Blood transfusion, Nutrition and water & electrolyte balance

Blood Products & TransfusionBlood Products & Transfusion
Nutrition in SurgeryNutrition in Surgery
Water & Electrolyte BalanceWater & Electrolyte Balance
Dr.Ramesh ParajuliDr.Ramesh Parajuli
MS (ORL-HNS)MS (ORL-HNS)
Chitwan Medical College Teaching Hospital, Bharatpur-10, chitwan, Nepal

Blood Transfusion:Blood Transfusion:
Blood Product :- AnyBlood Product :- Any
therapeutic substancestherapeutic substances
prepared from humanprepared from human
bloodblood
Blood & Blood Products:Blood & Blood Products:
1.Whole Blood1.Whole Blood
2.Blood & Plasma2.Blood & Plasma
componentscomponents
3.Plasma Derivatives:3.Plasma Derivatives:
albumin, coagulationalbumin, coagulation
factors, immunoglobulinfactors, immunoglobulin

Human Blood GroupsHuman Blood Groups
23 human blood group systems23 human blood group systems
eg. ABO,MN, Duffy, Lewis, Kelleg. ABO,MN, Duffy, Lewis, Kell
ABO-most importantABO-most important
RBC Cell surface: A ,B,AB antigensRBC Cell surface: A ,B,AB antigens
Plasma : anti-B, anti-A, anti-A & anti-BPlasma : anti-B, anti-A, anti-A & anti-B
- IgM antibody- IgM antibody

HistoryHistory
1900- Karl Landsteiner discovered A,B,O1900- Karl Landsteiner discovered A,B,O
1902-Decastrello & Sturli discovered AB1902-Decastrello & Sturli discovered AB
1939-Levine & Stetson1939-Levine & Stetson
1940-Landsteiner & Weiner1940-Landsteiner & Weiner Rh systemRh system

Rh SystemRh System
Rh antigens-RBC membraneRh antigens-RBC membrane
About 15% population= RhAbout 15% population= Rh
NegativeNegative
Rh antibody=IgG antibodyRh antibody=IgG antibody
Anti-Rh antibody= ‘‘rhogam”Anti-Rh antibody= ‘‘rhogam”

Blood GroupingBlood Grouping
1.Before a person gets blood donation1.Before a person gets blood donation
2.Before a person donates blood2.Before a person donates blood
3.Before a person donates an organ for transplantation3.Before a person donates an organ for transplantation
4.Before surgery4.Before surgery
5.Women planning to become pregnant or has first becomes5.Women planning to become pregnant or has first becomes
pregnantpregnant
6.To show whether two people could be blood relatives6.To show whether two people could be blood relatives
7.To check identity of a person suspected of committing7.To check identity of a person suspected of committing
crimecrime

Who can receive blood from whom?Who can receive blood from whom?
BloodBlood
groupgroup
AntigensAntigens AntibodieAntibodie
ss
Can giveCan give
blood toblood to
CanCan
receivereceive
blood fromblood from
AA AA anti-Banti-B A & ABA & AB A & OA & O
BB BB anti-Aanti-A B & ABB & AB B & OB & O
ABAB A & BA & B NONENONE ABAB AB,A,B,OAB,A,B,O
OO NONENONE A & BA & B AB,A,BAB,A,B
& O& O
OO

Complications & Risks:Complications & Risks:
For the Donor:For the Donor:
1.Vasovagal syncope1.Vasovagal syncope
2.Bruise at the needle site2.Bruise at the needle site
3.Hematoma at the needle site3.Hematoma at the needle site
4.Fatigue4.Fatigue
5.Nausea & vomiting5.Nausea & vomiting
For the Patient:For the Patient:
1.Febrile non hemolytic reaction1.Febrile non hemolytic reaction
2.Vol.overload2.Vol.overload
3.Iron overload3.Iron overload
4.Graft vs host disease4.Graft vs host disease
5.Acute hemolytic reactions5.Acute hemolytic reactions

Donor unit-Donor unit-
Must be refrigerated to prevent bacterial growthMust be refrigerated to prevent bacterial growth
Must begin within 3o min after taking out ofMust begin within 3o min after taking out of
fridgefridge
IntravenouslyIntravenously
Personal details of the patients to be matchedPersonal details of the patients to be matched
with the donorwith the donor to prevent transfusionto prevent transfusion
reactionsreactions

Contraindications for being a BloodContraindications for being a Blood
DonorDonor
For Recipient SafetyFor Recipient Safety
1.Donor who recently received transfusion1.Donor who recently received transfusion
2.Recent pregnancy2.Recent pregnancy
3.History of cancer eg. leukemia, lymphoma3.History of cancer eg. leukemia, lymphoma
4.Current infection4.Current infection
For Donor SafetyFor Donor Safety
1.Donors not healthy enough1.Donors not healthy enough
2.Nutritional status2.Nutritional status
3.Age-17 to 70 yrs3.Age-17 to 70 yrs

Blood products
Platelet
components
Red cell
components
Plasma
components &
derivatives
Apheresis

Red cellRed cell
PlasmaPlasma
PlasmaPlasma
derivativesderivatives
Red cellRed cell
concentrateconcentrate
Red cellRed cell
suspension (redsuspension (red
cells + additivecells + additive
solution)solution)
Buffy coatBuffy coat
depleted red cellsdepleted red cells
Leukocyte-Leukocyte-
depleted (filtered)depleted (filtered)
red cellsred cells
Fresh frozenFresh frozen
plasmaplasma
Liquid plasmaLiquid plasma
Freeze-driedFreeze-dried
plasmaplasma
Cryoprecipitate-Cryoprecipitate-
depleted plasmadepleted plasma
Viral-inactivatedViral-inactivated
plasmaplasma
CryoprecipitateCryoprecipitate
AlbuminAlbumin
CoagulationCoagulation
factorsfactors
ImmunoglobulinImmunoglobulin

Centrifugation at different rpm and duration
PRP FFP Cold room

Definition :Definition :
The transfusion of safe blood products to treat a conditionThe transfusion of safe blood products to treat a condition
leading to significant morbidity or mortality that can’t beleading to significant morbidity or mortality that can’t be
prevented or managed effectively by other means.prevented or managed effectively by other means.
-Can save life-Can save life
-Improve health-Improve health

1.Homologous Transfusion1.Homologous Transfusion
2.Autologous Transfusion2.Autologous Transfusion
Blood TransfusionBlood Transfusion

Functions of anticoagulant-preservativeFunctions of anticoagulant-preservative
solution in blood collection packsolution in blood collection pack
SolutionsSolutions FunctionsFunctions
CC Sodium citrateSodium citrate Binds with calcium ions in bloodBinds with calcium ions in blood
in exchange for the sodium saltin exchange for the sodium salt
so the blood does not clotso the blood does not clot
PP PhosphatePhosphate Supports metabolism of the redSupports metabolism of the red
cells during storage to ensurecells during storage to ensure
they release oxygen readily atthey release oxygen readily at
tissue leveltissue level
DD DextroseDextrose Maintains the red cellMaintains the red cell
membrane to increase storagemembrane to increase storage
lifelife
AA AdenineAdenine Provides energy sourceProvides energy source

Whole BloodWhole Blood::
1.Sterile, disposable plastic pack1.Sterile, disposable plastic pack
2.Anticoagulant-Preservative:-CPDA2.Anticoagulant-Preservative:-CPDA
3.Volume up to 510ml (63 ml anticoagulant,450ml blood)3.Volume up to 510ml (63 ml anticoagulant,450ml blood)
4.Hb-12gm/dl,Hct-35%4.Hb-12gm/dl,Hct-35%
5.No functional platelets5.No functional platelets
6.No labile coagulation factors (V & VIII)6.No labile coagulation factors (V & VIII)

Whole BloodWhole Blood
IndicationsIndications
– Red cell replacement in acute blood loss withRed cell replacement in acute blood loss with
hypovolemiahypovolemia
– Exchange transfusionExchange transfusion
– Patients needing red cell transfusions where redPatients needing red cell transfusions where red
cell concentrates or suspensions are not availablecell concentrates or suspensions are not available
ContraindicationsContraindications – (Risk of volume overload)– (Risk of volume overload)
– Chronic anemiaChronic anemia
– Incipient cardiac failureIncipient cardiac failure

Effects of storage on whole bloodEffects of storage on whole blood
Reduction in the pHReduction in the pH
Rise in plasma potassium concentrationRise in plasma potassium concentration
Progressive reduction in the red cell content of 2,3Progressive reduction in the red cell content of 2,3
diphosphoglycerate (2,3 DPG)diphosphoglycerate (2,3 DPG)
Loss of all platelet function in whole blood within 48 hoursLoss of all platelet function in whole blood within 48 hours
of donationof donation
Reduction in Factor VIII to 10–20% of normal within 48Reduction in Factor VIII to 10–20% of normal within 48
hours of donation. Coagulation factors such as VII and IXhours of donation. Coagulation factors such as VII and IX
are relatively stable in storageare relatively stable in storage

AdministrationAdministration
– Must be ABO and Rh compatible with theMust be ABO and Rh compatible with the
recipientrecipient
– storage:2-6*Cstorage:2-6*C
– Use within 35 daysUse within 35 days
– Transfuse within ½ hrs of removal fromTransfuse within ½ hrs of removal from
refrigeratorrefrigerator
– Complete transfusion within 4 hrs ofComplete transfusion within 4 hrs of
commencementcommencement
– Never add medication to a unit of bloodNever add medication to a unit of blood

