Variations in "normal" anatomy and characteristic airway anatomy resulting from pathological conditions can result in problems despite proper positioning and equipment. A small mouth opening, protruding upper teeth, a large tongue, immobility of the head, neck, and jaw all may result in airway difficulty as may the following conditions. Conditions that predispose to a difficult airway include: Infections epiglottitis, abscesses, croup, bronchitis, pneumonia. Trauma maxillofacial trauma, cervical spine injury, laryngeal injury. Endocrine morbid obesity, diabetes mellitus, acromegaly. Foreign Body Inflammatory Conditions ankylosing spondylitis, rheumatoid arthritis. Tumors upper and lower airway tumors. Congenital Problems choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff syndrome. Physiologic Conditions pregnancy.
Pathological Conditions Variations in "normal" anatomy and characteristic airway anatomy resulting from pathological conditions can result in problems despite proper positioning and equipment. A small mouth opening, protruding upper teeth, a large tongue, immobility of the head, neck, and jaw all may result in airway difficulty as may the following conditions. Conditions that predispose to a difficult airway include: Infections epiglottitis, abscesses, croup, bronchitis, pneumonia. Trauma maxillofacial trauma, cervical spine injury, laryngeal injury. Endocrine morbid obesity, diabetes mellitus, acromegaly. Foreign Body Inflammatory Conditions ankylosing spondylitis, rheumatoid arthritis. Tumors upper and lower airway tumors. Congenital Problems choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff syndrome. Physiologic Conditions pregnancy.
Obesity Obesity results in airway and respiratory problems due to altered respiratory pathophysiology and distorted upper airway anatomy. Because of a lowered functional residual capacity, the available oxygen "stores" during apnea are lowered. The increased work of breathing along with the changes in lung volumes that result in closure of small airways results in less time available to the anesthesiologist to secure the airway. A higher minute volume is required to maintain normocarbia even though the overall basal metabolic rate is normal. Fat tissue has high metabolic activity. Oxygen consumption is increased. With each breath, a large mass of tissue in the chest wall and abdomen must be mobilized. The chest wall compliance is decreased. The functional residual capacity and expiratory reserve volumes are reduced. The reduced functional residual capacity is near closing capacity, especially in the supine position. This results in distal airway collapse despite continued perfusion to the corresponding alveoli. V/Q mismatch with venous admixture results. These factors limit the period of "safe" apnea during unconscious laryngoscopy and intubation. Obese patients are at a higher risk of aspirating due to larger gastric residual volumes and more acidic pH. The upper airway examination should be carefully performed with special attention given to the presence of excessive, redundant folds of tissue in the oropharynx and neck. A history suggestive of obstructive sleep apnea such as excessive nocturnal snoring with or without apneic episodes suggest the potential of mechanical airway obstruction as consciousness is lost. Patients scheduled for tracheostomy or palatoplasty are especially likely to have upper airway problems.
Foreign Body The primary problem with a foreign body of the airway is obstruction. Instrumentation of the airway may result in advancing the foreign body deeper into the airway. Positive pressure ventilatory assistance may cause further obstruction or result in a ball-valve effect which may result in a tension pneumothorax. Radiographic studies may help to delineate the precise location of the foreign body, provided the aspirated objects are radiopaque.
Congenital Problems Congenital problems may be associated with airway difficulty due to mandibular hypoplasia, cervical vertebral abnormalities, large tongue, a high arched palate or cleft palate. Examples of congenital problems resulting in airway difficulty include: Down's syndrome, choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, and Hallermann-Streiff syndrome.
Airway Examination Note factors that may make mask ventilation difficult, such as the presence of a beard or edentulousness. Carefully assess mouth opening. An opening of at least two large finger breadths between the upper and lower incisors in the adult is desirable. The presence of loose teeth or protruding upper teeth, a high-arched palate or a long narrow mouth, and temporomandibular joint problems may predispose to difficulty with direct laryngoscopy. The neck should be examined for masses, mobility, and deviation of the trachea. The presence of a hoarse voice, stridor or previous tracheostomy should alert the clinician to possible stenosis at some level. One should identify the location of the cricothyroid membrane for possible use in unexpected airway loss. Determine if the patient is able to assume the sniffing position in the awake state. There are three specific tests which when used together have almost 100% reliability in predicting airway difficulty. These are the Mallampati test, the thyromental distance, and extension at the atlantooccipital joint.
