2 - Pv2) x 0.03]
(2)
: CvO2 2, SvO2
2, PvO2
2 . 1000 ml/min 2
250 ml/min 25 %,
75 % . 75 %
.

323

oxygen extraction ratio (OER) V2 / DO2,


, 25 % . 55 %,

OER 7 % 10 % .
2
, ,
(.. shunts, , ).
(2) , :
Sv2 = Sa2 - V2 / [Q x Hb x 1.34]
(3)
Sa2, V2, Q, Hb,
SvO2.


(SvO2) ,
,
. monitor,
.
DO2,
PaO2
. PaO2 DO2
,
PaO2 .
,
.
H
(SvO2) ,
. :

.
, , .

,
DO2.
.
12.1.3


.

12.1.3.1
,
. :
55 60 % ():
,
kg .
45 50 %.
80 90 % .

324

12 &

. 12-1. 70
kg.


(%)
36
24
19
5
60


(%)
60
40
32
8
100

(L)
25
17
13.5
3.5
42

(. 12-1):
:
24 % .
,
.
, ,
:
5 % .

7.5 % .
,
:
19 % .
:
36 % .
12.1.3.2
:
:
95 ml/kg
:
80 ml/kg
:
80 ml/ kg
:
70 ml/ kg .
:
60 ml/ kg .

Ht :
= x x [to Ht1 / Htm]
: , Ht0 , Ht1
Htm [to Ht1].
12.1.3.3

, (.122).
,
.
:
325

, ,
(, ),

.
:

(
)

.
. 12-2. .

(mEq/l)
(mEq/l)
(mEq/l)
(mEq/l)
(mEq/l)
(mEq/l)
(mEq/l)
(g/dl)

(g)
23.0
39.1
40.1
24.3
35.5
61.0
31.01

10
150
<1
50
4
10
75

145
4.5
3
2
105
24
2

142
4.5
3
2
110
28
2

16

12.1.3.4

:
:





:


.

(Na+ < 135 mEq/L)
.
+
125 < < 135 mEq/L:

120 < + <125 mEq/L:
, , ,
+ < 120 mEq/L:

+ < 110 mEq/L:
1 PO4-3 95 g.

326

12 &

, ,
.
+ :
+ (mEq/L) = [140 - + ] x 0.62 x
+
+ . :
+ 120 mEq/L + [140 120] x 60 L = 1200 mEq/L.

( 15.4.1).

(Na > 145 mEq/L)


:
145 < + < 155 mEq/L:
, ,
a+ > 155 mEq/L:
, , .
12.1.3.5

,
(
, ),
.


.

(osmolarity) 3
( ) .
285 295 mOsm/l :
O (mOsm/l) = [Na+ x 2] + [/18] + [/2.8].

(osmolality),
. 285
295 mOsm/kg.

.
a+ :
(mmHg) =19.3 x O


(tonicity).
,
,
.

:
2 x 0.6 0.5 .
3 , ,
sm. (msm)
1/1000 .

327

,
, )

(.. )
"" (.. ).
:
(
)
( .. , ,
) .

()
.

Starling:
Q = [(Pc - Pi) + ( - c)]
Q = , = , =
, [Pc Pi] =
, = ,
[ c] = ().


[Pc Pi], ,
, [ c], .
Starling :
:
> 25 - 30 mmHg

:
15 mmHg ( )
.

.

.

.
,
.
.

.
12.1.4

,

/
. H ,

.

328

12 &

monitoring :

.
:



.

, ,

.
12.1.4.1
,
.

:


.
:



.
:
2 4 L .
:
, 0.5 ml/kg/h
, 12 % oC >
37 oC.
.
:


.

:


.

.

(. 12-3)
:




329


()
()
.

. 12-3. .

5%

(% )
10 %

15 %


(.. stress)
.
, :
: ,
,
,
.
:
30% .
( 20 mmHg 20 /min) 20
% .
20 %
, , .
,
,
.
: ,
.
:
(< 0.5 ml/kg/h)
15 %
.
.

,
() :


.
> 1 ml/kg/h, ,
.
.
:

:


330

12 &



.
12.1.4.2

, :

pH



.

. :
:
.
2. .

:

(
)
> 1010
< 10 mmol/l
> 450 mOsm/kg

> 10:1.