Advantages:Advantages:
1.Requires only simple & inexpensive single collection pack1.Requires only simple & inexpensive single collection pack
2.Supplies all components & volume2.Supplies all components & volume
Disadvantages:Disadvantages:
1.Risk of circulatory overload, transmitting infection1.Risk of circulatory overload, transmitting infection
2.No functional platelet or labile clotting factors2.No functional platelet or labile clotting factors

Production of Whole BloodProduction of Whole Blood
Donor –whole blood-ABO & RhD testingDonor –whole blood-ABO & RhD testing
II
Test for infectious diseases markersTest for infectious diseases markers
II
Negative positiveNegative positive
I II I
Quarentine refrigerator discardQuarentine refrigerator discard
II
releaserelease
II
Blood bank refrigeratorBlood bank refrigeratorcompatibility testcompatibility testcompatiblecompatible ptspts

Red cell ConcentrateRed cell Concentrate
(Packed Red cells)(Packed Red cells)
Prepared by allowing the blood toPrepared by allowing the blood to
separate under gravity in refrigerator atseparate under gravity in refrigerator at
2-6*C overnight2-6*C overnight
oror
By centrifugingBy centrifuging

Red Cell ConcentrateRed Cell Concentrate

150-200ml red cells150-200ml red cells
Hb approx. 20gm/dl(not<45gm per unit)Hb approx. 20gm/dl(not<45gm per unit)
Hct 55 -75%Hct 55 -75%
– Replacement of red cells in anemic patientsReplacement of red cells in anemic patients
– Use with crystalloid replacement fluids or colloidUse with crystalloid replacement fluids or colloid
solution in acute blood losssolution in acute blood loss
– Same as whole bloodSame as whole blood
– To improve transfusion flow, normal saline (50–To improve transfusion flow, normal saline (50–
100 ml) may be added using a Y-pattern infusion100 ml) may be added using a Y-pattern infusion
setset

simple, cheapersimple, cheaper
--Increases viscosityIncreases viscosity
-Febrile Non haemolytic Transfusion Reaction-Febrile Non haemolytic Transfusion Reaction

Red cell SuspensionRed cell Suspension

150–200 ml red cells with minimal residual plasma150–200 ml red cells with minimal residual plasma
110 ml normal saline, adenine, glucose, mannitol110 ml normal saline, adenine, glucose, mannitol
solution (SAG-M) or an equivalent red cell nutrientsolution (SAG-M) or an equivalent red cell nutrient
solution addedsolution added
Hb approximately 15 g/dL (not < 45 g per unit)Hb approximately 15 g/dL (not < 45 g per unit)
Hct – 50–70%Hct – 50–70%
Indications – Same as red cell concentrateIndications – Same as red cell concentrate
Contraindications – exchange transfusion ofContraindications – exchange transfusion of
neonatesneonates

– Same as whole bloodSame as whole blood
– Better flow rates than red cell concentrateBetter flow rates than red cell concentrate
or whole bloodor whole blood
-Reduces viscosity-Reduces viscosity
-Better preservation of the red cells-Better preservation of the red cells
-Permits separated use of platelets & plasma-Permits separated use of platelets & plasma
-Cost a special blood collection set-Cost a special blood collection set
-Expensive equipment (refrigerated centrifuge)-Expensive equipment (refrigerated centrifuge)

Red cell suspension or concentrate containing < 5 x 10Red cell suspension or concentrate containing < 5 x 1066
white cells per packwhite cells per pack
Preparation – filtration through a leucocyte-depleting filterPreparation – filtration through a leucocyte-depleting filter
Leucocyte depletion removes the risk of transmission ofLeucocyte depletion removes the risk of transmission of
cytomegalovirus (CMV)cytomegalovirus (CMV)
Leucocyte-Depleted (Filtered) Red cellsLeucocyte-Depleted (Filtered) Red cells
or Whole Bloodor Whole Blood

– Minimizes white cell immunization inMinimizes white cell immunization in
patients receiving repeated transfusionpatients receiving repeated transfusion
– Reduces risk of CMV transmissionReduces risk of CMV transmission
– Patients who have experienced two orPatients who have experienced two or
more previous febrile reactions to red cellmore previous febrile reactions to red cell
transfusiontransfusion
ContraindicationsContraindications
– Will not prevent graft-vs-host diseaseWill not prevent graft-vs-host disease

--Decreases development of immunity toDecreases development of immunity to
white cellswhite cells
-Decreased transfusion reaction-Decreased transfusion reaction
-Decreases chance of transmitting viral-Decreases chance of transmitting viral
infection eg; CMVinfection eg; CMV
--Special instrument & blood pack neededSpecial instrument & blood pack needed
-Skilled & trained operator needed-Skilled & trained operator needed

Buffy Coat Depleted Red CellsBuffy Coat Depleted Red Cells
--White cells & platelets are removed byWhite cells & platelets are removed by
controlled centrifugationcontrolled centrifugation
-Red cells & only about 10% of the-Red cells & only about 10% of the
white cells remains in concentratewhite cells remains in concentrate
-Use to prepare platelets concentrates-Use to prepare platelets concentrates
DisadvantagesDisadvantages
--Expensive procedureExpensive procedure
-More skilled manpower needed-More skilled manpower needed

Platelet ConcentratesPlatelet Concentrates
Single donor unit in a volume of 50–60 ml ofSingle donor unit in a volume of 50–60 ml of
plasma should contain:plasma should contain:
– At least 55 x 10At least 55 x 1099
plateletsplatelets
– <1.2 x 10<1.2 x 1099
red cellsred cells
– <0.12 x 10<0.12 x 1099
leucocytesleucocytes
Single donor unit : platelets prepared from oneSingle donor unit : platelets prepared from one
donationdonation
Pooled unit : platelets prepared from 4 to 6 donorPooled unit : platelets prepared from 4 to 6 donor
units ‘pooled’ into one pack to contain an adultunits ‘pooled’ into one pack to contain an adult
dose of at least 240 x 10dose of at least 240 x 1099
plateletsplatelets
Bacterial contamination affects about 1% ofBacterial contamination affects about 1% of
pooled unitspooled units

Treatment of bleeding due to:Treatment of bleeding due to:
ThrombocytopeniaThrombocytopenia
Platelet function defectsPlatelet function defects
Prevention of bleeding due toPrevention of bleeding due to
thrombocytopenia, such as in bone marrowthrombocytopenia, such as in bone marrow
failurefailure

ContraindicationsContraindications
– Not generally indicated for prophylaxis ofNot generally indicated for prophylaxis of
bleeding in surgical patients, unless knownbleeding in surgical patients, unless known
to have significant pre-operative plateletto have significant pre-operative platelet
deficiencydeficiency
– Not indicated in:Not indicated in:
ITPITP
TTPTTP
DICDIC
Thrombocytopenia associated withThrombocytopenia associated with
septicemia, until treatment hassepticemia, until treatment has
commenced or in cases ofcommenced or in cases of
hypersplenismhypersplenism

DosageDosage
– 1 unit of platelet concentrate/10 kg body1 unit of platelet concentrate/10 kg body
weight : in a 60 or 70 kg adult, 4–6 singleweight : in a 60 or 70 kg adult, 4–6 single
donor units containing at leastdonor units containing at least 240 x 10240 x 1099
platelets should raise the platelet count byplatelets should raise the platelet count by
20–40 x 1020–40 x 1099
/L/L
– Increment will be less if there is:Increment will be less if there is:
SplenomegalySplenomegaly
DICDIC
SepticemiaSepticemia
Contd.

-After pooling, platelet concentrates should be-After pooling, platelet concentrates should be
infused asinfused as
soon as possible generally within 4 hourssoon as possible generally within 4 hours
– Must not be refrigerated before infusion as thisMust not be refrigerated before infusion as this
reduces platelet functionreduces platelet function
– 4–6 units of platelet concentrates should be4–6 units of platelet concentrates should be
infused through a fresh standard bloodinfused through a fresh standard blood
administration setadministration set
– Special platelet infusion sets are not requiredSpecial platelet infusion sets are not required

– Platelet concentrates should bePlatelet concentrates should be
infused over about 30 minutesinfused over about 30 minutes
– Platelet concentrates prepared fromPlatelet concentrates prepared from
Rh D positive donors should not beRh D positive donors should not be
given to a Rh D negative potentialgiven to a Rh D negative potential
child-bearing femalechild-bearing female
– Platelet concentrates that are ABOPlatelet concentrates that are ABO
compatible should be givencompatible should be given
whenever possiblewhenever possible

ComplicationsComplications
– Febrile Non-hemolytic ReactionsFebrile Non-hemolytic Reactions
– Allergic Urticarial ReactionsAllergic Urticarial Reactions
– Pooling increases transmission of infectionPooling increases transmission of infection

FRESH FROZEN PLASMAFRESH FROZEN PLASMA

Fresh Frozen PlasmaFresh Frozen Plasma
Pack containing the plasma separated from onePack containing the plasma separated from one
whole blood donation within 6 hours of collection andwhole blood donation within 6 hours of collection and
then rapidly frozen to –25°C or colderthen rapidly frozen to –25°C or colder
Contains normal plasma levels of stableContains normal plasma levels of stable clottingclotting
factors, albumin and immunoglobulinfactors, albumin and immunoglobulin
Factor VIII level at least 70% of normal fresh plasmaFactor VIII level at least 70% of normal fresh plasma
levellevel
Usual volume of pack is 200–300 mlUsual volume of pack is 200–300 ml
Smaller volume packs may be available for childrenSmaller volume packs may be available for children
Very low risk of infection if treated with methyleneVery low risk of infection if treated with methylene
blue/ultraviolet light inactivationblue/ultraviolet light inactivation

