This document discusses fluid and blood therapy. It begins by outlining the goals of fluid management during surgery and introduces the concepts of fluid deficits, insensible losses, and third spacing. It then critiques the classical fluid management strategy of aggressive fluid replacement and presents evidence that restrictive fluid protocols reduce complications. The document advocates goal-directed fluid therapy using cardiac output monitoring. It also discusses fluid choices, transfusion triggers, blood component therapy, and complications of blood transfusion.

1. Fluid and blood therapy
Helga Komen, MD
Department of Anesthesiology
Washington University in St. Louis

2. Goals of Fluid Management
Maintain intravascular volume and stroke volume
replace TIMELY insensible and surgical losses
Ultimate goal Optimizing O2 delivery
……Preop – Intraop – Postop fluid management…..
Fluid and blood therapy

3. Frank-Starling based stroke volume optimization
Fluid and blood therapy

4. Fluid load vs. complications
Fluid and blood therapy

5. Fluid Deficits - preop
• Fasting patients
– Solids allowed up until 6h before anesthesia
– Clear fluids up until 2h before induction
• Per ERAS protocol - 2 bottles (12 fl oz) Gatorade night before
surgery, 1 bottle 2 hours before surgery
• Bowel prep
preop neg. balans aprox. 500ml-1L (≈0.5ml/kg/h)
Fluid and blood therapy

6. Evaluation of fluid status
• Relies on clinical judgment
• Multiple indirect indicators…
Fluid and blood therapy

7. Classical Fluid Management
• Classical strategy:
– Replacement of preexisting fluid deficit
– Replacement of insensible losses
– Replacement of “third space” losses
+
– Replacement of blood loss
• Maintenance fluid 4-2-1 rule
Fluid and blood therapy

8. Classical Crystalloid Replacement
Surgical losses Maintenance Fluid rate
Fluid and blood therapy

9. Surgical losses
• Blood Loss Suction reservoir
• Surgical Drapes
• Lap pads - can hold 100 ml each
• Soaked 4x4 -10ml
• Confounded by irrigation!
Fluid and blood therapy

10. So Where Did The Classical Strategy Come
From?
• The assumption of 5 “facts”:
– Fasting patients are hypovolemic
– Insensible loses increase dramatically with skin incision
– Unpredictable massive fluid shift into the “Third space”
must be countered
– The kidneys will take care of any excess fluid
– Fluid unlike pressors are always safe
Fluid and blood therapy

11. • 20 adults after elective colon resection
– Aggressive intraoperative fluids 20 mL/kg/hr.
– Postoperatively, randomly assigned to
restrictive (< 2 L/day) or standard protocol (≥
3 L/day).
– Latter caused significant weight gain, later
return of bowel function and prolonged hospital stay.
Classical Fluid Optimization… - evidence
Fluid and blood therapy

12. • 40% of patients admitted to SICU had an
excessive increase in body water of more than
10% of preoperative weight.
• Perioperative weight gain:
–Marker of fluid storage outside circulatory space.
–Inversely related to patient outcome.
Fluid and blood therapy
Classical Fluid Optimization… - evidence

13. Chappell et al. Anesthesiology. 109(4):723-740, October 2008.
Fig. 2. Perioperative weight gain and
mortality of patients. No patient
survived if perioperative weight gain
was more than 20%.74 * P< 0.008
versus weight gain less than 10%.
Fluid and blood therapy
Classical Fluid Optimization… - evidence

14. ..Newer Approach to Fluid Management
• There is no intravascular deficit after fasting
• The ECV (effective circulating volume) is slightly
decreased
• Basal fluid loss via insensible perspiration is
approximately 0.5 mL/kg/hr
Extending to only 1 mL/kg/hr during
major abdominal surgery.
Fluid and blood therapy

15. Fluid and blood therapy
ERAS protocol (Enhanced Recovery After Surgery)

16. • Restrictive fluid management:
– Maintenance fluids at 2(3)ml/kg/hr of Ringer’s Lactate
– 250 ml boluses of crystalloid ( Ringer’s Lactate) or 5% albumin to
counter hypotension
• Maintain SVI (stroke volume index) 35-45 or SVV (stroke
volume variation) of < 10 %
• Total crystalloid not to exceed 3 liters for laparoscopic and
open cases. (Assuming average minimal blood loss)
• Use vasopressor infusion (phenylephrine) as needed to
maintain blood pressure.
• Blood transfusion as guided clinically and by lab results.
– transfusion trigger hematocrit of < 25% (may be higher if patient
has coronary disease)
Fluid and blood therapy
ERAS protocol (Enhanced Recovery After Surgery)
Protocol-based fluid restriction in major abdominal surgery