. :
/
.
12.1.4.3


.


:

.

schok schock:
schock = / = 0.5 0.8.
schok 2.5.
2 2
.

331


(, 9.3.2.2)
.
< 5 mmHg, ,
.
> 12 mmHg, :


.
250 ml, :
1 2 mmHg
> 5 mmHg
.



(SvO2).
,
(PCWP),
.
, ,
:


.
:
()


.
PCWP ( 9.3.2.2) :

, :
,
, .
PCWP.
PCWP
.
PCWP < 5 mmHg,
.
PCWP < 15 mmHg,
.
PCWP > 20 mmHg, .



.
.

.

332

12 &

Doppler
.


.
.
:
(CI)
2 (VO2)
2 (DO2)

.

(bacteria translocation)
(SIRS).


.
pH (pHi)


.
2 .

:
,



.

12.2

12.2.1
()
,
, .

:
:
, .


:
, .

.
:
333


5% ,
.

Ringers Lactated ,
.
109 mmol/l 28 mmol/l (. 12-4)
.

.
NaCl 0.9 % ( )
(154 mmol/l) (110 mmol/l),

, ,
(. 12-4).

NaCl 7.5 %, 2400
mosm/l.
,
. Ringers Lactated
:
,
20 %

3 ,

.
. 12-4. (
1000 ml).

NaCl 0.9 %
NaCl 0.45 %
5 %
Ringers
Lactated

pH
5
5.2
4
6.5

(mosm/l)
308
154
253
273

Na
(mmol/l)

K
(mmol/l)

Cl
(mmol/l)

(mmol/l)

(g/l)

154
77
130

154
77
109

28

50
-

12.2.2

shock, shock, ,

.

:

:

1.23 l ( 350 % ).

.
334

12 &

:
shock ,
,

.

.
:


.

.

.
.
.

:
( 24 - 48 )



.
. 12-5. .

-
( 3% 7.5% )




(> )



()






(. 12-5) :
:
335




:
.
30 - 60 min.
4 - 6 ml/kg
5 - 15 min .

,
(NaCl 7,5% 4 - 6 ml/kg)
.
12.2.3

.
H
.
20 - 30 min, 3 6 (. 12-6).
.
H :




2
().
:
( > HES)
()
(, HES)

Ca ++ ()

(HES)

:

( shock)

(.. ),

3 - 4 .
.
Y ,
, (. 12-8),
. .

336

12 &

. 12-6. ( Anesth Analg 1996;


83: 209-212).

(dalton)

(%)
(mmHg)

80
35.000
**
K
2 - 3
5%
100
69.000
19

15
20%
350
69.000
78

< 1
70
120
70.000
40

3 - 12
40
200
40.000
>100

2
6% etastarch
100
450.000
30
0.7
17
6% Voluven
100
130.000
???
0.4
6-12
* (
) .
.
** .
______________________________________________________________________

12.2.3.1 ( 5 % 25 %)
60 80 %
.
.
60C .
(< 3.0 %)
, , , .

.


.
12.2.3.2


10 90.000 daltons.


,
. :
70 (acrodex)
40 (Rheomacrodex).
6 2 .
:
,
VIII
(
)
(1-5%) : , ,
, ,

(
40).
:
337



.
: 1.5 g/kg 20 ml/kg /.
12.2.3.3

35.000

daltons,

:
:
Haemacell, Gelofusine.
(urea- crosslinked gelatins:
Polygeline.
:
Gelifundol.
(6.25 mmol)
.
pH,

.
.
3 - 4 (. 12-6).
:

,
.
.
.
.
. 12-7.
.


6 % 70
6 % HES 450/0.7
6 % HES 200/0.62

10 % 40
6 % HES 200/0.5
6% Voluven 130/0.4

6 % HES 70/0.5
3 %
5 %


(h)
5-6


(%)
100
100
100

3-4
175- 200
100
100
1 -2
70
70
70 - 90

12.2.3.4 Y (ydroxyethyl Starches = HES)

Y-
, .

.

338

12 &

HES
(
.
. 50.000 daltons 48
,
.


,
.
:
HES 450/0.7 (. 11-7), (450.000 daltons)
(0.7)
Pentastarch HES 280.000 daltons
Pentafraction Pentstarch
100 - 500.000 daltons.