– Replacement of multiple coagulation factorReplacement of multiple coagulation factor
deficiencies, e.g: -deficiencies, e.g: -
Liver diseaseLiver disease
Warfarin overdoseWarfarin overdose
Depletion of coagulation factors in ptsDepletion of coagulation factors in pts
receiving large volume transfusionsreceiving large volume transfusions
DICDIC
TTPTTP

Dosage –Dosage – Initial dose of 15 ml/kgInitial dose of 15 ml/kg
--Must normally be ABO compatible to avoid risk ofMust normally be ABO compatible to avoid risk of
hemolysis in recipienthemolysis in recipient
– No cross matching neededNo cross matching needed
– Before use, should be thawed in water which isBefore use, should be thawed in water which is
between 30°C and 37°C.between 30°C and 37°C.
– Higher temperatures will destroy clotting factors andHigher temperatures will destroy clotting factors and
proteinsproteins
– Infuse using a standard blood infusion set as soonInfuse using a standard blood infusion set as soon
as possible after thawingas possible after thawing
– Labile coagulation factors rapidly degrade;Labile coagulation factors rapidly degrade; useuse
within 6 hours of thawingwithin 6 hours of thawing
– Cant be refrozen for further storageCant be refrozen for further storage

Prepared from FFP by collecting thePrepared from FFP by collecting the
precipitate formed during controlled thawingprecipitate formed during controlled thawing
and re suspending it in 10–20 ml plasmaand re suspending it in 10–20 ml plasma
Contains about half of the Factor VIII andContains about half of the Factor VIII and
fibrinogen in the donated whole blood: e.g.fibrinogen in the donated whole blood: e.g.
Factor VIII: 80–100 I.U./pack; fibrinogen:Factor VIII: 80–100 I.U./pack; fibrinogen:
150–300 mg/pack150–300 mg/pack
Usually supplied as a single donor pack or aUsually supplied as a single donor pack or a
pack of 6 or more single donor unitspack of 6 or more single donor units

– As an alternative to Factor VIII concentrateAs an alternative to Factor VIII concentrate
in the treatment of inherited deficienciesin the treatment of inherited deficiencies
of:of:
Von Willebrand Factor (vonVon Willebrand Factor (von
Willebrand’s disease)Willebrand’s disease)
Factor VIII (haemophilia A)Factor VIII (haemophilia A)
Factor XIIIFactor XIII
As a source of fibrinogen in acquiredAs a source of fibrinogen in acquired
coagulopathies: e.g. (DIC)coagulopathies: e.g. (DIC)

Factor VIII ConcentrateFactor VIII Concentrate
Partially purified Factor VIII prepared from largePartially purified Factor VIII prepared from large
pools of donor plasmapools of donor plasma
Vials of freeze-dried protein usually about 250 i.u.Vials of freeze-dried protein usually about 250 i.u.
of Factor VIIIof Factor VIII
– Treatment of hemophilia ATreatment of hemophilia A
– Treatment of von Willebrand’s diseaseTreatment of von Willebrand’s disease
Factor VIII prepared in vitro using recombinantFactor VIII prepared in vitro using recombinant
DNA methods is commercially availableDNA methods is commercially available

Human Albumin SolutionsHuman Albumin Solutions
Prepared by fractionation of large pools of donatedPrepared by fractionation of large pools of donated
human plasmahuman plasma
PreparationsPreparations
– Albumin 5%: contains 50 mg/ml of albuminAlbumin 5%: contains 50 mg/ml of albumin
– Stable plasma protein solution (SPPS) and plasmaStable plasma protein solution (SPPS) and plasma
protein fraction (PPF): similar albumin content toprotein fraction (PPF): similar albumin content to
albumin 5%albumin 5%
– Replacement fluid in therapeutic plasma exchangeReplacement fluid in therapeutic plasma exchange
ContraindicationsContraindications - Not for use as IV nutrition- Not for use as IV nutrition

Volume of Blood ProductsVolume of Blood Products
Blood productBlood product VolumeVolume
Whole blood (CPDA-1)Whole blood (CPDA-1) 350 ml350 ml
Whole blood for componentWhole blood for component
separationseparation
450 ml450 ml
Packed red blood cells (CPD)Packed red blood cells (CPD) 150-200 ml150-200 ml
Packed red blood cells (SAGM)Packed red blood cells (SAGM) 200-250 ml200-250 ml
Fresh frozen plasmaFresh frozen plasma 100-150 ml100-150 ml
Cryo poor plasmaCryo poor plasma 100-150 ml100-150 ml
Platelet rich plasmaPlatelet rich plasma 100-150 ml100-150 ml
Platelet concentratePlatelet concentrate 50-70 ml50-70 ml
CryoprecipitateCryoprecipitate 15-20 ml15-20 ml
Buffy coatBuffy coat 50-70 ml50-70 ml

Component StorageComponent Storage
Blood & blood productsBlood & blood products Storage Temp.Storage Temp. DurationDuration
Whole blood (CPDA-1)Whole blood (CPDA-1) 2-62-600
CC 35 days35 days
Packed red blood cells (CPD)Packed red blood cells (CPD) 2-62-600
CC 28 days28 days
Packed red blood cells (CPDA-Packed red blood cells (CPDA-
1)1)
2-62-600
CC 35 days35 days
Washed red blood cellsWashed red blood cells 2-62-600
CC 24 hrs24 hrs
Packed red blood cellsPacked red blood cells
(SAGM)(SAGM)
2-62-600
CC 42 days42 days
Fresh frozen plasmaFresh frozen plasma -20-2000
CC 3-6 mths3-6 mths
Fresh frozen plasmaFresh frozen plasma -30-3000
CC 6-12 mths6-12 mths
Cryo poor plasmaCryo poor plasma -30-3000
C or lessC or less 6-12 mths6-12 mths
Platelet concentratePlatelet concentrate 22-2422-2400
CC 3 days3 days
CryoprecipitateCryoprecipitate -30-3000
CC 6-12 mths6-12 mths
Buffy coatBuffy coat 222200
CC 4-6 hrs4-6 hrs

Transfusion ReactionsTransfusion Reactions
Acute complications of transfusionAcute complications of transfusion
Category 1: Mild reactionsCategory 1: Mild reactions
Mild hypersensitivity: allergic, urticarial reactionsMild hypersensitivity: allergic, urticarial reactions
Category 2: Moderately severe reactionsCategory 2: Moderately severe reactions
Moderate–severe hypersensitivity (severe urticarial reactions)Moderate–severe hypersensitivity (severe urticarial reactions)
Febrile non-hemolytic reactions:Febrile non-hemolytic reactions:
—— Antibodies to white cells, plateletsAntibodies to white cells, platelets
—— Antibodies to proteins, including IgAAntibodies to proteins, including IgA
Possible bacterial contamination (early signs)Possible bacterial contamination (early signs)
PyrogensPyrogens
Category 3: Life-threatening reactionsCategory 3: Life-threatening reactions
Acute intravascular hemolysisAcute intravascular hemolysis
Bacterial contamination and septic shockBacterial contamination and septic shock
Fluid overloadFluid overload
Anaphylactic reactionsAnaphylactic reactions
Transfusion-associated Acute lung injury (TRALI)Transfusion-associated Acute lung injury (TRALI)

Delayed complications of transfusionDelayed complications of transfusion
Transfusion-transmitted infections :Transfusion-transmitted infections :
HIV-1 and HIV-2HIV-1 and HIV-2
HTLV-I and IIHTLV-I and II
Viral hepatitis B and CViral hepatitis B and C
SyphilisSyphilis
Chagas diseaseChagas disease
MalariaMalaria
CytomegalovirusCytomegalovirus
Other rare infections: e.g. human parvovirus B19 andOther rare infections: e.g. human parvovirus B19 and
hepatitis Ahepatitis A
Other delayed complications of transfusion :Other delayed complications of transfusion :
Delayed hemolytic reactionDelayed hemolytic reaction
Post-transfusion PurpuraPost-transfusion Purpura
Graft-vs-host diseaseGraft-vs-host disease
Iron overloadIron overload

Management of Transfusion ReactionsManagement of Transfusion Reactions
CategoryCategory SignsSigns SymptomsSymptoms
Category 1:Category 1:
Mild reactionsMild reactions
Localized cutaneousLocalized cutaneous
reactions: Urticaria, Rashreactions: Urticaria, Rash
Pruritus (itching)Pruritus (itching)
ModeratelyModerately
severesevere
reactionsreactions
FlushingFlushing
UrticariaUrticaria
RigorsRigors
FeverFever
RestlessnessRestlessness
TachycardiaTachycardia
AnxietyAnxiety
Pruritus (itching)Pruritus (itching)
PalpitationsPalpitations
Mild dyspnoeaMild dyspnoea
HeadacheHeadache
Life-Life-
threateningthreatening
reactionsreactions
RigorsRigors
FeverFever
RestlessnessRestlessness
Hypotension (fall of ≥20% inHypotension (fall of ≥20% in
SBP)SBP)
Tachycardia (rise of ≥20% in HR)Tachycardia (rise of ≥20% in HR)
Haemoglobinuria (red urine)Haemoglobinuria (red urine)
Unexplained bleeding (DIC)Unexplained bleeding (DIC)
AnxietyAnxiety
Chest painChest pain
Pain near infusion sitePain near infusion site
RespiratoryRespiratory
distress/SOBdistress/SOB
Loin/back painLoin/back pain
HeadacheHeadache
DyspnoeaDyspnoea

CATEGORY 1: MILDCATEGORY 1: MILD
1.Slow the transfusion1.Slow the transfusion
2.Administer antihistamine IM (e.g.2.Administer antihistamine IM (e.g.
chlorpheniramine 0.1 mg/kg orchlorpheniramine 0.1 mg/kg or
equivalent).equivalent).
3.If no clinical improvement within 303.If no clinical improvement within 30
minutes or if signs and symptomsminutes or if signs and symptoms
worsen,worsen, treat as Category 2.treat as Category 2.