17. Fluid and blood therapy

18. Goal directed fluid therapy (GDFT)
• Every patient - individualized fluid management plan.
• A zero-balance approach – to avoid perioperative
weight gain
• Avoid boluses and use a low-volume infusion of
balanced crystalloids.
• Patients undergoing major surgery - individualized
GDFT (minimally invasive cardiac output monitor)
• Crystalloids alone - where the glycocalyx is impaired
(e.g., septic patients in the operating room).
• Colloids - when patients having intact glycocalyx and
are receiving GDFT
Miller et al. Best Practice & Research Clinical Anaesthesiology 28 (2014) 261-73
Fluid and blood therapy

19. – Reduced perioperative complications
• cardiopulmonary events
• bowel motility disturbance
– Improved wound/anastomotic healing
– Reduced hospital stay
Fluid Optimization – better way
Fluid and blood therapy
ERAS protocol (Enhanced Recovery After Surgery)

20. Fluid Management - Monitoring
– CardioQ
– Cheetah
Fluid and blood therapy

21. Fluid and blood therapy
• pulse pressure variation
Fluid Management - Monitoring
• Lidco
• TEE

22. Crystalloids
• Combination of water and electrolytes
– Balanced salt solution: electrolyte composition and
osmolality similar to plasma (NS, Lactated Ringer’s,
Plasmalyte).
– Hypotonic salt solution: electrolyte composition lower
than that of plasma (D5W).
– Hypertonic solutions - fluids containing sodium
concentrations greater than normal saline.
• Available in 1.8%, 3%, 5%, 7.5%, 10% solutions.
• Hyperosmolarity creates a gradient that draws water out of cells;
therefore, cellular dehydration is a potential problem.
Fluid and blood therapy

23. Crystalloid Composition
Fluid and blood therapy

24. Colloids
• Fluids containing molecules sufficiently large
enough to prevent transfer across capillary
membranes.
• Examples: hetastarch (Hespan)(Voluven),
albumin, and dextran.
• Colloids used to replace plasma volume loss
• Infusion 1:1 with blood loss
Fluid and blood therapy

25. Colloids - Albumin
• Purified human protein from plasma
• Pasteurized at 60oC
• Half-life 16 hours
• 90% remains intravascular at 2h
Fluid and blood therapy

26. Effects of various fluids on ECV vs IVV
Fluid and blood therapy ECV-extracellular volume
IVV-intravascular volume

27. Conclusions
• Start replacing blood loss with colloids
• Limit crystalloid infusions to replace insensible
losses
• Whenever possible in major procedures,
optimize intravascular status with goal
directed fluid therapy, i.e CO, SVV, SVI
Fluid and blood therapy

28. Transfusion Therapy
When is Transfusion Necessary?
• “Transfusion Trigger”: Hb/Ht level at which transfusion
should be given.
– Varies with patients and procedures
• av. 8/25
• 10/30 in cardiac pts.
• Tolerance of acute anemia depends on:
– Maintenance of intravascular volume
– Ability to increase cardiac output
Fluid and blood therapy

29. Oxygen Delivery
• Oxygen Delivery - DO2 - is the oxygen that is
delivered to the tissues
DO2 = Cardiac Output (CO) x Oxygen Content (CaO2)
– Cardiac Output (CO) = HR x SV
– Oxygen Content (CaO2):
• (Hgb x 1.39) x O2 saturation + PaO2 (0.003)
• Hgb is the main determinant of oxygen content in the blood
Fluid and blood therapy

30. • Therefore: DO2 = HR x SV x CaO2
– If HR or SV are unable to compensate, Hgb is the
major determinant factor in O2 delivery
– Compromised patients may require Hgb levels above 10
gm/dL.
– Healthy patients have excellent compensatory
mechanisms and can tolerate Hgb levels of 6 gm/dL.
Fluid and blood therapy
Oxygen Delivery

31. Blood Types
Fluid and blood therapy

32. Type and Screen
• Donated blood that has been tested for
ABO/Rh antigens and screened for common
antibodies (not mixed with recipient blood).
– Used when usage of blood is unlikely, but needs to
be available (hysterectomy).
– Allows blood to be available for other patients.
– Chance of hemolytic reaction: 1:10,000
Fluid and blood therapy

33. Cross Match
• Major:
– Donor’s erythrocytes incubated with recipients plasma
• Minor:
- Donor’s plasma incubated with recipients erythrocytes
• Agglutination:
- Occurs if either is incompatible
• Type Specific:
- Only ABO-Rh determined
Fluid and blood therapy