Flexible Fiberoptic Bronchoscopic Intubation (FBI) Description: use of a flexible bronchoscope to intubate the trachea. The endotracheal tube is passed directly over the bronchoscope into the trachea. Advantages: This technique allows direct visualization of the airway, with confirmation of the position of the endotracheal tube by direct vision. Oxygen may be insufflated through the suction port of the brochoscope. Disadvantages: FBI requires expensive, fragile equipment. Special care must be taken during cleaning and storage of the equipment. There is a significant learning curve for FBI, requiring repeated practice in normal patients to allow mastery. There may be difficulty if blood or heavy secretions are present in the upper airway. Examples of Use: FBI is useful in managing patients with difficult airways. Special Uses of the Flexible Fiberoptic Bronchoscope: The technique is easier in elective cases, but can be used by skilled practitioners even in cases of unrecognized difficult airway. FBI can be used in awake/sedated patients, asleep/breathing patients and asleep/paralyzed patients. A retrograde wire guide may be passed up the suction port of the bronchoscope to guide the scope into the trachea. In young patients, a smaller bronchoscope may be used, or a wire guide may be passed into the trachea from the suction port of the bronchoscope. The scope is withdrawn and repositioned to ensure proper placement of the wire, which is used as a guide for placement of the endotracheal tube either directly or after placement of a catheter to provide a stiffer guide for intubation. FBI is also useful for preoperative evaluation and diagnosis of patients with suspected difficult airways. Fiberoptic Bronchoscope Ovassapian, Andranik, MD and Mesnick, Paul S., MD, MJ. The art of fiberoptic intubation. Anesthesiology Clinics of North America 1995 Jun; 13(2):391-409.
Mallampati Classification The Mallampati classification relates tongue size to pharyngeal size. This test is performed with the patient in the sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum. The subsequent classification is assigned based upon the pharyngeal structures that are visible. Class I = visualization of the soft palate, fauces, uvula, anterior and posterior pillars. Class II = visualization of the soft palate, fauces and uvula. Class III = visualization of the soft palate and the base of the uvula. Class IV = soft palate is not visible at all. The classification assigned by the clinician may vary if the patient is in the supine position (instead of sitting). If the patients phonates, this falsely improves the view. If the patient arches his or her tongue, the uvula is falsely obscured. A class I view suggests ease of intubation and correlates with a laryngoscopic view grade I 99 to 100% of the time. Class IV view suggests a poor laryngoscopic view, grade III or IV 100% of the time. Beware of the intermediate classes which may result in all degrees of difficulty in laryngoscopic visualization. Mallampati Classification Mallampati, S.R., Gatt, S.P., Gugino, L.D., Desai, S.P., Waraksa, B., Freiberger, D., Liu, P.L. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985 Jul;32(4):429-434.
Autologous blood donation and transfusion
Autologous Blood Donation and transfusion 1
What does ‘Autologous Transfusion’ mean? Autologous transfusion is where the donor and recipient are the same person.There are different types ofautologous transfusion including:•Preoperative autologousdonation (PAD)•Intra-operative cell salvage•Post-operative cell salvage•Acute normovolaemichaemodilution•Directed donation 2
Aims:To demonstrate an awareness of the different techniquesavailable as alternatives to allogeneic blood transfusionand an awareness of their appropriate use. Objectives: •To develop an awareness of better transfusionpractice. •Discuss different autologous transfusion techniquesavailable. •Identify alternative care strategies to avoid the use ofallogeneic blood. •To promote the appropriate and timely use oftransfusion alternatives. 3
Although the risks of blood transfusionhave been considerably minimised, the incidents highlighted in the SeriousHazards of Transfusion (SHOT) reports show the importance of continuing education in the appropriate use of blood. TRANSFUSE ONLY WHEN THE BENEFITS OUTWEIGH THE RISKS 4
Good Transfusion Practice - General Considerations Minimise amount of phlebotomy for lab samples Base practice on transfusion triggers, targets set by local guidelines, and individual patient assessment Establish target haemoglobin tolerable to the individual patient 5
Reducing transfusion requirementsPre-operative procedures include:Pre-operative surgical assessment units: blood tests should be performed Discuss treatment options with and reviewed in a timely manner for patient: this is of particular importance if diagnosis and treatment of anaemia e.g. the patient has any strong beliefs or iron deficiency anaemia. Assessment of thoughts about blood transfusion (not just patient’s previous clinical history e.g Jehovah’s Witness patients) - allow plenty bleeding disorders. of time to plan for any specificAssessment of patient’s current medication alternatives to transfusion to be - where possible plan to stop medications organised. pre-operatively e.g. anti-coagulant / anti- platelet drugs Maximum Surgical Blood Ordering Plan for possible cell salvage: Schedule: this is a guidance schedule many hospitals now provide peri or developed following agreement with post operative cell salvage - these surgeons and anaesthetists - it should be techniques can be used in a variety ofused as a guide/tool to indicate how many surgical procedures - individual units to order for different surgical patients should be assessed for procedures - hospital blood banks may suitability pre-operatively and optionsquestion clinicians if a request differs from discussed with the patient. 6 the MSBOS.