CATEGORY 2: MODERATELY SEVERECATEGORY 2: MODERATELY SEVERE
1. Stop the transfusion. Replace the infusion set and keep1. Stop the transfusion. Replace the infusion set and keep
IV line open with normal salineIV line open with normal saline
2. Notify the doctor and the blood bank immediately.2. Notify the doctor and the blood bank immediately.
3. Send blood unit with infusion set, freshly collected urine3. Send blood unit with infusion set, freshly collected urine
and new blood samples (1 clotted and 1 anticoagulated)and new blood samples (1 clotted and 1 anticoagulated)
from vein opposite infusion site to blood bank andfrom vein opposite infusion site to blood bank and
laboratory for investigations.laboratory for investigations.
4. Administer antihistamine IM (e.g. chlorpheniramine 0.14. Administer antihistamine IM (e.g. chlorpheniramine 0.1
mg/kg or equivalent) and oral or rectal antipyretic (e.g.mg/kg or equivalent) and oral or rectal antipyretic (e.g.
paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoidparacetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid
aspirin.aspirin.

5.5. Give IV corticosteroids and bronchodilators if there areGive IV corticosteroids and bronchodilators if there are
anaphylactoid features (e.g. bronchospasm, stridor).anaphylactoid features (e.g. bronchospasm, stridor).
6.6. Collect urine for next 24 hours for evidence ofCollect urine for next 24 hours for evidence of
hemolysis and send to laboratory.hemolysis and send to laboratory.
7.7. If clinical improvement, restart transfusion slowly withIf clinical improvement, restart transfusion slowly with
new blood unit and observe carefully.new blood unit and observe carefully.
8.8. If no clinical improvement within 15 minutes or if S/SIf no clinical improvement within 15 minutes or if S/S
worsen,worsen, treat as Category 3.treat as Category 3.

CATEGORY 3: LIFE-THREATENINGCATEGORY 3: LIFE-THREATENING
1.1. Stop the transfusion. Replace the infusion set and keepStop the transfusion. Replace the infusion set and keep
IV line openIV line open
2.2. Infuse NS (initially 20–30 ml/kg) to maintain SBP. IfInfuse NS (initially 20–30 ml/kg) to maintain SBP. If
hypotensive, give over 5 minutes and elevate patient’shypotensive, give over 5 minutes and elevate patient’s
legs.legs.
3.3. Maintain airway and give high flow oxygen by mask.Maintain airway and give high flow oxygen by mask.
4.4. Give adrenaline (as 1:1000 solution) 0.01 mg/kg bodyGive adrenaline (as 1:1000 solution) 0.01 mg/kg body
weight by slow intramuscular injection.weight by slow intramuscular injection.
5.5. Give IV corticosteroids and bronchodilators if there areGive IV corticosteroids and bronchodilators if there are
anaphylactoid features (e.g. bronchospasm, stridor).anaphylactoid features (e.g. bronchospasm, stridor).
6.6. Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
7.7. Notify the doctor and the blood bank immediately.Notify the doctor and the blood bank immediately.

8.8. Send blood unit with infusion set, fresh urine sample andSend blood unit with infusion set, fresh urine sample and
new blood samples (1 clotted and 1 anticoagulated) fromnew blood samples (1 clotted and 1 anticoagulated) from
vein opposite infusion site to blood bank and laboratoryvein opposite infusion site to blood bank and laboratory
for investigations.for investigations.
9.9. Check a fresh urine specimen visually for signs ofCheck a fresh urine specimen visually for signs of
haemoglobinuria (red or pink urine)haemoglobinuria (red or pink urine)
10.10. Start a 24-hour urine collection and I/O charting. MaintainStart a 24-hour urine collection and I/O charting. Maintain
fluid balance.fluid balance.
11.Assess for bleeding from puncture sites or wounds. If11.Assess for bleeding from puncture sites or wounds. If
there is evidence of DIC, give platelets (adult: 5–6 units)there is evidence of DIC, give platelets (adult: 5–6 units)
and either cryoprecipitate (adult: 12 units) or FFP (adult:and either cryoprecipitate (adult: 12 units) or FFP (adult:
3 units). Use virally-inactivated plasma coagulation3 units). Use virally-inactivated plasma coagulation
products, wherever possible.products, wherever possible.

12.12. Reassess. If hypotensive:Reassess. If hypotensive:
Give further saline 20–30 ml/kg over 5 minutesGive further saline 20–30 ml/kg over 5 minutes
Give ionotrope, if availableGive ionotrope, if available
13.13. If urine output falling or laboratory evidence of acuteIf urine output falling or laboratory evidence of acute
renal failure :renal failure :
Maintain fluid balance accuratelyMaintain fluid balance accurately
Give further frusemideGive further frusemide
Consider dopamine infusion, if availableConsider dopamine infusion, if available
Seek expert help: the patient may need renal dialysisSeek expert help: the patient may need renal dialysis
14.14. If bacteremia is suspected, start broad-spectrumIf bacteremia is suspected, start broad-spectrum
antibiotics IV, to cover pseudomonas and gramantibiotics IV, to cover pseudomonas and gram
positives.positives.

Massive Blood TransfusionMassive Blood Transfusion
Defined as the replacement of blood lossDefined as the replacement of blood loss
equivalent to or greater than the patient’s totalequivalent to or greater than the patient’s total
blood volume with stored blood in < 24 hoursblood volume with stored blood in < 24 hours
(70 ml/kg in adults, 80–90 ml/kg in children or(70 ml/kg in adults, 80–90 ml/kg in children or
infants)infants)
ComplicationsComplications
– AcidosisAcidosis
– HyperkalemiaHyperkalemia
– Citrate toxicity and hypocalcaemiaCitrate toxicity and hypocalcaemia
– Depletion of fibrinogen and coagulation factorsDepletion of fibrinogen and coagulation factors
– Depletion of plateletsDepletion of platelets
– DICDIC
– HypothermiaHypothermia
– Reduced 2,3 diphosphoglycerate (2,3 DPG)Reduced 2,3 diphosphoglycerate (2,3 DPG)
– MicroaggregatesMicroaggregates

(1)Preoperative Blood Deposit (PAD)(1)Preoperative Blood Deposit (PAD)
(2)Acute Normovolaemic Haemodilution(2)Acute Normovolaemic Haemodilution
(3)Blood salvage(3)Blood salvage
– Gauze filtrationGauze filtration
– Simple suction collection systemsSimple suction collection systems
– Automated suction collection systemsAutomated suction collection systems
– Modified drainModified drain
Autologous Blood TransfusionAutologous Blood Transfusion

Artificial Oxygen CarrierArtificial Oxygen Carrier
(1)Hemoglobin-based Oxygen Carriers (HBOC)(1)Hemoglobin-based Oxygen Carriers (HBOC)
(2)Products based on Perﬂuorocarbons (PF)(2)Products based on Perﬂuorocarbons (PF)
AdvantageAdvantage
– Can be sterilizedCan be sterilized
– Do not have any blood groupDo not have any blood group
– Could be stored for a long timeCould be stored for a long time
DisadvantageDisadvantage
-Very short half life=around 24 hrs-Very short half life=around 24 hrs
-High flow O2 required-High flow O2 required

Other Methods to Reduce Red Blood CellOther Methods to Reduce Red Blood Cell
TransfusionTransfusion
1.Recombinant Erythropoietin1.Recombinant Erythropoietin
2.Fibrin Glue:2.Fibrin Glue:
11stst
Syringe-calcium & human thrombinSyringe-calcium & human thrombin
22ndnd
Syringe- human fibrinogenSyringe- human fibrinogen
Injected simultaneously over the minor cutaneous bleedingInjected simultaneously over the minor cutaneous bleeding
sitessitesfibrin clot(glue)fibrin clot(glue)hemostasishemostasis
3.Tranexamic acid3.Tranexamic acid

Transfusions of blood productsTransfusions of blood products
can save lives, but are not withoutcan save lives, but are not without
risks or costsrisks or costs
Safe blood is a scarce andSafe blood is a scarce and
valuable resource that isvaluable resource that is
expensive to collect, process andexpensive to collect, process and
administeradminister

Limiting Transfusion to patientsLimiting Transfusion to patients
whose chance of survival or quality of life iswhose chance of survival or quality of life is
improved with blood will help to decreaseimproved with blood will help to decrease
the high demand for blood products andthe high demand for blood products and
will reduce unnecessary exposure ofwill reduce unnecessary exposure of
patients to the risks of transfusion.patients to the risks of transfusion.

