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FLUID AND BLOOD
RESUSCITATION
PRESENTER – ASHRAY . V
BODY FLUID COMPARTMENTS
• Total body water content = 60% of total body weight.
• Intracellular Fluid : 2/3 (40%)of TBW
• E...
CAUSES OF HYPOVOLEMIA :
Hemorrhagic hypovolemia
 Pulmonary parenchymal trauma
 Pulmonary vascular injury
 Intercostal v...
Nonhemorrhagic hypovolemia
• GI disorders: vomiting, diarrhea, ascites
• Burns
• Environmental exposure or neglect
• Renal...
Aim of Fluid resuscitation
• Early, complete restoration of tissue
oxygenation.
• Minimal biochemical disturbance
• Preser...
FLUID RESUSCITATION
How to know that the patient has Hypovolemic Shock?
The patient has the following sings and symptoms:
...
Composition of Different Fluids
Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3
- Dextrose mOsm/L
ECF 142 4 5 103 27 280-310
L...
The Influence of Colloid & Crystalloid
on Blood Volume:
1000cc
500cc
500cc
500cc
200 600 1000
Lactated Ringers
5% Albumin
...
Replacing Third Space Losses
• Superficial surgical trauma: 1-2 ml/kg/hr
• Minimal Surgical Trauma
(head and neck, hernia,...
Crystalloids
 Combination of water and electrolytes
Balanced salt solution: electrolyte composition and osmolality
simila...
A- 0.9% sodium chloride (Normal Saline)
 Contains only water, sodium (154 mEq/L), and chloride
(154 mEq/L).
 It's called...
When to be given?
1- to treat low extracellular fluid, as in fluid volume deficit from
- Hemorrhage - Severe vomiting or d...
When to be used?
• Fluid losses due to burns and trauma
• To replace GI tract fluid losses ( Diarrhea or vomiting )
• Pati...
Both 0.9% sodium chloride and LR may be used in many clinical
situations, but patients requiring electrolyte replacement (...
• It is considered an isotonic solution, but when the dextrose is
metabolized, the solution actually becomes hypotonic and...
 It provides 170 calories per liter, but it doesn't replace electrolytes.
 The supplied calories doesn't provide enough ...
- D5W shouldn't be used in isolation to treat fluid volume deficit
because it dilutes plasma electrolyte concentrations.
-...
 Be aware that patients being treated for hypovolemia can quickly
develop hypervolemia (fluid volume overload) following ...
 Frequently assess the patient's response to I.V. therapy,
monitoring for signs and symptoms of hypervolemia such as:
hyp...
 monitor for signs and symptoms of continued hypovolemia,
including:
 urine output of less than 0.5 mL/kg /hour /
 poor...
COLLOIDS
 Suspension of particle rather than a solution
 High Molecular Weight: Unable to pass through semi permeable
me...
TYPES OF COLLOIDS
1) Blood-derived: Albumin 5%( Heated, Antigenic)
2) Dextran: Dextran 70, Dextran 40
3) Gelfusine (Anaphy...
Colloids
Natural
colloids
Albumin
5%,20% 25%
Plasma
proteins 4% 5%
Artificial
colloids
HES
Fresh Frozen
Plasma
Dextrans
Ge...
Human albumin solution(1-5%):
- The most commonly utilized colloid solutions.
- It contains plasma protein fractions obtai...
DEXTRANS:
 Water soluble glucose polymers formed by bacterial
action(leucocytic mesenteroids)on sucrose through
enzyme su...
Large dextran molecule can block renal tubules and damage
kidney, so dextrans should not be given more than 1-2 L in 24 hr...
Disadvantages:
 Highest risk of anaphylaxis
 Prolongs BT- risk of bleeding
 Intereferes with grouping and blood typing
...
GELATINS:
 Second most common plasma expander after HES.
 Prepared from hydrolysis of polypeptides
 Derived from Bovine...
Each 100 ml contains:
 Polymer from degraded gelatine 3.5 gm
 Na 145 mEq/ml, K 5.1 mEq/ml, Ca 6.25 mEq/ml, Cl 145mEq/ml
...
Disadvantages:
 Bovine source- risk of transmission of disease
 Incidence of anaphylactic reaction
 Histamine release- ...
Hydroxy-ethyl starch (HETASTARCH):
 Natural non synthetic product
 Available along with isotonic NaCl
 Osmolarity is si...
Disadvantages:
 Severe pruritis; very rare chance of anaphylaxis (0.006%)
 Rise in serum amylase levels (macroamylasemia...