Module 4: Alternatives to Allogeneic Blood Transfusion Reducing transfusion requirements Intra-operative procedures include: Careful positioning Appropriate of the patient during use of surgical Use of intra- surgery - may help dissecting instruments - operative cell reduce blood loss by some instruments help to salvage minimising venous reduce blood loss congestion in the e.g. diathermy knives, operating field. lasers, ultrasonic scalpel. Maintain Preventing hypertension normothermia Use of fibrin seals / (controlled hypotension) (unless hypothermia is haemostatic agents / - hypertension may lead indicated) - drugs to help reduce to excessive bleeding coagulation factors surgical bleeding NOTE: this is a specialist may be less effective anaesthetic technique. at lower temperatures, increasing the risk of blood loss. 7
Advantages1 Prevent transfusion TTDs2 Prevent red cell Allo - immunization3 Supplements the blood supply in BTS4 Provide compatible blood for patient with Allo-antibodies5 Prevent adverse transfusion reactions6 Provide reassurance to patients concerned about blood risk7 reduce postoperative risk of bacterial infection8 reduce risk of cancer recurrence because the fewer effect of Immuno modulation 8
Disadvantages1 Same risk of bacterial contamination2 Same risk of ABO incompatibility error3 Costlier than allogenic blood4 Wastage of blood, if not switched over.5 Chances of unnecessary transfusion6 Subjects patient prone to perioperative anemia & increase likelihood of transfusion and side effect of iron supplementation7 same risk of clerical error8 anxiety to some patient 9
TYPES OF AUTOLOGOUS TRANSFUSION Preoperative autologous blood donation (PABD) Acute normovolemic hemodilution (ANH) Intra operative and post operative blood recovery (blood salvage) 10
Preop. Autologous donationInclusion: Stable patients scheduled for surgical procedure in which blood transfusion is likely. Donor Pt. should qualify criteria for blood donation in surgery that bleeding is more than 1000cc. Necessity: a. Close relation between clinician & blood bank (BB) b. Donor suitability by BB physician c. Oral Fe one week before & many weeks after e. at least Hb before operation is 11 * No limit of weight or aheage 11
CANDIDATES FOR P.A.B.D Stable patients M.S.O.B.S (surgical procedure with blood loss) Major orthopedic procedure Patients with alloantibodies Vascular surgery Thoracic or cardiac surgery Total joint replacement 12
Pre-op Autologous DonationContraindications:1 Evidence of infection and risk of bacteremia2 Scheduled surgery to correct aortic stenosis3 Unstable angina4 Active seizure disorder5 Myocardial infarction or CVA accidents in 6 mounth6 Significant cardiac or pulmonary disease7 Cyanotic heart disease8 Uncontrolled hypertension9 Malignant diseases10 high grade main coronary artery disease11 diarrhea12 dental operation13 skin ulcer14 Antibiotic use 13
Pre-op Autologous Donation Procedure Each blood centre or hospital that decides to conduct an autologous blood collection program must have its own policies, processes and procedures Patient’s physician initiates the request for autologous services, which then is approved by Transfusion Medicine physician after physical evaluation Patient advised oral supplemental iron from one week before operation Request by physician should include the patient name, unique identifying number, number of units and kind of component required, date of scheduled surgery, nature of surgical procedure 14
Pre-op Autologous Donation Procedure A sufficient number of units should be drawn to avoid exposure to allogenic blood In lower than 50 kg (weight*450cc/50) 15
It usually begins 3-5 weeks before scheduled surgery. usually 2-4 units on each occasion ,approximately 500 ml of blood are collected .patient with more than 50 kg body weight usually donate 500 ml of blood in one session .patient with less than 50 kg body weight donate smaller volumes. The volume collected shouldn’t be more than 10% of the patient’s estimated blood volume . One donation per week is usually scheduled, although more aggressive donation schedules are possible . In theory , donation every 3 days are feasible . The last donation takes place not later than 48-72 hour before surgery . This is to allow for the equilibration of blood volume. 16
