Fluid and Blood Therapy

1. Fluid and Blood Therapy Gerard T. Hogan, Jr., CRNA, MSN Clinical Assistant Professor Anesthesiology Nursing Program School of Nursing Florida International University

2. Fluid and Blood Therapy Importance of thorough preoperative evaluation of fluid balance status Patient History Systemic B/P Heart Rate Urine Output Hematocrit BUN Electrolytes CVP

3. Fluid and Blood Therapy Body Fluid Compartments Total body water is divided into: ECF (PV + ISF) ICF TBW content varies with: Age Gender Body Habitus

4. Fluid and Blood Therapy Perioperative Assessment of Intravascular Fluid Status Causes of Intravascular Volume Depletion Prolonged GI losses Chronic Hypertension Chronic Diuretic Use Sepsis Trauma

5. Fluid and Blood Therapy “If the eyes are the windows to the soul, then the kidneys are the windows to the body” Sandra Ouellette, CRNA, M.Ed., FAAN

6. Fluid and Blood Therapy Physical signs and symptoms of Hypovolemia: Supine Hypotension Orthostasis Oliguria Is Hematocrit a useful tool in determining hypovolemia? What are some of the initial (early) signs and symptoms of hypovolemic shock?????

7. Fluid and Blood Therapy Approximate distribution of electrolytes

8. Fluid and Blood Therapy Electrolyes Sodium (135-145 mEq/L) The major cation in blood Excitable cells depend on it for depolarization HYPERNATREMIA (>145mEq/L) is usually due to a total body water deficit

9. Fluid and Blood Therapy Electrolytes Sodium HYPONATREMIA (>135mEq/L) usually due to excess body water, or can be associated with burns, vomiting, diarrhea, etc. S/S include hypotension, tachycardia Neurologic signs (TURP Syndrome)

10. Fluid and Blood Therapy Electrolytes Potassium (3.5-5.0 mEq/L) Major intracellular cation Maintenance of cardiac rhythm Contribution to cellular energy production Deposition of glycogen by liver cells Transmission and conduction of nerve impulses Hyperkalemia (> 5.5mEq/L) Increased total body K+

11. Fluid and Blood Therapy Electrolytes Potassium Hyperkalemia Renal disease Role of Succinylcholine S/S of Hyperkalemia Usually only occur with an acute increase Many renal patients have elev. K+ chronically MOST DETRIMENTAL is cardiac conduction defects

12. Fluid and Blood Therapy Electrolytes Potassium Hyperkalemia Prolongation of the PR interval Widening of the QRS complex Peaking of the T wave Treatment Multiple treatments are available depending on severity and time frame

13. Fluid and Blood Therapy

14. Fluid and Blood Therapy Electrolytes Potassium Hypokalemia (<3.5mEq/L) Diuretics Nausea, Vomiting, Diarrhea NG Suction Maldistribution (Alkalosis) Stress induced catacholamines

15. Fluid and Blood Therapy Electrolytes Potassium Adverse effects of hypokalemia include: Decreased myocardial contractility Skeletal muscle weakness Increased automaticity in the atria Prolongation of PR interval, QT interval Flattening of the T wave

16. Fluid and Blood Therapy Electrolytes Potassium Treatment of hypokalemia Oral replacement in chronic hypokalemia questionably effective IV replacement slow and carefully with cardiac monitoring Surgical implications Debate as to whether or not to do elective surgery of K+ <3.5mEq/L)

17. Fluid and Blood Therapy Electrolytes Potassium Surgical Implications Avoid glucose containing solutions intraoperatively Capnography and maintenance of normocarbia 10-20mEq added to each liter of IV intraop Serial monitoring of K+ levels important D/C K+ containing fluids if cardiac depression becomes a problem perioperatively

18. Fluid and Blood Therapy Electrolytes Magnesium (1.5-2.5mEq/L) Intracellular cation Enzyme activity Essential fro protein synthesis Neurochemical transmission Muscular excitability Hypermagnesemia (>2.5mEq/L) PIHD, Laxative abuse, Antacid abuse CNS depression, decreased myocardial contractility Skeletal muscle weakness

19. Fluid and Blood Therapy Electrolytes Magnesium Hypermagnesemia Treatment includes antagonism with Calcium Establish diuresis IV fluid dilution Hypomagnesemia (<1.5mEq/L) Chronic alcoholism, protracted nausea Diarrhea S/S mirror hypocalcemia