Maximum Blood Ordering ScheduleMaximum Blood Ordering Schedule
Elective Surgical ProcedureElective Surgical Procedure
Agreement between Surgeons,Agreement between Surgeons,
Anaesthesiologists & HaematologistsAnaesthesiologists & Haematologists
ProcedureProcedure Blood OrderBlood Order
Tumor of palateTumor of palate G & SG & S
LaryngectomyLaryngectomy 2 units2 units
RNDRND 2 units2 units
CommandoCommando 4 units4 units

Getting The Right Blood to the RightGetting The Right Blood to the Right
Patient at the Right TimePatient at the Right Time

Nutrition inNutrition in
SurgerySurgery

30% – 50% of hospitalized patients – malnourished30% – 50% of hospitalized patients – malnourished
Malnutrition a/w increased morbidity and mortalityMalnutrition a/w increased morbidity and mortality
Most healthy patients can tolerate 7 days of starvation (withMost healthy patients can tolerate 7 days of starvation (with
adequate glucose and fluid replacement)adequate glucose and fluid replacement)
Preoperative nutritional support can significantly reducePreoperative nutritional support can significantly reduce
perioperative morbidity and mortality in patients with severeperioperative morbidity and mortality in patients with severe
malnutritionmalnutrition

Protein RequirementsProtein Requirements
– Avg. healthy adult : approximatelyAvg. healthy adult : approximately 0.8 g/kg0.8 g/kg
body weightbody weight
– Physiologically stressed :Physiologically stressed : 1.2 – 2.5 g/kg/day1.2 – 2.5 g/kg/day
– protein intake of 6.25 g equivalent to 1 g ofprotein intake of 6.25 g equivalent to 1 g of
nitrogennitrogen
– 15% of normal energy expenditure15% of normal energy expenditure
– 1 gm of protein = 4 kcal1 gm of protein = 4 kcal

Carbohydrate RequirementsCarbohydrate Requirements
– 40-60 % of normal energy expenditure40-60 % of normal energy expenditure
– 400 kcal of CHO/day minimizes protein400 kcal of CHO/day minimizes protein
breakdown, particularly after adaptation tobreakdown, particularly after adaptation to
starvationstarvation
– 1 gm of Enteral CHO = 4 kcal &1 gm of Enteral CHO = 4 kcal &
1gm of Parenteral CHO = 3.4 kcal/g1gm of Parenteral CHO = 3.4 kcal/g
Lipid Requirements :Lipid Requirements :
– 25% to 45% of normal energy expenditure25% to 45% of normal energy expenditure
– 1 gm of lipid = 9 kcal1 gm of lipid = 9 kcal

Daily Vitamins RequirementsDaily Vitamins Requirements

Daily Trace elements RequirementsDaily Trace elements Requirements

TheThe MetabolicMetabolic Response to Critical IllnessResponse to Critical Illness

Nutritional AssessmentNutritional Assessment
HistoryHistory
– Weight fluctuation or a change in dietary habitsWeight fluctuation or a change in dietary habits
– Recent weight lossRecent weight loss
5% in the last month5% in the last month
10% over 6 months10% over 6 months
Current body weight of 80% to 85% (or less)Current body weight of 80% to 85% (or less)
of ideal body weightof ideal body weight
Physical ExaminationPhysical Examination
– Muscle wasting (especially thenar, temporal &Muscle wasting (especially thenar, temporal &
gluteal muscles)gluteal muscles)
– Loose or flabby skinLoose or flabby skin
– Peripheral edema and/or ascitesPeripheral edema and/or ascites
– Skin rash, pallor, glossitis, gingival lesions, hairSkin rash, pallor, glossitis, gingival lesions, hair
changes, hepatomegaly, neuropathy, andchanges, hepatomegaly, neuropathy, and
dementiadementia

Anthropometric measurementsAnthropometric measurements
– Triceps skinfold thicknessTriceps skinfold thickness
– Mid-upper arm circumferenceMid-upper arm circumference
– BMIBMI
Laboratory testsLaboratory tests
– Serum albumin < 3.5 g/dLSerum albumin < 3.5 g/dL
– Half-life is 14 to 20 days.Half-life is 14 to 20 days.
– Serum Prealbumin (indicator of acute changes) :Serum Prealbumin (indicator of acute changes) :
10 to 17 mg/dL – mild depletion10 to 17 mg/dL – mild depletion
5 to 10 mg/dL – moderate depletion5 to 10 mg/dL – moderate depletion
< 5 mg/dL – severe depletion< 5 mg/dL – severe depletion
half-life is 2 to 3 days.half-life is 2 to 3 days.
– Serum transferrin < 200 mg/dLSerum transferrin < 200 mg/dL
half-life is 8 to 10 days.half-life is 8 to 10 days.

Immune FunctionImmune Function
– Delayed-type hypersensitivity (anergyDelayed-type hypersensitivity (anergy
to common skin antigens)to common skin antigens)
– Total lymphocyte count (TLC)Total lymphocyte count (TLC)
1,500 to 1,800/mm1,500 to 1,800/mm33
– mild– mild
depletiondepletion
900 to 1,500/mm900 to 1,500/mm33
– moderate– moderate
depletiondepletion
< 900/mm< 900/mm33
– severe depletion– severe depletion

Nutritional IndicesNutritional Indices
Body Mass Index (BMI)Body Mass Index (BMI)
BMI = weight (kg)/[height (m)]BMI = weight (kg)/[height (m)]22
BMI: Normal 18.5–24.9BMI: Normal 18.5–24.9
Overweight 25–29.9Overweight 25–29.9
Obese 30–40Obese 30–40
Morbid Obesity >40Morbid Obesity >40
Prognostic Nutritional Index (PNI)Prognostic Nutritional Index (PNI)
PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)
DH: >5 mm induration = 2; 1–5 mm induration = 1; anergyDH: >5 mm induration = 2; 1–5 mm induration = 1; anergy
= 0= 0
PNI: >50% = high risk for complicationsPNI: >50% = high risk for complications
40%–49% = intermediate risk40%–49% = intermediate risk
<40% = low risk<40% = low risk
Alb, albumin (g/dL); DH, delayed cutaneous hypersensitivity; TFN, transferrin (mg/dL); TSF,
triceps skinfold thickness (mm); UUN, 24-hr urine urea nitrogen excretion (g)

Estimation of CaloricEstimation of Caloric
RequirementsRequirements
TEE = BEE + EEA + EETTEE = BEE + EEA + EET
TEE : Total Daily Energy ExpenditureTEE : Total Daily Energy Expenditure
BEE : Basal Energy ExpenditureBEE : Basal Energy Expenditure
EEA : Energy Expenditure of Activity (25 %)EEA : Energy Expenditure of Activity (25 %)
EET : Energy Expenditure of Thermogenesis (10%)EET : Energy Expenditure of Thermogenesis (10%)

Calculating BEECalculating BEE ::
Harris - Benedict EquationHarris - Benedict Equation
Men:Men:
BEE=BEE=
66.5 + [13.75 x weight(kg)] + [5 x height(cm)] –[6.78 x66.5 + [13.75 x weight(kg)] + [5 x height(cm)] –[6.78 x
age(yrs)]age(yrs)]
WomenWomen::
BEE=BEE=
65.5 + [9.56 x weight(kg)] + [1.85 x height(cm)] –65.5 + [9.56 x weight(kg)] + [1.85 x height(cm)] –
[4.68xage(yrs)][4.68xage(yrs)]
– 25 kCal/kg – 35kCal/kg25 kCal/kg – 35kCal/kg
TEE = BEE x specific stress factorsTEE = BEE x specific stress factors
StarvationStarvation 0.80–1.000.80–1.00
Elective operationElective operation 1.00–1.101.00–1.10
Adult respiratory distress syndrome orAdult respiratory distress syndrome or
sepsissepsis
1.30–1.351.30–1.35

Caloric requirements may be 150% more than the basalCaloric requirements may be 150% more than the basal
energy expenditure in pts undergoing major surgeryenergy expenditure in pts undergoing major surgery
Phases following SurgeryPhases following Surgery
(1)Phase I: Catabolic phase lasting 3-7 days, increased(1)Phase I: Catabolic phase lasting 3-7 days, increased
protein consumptionprotein consumption
(2)Phase II: Protein consumption & production are equal(2)Phase II: Protein consumption & production are equal
(3)Phase III: Anabolic phase, protein production exceeds(3)Phase III: Anabolic phase, protein production exceeds
consumptionconsumption
(4)Phase IV: Restoration of lipid stores(4)Phase IV: Restoration of lipid stores

Pre-operative PreparationPre-operative Preparation
In patients with severe nutritional risk, start nutritionIn patients with severe nutritional risk, start nutrition
supplement 2 wks prior to surgerysupplement 2 wks prior to surgery
Solid foods allowed up to 6 hrsSolid foods allowed up to 6 hrs
Liquid foods allowed up to 4hrsLiquid foods allowed up to 4hrs
Clear liquid allowed up to 2 hrsClear liquid allowed up to 2 hrs
Preoperative carbohydrate loading, the night before andPreoperative carbohydrate loading, the night before and
2 hr before surgery recommended2 hr before surgery recommended