New Program SOPs at each step Testing Protocol: Once in 30 days Separate inventory to avoid mix-ups Separate tags/ green labels to ensure that the right unit goes to right patient X-match & Issue Discarding unused unit and not used as allogenic because of different criteria and chances of clerical error 17
Pre-op Autologous Donation Procedure ABO and Rh typing on labeled samples of patient. Units should have ‘green label’ with patient name & number & marked ‘FOR AUTOLOGOUS USE ONLY’ Longest possible shelf life for collected units increases flexibility for the patient and allows time for restoration of red cell mass, between collection and surgery. Special Autologous label may be used with numbering to ensure that oldest units are issued first. 18
PAD Complications Anemia and hypovolemia vasovagal reaction Venous access Pediatrics- low volume challenges Donor adverse reactions Clerical errors leading to the use of regular donors before autologous units Over transfusion 19
RISKS OF P.A.B.D1-Mistake of transfusion2-Human error (ABO incompatibility)3-Bacterial contamination 20
PABPD CONTRAINDICATION 1-Anemia 2-Serious cardiac disease 3-Predisposing to bacteremia (e.g. urinar catheter or device) 4-HBV, HCV, HIV positive 21
SAMPLE OF PROTOCOLSSelect of patientDetection of number unitsRecommendation to interval collectingUse of iron supplementsTransport of unitsReview of criteria autologousManage of reactionPolicies programAdditional information 22
IRON SUPPLEMNTSPrescription of ironSuitable dose for decrease GI side effectsMaybe can not store of iron 23
Acute Normovolemic HemodilutionDefinition:It is the removal whole blood from apatient just before the surgery andtransfused immediately after thesurgery. It is also known as ‘preoperativehemodilution’. 25
PHYSIOLOGIC CONSIDERATION Reduction of RBC losses Increase of perfusion’s tissues Improved oxygenation Decrease blood viscosity (The best oxygen delivery Hct 30-35%) Preservation of hemostasis 26
Acute Normovolemic Hemodilution Properly labeled units are stored at RT for up to 8 hours, unused units must be stored within 8 hours at 1-6 C, outdates in 24h Re infuse units in reverse order to provide maximum hemostatic functions ANH is equivalent to PAD in radical prostatectomy, knee and hip replacement 27
CLINICAL STUDIES OF A.N.H 1-A.N.H equivalent to PAD 2-Minimized cost 3-Elimination waste of units 4-No inventory or testing 5-Never leaves the patient’s room (minimize clerical error &ABO incompatible) 28
CRITERIA FOR SELECTION OF A.N.H 1-Likliehood of transfusion exceeds 2-Preoperative Hb at least 12 g/dl 3-Absence of coronary, pulmonary, renal or liver disease 4-Absence of sever hypertension 5-Absence of infection & bacteremia 29
INDICATIONS FOR A.N.HHct>34%Intraoperative blood loss>1 litAny type of surgery with significant blood lossWhen the blood can be drawn afteraneasthesia and transfused 30
CONTRAINDICATION FOR ANH1-Anemia2-Impaired renal function3-C.A.D, A.S, (no compensatorymechanism)4-Limitation of cardiac or pulmonaryfunction5-Untreated hypertention6-Coagulation disorder 31
PRACTICAL CONSIDERATION 1-ANH related to procedure & volume of blood & target Hct 2-Documented the manner 3-Exact monitoring 4-Aseptic collection 5-Labelling 6-Storage (room temperature=8h & refrigirator=24h) 7-Increase time staying in the operating 32 room
TYPES OF ANH PROCEDURES Cardiovascular Vascular Orthopedic Organ transplant Neuro Others 33
WHO IS A CANDIDATE FOR ANH? Every one Loose >500 ml of the blood Unpredictable blood loss Need for homologous transfusion 34
WHAT ARE CONTRAINDICATIONS FOR A.N.H? (RELATIVE) Anemia Hct<28% Hb<10 Impaired renal function Limitation of cardiac, pulmonary function Untreated hypertension Impossible compensatory C.O. Coagulation disorder 35
WHAT ARE THE POST-OPCONCERNS FOLLOWING A.N.H? 1-Fluid overload 2-High blood loss procedure 3-Excessive hemodilution (diuretics) 36