B- HYPOTONIC FLUIDS
 Compared with intracellular fluid (as well as compared with isotonic
solutions), hypotonic solutions...
TYPES OF HYPOTONIC FLUIDS
 0.45% sodium chloride (0.45% NaCl), 0.33% sodium
chloride, 0.2% sodium chloride, and 2.5% dext...
Precautions with hypotonic solutions
• Never give hypotonic solutions to patients who are at risk for
increased ICP becaus...
HYPERTONIC SOLUTIONS
• Solutions that have a higher tonicity or solute concentration than
the plasma of blood
• Hypertonic...
HYPERTONIC SOLUTIONS
Some examples and Indications:
1) 3% sodium chloride (3% NaCl):
 May be prescribed for patients in c...
HYPERTONIC SOLUTIONS
Precautions with hypertonic fluids:
• Hypertonic sodium chloride solutions should be administered onl...
COMPARING CRYSTALLOID V/S
COLLOID
CRYSTALLOIDS COLLOIDS
Aqueous solutions of low molecular
weight ions with or without glu...
MAINTENANCE THERAPY
How to calculate maintenance fluid flow rates?
The most commonly used formula is (4/2/1) rule a.k.a ( ...
HOW TO CALCULATE IV FLUID FLOW RATES
• Intravenous fluid must be given at a specific rate, neither too fast nor
too slow.
...
The formula for working out flow rates is:
Example:
1500 ml IV Saline is ordered over 12 hours. Using a drop factor of
15 ...
FLUID RESUSCITATION IN BURNS
 Parkland formula is used for resuscitation of burns patients:
• Total Fluid requirement in ...
FLUID OVERLOAD (HYPERVOLEMIA)
Signs and Symptoms
1- Edema (swelling) - particularly feet, and ankles
2- Difficulty in brea...
MANAGEMENT OF HYPERVOLEMIA
1- Prevention is the best way
2- Sodium restriction
3- Fluid restriction
4- Diuretics
5- Dialys...
BLOOD TRANSFUSION
 It is a procedure in which a patient receives a blood product
through an intravenous line.
 A process...
TYPES OF BLOOD TRANSFUSION
 Based on time of transfusion
◦ Fresh whole blood transfusion
◦ Transfusion of stored Blood
 ...
Whole Blood
Packed Red Blood Cells Platelet Rich Plasma
Slow Centrifugation
High Speed Centrifugation
1 Unit of Random Don...
SCREENING BEFORE BLOOD
TRANSFUSION
Donor’s blood sample should be screened for :
• HIV 1 & 2.
• HbsAg.
• HCV.
• Malaria.
•...
WHOLE BLOOD
 Storage
◦ Stored At 4°c for up to 35 days
 Indications
◦ Massive Blood Loss/Trauma/Exchange Transfusion
 C...
PACKED RED CELLS
 Storage
◦ 4° for up to 42 days, can be frozen
 Indications
• Anemia
• Hypoxia.
 Considerations
◦ Reci...
Typing of RBC’s for ABO and Rh are determined for both donor
and recipient
 Crossmatching:
◦ Donor cells and recipient se...
PLATELETS
 Storage
◦ Can be stored Up to 5 days at 20-24°c
 Indications
◦ Thrombocytopenia – Platelet count <15,000
◦ Bl...
FRESH FROZEN PLASMA
 Contains all Clotting Factors (1 unit/ml)
 Storage
◦ Comes in 200ml bags.
 Can be stored upto 12 m...
CRYOPRECIPITATE
 Description
◦ Precipitate formed/collected when FFP is thawed at 4°c.
Each unit (around 10 to 15 mL) typ...
TRANSFUSION REACTIONS
1). Allergic reactions.
2) Hemolytic reactions
3) Febrile non hemolytic reactions .
4) Bacterial Con...
ALLERGIC REACTIONS
 Most common type of transfusion reaction , it usually occurs due
to allergies to specific proteins in...
HEMOLYTIC REACTIONS
 Incidence of 1 in ~25,000 transfusions ; fatality rate 10% .
 Most often Occurs due to ABO mismatch...
FEBRILE TRANSFUSION
REACTION
 Defined to be a rise in temperature of 1 °C or more and >=38 °C,
within 60-90 mins after tr...
BACTERIAL CONTAMINATION
 More common and more severe with platelet transfusion
(Because platelets are stored at room temp...
Transfusion-associated graft-versus-
host disease (TA-GVHD).
 Occurs due to the donor T-cells attacking the recipient’s t...
Transfusion Related Acute Lung Injury
(TRALI)
 It is “noncardiogenic pulmonary edema”.
 Defined as ARDS which occurs wit...
