1. FLUID MANAGEMENT & BLOOD TRANSFUSION Prof. Izdiad Badran Jordan University Hospital

2. FLUID MANAGEMENT Physiological Considerations Plasma is the fluid compartment of the blood surrounding the red blood cells Plasma is the fluid compartment of the blood surrounding the red blood cells Intracellular Fluid (ICF) is the fluid within the body cells Intracellular Fluid (ICF) is the fluid within the body cells Interstitial Fluid (ISF) is the fluid found between the cells, outside of blood vessels Interstitial Fluid (ISF) is the fluid found between the cells, outside of blood vessels Extracellular Fluid (ECF) is the sum of plasma fluid and interstitial fluid Extracellular Fluid (ECF) is the sum of plasma fluid and interstitial fluid Water moves freely between these compartments under the influence of osmotic pressure gradient Water moves freely between these compartments under the influence of osmotic pressure gradient

3. Physiological Considerations (cont.) Water accounts for 60% of adult male body weight, 50- 55% of female adult body weight Water accounts for 60% of adult male body weight, 50- 55% of female adult body weight Total Body Water (TBW) = 42 Litres of a 70 Kg adult Total Body Water (TBW) = 42 Litres of a 70 Kg adult Plasma Water (PW) = 3 Litres Plasma Water (PW) = 3 Litres Interstitial Fluid (ISF) = 11 Litres Interstitial Fluid (ISF) = 11 Litres Intracellular Fluid (ICF) = 28 Litres Intracellular Fluid (ICF) = 28 Litres Osmolality is kept constant between all compartments by movement of water by osmosis Osmolality is kept constant between all compartments by movement of water by osmosis Albumin in the intravascular compartment is 40 g / Litre Albumin in the intravascular compartment is 40 g / Litre Albumin in the interstitial compartment is 10 g / Litre Albumin in the interstitial compartment is 10 g / Litre

4. Physiological Considerations (Cont.) The predominant ECF anion is Sodium The predominant ECF anion is Sodium The predominant ICF anion is Potassium The predominant ICF anion is Potassium Normal Fluid Balance of 70 Kg adult: Normal Fluid Balance of 70 Kg adult: Intake: 1500 ml Liquid Intake: 1500 ml Liquid 750 ml Food 750 ml Food 250 ml From Metabolism within the body 250 ml From Metabolism within the body 2500 ml Total 2500 ml Total Output: 1500 ml Urine Output: 1500 ml Urine 100 ml Feces 100 ml Feces 900 ml Insensible Loss 900 ml Insensible Loss 2500 ml Total 2500 ml Total * Balance is normally regulated to maintain ECF volume and osmolality. Changes are detected by baroreceptors and osmoreceptors with resultant compensatory mechanisms

5. Approximate composition of body fluid compartments (mmol/L) CompartmentNaKHCO3ClCaMgSO4HPO4+PO4 IntracellularFluid1015010333020100 InterstitialFluid1405301105312 Plasma1405281105312

6. Some important fluid composition in surgical patients Fluid 24 hr Volume ( ml) ( ml) Na + (mEq/L) K+ (mEq/L) Cl- (mEq/L) HCO3- (mEq/L) Saliva500-20002-1020-308-1830 Stomach1000-200060-10010-20100-1300 Pancreas300-800135-1455-1070-9095-120 Bile300-600135-1455-1090-13030-40 Jejunum2000-4000120-1405-1090-14030-40 Ileum1000-200080-1502-845-14030 Colon---------603040---------

7. Factors Affecting Perioperative Fluid Regimen 1- Patient size, weight and body composition 2- Preoperative fluid losses, hydration and volume status 3- Co-morbid disease, sepsis, renal, cardiac and hepatic impairment 4- Normal maintenance requirement 5- Fever 6- Temperature of environment 7- Anaesthetic technique 8- Type and duration of operation 9- Operative losses 10- Neuro-hormonal stress response 11- Postoperative losses 12- Speed of return to oral intake

8. Planning a fluid regimen 1- Minor body surface surgery No need for intravenous fluid perioperatively unless: a- There is a delay in return to oral intake a- There is a delay in return to oral intake b- Poor preoperative hydration b- Poor preoperative hydration 2- Intermediate surgery Fluid may be given only during surgery or continued for few hours postoperatively, normally 5-10 ml/Kg/h 3- Major surgery Most laparotomies will require 10-20 ml/Kg/h of balanced salt solutions during operation as a baseline,.increased for larger operations to 20-30 ml/Kg/h. Estimated blood loss will need to be replaced.

