Perioperative Fluid and Blood Administration

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Perioperative Fluid and Blood Administration
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Jeffrey Groom, PhD, CRNADirector and Clinical
Associate ProfessorNurse Anesthetist
ProgramFlorida International University
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Fluid and Blood Administration

• Primary objective of perioperative fluid
  management is maintenance of adequate tissue
  perfusion and oxygen transport.

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Clinical Indicators

• Mental status
• Urine output
• Capillary refill
• Skin color texture
• Pulse rate
• Blood pressure
• Temperature
• Frank Starling Curve
• Acid-base status
• BP, CVP, PA pressures
• Oxygen consumption
• Mixed Venous Oxygen Saturation

Surgical patient who exhibits signs of low
perfusion, such as oliguria or hypotension, the
most common etiology is insufficient
intravascular volume.
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Quantitative Assessment

• Calculate fluid deficit
• Calculate fluid needs
• Calculate fluid losses
• The amount of fluid to be administered is best
  quantitated by continuous evaluation of the
  response to that which is infused.

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Physiologic Response to Hemodilution Anemia

• Increased cardiac output
• Increased heart rate, stroke volume,
  contractility
• Decreased peripheral vascular resistance
• Increased release of oxygen by erythrocyte
• Decreased blood viscosity
• Increased O2 consumption/demand

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Hemostatic Mechanisms

• Primary Hemostasis
• Coagulation
• Fibrinolysis

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Hemostatic Mechanisms

• Primary Hemostasis
• Platelet adhesion (Factor VIII aka vWF)
• Platelet activation (Thrombin aka IIa)
• Platelet aggregation (ADP, thromboxane A2)
• Fibrin production (ex- in- trinsic common
  pathways)

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Hemostatic Mechanisms
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ASA NSAIDS

• Thrombin
• È
• Phospholipid
• È
• Arachidonic acid
• È
• Cyclo-oxygenase
• È
• Prostaglandins
• È
• Thromboxane A2(platelet aggregation)

platelet aggregation inhibited ASA- 8-12
days NSAID 24-48 hrs
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Clotting Cascade
Coumadin PT and INR
Heparin PTT and ACT
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Coagulation Studies

• History ask about bleeding disorders or
  bleeding symptoms
• Partial Prothrombin Time (PTT)
• Prothrombin Time (PT)
• Bleeding Time
• Activated Clotting Time (ACT)

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Coagulation Studies

• Partial Prothrombin Time (PTT)
• Evaluates the INTRINSIC pathway of the clotting
  cascade system
• Normal range 25 to 35 seconds
• Assumes normal clotting factors, will be elevated
  with heparin
• Not all abnormal PTT values equal Bleeding

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Coagulation Studies

• Prothrombin Time (PT)
• Evaluates the EXTRINSIC pathway of the clotting
  cascade system
• Normal range 12 14 sec
• May be normal in the presence of certain factor
  deficiencies (VIII, IX, XI, XII) and very
  sensitive to VII deficiency

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Coagulation Studies

• Thrombin Time (TT)
• Evaluates the final common pathway which is
  conversion of fibrinogen to fibrin
• Normal range 12 20 sec
• Patients with low/abnormal fibrinogen may have
  normal or slightly elevated PT PTT but
  prolonged TT

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Coagulation Studies

• Bleeding Time (3-10 minutes)
• Evaluates interaction of platelets with vessel
  endothelium
• Prolonged BT can be caused by dysfunctional or
  low platelets, vonWillebrands deficiency
  (adhesion),or fibrinogen (fiber) deficiency
• Normal range results vary with many factors
  (technique, tech, pathology)

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Coagulation Studies
Anticoagulant Factors Inhibited PT PTT
Heparin II, IX, X, XI, XII Normal Prolonged
Coumadin II, VII, IX, X Prolonged Normal
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Coagulation Studies
ACTIVATED CLOTTING TIME

• Activated Clotting Time (ACT)-most commonly used
  test to evaluate adequacy of anticoagulation
  prior to vascular clamp or bypass.
• ACT measures the time required for thrombus
  formation when blood is mixed in a tube with a
  clotting accelerator such as diatomaceous earth.
• Normal ACT is 80 - 150 seconds. BEFORE
  heparinization obtain a baseline ACT.
• Acceptable anticoagulation for CPB is ACT of gt
  400-480 seconds.
• If ACT lt 400 seconds, additional heparin 100u/kg
  is given.