 Monitor patient clinical status and vital signs.
 Monitor renal status (BUN, creatinine).
 Monitor coagulation status ...
IV FLUIDS AND BLOOD IN RESUSCITATION
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IV FLUIDS AND BLOOD IN RESUSCITATION

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IV FLUIDS AND BLOOD IN RESUSCITATION

  1. 1. FLUID AND BLOOD RESUSCITATION PRESENTER – ASHRAY . V
  2. 2. BODY FLUID COMPARTMENTS • Total body water content = 60% of total body weight. • Intracellular Fluid : 2/3 (40%)of TBW • Extracellular Fluid: 1 /3 (20%)of TBW • Interstitial Fluid : 3/4 (15%)of extracellular water • Intravascular Fluid [plasma]: 1/4 (5%)of extracellular water.
  3. 3. CAUSES OF HYPOVOLEMIA : Hemorrhagic hypovolemia  Pulmonary parenchymal trauma  Pulmonary vascular injury  Intercostal vascular injury  Aortic disruption  Massive hemoptysis  Abdomen/pelvis/retroperitoneum  Solid-organ injuries (liver, spleen, kidney)  Vascular (trauma, aneurysmal rupture)  GI hemorrhage (esophageal varices, ulcers, vascular anomalies, etc.)  Gynecologic disorders (ruptured ectopic pregnancy, peripartum hemorrhage, abnormal uterine bleeding, ovarian cyst rupture, etc.) Orthopedic  Pelvic fracture  Large bone fractures  Multiple fractures  Major vascular injuries  Large soft tissue injuries
  4. 4. Nonhemorrhagic hypovolemia • GI disorders: vomiting, diarrhea, ascites • Burns • Environmental exposure or neglect • Renal salt wasting
  5. 5. Aim of Fluid resuscitation • Early, complete restoration of tissue oxygenation. • Minimal biochemical disturbance • Preservation of renal function • Avoidance of transfusion complications.  First Priority: Restore volume  Second Priority: Restore blood - oxygen carrying capacity  Third Priority: Normalize coagulation status
  6. 6. FLUID RESUSCITATION How to know that the patient has Hypovolemic Shock? The patient has the following sings and symptoms: 1- Anxiety or agitation 2- Cool, Pale skin 3- Confusion 4- Decreased or no urine output 5- Rapid breathing 6- Disturbed consciousness 7- Low blood pressure 8- Low body temperature 9- Rapid pulse, often weak and thready
  7. 7. Composition of Different Fluids Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3 - Dextrose mOsm/L ECF 142 4 5 103 27 280-310 Lactated Ringer’s 130 4 3 109 28 273 0.9% NaCl 154 154 308 0.45% NaCl 77 77 154 D5W D5/0.45% NaCl 77 77 50 406 3% NaCl 513 513 1026 6% Hetastarc h 500 154 154 310 5% Albumin 250,500 130- 160 <2.5 130- 160 330 25% Albumin 20,50,100 130- 160 <2.5 130- 160 330
  8. 8. The Influence of Colloid & Crystalloid on Blood Volume: 1000cc 500cc 500cc 500cc 200 600 1000 Lactated Ringers 5% Albumin 6% Hetastarch Whole blood Blood volume Infusion volume
  9. 9. Replacing Third Space Losses • Superficial surgical trauma: 1-2 ml/kg/hr • Minimal Surgical Trauma (head and neck, hernia, knee surgery) : 3-4 ml/kg/hr • Moderate Surgical Trauma (hysterectomy, chest surgery): 5-6 ml/kg/hr • Severe surgical trauma: (AAA repair, nehprectomy) :8-10 ml/kg/hr
  10. 10. Crystalloids  Combination of water and electrolytes Balanced salt solution: electrolyte composition and osmolality similar to plasma; example: lactated Ringer’s, Plasmlyte, Normosol. - Hypotonic salt solution: electrolyte composition lower than that of plasma; example: D5W.  They are True solutions , No particulate  Expands IVC adequately (less than colloids), however Small increase in plasma volume is observed.  Replenishes interstitial compartment  It leaves IVC faster ( t/2 20-30 minutes)  Cheap  Increase GFR  No risk of allergic reaction
  11. 11. A- 0.9% sodium chloride (Normal Saline)  Contains only water, sodium (154 mEq/L), and chloride (154 mEq/L).  It's called "normal saline solution" because the percentage of sodium chloride in the solution is similar to the concentration of sodium and chloride in the intravascular space. ISOTONIC FLUIDS Solutions Na+ K+ Ca2+ Mg2+ Cl- HCO3 - Dextrose mOsm/L 0.9% NaCl 154 154 308
  12. 12. When to be given? 1- to treat low extracellular fluid, as in fluid volume deficit from - Hemorrhage - Severe vomiting or diarrhea - Heavy drainage from GI suction, fistulas, or wounds 2- Shock 3- Mild hyponatremia 4- Metabolic acidosis (such as diabetic ketoacidosis) 5- It’s the fluid of choice for resuscitation efforts. 6- it's the only fluid used with administration of blood products.