Voluven 130.000 daltons, 0.4.
Voluven
50 mg/kg.
:

VIII
von Willebrand.

20 mg/kg/
, .
12.2.3.5
NaCl 7.5% ,
(HES 6% 200.000 daltons) 70 ( 6%).
2460 -2560 mosml/L.
-
.
(4 mg/kg)
.
shock
.
12.2.4 :


,

.

.

.
Ringers Lactate NaCl pH,

.
339

12.2.4.1


, .

.
,
,
.


.
12.2.4.2
:
,
,
,
,


-



:



.

( )

.
(PCWP) .
" " (capillary leak),
.

,
, , shock, ARDS, .

,
.

.
:

( ).

H
.
340

12 &

(10 % S)
,
2 (DO2) ,
.

.
. (
, ) .

12.3
12.3.1


.
(ADH), (RAAS)
()
.
:
,

,
.
ADH, RAAS, stress
.
12.3.1.1
:
=
x [ / ].
: 500 ml
70 kg ( = 42 L, = 3 L, =
14 L) :
5 %:
5 % = 500 ml x [42 l / 3 L] = 7 L
Ringers Lactated:
Ringers Lactated = 500 ml x [14 L / 3 L] = 2.3 L.
,
:
+ :
Ringers Lactated Cl 0.9 %: +

Cl 0.45 %:

Cl 1.8 %:
.
+ ( 5 %) :

.
341

.

.
14.3.1.2

,
.

,
.
( )
,
,
.
, ,
80 % .
.
:
,
.

.

:



.
. 12-1. "" ( ICF =
, ISF = , PV = ).



:
342

12 &

,
,
( 4 x 4 cm = 10 ml , = 100 150 ml )
( 20 %
)
t,
.
.

:

.
.
:

,
. Shires

,
, " " (. 12-1).

" "


. " "
.

.
1 - 3
.

(Ringers Lactated 0.9 % NaCl)
1 - 2 ml/kg/h.
:
3 ml/kg/h
6 - 8 ml/kg/h
10 - 19 ml/kg/h.
:
.

, , ,
.
, a+, K+ (
)
. .
"4 2 1"
:
4 ml/kg/h 10 kg
2 ml/kg/h 10 kg
1 ml/kg/h kg > 20 kg.
: 70 kg 10 :
(40 + 20 + 50) ml/h x 10 h = 1100 ml.

343


.

:





.

(. 12-8)
. > 1000 ml
(. 12-2).
. 12-8.

Na
(mEq/l)
30 - 50
2 - 40

K+
(mEq/l)
5
10 - 30

Cl(mEq/l)
45 - 55
6 - 30

10 - 30
70 - 140
115 - 180
130 - 160
40 - 135
20 - 160

5 - 40
5 - 40
5
5
5 - 30
10 - 40

80 - 150
55- 99
55 - 95
90 - 120
20 - 90
30 - 120

HCO3(mEq/l)
30
5 - 25
60 - 110
30 - 40
20 - 30
30 - 50

12.3.2

,

.
10 % :

> 20 % :
, , .

,
.


,


.
.

.
:

(. 12-9).
344

12 &


, ,
.
:
1.5 2 ml/kg/h .
, .

5 %, ,
, .


.
Ringers Lactated (. 12-9):
( 4-2-1)
3 4 ml/kg/h .

.
.
, ,


- a+.
:
( )
a+ ( a+

).
. 12-9. .
1 :
:
4-2-1
2 :
:
3 - 4 ml/kg/h *
5 - 6 ml/kg/h **
7 - 8 ml/kg/h ***
3 :
:
( )


4
:


1 ml/kg/h
*
**

345

***



.
a+
2 L
13 % .
Ringers Lactated
10 %. ,
, Ringers Lactated
(. 12-9):
7 ml/kg
6 ml/kg/h.

(
, ) 8-10 ml/kg/h

monitoring (. 12-9).
24 %
15 % a+, , ,
- .
12.3.3


.
.

:
( )
( )
.
,

.
.


.
12.3.3.1

.


1/3 2/3 .
,
.
,
, ,
,
.
346

12 &


DO2. ,

.

1 ml 3 ml .
2/3
1:10.