34. Component Therapy
• A unit of whole blood is divided into components; Allows
prolonged storage and specific treatment of underlying
problem with increased efficiency:
– packed red blood cells (pRBC’s)
– platelet concentrate
– fresh frozen plasma (contains all clotting factors)
– cryoprecipitate (contains factors VIII and fibrinogen; used in Von
Willebrand’s disease)
– albumin
– plasma protein fraction
– leukocyte poor blood
– factor VIII
– antibody concentrates
Fluid and blood therapy

35. Packed Red Blood Cells (PRBC)
• 1 unit = 350 ml. Hct. = 70-80%.
• 1 unit pRBC’s raises Hgb 1 gm/dL.
• LR has calcium which may cause clotting if mixed
with PRBCs.
• High levels of free K+
• Cell saver – cardiac/ortho/spine surgery
Fluid and blood therapy

36. Platelet Concentrate
• Treatment of thrombocytopenia
• Intraoperatively used if platelet count drops
below 50,000 cells/mm3 (lab analysis).
– Ortho/neuro cases – 100,000 cells/mm3
• 1 unit of platelets increases platelet count 5000-
10000 cells/mm3.
• Risks:
– Sensitization due to HLA on platelets
– Viral transmission
Fluid and blood therapy

37. Fresh Frozen Plasma -FFP
• Plasma from whole blood frozen within 6 hours
of collection.
– Contains all coagulation factors except platelets
– Used for treatment of isolated factor deficiences,
reversal of Coumadin effect, TTP, etc.
– Used when PT and PTT are >1.5 normal
• Risks:
– Viral transmission (CMV, HIV)
– Allergy
Fluid and blood therapy

38. Prothrombin complex concentrat
• Fast reversal of warfarin th.,
• Th. for hemophilia B
• Made from human plasma
• Factors II, IX, X, (VII)
• 10x concentrate of FPP factors (smaller volume)
• Gives effect within 30 mins of administration
Fluid and blood therapy

39. Complications of Blood Therapy
• Transfusion Reactions:
– Febrile: most common, usually controlled by
slowing infusion and giving antipyretics
– Allergic: increased body temp., pruritis, urticaria.
Rx: antihistamine,discontinuation. Examination of
plasma and urine for free hemoglobin helps rule
out hemolytic reactions.
Fluid and blood therapy

40. • Transfusion-related acute lung injury - TRALI
– Syndrom of acute respiratory distress following transfusion
- within 6 hours of a transfusion
– rare complication of allogeneic blood transfusion (plasma-
containing blood products - donor antibodies directed
against recipient leukocytes)
– 1/1,120 and 1/57,810 units transfused
– significant mortality rate - 5-10%
Fluid and blood therapy
Complications of Blood Therapy

41. Complications of Blood Therapy
• Hemolytic:
– Wrong blood type administered.
– Activation of complement system leads to intravascular
hemolysis, spontaneous hemorrhage.
– Signs are easily masked by general anesthesia.
– Free Hgb in plasma or urine
– Acute renal failure
– Disseminated Intravascular Coagulation (DIC)
Fluid and blood therapy

42. Autologous Blood
• Pre-donation of patient’s own blood prior to elective
surgery
• 1 unit donated every 4 days (up to 3 units)
• Last unit donated at least 72 hrs prior to surgery
• Reduces chance of hemolytic reactions and
transmission of blood-borne diseases
• Not desirable for compromised patients
Fluid and blood therapy

43. Blood Substitutes
• Experimental oxygen-carrying solutions: developed to
decrease dependence on human blood products
• Multiple approaches:
– Outdated human Hgb reconstituted in solution
– Genetically engineered/bovine Hgb in solution
– Liposome-encapsulated Hgb
– Perflurocarbons
• Potential advantages: no cross-match requirements, long-term shelf
storage, no blood-borne transmission
• Potential disadvantages: undesirable hemodynamic effects (mean arterial
pressure and pulmonary artery pressure increases), short half-life in
bloodstream (24 hrs), still in clinical trials/unproven efficacy
Fluid and blood therapy

44. • Transfusion trigger
– 8/25 (Hb/Htc) - `healthy` patient
– 10/30 (Hb/Htc) – cardiac patient
• Mostly given blood products – PRBCs, FFP,
platelets
• Transfusion reactions – febrile, allergic, TRALI,
hemolytic
Fluid and blood therapy
Conclusions

45. Questions?
Fluid and blood therapy