  13. 13. When to be used? • Fluid losses due to burns and trauma • To replace GI tract fluid losses ( Diarrhea or vomiting ) • Patients experiencing acute blood loss or hypovolemia due to third-space fluid shifts. Ringer's lactate or Hartmann solution
  14. 14. Both 0.9% sodium chloride and LR may be used in many clinical situations, but patients requiring electrolyte replacement (such as surgical or burn patients) will benefit more from an infusion of LR. - LR is metabolized in the liver, which converts the lactate to bicarbonate. LR is often administered to patients who have metabolic acidosis not patients with lactic acidosis. - Don't give LR to patients with liver disease as they can't metabolize lactate - used cautiously in patients with sever renal impairment because it contains some potassium - LR shouldn't be given to a patient whose pH is greater than 7.5
  15. 15. • It is considered an isotonic solution, but when the dextrose is metabolized, the solution actually becomes hypotonic and causes fluid to shift into cells. • D5W provides free water that pass through membrane pores to both intracellular and extracellular spaces. Its smaller size allows the molecules to pass more freely between compartments, thus expanding both compartments simultaneously Dextrose 5% Solutions Na + K + Ca 2+ Mg 2+ Cl - HCO3 - Dextrose mOsm/L D5W 50gm/l 278
  16. 16.  It provides 170 calories per liter, but it doesn't replace electrolytes.  The supplied calories doesn't provide enough nutrition for prolonged use. But still can be added to provide some calories while the patient is NPO. - D5W is not good for patients with renal failure or cardiac problems since it can cause fluid overload. - patients at risk for intracranial pressure should not receive D5W since it could increase cerebral edema.
  17. 17. - D5W shouldn't be used in isolation to treat fluid volume deficit because it dilutes plasma electrolyte concentrations. - Never mix dextrose with blood as it causes blood to hemolyze. - Not used for resuscitation, because the solution won't remain in the intravascular space. - Not used in the early postoperative period, because the body's reaction to the surgical stress may cause an increase in antidiuretic hormone secretion
  18. 18.  Be aware that patients being treated for hypovolemia can quickly develop hypervolemia (fluid volume overload) following rapid or overinfusion of isotonic fluids.  Document baseline vital signs, before beginning the infusion, and continue monitoring during and after the infusion. Precautions in usage of Isotonic solutions
  19. 19.  Frequently assess the patient's response to I.V. therapy, monitoring for signs and symptoms of hypervolemia such as: hypertension / bounding pulse / pulmonary crackles / peripheral edema / dyspnea/ shortness of breath / jugular venous distention (JVD)  Monitor intake and output  Elevate the head of bed at 35 to 45 degrees, unless contraindicated.  If edema is present, elevate the patient's legs.
  20. 20.  monitor for signs and symptoms of continued hypovolemia, including:  urine output of less than 0.5 mL/kg /hour /  poor skin turgor  tachycardia  weak, thready pulse  hypotension  Educate patients and their families about signs and symptoms of volume overload and dehydration  instruct patients to notify if they have trouble breathing or notice any swelling.  Instruct patients and families to keep the head of the bed elevated (unless contraindicated).
  21. 21. COLLOIDS  Suspension of particle rather than a solution  High Molecular Weight: Unable to pass through semi permeable membrane  Remains confined to intra-vascular compartment (at least initially)  Do not correct water and electrolyte deficiencies  Examples: hetastarch (Hespan), albumin, dextran  Most logical choice for intravascular expansion.  Since greater portion remains in IVC & for longer time ( t/2 3-6 hours).  Less volume is required& initial resuscitation is rapid.  500 ml of colloids expands plasma by 500ml.
