Professional Documents
Culture Documents
Dr. Pangkuwidjaja P
Exsanguination
Predictors of death
Estimated blood loss > 5,000 mls
Red cell transfusion > 4,000 mls
Total blood transfusion > 5,000 mls
OR fluid transfusion > 12,000 mls
Transfusion rates > 12 mls/min
pH < 7.2
Temp < 34C
HCO3 < 15 mmol/l
Therapeutic infusion
further alters compartmental volumes
and composition
Emergency Resuscitation
How much?
What Fluid?
Which Endpoints?
FLUID THERAPY
Resuscitation
Crystalloid
Colloid
Maintenance
Electrolytes
Nutrition
1. Replace normal
loss (IWL + urine +
faecal)
2. Nutrition support
66% ICF
Intracellular Fluid
28 L
Total body
water
33% ECF
Interstitial Fluid
11 L
Plasma
3L
70 kg male TBW
Water Homeostasis
Ingested fluids
Solid food
Metabolic water
1300
800
400
ICF
ECF
Skin
Lungs
500
400
Urine
1500
Faeces 100
Solutes
10 HPO4150SO4-4 HCO3Prot
Water
114
30
Water
280 310 mOsm/l
ICF
ECF
H2O
H2O
ICF
H2O
ECF
Na+
Na+
Na+
Na+
Na+
ICF
ECF
Isotonic = NO Water Exchange
H2O
H2O
Dynamics of IV Fluids
Water solution Intracellularly
All hypotonic solutions e.g. 5% dextrose called as maintenance type
of fluids
Electrolyte solutions
Interstitial compartment
Isotonic
Called replacement of fluids
Electrolyte Contents
Electrolyte contents (mEq/l)
+
g/L
Solution
Na
Cl-
K+ Ca2 Glucose+
Lactate
R/Plasma
Osmolarity
(mOsmol.L1
)
Hypotonic
253
Hypotonic
154
!! Isotonic
273
Isotonic
308
Dextrose 5%
(D5W)
50
NS
77
77
Lactated Ringer
130
109
N Saline
154
154
D5 NS
38.
5
38.5
50
!! Hypotonic
335
D5 NS
77
77
50
!! Hypotonic
432
3% S
513
513
Hypertonic
1026
28
Vasodilatory factors
Intrinsic renal
autoregulation
Renal vasodilatory effect
of prostaglandins
Colloid
Intravascular persistance
Poor
Good
Haemodynamic stabilisation
Transient
Prolonged
Large
Moderate
Obvious
Insignificant
Poor
Good
Risk of anaphylaxis
Nil
Low to
moderate
Reduced
Maintained
Cost
Inexpensive
Expensive
Persistence of Fluids in
Circulation
IMG_2009
H2O
750 ml
estimate
Class I
Class II
Class III
Class IV
750
750 - 1500
1500 2000
2000
15
15 - 30
30 - 40
40
Fluid replacement (3 :
1 rule)
crystalloid crystalloid
crystalloid
and blood
crystalloid
and blood
Pulse rate
< 100
> 100
> 120
14
BP
normal
normal
decreased
decreased
Pulse pressure
Normal or decreased
increased
decreased
decreased
normal
positive
positive
positive
14 20
20 30
30 40
> 35
30
20 - 30
5 - 15
negligible
Mental status
anxious or
confused
confused or
lethargic
Hemodynamic Parameters
Parameter
findings
Comment
HR
Increase
BP
Decrease
CVP
Decrease
< 5 mmHg
Increase
> 1 2 mmHg
> 5 mmHg
> 12 mmHg (rule out RV
dysfunction)
PAOP
Decrease
< 8 mmHg
> 12 mmHg (rule out LV
dysfunction)
Findings
HCT
Increase
pH
< 7.36
> 1010
UO
Urinary Sodium
< 10 mEq/L
Urinary Osmolality
Blood Na+
BUN/creatinine
> 10:11
M 0.4 0.55
F 0.36 0.47
Fluid Requirement
0-2 ml/kg/hr
Moderate (e.g.
