Fluid Management and Transfusion Franklin L. Scamman, MD

Evaluation of Intravascular Volume Clinical signs Laboratory values Cardiovascular parameters Shock: intravascular volume is less than intravascular space.

Signs of Fluid Loss as % of Total Body Water Sign5%10%15% Mucous membranes DryVery DryParched SensoriumNormalLethargicObtunded OrthostasisMildPresentMarked UrineMildly decreasedDecreasedMarkedly decreased PulseNormalIncreasedTachy BPNormalMildly decreasedDecreased

Laboratory Evaluation Rising HCT Urinary SPG > Urinary Sodium < 20 meq/l Urinary Osmolality > 450 mosm/l BUN to Creatinine ratio > 10:1

Hemodynamic Evaluation CVP PCWP Delta Down > 15 mmHg –From an arterial line, measure the depression in systolic pressure with each ventilator cycle.

IV Fluids-Crystalloids Lactated Ringers (LR) –Balanced salt solution that maintains bicarb Normal Saline (NS) –Hypertonic and dilutes plasma bicarb, causes a metabolic acidosis Plasmalite –Balanced salt solution that lacks calcium so can be used to dilute packed cells

IV Fluids-Colloids Dextran 40 and 70 –Tend to coat red cells and platelets; helps out with blood flow but may cause poor clotting Starches-Hespan –6% in NS, dilutes bicarb Albumin 5% and 25% –Infection free but cannot use in JW patients FFP –To replace clotting factors

Maintenance Fluids 4 ml/kg/hr for the first 10 kg 2 ml/kg/hr for the next 10 kg 1 ml/kg/hr for the next 10 kg ½ ml/kg/hr thereafter

Replacing Deficit ½ the deficit during the 1 st hour ¼ of the deficit during the 2 nd hour Clinical evaluation from thereon

Surgical Fluid Losses Blood Loss Replacement –With crystalloid X the EBL –With colloid - 1 X the EBL –Can let the HCT drift down towards high 20s –Replace RBC for RBC thereafter –Watch coags after 50% EBV replacement for FFP and platelets (keep above 50K) –Watch calcium levels with massive transfusion

Surgical Fluid Losses Third Space –Evaporation –Weeping surfaces –Edema –Abdominal - 10ml/kg/hr for 1 st 3 hours –ENT - almost none

Fluid Replacement for Head and Neck Cancer Surgery We suspect that ADH levels are very high during the dissection portion that usually finishes by 2 p.m. We should not force urine output until then but replace deficit and continue maintenance. After 2 p.m., would like to see UO be ½ to 1 ml/kg/hr.

Massive Transfusion Protocol Number of Red Blood Cell units (full units, not pediatric or partial units) within 24 hours Adult > 10 units 6-12 year old child > 5 units 4-5 year old child > 3 units 2-3 year old child > 2 units 0-1 year old child > 1 unit

Massive Transfusion Protocol Call for help; Pathology resident will monitor coags and authorize dispensing of FFP and platelets and other clotting factors. Watch potassium, calcium and base excess Watch patient temperature Talk with surgeon to see if patient is clotting