  22. 22. TYPES OF COLLOIDS 1) Blood-derived: Albumin 5%( Heated, Antigenic) 2) Dextran: Dextran 70, Dextran 40 3) Gelfusine (Anaphylaxis) 4) Hydroxy ethyl ether 5) Hetastarch 6% MW = 450 000 Effective Plasma Expander Least Antigenicity &Effect on Coagulation
  23. 23. Colloids Natural colloids Albumin 5%,20% 25% Plasma proteins 4% 5% Artificial colloids HES Fresh Frozen Plasma Dextrans Gelatins
  24. 24. Human albumin solution(1-5%): - The most commonly utilized colloid solutions. - It contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma volume used for:  volume expansion  moderate protein replacement  achievement of hemodynamic stability in shock states. - considered a blood transfusion product and requires all the same nursing precautions used when administering other blood products. -It can be expensive and its availability is limited to the supply of human donors
  25. 25. DEXTRANS:  Water soluble glucose polymers formed by bacterial action(leucocytic mesenteroids)on sucrose through enzyme sucrase  Effective plasma volume expander due to colloid osmotic effect  Sp. Gravity is slightly greater than blood  Broken down enzymatically to dextranase and excreted in urine. Preparation:  Dextran 150 - 6% dextran in 5% glucose on normal saline  Dextran 110 – 5% dextran in 5% glucose on normal saline  Dextran 70 – 6% dextran  Dextran 60 – 3% dextran  Dextran 40 -- 10% dextran
  26. 26. Large dextran molecule can block renal tubules and damage kidney, so dextrans should not be given more than 1-2 L in 24 hrs. Limited daily dosing of 20ml/kg. Advantages:  Decreases blood viscosity, platelet viscosity,RBC aggregation  Improves blood flow through microcirculation  Preloading with 10-15 ml/kg of dextran before SA block prevents hypotension Clinical advantages of Dextran:  Periphereal vascular disease-improves blood flow through microcirculation  Prevention of excessive platelet activation and release of micro emboli during end arterectomy & skin grafting and other vascular procedures
  27. 27. Disadvantages:  Highest risk of anaphylaxis  Prolongs BT- risk of bleeding  Intereferes with grouping and blood typing  Worsens renal failure  Impairs BT,Platelet function ,ESR Contraindications:  Known sensivity of dextran  Fixed low cardiac outpatient status  Cerebral edema  Raised ICT and marked hemorrhagic tendencies eg thrombocytopenia.
  28. 28. GELATINS:  Second most common plasma expander after HES.  Prepared from hydrolysis of polypeptides  Derived from Bovine collagen  Mol wt 30-35 KDA  Plasma half life 4-6 hrs Formulations:  Cross linked gelatins- eg Gelofondiol  Urea linked gelatins- eg Haemaccel  Succinylated gelatins- eg Gelofusine  Haemaccel(300ml,500ml) obtained from high grade gelatins
  29. 29. Each 100 ml contains:  Polymer from degraded gelatine 3.5 gm  Na 145 mEq/ml, K 5.1 mEq/ml, Ca 6.25 mEq/ml, Cl 145mEq/ml  Molecular wt 30,000-35,000 Indications:  Procedures involving extra corporeal circulation, eg -priming the heart lung machine  Prevention and treatment of hypovolemia(burns, post op blood loss, spinal/epidural anaesthesia) Advantages:  Preservative free preparations  Rapid excretion through urine, plasma clearance of 3 days, complete excretion from body in 1 wk.  No effects on coagulation
  30. 30. Disadvantages:  Bovine source- risk of transmission of disease  Incidence of anaphylactic reaction  Histamine release- Haemaccel preparation  Cannot be given with blood  Not more than 1L in 24 hrs Contraindications:  Shock due to septicemia, cardiogenic, anaphylactoid shock  Oedema due to CCF,RF, DIC
  31. 31. Hydroxy-ethyl starch (HETASTARCH):  Natural non synthetic product  Available along with isotonic NaCl  Osmolarity is similar to normal physiological osmolarity  Dosage 20ml/kg/hr  Available concentration 3% 6% 10% in isotonic NaCl or RL with or without dextrose  Teratogenic potential Features of HES:  Low incidence of anaphylactoid reaction  Metabolized by body amylase and excreted by renals  Undergoes phagocytosis in RE system  Improve splanchnic perfusion in both trauma and septic patients
  32. 32. Disadvantages:  Severe pruritis; very rare chance of anaphylaxis (0.006%)  Rise in serum amylase levels (macroamylasemia)  Dehydration of interstitial space may occur and impair transport and exchange of nutrients between the body compartments  Bleeding tendency Indications:  Hypovolemia  Cardiac priming during cardiopulmonary bypass  Hemodilution Contraindications:  Hemorrhagic disorders  Severe CCF  Renal failure  Patient allergic to starch
  33. 33. B- HYPOTONIC FLUIDS  Compared with intracellular fluid (as well as compared with isotonic solutions), hypotonic solutions have a lower concentration of solutes (electrolytes). And osmolality less than 250 mOsm/L .  Hypotonic crystalloid solutions lowers the serum osmolality within the vascular space, causing fluid to shift from the intravascular space to both the intracellular and interstitial spaces.  These solutions will hydrate cells, although their use may deplete fluid within the circulatory system.