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Coagulation Studies

• Platelets
• Normal range 150,000 to 400,000 cells/ml
• Life span 8 to 12 days
• Approximately 1/3 of platelets are sequestered in
  the spleen

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Indications for Transfusion

• 1. ANEMIA loss of RBCs
• Xfuse at Hematocrit
• CAD 25-30
• Healthy 20-25
• No choice (?) 15-20

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Indications for Transfusion
Hemoglobin Level Mortality
lt 6 g/dL 62
6 8 g/dL 33
8 10 g/dL 0
gt 10 g/dL 5
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Conditions where a higher Hb is needed (keep Hb
over 10 g/dL )

• Coronary artery disease
• Congestive heart failure
• Chronic obstructive pulmonary disease
• Peripheral vascular disease
• Stroke
• Use of beta blockers
• Blood loss expected
• Elderly

From Carson JL Mordidity Risk Assessment in the
Surgically Anemic Patient Am J Surg Dec 1995 vol
170, no 6A (Suppl) pp. 32S-36S
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Indications for Transfusion

• Estimating Blood Volumes
• Estimated Blood Loss add all sources of loss
• EBLSuction sponges drapes floor etc.
• Allowable Blood Loss calculated estimate
• ABL Hct(s) Hct(a) X BloodVol / Hct(a)
• Volume to Transfuse calculated replacement
• VtTHct(d) Hct(p) X BloodVol / Hct(blood)
• Avg adult BloodVol 7 of lean mass or 70ml/kg

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Indications for Transfusion

• 2. THROMBOCYTOPENIA
• Spontaneous bleeding occurs withlt 20,000
  platelets
• Surgical hemostasis may requiregt 50,000
  platelets
• Platelet transfusion _at_ lt 50,000
• Causes- decreased production, increased
  utilization, destruction, drug effect, massive
  transfusion

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Indications for Transfusion

• 3. COAGULOPATHY bleeding associated with Factor
  losses or prolonged clotting times (PT, PTT, BT,
  ACT)

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Guidelines for Transfusion

• Transfusion need should be assessed on a
  case-by-case basis.
• Blood should be transfused one unit at a time,
  followed by an assessment of benefit and further
  need.
• Exposure to allogeneic blood should be limited to
  appropriate need.
• Does this pt need to be transfused?
• Appropriate transfusion trigger for this pt (HH)
• Donor-directed transfusion (?)

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Guidelines for Transfusion

• Perioperative blood loss should be prevented or
  controlled.
• Stop anticoagulant meds preop
• Assess/manage preop coagulopathy
• Restrict perioperative phlebotomy
• Consider regional anesthesia
• Consider hypotensive anesthesia
• Surgical technique options
• Antifibrinolytic drugs

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Guidelines for Transfusion

• Autologous blood should be considered for use as
  an alternative to allogeneic transfusion.
• preoperative autologous blood
• intraoperative acute normovolemic hemodilution
• intraoperative autologous blood salvage and
  autotransfusion
• postoperative autologous blood salvage and
  autotransfusion

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Guidelines for Transfusion

1. Efforts should be made to maximize oxygen
   delivery in the surgical patient.
2. RBC mass should be increased or restored by means
   other than RBC transfusion.
3. The patient should be involved in the transfusion
   decision.
4. The reasons for and results of the transfusion
   decision should be documented contemporaneously
   in the patient's record.
5. Hospital transfusion policies and procedures
   should be developed as a cooperative effort that
   includes input from all those involved in the
   transfusion decision and reviewed annually.
6. ASA Guidelines know professional standards

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Blood Typing Cross-Matching

• ABO Blood Groups
• 1.Type A with A antigens on the red cells and
  anti B antibodies in the plasma
• 2.Type B with B antigens on the red cells and
  anti A antibodies in the plasma
• 3.Type AB with both A and B antigens on the red
  cells and no type antibodies in the plasma
• 4.Type O with no type antigens on the red cells
  and both anti A and anti B antibodies in the
  plasma

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Blood Typing Cross-Matching

• ABO Blood Groups in the Population

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Blood Typing Cross-Matching

• Rh blood typing test the presence () or
  absence (-) of the Rh antigen.
• If your red blood cells
• Contain the Rh antigen, your blood is
  Rh-positive.
• Do not contain the Rh antigen, your blood is
  Rh-negative.