Access- Possibilities for Nutrition
Nasogastric tube
Whole food
by mouth
Gastrostomy tube
Jejunostomy tube
Nasoduodenal tube
Nasojejunal tube
PP
N
TPN
Intravenous Alimentation

Preferred over the Parenteral routePreferred over the Parenteral route
Simple, physiologic, relatively inexpensive, and wellSimple, physiologic, relatively inexpensive, and well
tolerated by most patientstolerated by most patients
Maintains the GI tract cytoarchitecture and mucosal integrityMaintains the GI tract cytoarchitecture and mucosal integrity
(via trophic effects), absorptive function, and normal(via trophic effects), absorptive function, and normal
microbial floramicrobial flora
IndicationsIndications : patients who have a functional GI tract but are: patients who have a functional GI tract but are
unable to sustain an adequate oral dietunable to sustain an adequate oral diet
ContraindicationsContraindications : intestinal obstruction, ileus, GI: intestinal obstruction, ileus, GI
bleeding, severe diarrhea, vomiting, enterocolitis, or a high-bleeding, severe diarrhea, vomiting, enterocolitis, or a high-
output enterocutaneous fistulaoutput enterocutaneous fistula
Enteral NutritionEnteral Nutrition

Enteral Feeding ProductsEnteral Feeding Products
– Standard Solutions – 1 kcal/mlStandard Solutions – 1 kcal/ml
- Calorically concentrated solutions – >1 kcal/ml- Calorically concentrated solutions – >1 kcal/ml
-Dietary Formulations-Dietary Formulations
Nutritionally complete formulas (standardNutritionally complete formulas (standard
enteral diets)enteral diets)
Chemically defined formulas (elementalChemically defined formulas (elemental
diets)diets)
Modular formulations (in specific clinicalModular formulations (in specific clinical
situations)situations)

Bolus FeedingsBolus Feedings
– Reserved for patients with nasogastric or gastrostomyReserved for patients with nasogastric or gastrostomy
feeding tubesfeeding tubes
– Administered by gravityAdministered by gravity
– Begin at 50 to 100 mL every 4 hours, and increased inBegin at 50 to 100 mL every 4 hours, and increased in
50-mL increments until goal intake reached (usually 24050-mL increments until goal intake reached (usually 240
to 360 mL every 4 hours)to 360 mL every 4 hours)
– Tracheobronchial aspiration is a potentially seriousTracheobronchial aspiration is a potentially serious
complicationcomplication
Enteral Feeding Protocols

Continuous InfusionContinuous Infusion
– Administered by a pumpAdministered by a pump
– Generally required for nasojejunal, gastrojejunal,Generally required for nasojejunal, gastrojejunal,
or jejunal tubesor jejunal tubes
– Initiated at 20 mL/hour and increased in 10 toInitiated at 20 mL/hour and increased in 10 to
20mL/hour increments every 4 to 6 hours until20mL/hour increments every 4 to 6 hours until
the desired goal reachedthe desired goal reached
– Can be infused over 8 to 12 hours at nightCan be infused over 8 to 12 hours at night

Conversion to Oral FeedingConversion to Oral Feeding
– Resumed graduallyResumed gradually
– Enteral Feeding modified asEnteral Feeding modified as
Providing fewer feedingsProviding fewer feedings
Holding daytime feedingsHolding daytime feedings
Decreasing the volume of feedingsDecreasing the volume of feedings
When oral intake provides approximately 75% ofWhen oral intake provides approximately 75% of
the required calories, tube feedings can bethe required calories, tube feedings can be
stoppedstopped

Administration of medicationsAdministration of medications
– Many oral medications can be administeredMany oral medications can be administered
– Not suitable for administration through a feedingNot suitable for administration through a feeding
tube includetube include
Enteric-coated medicationsEnteric-coated medications
Drugs in gelatinous capsulesDrugs in gelatinous capsules
Medications that are designed for sublingualMedications that are designed for sublingual
useuse
Most sustained-release medicationsMost sustained-release medications

Complications of EnteralComplications of Enteral
NutritionNutrition
Metabolic ComplicationsMetabolic Complications
CloggingClogging (prevented by careful routine flushing of the(prevented by careful routine flushing of the
feeding tube)feeding tube)
Tracheobronchial AspirationTracheobronchial Aspiration
High Gastric ResidualsHigh Gastric Residuals
DiarrheaDiarrhea

Parenteral NutritionParenteral Nutrition
Indicated for patientsIndicated for patients
– Who cannot meet their needs through oral intakeWho cannot meet their needs through oral intake
– Enteral feeding is contraindicated or not toleratedEnteral feeding is contraindicated or not tolerated
Peripheral parenteral nutrition (PPN)Peripheral parenteral nutrition (PPN)
– Osmolarity of PPN solutions limited to 1,000 mOsmOsmolarity of PPN solutions limited to 1,000 mOsm
(approximately 12% dextrose solution)(approximately 12% dextrose solution) to avoid phlebitisto avoid phlebitis
– Unacceptably large volumes (>2,500 ml) necessaryUnacceptably large volumes (>2,500 ml) necessary
– Temporary nutritional supplementationTemporary nutritional supplementation
Total parenteral nutrition (TPN)Total parenteral nutrition (TPN)
– Complete nutritional supportComplete nutritional support
– Central venous catheter requiredCentral venous catheter required
– Replaced for unexplained fever or bacteremiaReplaced for unexplained fever or bacteremia

TPN SolutionsTPN Solutions
– 3-in-1 admixture3-in-1 admixture
Protein, as amino acids (10%; 4 kcal/g)Protein, as amino acids (10%; 4 kcal/g)
Carbohydrate, as dextrose (70%; 3.4 kcal/g)Carbohydrate, as dextrose (70%; 3.4 kcal/g)
Fat, as a lipid emulsion of soybean or safflower oilFat, as a lipid emulsion of soybean or safflower oil
(20%; 9 kcal/g)(20%; 9 kcal/g)
– Alternatively, the lipid emulsion can be administeredAlternatively, the lipid emulsion can be administered
as a separate intravenous infusionas a separate intravenous infusion
– Standard preparations availableStandard preparations available

AdditivesAdditives
– Electrolytes : sodium, potassium, chloride, acetate,Electrolytes : sodium, potassium, chloride, acetate,
calcium, magnesium, phosphate adjusted dailycalcium, magnesium, phosphate adjusted daily
– Number of cations and anions must balanceNumber of cations and anions must balance
– Calcium : Phosphate ratio must be monitored toCalcium : Phosphate ratio must be monitored to
prevent salt precipitationprevent salt precipitation
MedicationsMedications
– Albumin, HAlbumin, H22-receptor antagonists, heparin, iron,-receptor antagonists, heparin, iron,
dextran, insulin, and Metoclopramidedextran, insulin, and Metoclopramide
– Regular Insulin after adjusting doseRegular Insulin after adjusting dose

Other additivesOther additives
– Trace elements added daily eg. commerciallyTrace elements added daily eg. commercially
prepared mixtureprepared mixture
– Multivitamins generally added daily using aMultivitamins generally added daily using a
commercially prepared mixturecommercially prepared mixture (e.g., 10 mL MVI-12)(e.g., 10 mL MVI-12)
– Vitamin K not included in most multivitamin mixturesVitamin K not included in most multivitamin mixtures
and must be added separatelyand must be added separately (10 mg once a week)(10 mg once a week)
– Vitamins A and C and zinc essential for proper woundVitamins A and C and zinc essential for proper wound
healing.healing.

Routine Physiologic and Laboratory MonitoringRoutine Physiologic and Laboratory Monitoring
– On a scheduled basisOn a scheduled basis
– More frequently whose postoperative course has notMore frequently whose postoperative course has not
stabilizedstabilized
– Vital signs and serum glucoseVital signs and serum glucose every 6 hoursevery 6 hours
– Weight, serum electrolytes, and blood urea nitrogenWeight, serum electrolytes, and blood urea nitrogen
dailydaily
– Triglycerides, CBC, PT, liver enzymes, and bilirubinTriglycerides, CBC, PT, liver enzymes, and bilirubin
weeklyweekly

Administration of TPNAdministration of TPN
Introduction of TPNIntroduction of TPN
– Gradual. e.g. approximately 1,000 kcal in 1Gradual. e.g. approximately 1,000 kcal in 1stst
dayday
– Caloric goal achieved over 1 to 2 daysCaloric goal achieved over 1 to 2 days
TPN solutionsTPN solutions
– Continuous infusionContinuous infusion
Cyclic administration of TPN solutionsCyclic administration of TPN solutions
– Useful for selected patientsUseful for selected patients
Discontinuation of TPNDiscontinuation of TPN
– Satisfies 75% of his or her caloric and protein needsSatisfies 75% of his or her caloric and protein needs
with oral intake or enteral feedingwith oral intake or enteral feeding

Complications Associated withComplications Associated with
TPNTPN
Catheter-Related ComplicationsCatheter-Related Complications
Metabolic Complications – Na overload, CHF,Metabolic Complications – Na overload, CHF,
electrolyte imbalance, hyperglycemia andelectrolyte imbalance, hyperglycemia and
hyperosmolarityhyperosmolarity
(hyperglycemia may be the first indication of occult(hyperglycemia may be the first indication of occult
infection)infection)
Refeeding Syndrome – in severely malnourishedRefeeding Syndrome – in severely malnourished
patientpatient
Hepatic Dysfunction – steatosis, raised AST,Hepatic Dysfunction – steatosis, raised AST,
ALT, ALP & Bil. finally cirrhosisALT, ALP & Bil. finally cirrhosis
Cholecystitis – Acalculous type d/t CholestasisCholecystitis – Acalculous type d/t Cholestasis