  34. 34. TYPES OF HYPOTONIC FLUIDS  0.45% sodium chloride (0.45% NaCl), 0.33% sodium chloride, 0.2% sodium chloride, and 2.5% dextrose in water  Hypotonic fluids are used to treat patients with conditions causing intracellular dehydration, when fluid needs to be shifted into the cell , such as: 1. Hypernatremia 2. Diabetic ketoacidosis 3. Hyperosmolar hyperglycemic state.
  35. 35. Precautions with hypotonic solutions • Never give hypotonic solutions to patients who are at risk for increased ICP because it may exacerbate cerebral edema. • Don't use hypotonic solutions in patients with liver disease, trauma, or burns due to the potential for depletion of intravascular fluid volume • The decrease in vascular bed volume can worsen existing hypovolemia and hypotension and cause cardiovascular collapse. • Monitor patients for signs and symptoms of fluid volume deficit . • In older adult patients, confusion may be an indicator of a fluid volume deficit.
  36. 36. HYPERTONIC SOLUTIONS • Solutions that have a higher tonicity or solute concentration than the plasma of blood • Hypertonic fluids have an osmolarity of 375 mOsm/L or higher  The osmotic pressure gradient draws water out of the intracellular space, increasing extracellular fluid volume, so they are used as volume expanders.
  37. 37. HYPERTONIC SOLUTIONS Some examples and Indications: 1) 3% sodium chloride (3% NaCl):  May be prescribed for patients in critical situations of severe hyponatremia.  Patients with cerebral edema may benefit from an infusion of hypertonic sodium chloride. 2) 5% Dextrose with normal saline (D5NS): • It replaces sodium, chloride and some calories.
  38. 38. HYPERTONIC SOLUTIONS Precautions with hypertonic fluids: • Hypertonic sodium chloride solutions should be administered only with constant surveillance for potential complications . • Maintain vigilance when administering hypertonic saline solutions because of their potential for causing intravascular fluid volume overload and pulmonary edema.
  39. 39. COMPARING CRYSTALLOID V/S COLLOID CRYSTALLOIDS COLLOIDS Aqueous solutions of low molecular weight ions with or without glucose High molecular weight substances, similar to plasma proteins Readily pass through semi-permeable membrane (“Extra vascular space expanders”) Molecular size is large and do not cross capillary membrane (“Intravascular space expanders”). Intravascular t1/2 = 20-30 minutes Intravascular t1/2= 2-8 hours Reduce plasma colloid osmotic pressure Maintain plasma colloid osmotic pressure Have poor capillary perfusion Have good capillary perfusion Risk of over hydration/tissue edema is obvious It is insignificant No anaphylactic reaction Risk of anaphylaxis is more Inexpensive Expensive Readily available, easy to store and well tolerated by patients – some advantages Not so Indications:  Rx of dehydration of any cause,  Hypoglycemia (5% 10% D)  Hypochloremia, hyponatremia of any cause Preloading fluid in regional block(SA)  Intraoperative/postoperative maintenance fluid Indications:  Fluid resuscitation prior to arrival of blood  Severe hypoglobuminemia  Burns  Fluid boluses in critically ill patient where crystalloid use would be excessive.
  40. 40. MAINTENANCE THERAPY How to calculate maintenance fluid flow rates? The most commonly used formula is (4/2/1) rule a.k.a ( Weight+40), which is used for both adults and pediatrics. 4/2/1 rule  4 ml/kg/hr for first 10 kg (=40ml/hr)  then 2 ml/kg/hr for next 10 kg (=20ml/hr)  then 1 ml/kg/hr for any kgs over that This always gives 60ml/hr for first 20 kg then you add 1 ml/kg/hr for each kg over 20 kg Weight in kg + 40 = Maintenance IV rate/hour For any person weighing more than 20kg
  41. 41. HOW TO CALCULATE IV FLUID FLOW RATES • Intravenous fluid must be given at a specific rate, neither too fast nor too slow. • The specific rate may be measured as : ml/hour, L/hour or drops/min. • To control or adjust the flow rate only drops per minute are used. What is a drop factor? Drop factor is the number of drops in one milliliter used in IV fluid administration (also called drip factor). A number of different drop factors are available but the Commonest are: 1) 10 drops/ml (blood set) 2) 15 drops / ml (regular set) 3) 60 drops / ml (microdrop, burette)
  42. 42. The formula for working out flow rates is: Example: 1500 ml IV Saline is ordered over 12 hours. Using a drop factor of 15 drops / ml, how many drops per minute need to be delivered? Volume (ml) X drop factor (gtts / ml) --------------------------------------------- time (min) = gtts / min (flow rate) 1500 (ml) X 15 (drop / ml) --------------------------------------------------- 12 x 60 (gives us total minutes) = 31 drop/ minute
  43. 43. FLUID RESUSCITATION IN BURNS  Parkland formula is used for resuscitation of burns patients: • Total Fluid requirement in 1st 24 hrs = 4 x Patient’s weight in Kg x Percentage of burns. • 50% of the fluid given in 1st 8 hrs • Rest 50 % fluid given over next 16 hrs .