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Blood Typing Cross-Matching
ABO Blood Groups Rh Type in the Population
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Blood Typing Cross-Matching

• Screening Tests Performed on Donated Blood
• Hepatitis B surface antigen (HBsAg)
• Hepatitis B core antibody (anti-HBc)
• Hepatitis C virus antibody (anti-HCV)
• HIV-1 and HIV-2 antibody (anti-HIV-1
  anti-HIV-2)
• HIV p24 antigen
• HTLV-I HTLV-II antibody (anti-HTLV-I
  anti-HTLV-II)
• Serologic test for syphilis
• Nucleic Acid Amplification Testing (NAT)

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Blood Typing Cross-Matching

• Donor Recipient blood is typed on ABO antigen
  group and Rh factor. Screening tests for other
  antigen/antibodies.
• Cross-matching tests patients plasma with
  donors RBCs to test for hemolysis.
• Emergency transfuse type specific ORO-negative
  and type specific ASAP

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Blood Typing Cross-Matching
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Blood Component Therapy

• Whole Blood 500 ml
• Contains
• RBCs, WBCs, Platelets, Plasma
• Indications
• Replace plasma volume and RBCs
• WBCs platelets nonfunctional gt 72 hr.
• Deficient in Factors V, VII

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Blood Component Therapy

• Packed RBCs 250 ml
• Contains
• RBCs, WBCs, platelets, minimal plasma
• Indications
• Increase RBCs increase O2 xport
• WBCs platelets nonfunctional gt 72 hr.
• Deficient in Factors V, VII

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Blood Component Therapy

• Packed RBCs 250 ml
• One unit of PRBCs 70 Hct
• One unit will raise patients Hct approximately
  3 or HgB 1 gm/dL
• Volume to Transfuse
• calculated replacement
• VtTHct(d) Hct(p) X BloodVol / Hct(blood)

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Emergency Transfusion

• If pt ABO is known, use an abbreviated
  cross-match to check ABO compatibility
• If not known, give O neg packed RBCs
• O neg whole blood contains anti-A anti-B
  antibodies
• May react with patients A or B antigens
• May react with subsequent A or B blood
• If O neg whole blood used, continue until anti-A
  and anti-B titers are done

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Massive Transfusion Risks

• Coagulopathy
• Citrate Toxicity
• Hypothermia
• Acid-Base Imbalance
• Hyperkalemia
• Increased opportunity for error
• Increased opportunity for infection
• Increased risk to providers

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Blood Component Therapy

• Platelet Concentrate 50 ml
• Contains
• gt 5 x 1010 platelets, RBCs, WBCs, platelets,
  minimal plasma
• Indications
• Bleeding from thrombocytopenia or
  thrombocytopathy

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Blood Component Therapy

• Platelet Concentrate 50 ml
• One unit of PC increases platelet count 5000
  10,000 cells/mm

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Blood Component Therapy

• Fresh Frozen Plasma 220 ml
• Contains
• Contains plasma with coagulation factors but no
  platelets
• Indications
• Correction of coagulopathy

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Blood Component Therapy

• Fresh Frozen Plasma 220 ml
• Dose of 10-15 ml/kg increases coagulation factors
  by 30
• Fibrinogen increases 1mg/ml of FFP
• Rapid reversal of warfarin usually requires 5
  10 ml/kg of FFP

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Blood Component Therapy

• Cryoprecipitate 15 - 25 ml
• Contains
• Fibrinogen, Factors VIII, XIII, von Willebrands
• Indications
• Correction of coagulopathy where Fibrinogen,
  Factors VIII, XIII, or von Willebrands are
  deficient

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Blood Component Therapy

• Cryoprecipitate 15 - 25 ml
• Dose of 1 unit per 10 kg raises fibrinogen level
  50 mg/dL