9. The suggested monitoring during very major operations 1- Pulse Rate 2- Blood Pressure (within 20% of normal) 3- Urine Output (0.5-1.0 ml/Kg/h) 4- Central Venous Pressure (6-12 Cm H2O) 5- Normal pH, O2, BE etc 6- Haemoglobin >7.5 g/100 ml

10. Fluid Preparations 1- Crystalloids Solution of crystalline solids in water Solution of crystalline solids in water Rapidly and evenly distributed throughout the ECF space Rapidly and evenly distributed throughout the ECF space Only 25-30% remain in intrvascular compartment Only 25-30% remain in intrvascular compartment They should be given in 3 times the volume of estimated blood loss They should be given in 3 times the volume of estimated blood loss 2- Colloids Composition of high molecular weight particles (Gelatin, Protein, Starch) Composition of high molecular weight particles (Gelatin, Protein, Starch) They are prepared in solutions of N/S or 5% glucose They are prepared in solutions of N/S or 5% glucose They remain much longer intravascularely than Crystalloid Solutions They remain much longer intravascularely than Crystalloid Solutions They should be given in equivalent volume to estmated blood loss (limitation of maximum volume infused) They should be given in equivalent volume to estmated blood loss (limitation of maximum volume infused)

11. Fluid Preparations (Cont.) 3- Blood Primary function of Haemoglobin is to deliver Oxygen to the tissues Primary function of Haemoglobin is to deliver Oxygen to the tissues Haemoglobin level should be kept >7-7.5 g/dL (in ischaemic heart disease >9 g/dL) Haemoglobin level should be kept >7-7.5 g/dL (in ischaemic heart disease >9 g/dL) Transfusion of one unit of packed red cells will raise Hb by 1-1.5 g/dL Transfusion of one unit of packed red cells will raise Hb by 1-1.5 g/dL 4- Blood Products Whole blood Whole blood Packed Red Cells Packed Red Cells Frozen blood Frozen blood Platelets Platelets Fresh Frozen Plasma Fresh Frozen Plasma Platelets Platelets Fresh Frozen Plasma Fresh Frozen Plasma Cryoprecipitate Cryoprecipitate Human Albumin Human Albumin

13. BLOOD TRANSFUSION Indications for Blood Transfusion 1- To increase the Oxygen Carrying Capacity 2- To increase intravascular volume especially in severe acute haemorrhage exceeding 20% of blood volume 3- To compensate for acute reduction of Haemoglobin to bring it to >7-7.5 g/dL in normal patients or to >10 g/dL in patients with emphysema or ischaemic heart disease Compatibility Testing Is the ABO-Rh typing, Crossmatching and Antibody Screen

14. Storage of Blood 1- CPDA Citrate phosphate dextrose adenin is an anticoagulant preservative in which blood is stored at 1-6 o C (Citrate “C” is an anticoagulant binding calcium, Phosphate “P” serves as a buffer, Dextrose “D” is a red cell energy source, Adenine “A” allows RBC to resenthesize adenosin triphosphate “ATP”, which extends the storage time from 21 to 35 days) The metabolism of RBC in stored blood produce the following( at 35 days) in whole blood and packed cells units: Parameter Whole blood Packed Cells pH6.736,71 Plasma Hb (mg/dL) 46246 Plasma Potassium (mEq/L) 17.276 Plasma Sodium (mEq/L) 153122 Blood Dextrose (mg/dL) 28284 2-3DPG (micM/ml) <1<1

15. 2- Frozen Storage The advantages of frozen RBCs are: 1- Blood of rare types 1- Blood of rare types 2- Less allergic 2- Less allergic 3- Reduce the risk of transfusion hepatitis 3- Reduce the risk of transfusion hepatitis 4- Safer in massive blood transfusion 4- Safer in massive blood transfusion 5- Normal levels of 2-3DPG are retained 5- Normal levels of 2-3DPG are retained 3- Heparin Whole blood stored in heparin can be used within 24-48 hours of collection in: 1-Priming pumps in CPB 1-Priming pumps in CPB 2- In open heart surgery 2- In open heart surgery 3- Factor VIII is more stable 3- Factor VIII is more stable 4- In Autologous blood transfusion in Acute Haemodilution Technique 4- In Autologous blood transfusion in Acute Haemodilution Technique

16. Massive Blood Transfusion Is defined as either a transfusiuon of 10 units of blood within 6 hours or transfusion of 5 units of blood within 1 hour or replacement of blood volume with transfused blood within 24 hours.

17. Complications of Blood Transfusion 1- Change in oxygen transport 2- Dilutional thrombocytopenia 3- Low factor V and VIII 4- DIC 5- Haemolytic Transfusion Reaction a- Incompatibility reaction a- Incompatibility reaction b- Delayed Haemolytic transfusion reaction b- Delayed Haemolytic transfusion reaction 6- Citrate intoxication 7- Hyperkalaemia 8- Hypothermia 9- Acid-Base abnormalities 10- Transfusion microaggrigates

18. 11- Non Haemolytic Transfusion Reactions 12- Transmission of diseases a- Hepatitis a- Hepatitis b- HIV b- HIV c- Cytomegalovirus c- Cytomegalovirus d- Bacterial diseases d- Bacterial diseases 13- Transfusion associated Graft-Versus-Host disease 14- Acute Lung Injury 15- Transfusion induced immunodepression

19. Blood Components 1- Packed RBCs 2- Leukocyte-Reduced blood 3- Platelet Concentrate 4- Fresh Frozen Plasma 5- Cryoprecipitate 6- Prothrombin Complex 7- Albumin and Plasma Protein Preparations 8- Granulocyte Concentrate 9- Whole Blood