  44. 44. FLUID OVERLOAD (HYPERVOLEMIA) Signs and Symptoms 1- Edema (swelling) - particularly feet, and ankles 2- Difficulty in breathing while lying down 3- Crepts on auscultation 4- High blood pressure 5- Cough 6- Jugular vein distension 7- Shortness of breath (dyspnea) 8- Strong, rapid pulse
  45. 45. MANAGEMENT OF HYPERVOLEMIA 1- Prevention is the best way 2- Sodium restriction 3- Fluid restriction 4- Diuretics 5- Dialysis
  46. 46. BLOOD TRANSFUSION  It is a procedure in which a patient receives a blood product through an intravenous line.  A process of transferring blood-based products from one person into the circulatory system of another.  Blood Transfusion = Liquid organ Transplantation. blood and blood transfusions 46
  47. 47. TYPES OF BLOOD TRANSFUSION  Based on time of transfusion ◦ Fresh whole blood transfusion ◦ Transfusion of stored Blood  Based on composition ◦ Whole blood ◦ Blood components ( Packed red cells , FFP , Platelets ).  Based on the donor ◦ Autologous blood transfusion ◦ Blood from different donor’s. blood and blood transfusions 47
  48. 48. Whole Blood Packed Red Blood Cells Platelet Rich Plasma Slow Centrifugation High Speed Centrifugation 1 Unit of Random Donor Platelets 1 Unit of Fresh Frozen Plasma Cryoprecipitate Thawing precipitates the plasma proteins BLOOD COMPONENTS
  49. 49. SCREENING BEFORE BLOOD TRANSFUSION Donor’s blood sample should be screened for : • HIV 1 & 2. • HbsAg. • HCV. • Malaria. • Cross matching should be done between Donor’s RBC’s and Patients plasma and serum .
  50. 50. WHOLE BLOOD  Storage ◦ Stored At 4°c for up to 35 days  Indications ◦ Massive Blood Loss/Trauma/Exchange Transfusion  Considerations  Blood of same ABO group and Rh Type as that of the recipient’s blood should be transfused.
  51. 51. PACKED RED CELLS  Storage ◦ 4° for up to 42 days, can be frozen  Indications • Anemia • Hypoxia.  Considerations ◦ Recipient must not have antibodies to donor RBC’s ◦ Usual dose 10 cc/kg (will increase Hb by 2.5 gm/dl) ◦ Usually transfuse over 2-4 hours . ◦ Transfusion of 1 unit of whole blood or packed red cells will raise the hematocrit by 3% and the hemoglobin by 1-1.5 gm/dL .
  52. 52. Typing of RBC’s for ABO and Rh are determined for both donor and recipient  Crossmatching: ◦ Donor cells and recipient serum are mixed and evaluated for agglutination.  Dose ◦ It is Supplied in 250ml bags. ◦ Usual dose of 10 cc/kg infused over 2-4 hours ◦ Maximum dose of 15-20 cc/kg can be given.
  53. 53. PLATELETS  Storage ◦ Can be stored Up to 5 days at 20-24°c  Indications ◦ Thrombocytopenia – Platelet count <15,000 ◦ Bleeding and Platelet count of <50,000 ◦ While performing Invasive procedures when Platelet count is <50,000.  Considerations ◦ 1 unit/10 kg of body weight increases Plt count by 50,000 ◦ Donor and Recipient preferably must of same blood group , However platelets of any group can be transfused in cases of emergency. • One unit will usually raise the platelet count 5-10,000/ dl. • Each unit of platelets should be administered over 20-40 minutes.