cholecystectomy)
2-4 ml/kg/hr
4-8 ml/kg/hr
Maintain normovolemia
till the danger of anemia outweighs
the risk of transfusion
ie. 7-8 Gm/dl (HCT of 21-24%)
Blood volume
Premature
95 mL/kg
Full term
85 mL/kg
Infants
Adults
80 mL/kg
Men
75 mL/kg
Women
65 mL/kg
65 ml X kg 85 = 5525 ml
267 X 3 = 801 ml
Decision:
should be based upon the clinical judgment that oxygencarrying capacity of the blood must be increased to prevent Vo2 from
outstripping Do2
Do2 = Cao2 x CO x 10
: 55 70%
: 7 10%
The heart
has a high extraction ratio
must rely upon redistribution blood flow to O2 supply
greatest risk !!!
Chronic anemia
CO may not change until Hgb decreases to 7 8 g/dl
synthesis of supranormal level of 2,3 DPG begin at Hgb 9
g/dl
right shifted
Inability to redistribute CO
Low SVR state (sepsis, post-CPB)
Occlusive vascular disease (cerebral, coronary)
Abnormal Hemoglobins
Presence of stored Hgb (decreased 2,3-DPG)
Hgb S
Patient
Consent
4
12
Low Risk
High Risk
Younger patient
Slower blood loss
Chronic anemia
Temporary intra-op
hypothermia or
hemodilution
Atherosclerotic
vasc. Dse
Perioperative
ischemia
Pulmonary dse
Rapid blood loss
Anticipated post-op
blood loss
8
Acute Blood
loss and
hypovolemia
10
Compatibility testing
The cross-match
Donor RBCs mixed with recipient serum
stimulating the actual anticipated transfusion
3 phases
1. Immediate phase
2. Incubation phase
3. Antiglobulin phase
Is cross-match necessary?
ABO-Rh status alone
With antibody screen
With complete cross-match
99.8% compatible
99.94% compatible
99.95% compatible
Citrate intoxication
Citrate prevent coagulation of stored blood
by chelating ionized Calcium
large volume (>1 blood volume)
administered rapidly (> 1 ml/kg/minor 1 unit/5 mins)
impaired liver function
temporary reduction of ionized Ca levels
Signs:
hypotension
narrow pulse pressure
VEDP
CVP
ECG
prolonged QT interval
widened QRS complexes
flattened T waves
Acid-base Changes
CPD pH to 7.0 7.1
during storage
ongoing metabolism of glucose to lactate
production of CO2
Citrate metabolized to bicarbonate
Decreases in 2,3-DPG
left shift of O2-Hgb dissociation curve
less efficient O2
Hyperkalemia
to maintain electrochemical neutrality
H+ generated during storage
RBCs lysis
with normal infusion rate K+ is distributed
rates > 90 120 ml/min hyperkalemia
aggravated by
hypovolemia
hypothermia
acidosis
Hypothermia
from rapid transfusion of large volumes of cold blood
stored at temp 1 6C
CO
tissue perfusion impaired
vasoconstriction
left-shifting of O2-Hgb dissociation curve
metabolic acidosis
shivering
O2 consumption by 300-400%
hemostatic dysfunction
citrate toxicity
ventricular irritability
Dilutional coagulopathy
platelets
clotting factors
V and VIII
hemolysis
release hemoglobin to the blood
renal damage
renal blood flow
mechanical obstruction in the renal tubule
free Hgb, RBC stroma
deposition of antigen-antibody complexes (G)
deposition of fibrin (DIC)
Signs and symptoms
fever, chill, nausea and vomiting
hypotension and tachycardia
flushed and dyspneic
chest and back pain
restless
hemoglobinuria
diffuse bleeding
renal failure
Coagulopathy
Hypothermia
Citrate toxicity
Hyperkalemia
2,3 DPG
Emergency Transfusion
Choices:
Type-specific partially cross-matched blood
Type-specific uncross-matched blood
O-negative (universal donor) PRBCs