WHAT IS NEEDED FOR ASUCCESSFUL A.N.H PRGRAM? 37
Acute Normovolemic Hemodilution Procedure Blood collected in ordinary blood bags with 2 phlebotomies & minimum of 2 units are collected The blood is then stored at room temp. and re-infused in operating room after major blood loss. Carried out usually by anesthetists in consultation with surgeons. 38
Acute Normovolemic Hemodilution Procedure Theme behind: Patient losses diluted blood during surgery and replaced later with autologous blood. Withdrawal of whole blood and replacement of with crystalloid/ colloid solution decreases arterial O2 content but compensatory hemo-dynamic mechanisms and existence of surplus O2 delivery capacity mechanism make ANH safe. 39
Acute Normovolemic Hemodilution Procedure Drop in red cell number lowers blood viscosity, decreasing peripheral resistance and increasing cardiac output. Administrative costs are minimized and there is no inventory or testing cost This also eliminates the possibility of administrative or clerical error Usually employed for procedures with an anticipated blood loss is one liter or more than 20% of blood volume. 40
Acute Normovolemic Hemodilution Procedure Decision about ANH should be based on surgical procedure, preoperative blood volume and hematocrit, target hemodilution hematocrit, physiologic variables Careful monitoring of patient’s circulating volume and perfusion status Blood must be collected in an aseptic manner Units must be properly labeled and stored 41
procedure For first litre compensate with 1 litre colloid after that blood must be compensated with 3 crystalloid. For every litre of blood we must give 3 litre crystalloid. 42
Before you start you have to calculate how much blood you can safely remove from your patient you may want to use the following equation to calculate the tolerable blood loss. ABV=EBV * (H0-HT) (H0+HT)/2Where ABV is the autologous blood volume to be withdrawn; H0 is the prehemodilution hematocrit(zero time);HT is the target hemoglobin and EBV is estimated blood volume of patient. 43
AGENTS AFFECT ON WEIGHT ADULT MALE ADULT FEMALEBODY FLUID (ml/kg) (ml/kg) MUSCULAR 75 70 AVERAGE 70 65 THIN 65 60 OBESE 60 55 44
It is a matter of knowledge and experience to define a reasonable target hemoglobin : mild (hematiocrit 20- 24%) , and profound/server/extreme (hematocrit<20%) .Some consider a target hematocrit less than 20%, in the absence of hypothermia and cardiopulmonary bypass,too risky, since it is considered to impair oxygen delivery. 45
WHAT ARE THE COMPENSATORY MECHANISMS WHEN DILUTING THE PATIENT Increase total & local flow rate Increase extraction of 02 Right shift of 02 diassociative curve 46
Intra-operative Blood CollectionDefinition:Whenever there is blood loss andcollected inside the body cavity, it istransfused back to the patient. 47
SAMPLE PROTOCOL Phlebotomy (agreement with surgeon The units of blood with Storage at room or refrigerator 1 ml blood 3ml crystalloid 1ml blood 1ml colloid Salvage Transfusion Blood loss-fluid replacements-U/O 48
Intra-operative Blood Collection Oxygen transport properties of recovered red cell are equivalent to stored allogenic red cells Contraindicated when pro-coagulant materials are applied. Micro aggregate filter(40 micron) are used as recovered blood contain tissue debris, blood clots, bone fragments 49
Intra-operative Blood Collection Hemolysis of red cells can occur during suctioning from surface (vacuum not more than 150 torr is recommended) Indications: Blood collected in thoracic or abdominal cavity due to organ rupture or surgical procedures. Contraindications: Malignant neoplasm, infection and contaminants in operative field. Blood is defibrinated but it does not coagulate 50
SIDE EFFECTS OF INTRAOPERATIVE RECOVERY Air embolous Hemolysis Higher plasma free hemoglobin Positive bacterial culture (clinical infection is rare) 51
PRACTICAL CONSIDERATION FOR INTRAOPERATIVE CELL RECOVERY Sterile operating field A device for intraoperative blood collection with 0.9% saline Storage (room temperature 4 h after terminating collection) Transfusion begins 6h of initiating the collection Labeling Stored in the blood bank 52