.
2 DO2
.
. 12-10.
. 12-10.
1.000 ml.

5 %
Ringers Lactated
5 %
25 %

(ml)
1.000
1.000
1.000
1.000

(ml)
14.000
4.700
1.000
250

(ml)
+ 3.700
+ 3.700

(ml)
9.300

- 750

,
.
, .

,
,
. 30 %

.
: :
40 %
,
30 %

.
12.3.3.2

.
,
shock.


.

.
347

,
(. 12-9):
( )

.

: 2 - 3 L Ringers Lactated
20 ml/kg
.
:
(NaCl 7.5 % 4 - 6 ml /kg)

,
( 12.2.3).
:
4 /ml/kg 2 - 5 min

.
( )

.
.


.
,
.
12.3.3.3

(small volume resuscitation)


( 2 min) (.. 4 ml/kg ) (7.5 % NaCl / 6 % Dextran 60)
.
(30 - 60 min)
NaCl
.
6 %
70 (1g 20 ml ) 6% -
200.000 (. 12-11).
:
( )

:
,
,

,


.
348

12 &

. 12-11.



, :


.
:



,
.
4 - 6ml/kg 2-5 min.
:



.

12.4

1940
Rhesus, ,
,
, , , .
,
.

.
,
,
. (
)
, .
12.4.1
-, -
,
HTLV-1 ( 1 /), CMV ()
HIV ( AIDS),
.

:
349


( ),

.
Hb
. Hb
,
.
,
, , .
1988 ()
:

30 %

21 % 7 g/dl ..
6 g/dl


8 g/dl
, ..
10
g/dl.
.
Hb
,
.

, ,

,
.

.
FFP.
( )
, A .

- .
Rhesus.
12.4.2


.
/ CPD-A 35 4C. CPD-A
:
350

12 &

(C), Ca++

(),
2,3 DPG ( )
(D) (),
.
(. 12-12):



.
, 4 C :



, CPD-A 5
70 %
ATP 2,3 -DPG

+, +
VIII 50 80 %

XI 20 %
V 50 % 10-14 .

,
.
. 12-12.
.
(ml)
(ml)
(g)
(g)
+
Na (mEq)
K+ (mEq)
-


517
200 (40 %)
12.5
6.25
45
15
1:1


300
200 (70 %)
4
2
15
4
4:1

12.4.3
12.4.3.1
,
. T

. NaCl 0.9 %.
5 % ,
Ca++, Ringers Lactated, , Ca++
() .
, .

. 12-12.

351

:

.
12.4.3.2

.
.
20 - 24C pH.
.
1 7 .

50 ml
5.000 7000 1 2 % V VIII.
:



1.5

15.000 20.000/ml.

< 50.000/dl
.

100.000/dl.
12.4.3.3
(FFP) 6
-30C,
. FFP
.

200 - 250 ml
2 3 % (V, VIII) .
10 15 ml/kg.
:



(DIC)


.
FFP ,

(HIV), .
. , FFP 37C
.
12.4.3.4
:
352

12 &

(FFP),
, (10 5.000).

,


.
.
:

60 80 %,
1g 60 17.4 ml .
5 % 25 % ( 11.2.3.1)

.


. , IgE, IgM, IgA
.

,
4C.
, VIII,
(
10 37C. :

(DIC)
von Willebrand.


100-150 mg %.

:
IX
- , VII
.


.

, .
, HBV, HCV, HIV1, HIV2,
(> 2000 ).
12.4.4
" "

,
.
, :

shock

353

(AIDS)

:
,




.
:


.

12.5
12.5.1


24 10 20

35 ml/kg/h.
shock
.


. ,
.
.

.
12.5.1.1

.
.

. 21
, , , V, VIII,
.
V
V , 21
55 % ,
.
VIII
V , 21
30 % ,
354

12 &


() ().
37
% VIII.

, 7
.
,
37 %
.. 250.000 92.000. 100.000
, 50.000
.
.

FFP.
12.5.1.2

,
, 63 %
.
, 5
()
(FFP) 37 % (..
37 % x 14 g = 5.2 g) 37 %
( 37 % x 5.2 g = 1.9 g).

, .
.
12.5.1.3

> 30 0C, .
,
33 0C
5% .
shock.