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Blood Administration

• Check and double check IDs Labels.
• Blood should not be infused with D5W ?hemolysis
• Blood should not be infused with LR ?Ca in LR
  may induce clot formation
• RBCs are compatible withNormal saline, 5
  albumin, FFP

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Blood Administration

• Blood Filters
• 80 mcm filters should be used for all blood
  components
• 170 mcm filters should be used to administer
  platelets
• Leukocyte filters for patients with febrile rxn
  history, maybe for all to prevent
  alloimmunization to foreign leukocyte antigens

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Blood Administration

• Future Blood Substitutes
• Fluosol-DA 20
• Free hemoglobin solutions

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Plasma Substitutes

• Albumin
• Isotonic Albumin 5
• Hypertonic Albumin 20 25
• Intravascular half-life 10 to 15 days

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Plasma Substitutes

• Dextran
• Dextran 70 Macrodex and Dextran 40
  Rheomacrodex
• Intravascular half life 2 to 8 hours
• Decreases platelet adhesion and VIII
• Coag changes gt 1.5g/kg
• 1 incidence of anaphylactoid reactions
• Give 20 ml Promit to inhibit dextran binding
  antibodies

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Plasma Substitutes

• Hespan ( Hydroxyethyl starch )
• small molecules broken down by kidneys, large
  molecules by amylase
• Nonantigenic, anaphylactoid reactions are rare
• Coag studies not impaired
• Half-life 24-36 hours

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Blood Conservation Techniques

• Autologous Donation
• Donation 5 weeks pre-op, must have HgB gt 11 g/dL,
  can donate Q 3 days, last donation gt 72 hr pre-op
• Not all patients tolerate donation
• Transfusion reaction risk is reduced but human
  error component is still present transfuse with
  same criteria precautions

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Blood Conservation Techniques

• Hemodilution Techniques (?)
• Remove 1 to 2 units of whole blood (Hct 25-30)
• Replace volume with LR or colloids
• Intraop loss then is greater plasma loss and less
  RBC loss
• Reinfuse fresh autologous blood (Hct will be the
  same as pre-op, not PRBC)

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Blood Conservation Techniques

• Cell Saver
• Intraop autotransfusion
• Double lumen suction aspirates blood from clean
  field (heparin saline blood)
• Collected blood is filtered and washed prior to
  reinfusion
• RBCs in saline Hct 50
• No plasma, clotting factors or platelets

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Complications of Transfusion

• Acute Hemolytic Reactions
• ABO-incompatiability
• Occur 1 in 33,000 most due to human error,
  fatal in 1300k to 700k
• Symptoms may be masked by anesthesia (agitation,
  chest or flank pain, headache, dyspnea, chills)
• Signs include fever, tachycardia, hypotension,
  DIC, hemoglobinuria

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Complications of Transfusion

• Acute Hemolytic Reactions
• STOP the infusion
• Establish a noncontaminated IV
• Send unused donor blood to lab with blood sample
  from patient for rematch
• Send blood for Hgb, haptoglobin, Coombs and DIC
  screening
• Rx hypotension fluids vasopressors prn
• May give corticosteroids
• Preserve renal function fluids, dopamine,
  diuertic maintain UO 1-2ml/kg/hr
• R/O DIC

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Complications of Transfusion

• Non-Hemolytic Reactions
• Allergic or febrile rxn to antibodies to donor
  WBCs or platelets
• Transfused allergens in plasma interact with the
  patient's tissue mast cells, causing them to
  degranulate and release inflammatory mediators
  (histamine, tryines, etc.)

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Complications of Transfusion

• Non-Hemolytic Reactions
• STOP the transfusion, establish clean IV and send
  labs
• Mild rxn diphenhydramine 25-50 mg IV
  hydrocortisone 50-100 mg IV, acetaminophen 650 mg
• May resume transfusion slowly (?)
• Rx other symptoms prn

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Complications of Transfusion

• Infection Risk

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Complications of Transfusion
Population
Donor Screen
Blood Units
Hepatitis B 1 200 1 2,000 1 200,000
Hepatitis C 1 70 to 1 500 1 400 1 4,000 to 1 100,000
HIV 1 125 to 1 250 1 12,500 1 550,000
HTLV ? 1 10,000 1 100,000
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SUMMARY

• Blood components
• Coagulation system and tests
• Blood and fluid administration