Adverse Effects and RisksAdverse Effects and Risks
Parenteral NutritionParenteral Nutrition
OverfeedingOverfeeding
HyperglycemiaHyperglycemia
Infectious ComplicationsInfectious Complications
Gut Mucosal Atrophy?Gut Mucosal Atrophy?
Bacterial translocation?Bacterial translocation?
Early Enteral NutritionEarly Enteral Nutrition
Procedure-relatedProcedure-related
complicationscomplications
High gastric residualsHigh gastric residuals
Bacterial colonization ofBacterial colonization of
the stomachthe stomach
Aspiration PneumoniaAspiration Pneumonia

Water & Electrolyte BalanceWater & Electrolyte Balance

Body Fluid CompartmentsBody Fluid Compartments
K+
, Mg+
,
PO4
-
,
Proteins
Na+
,
Cl-
,
HCO3
-
Male – 60 %
Female – 50
%

Principles of Fluid ManagementPrinciples of Fluid Management
2,000-2,500 ml daily requirement2,000-2,500 ml daily requirement
Daily water lossesDaily water losses
– 1,000-1,500 ml in urine1,000-1,500 ml in urine (minimum UO to excrete(minimum UO to excrete
catabolic end products of metabolism – 400 ml)catabolic end products of metabolism – 400 ml)
– 250 ml in stool250 ml in stool
– 750 ml insensible loss750 ml insensible loss (increase with hypermetabolism,(increase with hypermetabolism,
fever & hyperventilation)fever & hyperventilation)

MaintenanceMaintenance
– Maintain urine output of 0.5 to 1 ml/kg/hour inMaintain urine output of 0.5 to 1 ml/kg/hour in
adult & 1 to 2 ml/kg/hr in childrenadult & 1 to 2 ml/kg/hr in children
eg. in adult UO at least 30 ml/hreg. in adult UO at least 30 ml/hr
– Estimation of Maintenance FluidEstimation of Maintenance Fluid
First 10 kg – 100 ml/kg/dayFirst 10 kg – 100 ml/kg/day
Second 10 kg – 50 ml/kg/daySecond 10 kg – 50 ml/kg/day
Then for subsequent kg – 20 ml/kg/dayThen for subsequent kg – 20 ml/kg/day

NaNa++
- 1 to 2 mmol/kg/day- 1 to 2 mmol/kg/day
KK++
- 0.5 to 1 mmol/kg/day- 0.5 to 1 mmol/kg/day
Maintenance Fluid formula:-Maintenance Fluid formula:-
4 ml/kg/h for the first 10 kg4 ml/kg/h for the first 10 kg
2 ml/kg/h for the next 10 kg2 ml/kg/h for the next 10 kg
1 ml/kg/h for every kg over 20 kg1 ml/kg/h for every kg over 20 kg
Therefore a 70 kg patient using the calculation:Therefore a 70 kg patient using the calculation:
40+20+50=11040+20+50=110
will require 110 ml/hwill require 110 ml/h
Preoperative managementPreoperative management

Intraoperative fluid managementIntraoperative fluid management
– duration of the caseduration of the case
– hemorrhagehemorrhage
– third-space lossesthird-space losses
Estimation of Intraoperative Fluid Loss and Guide forEstimation of Intraoperative Fluid Loss and Guide for
ReplacementReplacement
Preoperative deficitPreoperative deficit Maintenance IVF × hr NPO, plusMaintenance IVF × hr NPO, plus
preexisting deficit related topreexisting deficit related to
disease statedisease state
Maintenance fluidsMaintenance fluids Maintenance IVF × duration ofMaintenance IVF × duration of
casecase
Third-space andThird-space and
insensible lossesinsensible losses
1–3 mL/kg/hr for minor procedure1–3 mL/kg/hr for minor procedure
(small incision)(small incision)
3–7 mL/kg/hr for moderate3–7 mL/kg/hr for moderate
procedure (medium incision)procedure (medium incision)
9–11 mL/kg/hr for extensive9–11 mL/kg/hr for extensive
procedure (large incision)procedure (large incision)
Blood lossBlood loss 1 mL blood or colloid per 1 mL1 mL blood or colloid per 1 mL
blood loss, or 3 mL crystalloid perblood loss, or 3 mL crystalloid per
1 mL blood loss1 mL blood loss

Postoperative FluidPostoperative Fluid
ManagementManagement
– Sequestration of ECF can continue for > 12Sequestration of ECF can continue for > 12
hours after operationhours after operation
– Maintain Urine OutputMaintain Urine Output
– GI lossesGI losses from NG or Gastrostomy tube suctionfrom NG or Gastrostomy tube suction
Replaced with an equal volume ofReplaced with an equal volume of CrystalloidCrystalloid
– Mobilization of Peri-operative third-space fluidMobilization of Peri-operative third-space fluid
losses typically begins 2 to 3 days afterlosses typically begins 2 to 3 days after
operationoperation

Commonly Used Parenteral SolutionsCommonly Used Parenteral Solutions
IVIV
solutionsolution
OsmolalityOsmolality
(mOsm/L)(mOsm/L)
[Glucose][Glucose]
(g/L)(g/L)
[Na[Na++
]]
(mEq/L)(mEq/L)
[Cl[Cl--
]]
(mEq/L)(mEq/L)
[HCO[HCO33
--
]]
equivalentsequivalents
(mEq/L)(mEq/L)
DD55WW 278278 5050 00 00 00
DD1010WW 556556 100100 00 00 00
DD5050WW 27782778 500500 00 00 00
0.225%0.225%
NaClNaCl
7777 00 38.538.5 38.538.5 00
0.45% NaCl0.45% NaCl 154154 00 7777 7777 00
0.9% NaCl0.9% NaCl 308308 00 154154 154154 00
3% NaCl3% NaCl 10261026 00 513513 513513 00
Lactated*Lactated*
Ringer'sRinger's
274274 00 130130 109109 2828
*Also contains 4 mEq/l K+
, 1.5 mEq/l Ca++
, and 28 mEq/l lactate.

IV solutionIV solution OsmolalityOsmolality
(mOsm/L)(mOsm/L)
[Glucose][Glucose]
(g/L)(g/L)
[Na[Na++
]]
(mEq/L)(mEq/L)
[Cl[Cl--
]]
(mEq/L)(mEq/L)
HCOHCO33
--
equivalentequivalent
s (mEq/L)s (mEq/L)
6%6%
hetastarchhetastarch
310310 00 154154 154154 00
10%10%
dextran-40dextran-40
300300 50/050/0**
0/1540/154**
0/1540/154**
00
6%6%
dextran-70dextran-70
300300 50/050/0**
0/1540/154**
0/1540/154**
00
5% albumin5% albumin$$
330330 00 130–160130–160 130–160130–160 00
25%25%
albuminalbumin$$
330330 00 130–160130–160 130–160130–160 00
*
Dextran solutions available in 5% dextrose or 0.9% NaCl
$
< 2.5 mmol/L K+

Composition of Gastrointestinal SecretionsComposition of Gastrointestinal Secretions
SourceSource
VolumeVolume
(mL/24 hr)(mL/24 hr)
NaNa++
(mmol/L)(mmol/L)
KK++
(mmol/L)(mmol/L) ClCl--
(mmol/L)(mmol/L)
HCOHCO33
--
(mmol/L)(mmol/L)
SalivarySalivary 1,5001,500
(500–2,000)(500–2,000)
1010
(2–10)(2–10)
2626
(20–30)(20–30)
1010
(8–18)(8–18)
3030
StomachStomach 1,5001,500
(100–4,000)(100–4,000)
6060
(9–116)(9–116)
1010
(0–32)(0–32)
130130
(8–154)(8–154)
00
DuodenumDuodenum (100–2,000)(100–2,000) 140140 55 8080 00
IleumIleum 3,0003,000 140140
(80–150)(80–150)
55
(2–8)(2–8)
104104
(43–137)(43–137)
3030
ColonColon (100–9,000)(100–9,000) 6060 3030 4040 00
PancreasPancreas (100–800)(100–800) 140140
(113–185)(113–185)
55
(3–7)(3–7)
7575
(54–95)(54–95)
115115
BileBile (50–800)(50–800) 145145
(131–164)(131–164)
55
(312)(312)
100100
(89–180)(89–180)
3535

SodiumSodium
Serum conc. – 135 to 145 mmol/LSerum conc. – 135 to 145 mmol/L
Potential sources of significant NaPotential sources of significant Na++
loss – sweat, urine,loss – sweat, urine,
and GI secretionsand GI secretions
PPosmosm – 290 to 310 mOsm/L– 290 to 310 mOsm/L
• Hyponatremia – [Na+
] <135 mEq/L
• Hypernatremia – [Na+
] >145 mEq/L

C/F :C/F :
– Predominantly NeurologicPredominantly Neurologic
– Lethargy, confusion, nausea, vomiting, seizures, andLethargy, confusion, nausea, vomiting, seizures, and
comacoma
– Chronic hyponatremia often asymptomatic until serumChronic hyponatremia often asymptomatic until serum
NaNa++
concentration < 110 to 120 mEq/Lconcentration < 110 to 120 mEq/L
Rx :Rx :
– Correct the underlying disorderCorrect the underlying disorder
– Fluid Restriction (1,000 mL/day)Fluid Restriction (1,000 mL/day)
– Hypovolemic hyponatremia – administer 0.9% NaCl toHypovolemic hyponatremia – administer 0.9% NaCl to
correct volume deficits and replace ongoing losses.correct volume deficits and replace ongoing losses.
Rapid correction should be avoidedRapid correction should be avoided