.
5 %
33 0C.
12.5.1.4
ACD
pH 6.5
. CPD pH 7.1
17 pH 6.7.
:

CO2
.
CO2

355

.
,
.
12.5.1.5

.


(172 meq/l) .
163 meq/l.
.


17 mmol/l 21 .
4 meq .
100 ml/min
shock 7.8 meq/l.
, 25 g
5 10 min.
.

.

.
,
5 min.
,
.
10 .


+ C++
, ,
QRS ST QT.
.
12.5.1.6
:

,
2-3 DPG
50 ( 2 50 %
). 50 27 mmHg, , 19
- 23 mmHg 25 % 2 .
PaCO2, p
.

:


, .
356

12 &

12.5.2
,



, .
,
,
,
. ,
, ,
, .
:
B C
HIV-1 HIV-2
(HTLV-1 , HTLV-2)
(CMV) Epstein-Barr (EBV).


3:10.000
.

12.5.2.1


7 10 %. 90 %
C.
< 1 % ( 1:150 1:5.000 ). 75 %
, 50 %
10 20 % .

.
AIDS :
HBV 1:200.000
HCV 1:3.000 .
(DS)
HIV 1:200.000
. HIV 1
.
anti-HIV- 1 , .
6 - 8
,
. HIV-2,
AIDS .
AIDS 1:40.000
1:3.000.000 (1:225.000 HIV-1+2).
HIV-1+2 , ,
.

,
,

.
357

12.5.2.2
(CMV) Epstein Barr (EBV)
.

.
( )
CMV .
CMV .
HTLV-1 HTLV-2

. parvo-

.

.
12.5.2.3
,
, ,
. ,
, ,
.
.
,
,
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12.7
1. American College of Physicians: Practice Strategies for Elective Red Blood Cell
Transfusion. Ann Intern Med 1992; 16: 403-406.
2. : - .
1994; 28: 79-94.
3. : Hb .
1993; 27: 133-136.
4. Bickell WH, Wall MJ, Pepe PE, et al: Immediate versus delayed fluid resuscitation
for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331:
1105-1109.
5. Bihari D. et al: The effects of vasodilatation with prostacyclin on oxygen delivery
and uptake in critically ill patients. N Eng J Med 1987; 317: 397-403.
6. Boldt J. Volume replacement in the surgical patient does the type of solution
make a difference? BJA 2000; 84:783-793.
7. Bryan-Brown CW: Oxygen Transport in the critically ill patient. Clinical
Anaesthesiology 1992; 6: 25-38.
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583-585.
9. Deitch FA: Multiple organ failure. Pathophysiology and potential future therapies.
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10. Dietz NM, Joyner MJ, Warner MA: Blood Substitutes: Fluids, Drugs or Miracle
Solutions? Review article. Anesth Analg 1996, 82: 390-405.
11. Edwards JD: Treatment of Hypovolemic Shock. Year book of Intensive Care
Medicine 1994; 20: 927-935.
12. Edwards JD: Oxygen Transport Following Major Trauma. In: Vincent JL (ed).
Update in Intensive Care and Emergency Medicine. Springer-Verlag, Heidelberg,
1988, pp 25-31.
13. dwards JD: A New Debate: Colloids versus colloid? In: Vincent JL (ed). Update
in Intensive Care and Emergency Medicine, Springer-Verlag, Heidelberg, 1995,
pp ???.
14. Fleming A, Bishop M, Shoemaker W, et al. Prospective trial of supranormal values
as goals of resuscitation in severe trauma. Arch Surg 1992; 127: 1175-1181.
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(Suppl. 14): 35-37.
16. Hillaman K: Fluid therapy. Anaesth Analg 1989; 16: 105-124.
17. Kramer G.C, Wallfisch HK: Recent trends in fluid therapy. Current Opinion in
Anaesthesiology 1992; 5: 272-277.
18. Jones JA: Red blood cell substitutes: current status. BJA 1995; 74: 697-703.
19. Kreimeier U: Hypertonic saline in Haemorrhagic shock. ESA Refresher Course
Lectures 1995, pp 123-134.
20. Landers D F, Hill C E, Wong K C, Fox IJ. Blood Transfusion - Induced
Immunomodulation. Review Article. Anesth Analg 1996; 82: 187-204.
21. Leone BJ, Spahn DR. Anemia, hemodilution and oxygen delivery. Editorial.
Anesth Analg 1992; 75:651-653.
22. Lichtenstein , WF Eckhart, KJ Swanson, CA Vacanti, WM Zapol: Unplanned
intraoperative and postoperative hemodilution: Oxygen transport and
consumption during anaemia. Anesthesiology 1988; 69; 119-122.
23. Lindahl GE: Thinner than blood. Anaesth Analg 1995; 80: 217-218.
24. Miller RD: Current Perspectives on Blood Transfusion. ASA Refresher Courses
1992; 20: 57-60.
367