  54. 54. FRESH FROZEN PLASMA  Contains all Clotting Factors (1 unit/ml)  Storage ◦ Comes in 200ml bags.  Can be stored upto 12 months at -18 degrees.  It is a source of vit k- dependent clotting factors and factor - V.  Indications for Transfusion: ◦ Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, conditions with raised APTT.  Considerations ◦ Plasma should be recipient RBC ABO compatible ◦ Preferably , should also be Rh compatible. ◦ Usual dose is 20 cc/kg ◦ 1 unit FFP = 3% increase in CF levels
  55. 55. CRYOPRECIPITATE  Description ◦ Precipitate formed/collected when FFP is thawed at 4°c. Each unit (around 10 to 15 mL) typically provides:  Fibrinogen- 150-250 mg with a half-life of 100-150 hours.  Factor VIII - 80-150 U with a half-life of 12 hours.  Von Willebrand Factor - 100-150 U with a half-life of 24 hours.  Factor XIII - 50-75 U with a half-life of 150-300 hours.  Storage ◦ After collection, refrozen and stored up to 1 year at -18°  Indication ◦ Fibrinogen deficiency or dysfibrinogenemia ◦ Von Willebrands Disease ◦ Factor VIII or XIII deficiency ◦ DIC .  Considerations ◦ ABO compatible preferred (but not limiting) ◦ Usual dose is 1 unit/5-10 kg of recipient body weight.
  56. 56. TRANSFUSION REACTIONS 1). Allergic reactions. 2) Hemolytic reactions 3) Febrile non hemolytic reactions . 4) Bacterial Contamination . 5) Graft Versus Host Disease (GVHD). 6) Transfusion related acute lung injury (TRALI).
  57. 57. ALLERGIC REACTIONS  Most common type of transfusion reaction , it usually occurs due to allergies to specific proteins in the donor’s plasma.  Symptoms – Flushing , itching , urticaria , difficulty in breathing/  can be avoided with future transfusions by pretreatment with antihistamines or steroids.  Management – antihistaminics preferred , if not controlled then I.M - Adrenaline can be given.
  58. 58. HEMOLYTIC REACTIONS  Incidence of 1 in ~25,000 transfusions ; fatality rate 10% .  Most often Occurs due to ABO mismatch of transfused blood (i.e., the wrong blood and/or the wrong recipient). Symptoms : Fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest or back pain, flushing and severe anxiety and pain at the infusion site. Management:  Stop the transfusion  Keep the vein open by running in saline  Check the urine for hemoglobin  Give mannitol for inducing Diuresis.  Monitor for DIC.
  59. 59. FEBRILE TRANSFUSION REACTION  Defined to be a rise in temperature of 1 °C or more and >=38 °C, within 60-90 mins after transfusion ,without evidence of a hemolytic transfusion reaction.  It is caused due to cytokines in the blood itself and/or produced in the patient from sensitivity to the HLA molecules on platelets and white cells of the donors blood. Management : • Blood transfusion should be stopped immediately. • Antihistaminics and Antipyretics should be administered.
  60. 60. BACTERIAL CONTAMINATION  More common and more severe with platelet transfusion (Because platelets are stored at room temperature 20-240 ).  Organisms ◦ Platelets—Gram (+) organisms, ie Staph/Strep ◦ RBC’s—Yersinia, enterobacter Management :  Transfusion should be stopped and the bag sent for gram stain and culture.  The Blood Bank should be notified.  The patient should have blood cultures obtained and, if appropriate, IV antibiotic therapy begun
  61. 61. Transfusion-associated graft-versus- host disease (TA-GVHD).  Occurs due to the donor T-cells attacking the recipient’s tissues.  Symptoms occur within 1-2 weeks after transfusion. Features:  Anorexia  Nausea  Vomiting  Thrombocytopenia.  Chronic hepatitis  Weight loss  Recurrent infections blood and blood transfusions 61
  62. 62. Transfusion Related Acute Lung Injury (TRALI)  It is “noncardiogenic pulmonary edema”.  Defined as ARDS which occurs within 6 hours of a transfusion with no other clear cause .  It occurs when donor plasma contains an antibody, usually against the patient's HLA or leukocyte specific antigens.  The cause is apparently antibodies in the donor plasma against the patient’s neutrophils (which, in the sick, are marginated in the lung vessels).  Incidence of 1 in 1000; fatality rate <1% with estimates varying widely
  63. 63.  Monitor patient clinical status and vital signs.  Monitor renal status (BUN, creatinine).  Monitor coagulation status (DIC panel– PT/PTT, fibrinogen, D- dimer/FDP, Plt, Antithrombin-III).  Monitor for signs of hemolysis (LDH, serum bilirubin).  Treatment is mainly supportive .

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