C/F :C/F :
– Primarily NeurologicPrimarily Neurologic
– Lethargy, weakness, & irritabilityLethargy, weakness, & irritability
– Fasciculations, seizures, coma, & irreversibleFasciculations, seizures, coma, & irreversible
neurologic damageneurologic damage
Rx :Rx :
– Water deficit (L) = 0.60 × total body weight (kg) ×Water deficit (L) = 0.60 × total body weight (kg) ×
[(serum Na[(serum Na++
in mmol/L/140) – 1]in mmol/L/140) – 1]
– Gradual correctionGradual correction
– Treat specific causeTreat specific cause

PotassiumPotassium
Serum conc. – 3.5 to 5 mmol/LSerum conc. – 3.5 to 5 mmol/L
90 % of K90 % of K++
excreted renally, remainder in stoolsexcreted renally, remainder in stools
HypokalemiaHypokalemia –– [K[K++
] <3.5 mEq/L] <3.5 mEq/L
Hyperkalemia – [KHyperkalemia – [K++
] >5.0 mEq/L] >5.0 mEq/L

Causes :Causes :
– Inadequate intakeInadequate intake
– GI losses (e.g., diarrhea, persistent vomiting,GI losses (e.g., diarrhea, persistent vomiting,
Nasogastric suctioning)Nasogastric suctioning)
– Renal losses (e.g., diuretics, fluid mobilization)Renal losses (e.g., diuretics, fluid mobilization)
– Cutaneous losses (e.g., burns)Cutaneous losses (e.g., burns)
– Acute intracellular KAcute intracellular K++
uptake (insulin excess, metabolicuptake (insulin excess, metabolic
alkalosis, hypothermia, theophylline toxicity)alkalosis, hypothermia, theophylline toxicity)
– Refeeding Syndrome – in malnourished patient afterRefeeding Syndrome – in malnourished patient after
initiation of TPNinitiation of TPN
HypokalemiaHypokalemia

C/F :C/F :
– Mild hypokalemia [KMild hypokalemia [K++
>3 mmol/L] generally>3 mmol/L] generally
asymptomaticasymptomatic
– Severe KSevere K++
deficiency [Kdeficiency [K++
<3 mmol/L] – primarily<3 mmol/L] – primarily
cardiovascularcardiovascular (ECG manifestations – ectopy, T-wave(ECG manifestations – ectopy, T-wave
depression, and prominent U waves)depression, and prominent U waves)
– Fatigue, myalgias, and muscular weakness or crampsFatigue, myalgias, and muscular weakness or cramps
of the lower extremitiesof the lower extremities
– Constipation ,paralytic ileusConstipation ,paralytic ileus
– Complete paralysis, hypoventilation, orComplete paralysis, hypoventilation, or
rhabdomyolysisrhabdomyolysis
Rx :Rx :
– Oral replacement (40 to 100 mmol)Oral replacement (40 to 100 mmol)
– Parenteral therapy (not exceeding 40 mmol/L & notParenteral therapy (not exceeding 40 mmol/L & not
exceeding 20 mmol/hour)exceeding 20 mmol/hour)

HyperkalemiaHyperkalemia
Causes :Causes :
– PseudohyperkalemiaPseudohyperkalemia
– Abnormal redistribution of KAbnormal redistribution of K++
Insulin deficiencyInsulin deficiency
β-β-adrenergic receptor blockadeadrenergic receptor blockade
Acute acidosisAcute acidosis
RhabdomyolysisRhabdomyolysis
Cell lysis (after chemotherapy)Cell lysis (after chemotherapy)
Digitalis intoxicationDigitalis intoxication
Reperfusion of ischemic limbsReperfusion of ischemic limbs
SuccinylcholineSuccinylcholine

C/F :C/F :
– Mild Hyperkalemia [KMild Hyperkalemia [K++
= 5 to 6 mmol/L] generally= 5 to 6 mmol/L] generally
– Severe Hyperkalemia [KSevere Hyperkalemia [K++
>6.5 mmol/L] – arrhythmia>6.5 mmol/L] – arrhythmia
(ECG abnormalities : symmetric peaking of T waves,(ECG abnormalities : symmetric peaking of T waves,
reduced P-wave voltage, and widening of the QRSreduced P-wave voltage, and widening of the QRS
complex, ultimately sinusoidal ECG pattern)complex, ultimately sinusoidal ECG pattern)
– Weakness, flaccid paralysis & hypoventilationWeakness, flaccid paralysis & hypoventilation
Rx :Rx :
– Mild Hyperkalemia :Mild Hyperkalemia :
Reduction of daily KReduction of daily K++
intakeintake
Loop diureticLoop diuretic
Withdrawal of drugs impairing KWithdrawal of drugs impairing K++
homeostasishomeostasis

-Severe Hyperkalemia-Severe Hyperkalemia
Temporizing MeasuresTemporizing Measures
– Calcium gluconateCalcium gluconate
– Insulin with dextroseInsulin with dextrose
– Inhaled βInhaled β22-agonists-agonists
– NaHCONaHCO33
Therapeutic MeasuresTherapeutic Measures
– Sodium polystyrene sulfonate (Kayexalate), aSodium polystyrene sulfonate (Kayexalate), a
NaNa++
-K-K++
exchange resinexchange resin
– Hydration in combination with a loop diureticHydration in combination with a loop diuretic
– DialysisDialysis

CalciumCalcium
Serum Calcium – 2.23 to 2.57 mmol/L (8.9 to 10.3Serum Calcium – 2.23 to 2.57 mmol/L (8.9 to 10.3
mg/dL), exists in three formsmg/dL), exists in three forms
– Ionized (45%)Ionized (45%)
– Protein bound (40%)Protein bound (40%)
– Complexed to freely diffusible compounds (15%)Complexed to freely diffusible compounds (15%)
Free ionized CaFree ionized Ca2+2+
(4.6 to 5.1 mg/dL) is physiologically(4.6 to 5.1 mg/dL) is physiologically
activeactive
Calcium Homeostasis – PTH, Vit. D & CalcitoninCalcium Homeostasis – PTH, Vit. D & Calcitonin

HypocalcemiaHypocalcemia
Serum Calcium <8.4 mg/dL with a normal serum albuminSerum Calcium <8.4 mg/dL with a normal serum albumin
or an ionized calcium <4.2 mg/dLor an ionized calcium <4.2 mg/dL
Causes :Causes :
– Calcium sequestration (acute pancreatitis,Calcium sequestration (acute pancreatitis,
rhabdomyolysis, or rapid administration of blood)rhabdomyolysis, or rapid administration of blood)
– Vitamin D deficiencyVitamin D deficiency
– Total thyroidectomyTotal thyroidectomy
– ParathyroidectomyParathyroidectomy
– Acute alkalemiaAcute alkalemia

C/F :C/F :
– Perioral Numbness and TinglingPerioral Numbness and Tingling
– TetanyTetany
ECG - QT-interval prolongation and ventricularECG - QT-interval prolongation and ventricular
arrhythmiasarrhythmias
Rx :Rx :
– Parenteral therapy (overt tetany, laryngeal spasm, orParenteral therapy (overt tetany, laryngeal spasm, or
seizures)seizures)
– Oral therapy (Ca & vit. D)Oral therapy (Ca & vit. D)

HypercalcemiaHypercalcemia
Serum Calcium >10.3 mg/dl with a normal serum albuminSerum Calcium >10.3 mg/dl with a normal serum albumin
or an ionized calcium >5.2 mg/dlor an ionized calcium >5.2 mg/dl
Causes :Causes :
– MalignancyMalignancy
– HyperparathyroidismHyperparathyroidism
– HyperthyroidismHyperthyroidism
– Vitamin D intoxicationVitamin D intoxication
– ImmobilizationImmobilization
– Long-term total parenteral nutritionLong-term total parenteral nutrition
– Thiazide diureticsThiazide diuretics
– Granulomatous diseaseGranulomatous disease

C/F :C/F :
– Mild Hypercalcemia (Calcium <12 mg/dl) is generallyMild Hypercalcemia (Calcium <12 mg/dl) is generally
– Altered mental status, diffuse weakness, dehydration,Altered mental status, diffuse weakness, dehydration,
adynamic ileus, nausea, vomiting, and severeadynamic ileus, nausea, vomiting, and severe
constipationconstipation
– Hypercalcemia of hyperparathyroidism –associatedHypercalcemia of hyperparathyroidism –associated
infrequently with classic parathyroid bone disease andinfrequently with classic parathyroid bone disease and
nephrolithiasis.nephrolithiasis.
ECG - QT-interval shortening and arrhythmiasECG - QT-interval shortening and arrhythmias
Rx :Rx :
– NaCl 0.9% and loop diuretics mayNaCl 0.9% and loop diuretics may
– Salmon calcitoninSalmon calcitonin
– Pamidronate disodiumPamidronate disodium

Thank youThank you
CooperationCooperation
is the Keyis the Key
to Success!!!to Success!!!

Blood transfusion, Nutrition and water & electrolyte balance

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