25. - : . 1983; 43: 244248.


26. Miller RD: Coagulation and packed red blood cell transfusions. Editorials. Anesth
Analg 1995; 80: 215-216.
27. National Institutes of Health Consensus Development Conference Statementon
Perioperative red cell transfusions. 1988; 7: 27-29.
28. Prough DS. Perioperative fluid and electrolyte management. Anesth Analg 1990;
68:14-23.
29. Prough DS: Perioperative Fluid and Electrolyte Management. Anesth Analg
1990; 68: 14-23.
30. Ramsay JG: Methods of Reducing blood loss and non-blood substitutes. Can J
Anaesth 1991; 38: 595-612.
31. Ratner EL, Smith GW: Intraoperative Fluid Management. Surg Clin North Amer
1993; 73: 229-241.
32. Silvergleid: Preoperative autologous donation: What have we learned?
Transfusion 1990; 31: 119-121.
33. Takaori M. Perioperative autotransfusion: aemodilution and red cell salvaging.
Can J Anaesth 1991; 38:604-607.
34. Task Force of the Britich Committee for Standards in Haematology, lood
Transfusion. uidelines for autologus transfusion. Clin Lab Haematol 1998; 10:
193-201.
35. Taylor RJ, Pearl RG: Crystalloid versus Colloid: All Colloids are not created
equal. Editorial. Anesth Analg 1996; 83: 209-212.
36. Pepe PE: Controversies in resuscitation: to infuse or not to infuse. Editorial.
Rescuscitation 1996; 31: 7-10.
37. van Woerkens ECSM, Trouwborst A, van Lanschot JJB: Profound Hemodilution:
What is the Critical Level of Hemodilution at which Oxygen Delivery-Dependent
Oxygen Consumption Starts in an Anesthetized Human. Anesth Analg 1992; 75:
818-21.
38. Vincent JL: The relationship between oxygen demand, oxygen uptake and oxygen
supply. Int Care Med 1990; 16 (Suppl 2): S 145-S 148.
39. Wedgwood JJ, Thomas JG: Perioperative haemoglobin: an overview of current
opinion regarding the acceptable level of haemoglobin in the perioperaive period.
Review. Eur J Anesthesiol 1996; 13: 313-324.
40. Wheatley T, Veitch PS. Effect of blood transfusion on perioperative
immunocompetence. BJA 1997; 78:489-492.
12.8 H (PBLD4)

12.8.1 -

70 , 70kg,
. .
, 20 mg/dl,
1.5 mg/dl b=12.4g/dl,.

4 PBLD = Problem based learning discussions

368

12 &

4 .
900ml 750ml
3500ml Ringer's Lactated.
1 =
130/70 mmHg 18 /min. 20 ml
Hb = 10.4, Na = 130 mEq/L, K = 3.8
mEq/L, PaO2 = 156 mmHg, PaCO2 = 38 mmHg, Cl = 104 mEq/L, pH=7.29, = - 10
mEq/L .

1.
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12.8.2

55 , 73 kg
.
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mEq/L, 82 /min / .

.

monitoring

.
140/75 mmHg, 71 /min, 9 cm H2O, SpO2 99% TCO2 37 mmHg.
60 ,
2400 ml, 95/50 mmHg,
2 cmH2O, SpO2 95% TCO2 31 mmHg.
Hb = 8.3 g/dl, Ht 22% , PaO2 = 96 mmHg ( FIO2), PaCO2 = 38
mmHg, pH=7.29 BE -5.
,
22/min, 106 /min, -
54 mmHg .

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;
12.8.3

369


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370