Intra-Operative Cell Salvage (ICS)Advantages Reduction in allogeneic blood usage. Can be used regardless of patient’s medical fitness. Life saving where there is uncontrolled bleeding. System accepted by some Jehovah’s Witnesses.Disadvantages Restricted to operations with high blood loss (>20 % of total blood volume). Cannot be used where wound site has an infection. Not normally used where cancer cells are in the operative field. Not suitable for patients with sickle cell disease. Requires capital outlay and trained operators - needs sufficient suitable operations to becost effective. Only red cells are returned without platelets or plasma. 53
Intraoperative Blood Collection Complications are rare but have been reported- DIC, hemolysis due to high pressure suction and mechanical compression in roller pumps 54
Postoperative Blood Collection Recovery of blood from surgical drain followed by re-infusion with or without processing Shed blood is collected into sterile canister and re-infused through a micro-aggregate filter Recovered blood is diluted, partially hemolysed and de-fibrinated and may contain high concentrate of cytokines Upper limit on the volume(1400 ml) of unprocessed blood can re-infused 55
RECOVERED BLOOD Dilute Partially hemolyzed Defibrinated High cytokines 56
HARMFUL MATERIAL IN RECOVERED BLOOD Free Hb RBC Stroma Marrow fat Toxic irritant Tissue or debris Fibrin degradation product Activated coagulation factors Complement 57
Postoperative Blood Collection Transfusion should be within 6 hours of initiating collection Infusion of potentially harmful material in recovered blood, free Hb, red cell stroma, marrow, fat, toxic irrigant, tissue debris, fibrin degradation activated coagulation factors and complement Most common in orthopedic procedures such as hip or knee replacement. 58
Transfusion Algorithm Avoid Transfusion : medical and surgical Alternatives replacement fluids: crystalloids and non plasma colloids over plasma pharmacologic agents to reduce bleeding Autologous donation Minimize exposure to allogeneic transfusion 59
Transfusion AlgorithmIt is possible to avoid transfusion ?Medical:Treat underlying cause of asymptomaticanemias:Nutritional deficiencies-supplementsChronic GI bleeds-medicationsRenal failure- erythropoietin 60
Transfusion AlgorithmIs it possible to avoid transfusion?Surgical:Excellent surgical skill (Factor XIV!=avoidtissue trauma, attention to hemostasis, utilizeavascular plane etc)Use of topical hemostatic agents in OREg. Fibrin Glue- Fibrin sealant :Tisseel Collagen- platelet adhesion 61
Transfusion Algorithm When transfusion is deemed necessary, a physician must obtain informed consent from patient. “Informed Consent to the administration of blood and blood products involves the following: an explanation by the physician in language the patient will understand of the risks and benefits of, and options to, an allogeneic blood transfusion 62
Informed Consent- patient decides Information provided by physician: 1. product description. 2. Benefit and potential risks. 3. Alternatives if available-including risks and benefits. 4.Risks of refusing transfusion Opportunity for questions and clarification Patient’s documentation of consent or refusal 63
Transfusion Algorithm Strategies to minimize exposure to allogeneic transfusion1. replacement fluids- crystalloids and non plasma colloids2. pharmacologic agents to reduce bleeding3. Autologous Transfusion 64
Transfusion Algorithm Strategies to minimize exposure to allogeneic transfusion1. replacement fluids- crystalloids and non plasma colloids2. pharmacologic agents to reduce bleeding3. Autologous Transfusion4. Minimize allogeneic donor exposure in neonatal transfusion 65
Red Cell Transfusion- Is a clinical decision!!! Tissue oxygenation does NOT depend on hemoglobin concentration alone! Cardiac performance Pulmonary function O2 Binding Coefficient Demand of Tissue (physical activity) 66