20. Fluid and Blood Therapy Electrolytes Calcium (4.5-5.5 mEq/L, 9-11mg/dL) Extracellular and intracellular functions Formation of bones and teeth Transmission of nerve impulses Contraction of muscles COAGULATION Maintenance of cellular permeability Cardiac action potential and pacemaker activity

21. Fluid and Blood Therapy Electrolytes Calcium Hypercalcemia (>5.5mEq/L) Hyperparathyroidism Neoplastic disorders with bone mets S/S include Prolonged PR interval Widened QRS complex Shortened QT interval Hydration and Urinary output important

22. Fluid and Blood Therapy Electrolytes Calcium Hypocalcemia (< 4.5 mEq/L) Decreased serum albumin Hypoparathyroidism Pancreatitis Renal failure S/S include Skeletal muscle spasm Laryngospasm Respiratory alkalosis can further decrease Ca++ levels

23. Fluid and Blood Therapy Metabolic effects of fasting To withstand fasting and the catabolic effects of surgery, the body must mobilize nutrients from it fuel stores Glycogen First to go, but cannot maintain the body for more than 1 day Protein Mobilized and converted to glucose Fats Ketones and fatty acids, packed with energy, but there is a price to pay!

24. Fluid and Blood Therapy Intraoperative Fluid Replacement In healthy adults undergoing elective surgery, the following must be taken into consideration: NPO loss Insensible loss EBL Replacement Maintenance

25. Fluid and Blood Therapy Intraoperative Fluid Replacement The predicted daily maintenance fluid requirements for healthy adults may exceed 2500ml/day including 20 mEq/L Sodium and 15-20mEq/L Potassium Insensible loss (diaphoresis, respiration, etc.) may exceed 1000ml/day Urinary losses to maintain renal function average 1000ml/day, GI losses 200ml/day

26. Fluid and Blood Therapy Intraoperative Fluid Replacement Surgical Patients require additional fluids and electrolytes to replace losses from the ECF to nonfunctional “third space” We base our fluid replacement on the anticipated need categorized by the amount and duration of tissue trauma caused

27. Fluid and Blood Therapy Intraoperative Fluid Replacement The following is an accepted example of “third space” replacement Minor trauma 4 ml/kg/hr Moderate trauma 6ml/kg/hr Extensive trauma 8ml/kg/hr Keep in mind that colloids may be required if EBL is extensive

28. Fluid and Blood Therapy Intraoperative fluid replacement Maintenance fluid Maintained with isotonic solution 4cc/kg for the 1st 10kg of body weight 2cc/kg for the next 10kg of body weight 1cc/kg for the rest of the body weight This formula works for children and adults In an adult weighing over 30kg, just add 40 to the weight to find the maintenance rate

29. Fluid and Blood Therapy Deficit Deficit is described as the maintenance rate x the hours of NPO Example – 70 kg man has a maintenance rate of 110cc/hr. If he was NPO after midnight at his surgical procedure is to begin at 0800, then his deficit is 880ml. Give ½ in the first hour, ¼ in the second hour, and ¼ in the third hour. It is OK to give it faster, if needed (regional)

30. Fluid and Blood Therapy

31. Fluid and Blood Therapy Fluid Selection Crystalloids Appropriate for maintenance and fluid replacement in the absence of specific fluid losses that require protein replacement Anesthesia providers avoid glucose containing solutions for multiple reasons Unnecessary with hyperglycemic response Iatrogenic hyperglycemia can induce osmotic diuresis Hyperglycemia can aggravate ischemic neurologic injury

32. Fluid and Blood Therapy Crystalloids Isotonic solutions Lactated Ringer’s Solution Has electrolyte composition most resembling ECF pH is around 6.6 (kind of acidic) Plasmalyte (Normosol) pH 7.4, more physiologic D5W 0.9% Normal Saline

33. Fluid and Blood Therapy Crystalloid replacement scheme Maintenance hourly NPO deficit as follows ½ 1st hour ¼ 2nd hour ¼ 3rd hour Insensible loss (Replacement) 4cc/kg minimal trauma 6cc/kg moderate trauma 8cc/kg extensive trauma

34. Fluid and Blood Therapy

35. Fluid and Blood Therapy Intraoperative assessment of blood loss Visual estimation Sponges Laps Drapes Suction Most tend to underestimate Urinary output is a good indicator Tachycardia and hypotension also important

36. Fluid and Blood Therapy Calculating allowable blood loss Most say that nowadays we should be monitoring H&H for decision to transfuse How can we figure a quick and painless way to calculate how much a patient can lose? Multiple formulas exist, so let’s look at some examples:

37. Fluid and Blood Therapy Calculating allowable blood loss Estimated Blood Volume (EBV) and ABL Blood Volume as a function of total body water composition decreases with age Premature 100-120cc/kg Newborn 80-90cc/kg Infant (age 3-12 months) 75-80cc/kg Adult male 70cc/kg Adult female 65cc/kg

38. Fluid and Blood Therapy Calculating allowable blood loss Hematocrit If you know what the preoperative HCT is, you can calculate MABL this way: MABL = EBV x (Starting HCT – Target HCT Starting HCT MABL = (70cc/kg x 70kg) x (45%-30%) 45% MABL = (4900 x 15)/45 = 1633cc

39. Fluid and Blood Therapy Blood considerations Acute blood losses in the range of 1500 to 2000ml (or approximately 30% of EBV) exceed the ability of crystalloids to replace without jeopardizing O2 carrying capacity of the blood Compensatory mechanisms maintain homeostasis up until that point

40. Fluid and Blood Therapy Blood Considerations Decision to transfuse never taken lightly Based on risk that anemia poses on the patient’s ability to compensate for loss of O2 carrying capacity vs. inherent risk of transfusion (with acute blood loss, blood viscosity decreases and CO increases) Otherwise healthy patients with a Hgb of 10g/dl rarely need transfusion

41. Fluid and Blood Therapy Blood considerations Any healthy patient with an acute blood loss with a Hgb of 6 or lower needs to be transfused Certain disease processes may require transfusion at a higher Hgb COPD CAD

42. Fluid and Blood Therapy Blood considerations O2 transport peaks at a Hgb of 10, and remains constant between 10-15, so going over 10 is not necessary Concern for viral illnesses (Hepatitis, HIV) Possibility of transfusion reaction Directed donation Autologous

43. Fluid and Blood Therapy Blood considerations Adequacy of intraoperative blood replacement is ascertained by improvements in B/P, HR, U/O, Arterial Oxygenation, and pH These parameters are monitored, and if they return to normal levels, you may consider checking H&H to see if further therapy is indicated

44. Fluid and Blood Therapy

45. Fluid and Blood Therapy Blood components Whole blood Not readily available because it is better utilized by components 450ml blood with 63ml anticoagulant Generally WB will increase HCT 3-4% per unit in a 70kg non-bleeding adult Indicated in acute blood loss >30% of EBV If over 24hrs old, no viable platelets, and factors V and VIII are markedly reduced

46. Fluid and Blood Therapy Packed RBCs Approx 200ml RBC and 50ml plasma Indicated in expansion of red cell mass Come in different forms PRBCs Washed PRBCs Leukocyte Poor PRBCs Frozen RBCs

47. Fluid and Blood Therapy Packed RBCs Remember PRBCs restore O2 carrying capacity but do not contain any plasma proteins important for coagulation Removal of plasma removes fibrinogen (factor I) High viscosity, so many providers dilute with 100-200ml of appropriate crystalloid HCT of PRBCs 70-80%

48. Fluid and Blood Therapy

49. Fluid and Blood Therapy Emergency release blood Type specific partially crossmatched is safer than O negative O negative contains high titers of anti-A and anti-B hemolytic antibodies Once you’ve given 2 units of O negative, it is advised to continue to do so until antibody panel can be evaluated

50. Fluid and Blood Therapy Platelets Treatment of thrombocytopenia Not required unless PLT count 50k or lower HLA sensitization can occur Transmission of viral diseases Pooled from many donors Storage at room temperature increases chance of infection One unit increases PLT count 5-10k

51. Fluid and Blood Therapy Fresh Frozen Plasma (FFP) Restores coagulation factors lost with hemodilution Can be stored for 1 year Indicated in Coumadin reversal Coagulopathies Volume expansion

52. Fluid and Blood Therapy Fresh Frozen Plasma All coagulation factors except platelets are present Most providers judge need based on PT and PTT being 1.5 times greater than preoperative level Risk of viral illnesses and transfusion reaction

53. Fluid and Blood Therapy Cryoprecipitaate Fraction that precipitates when plasma is thawed Useful in treating Hemophilia A (high amount of factor VIII) Used to treat hypofibrinogenemia

54. Fluid and Blood Therapy Transfusion reactions in the OR Febrile Accompany 1% of all transfusions Difficult to assess during GA Antibody-antigen response Allergic Fever, pruritis, urticaria Treated with antihistamines May need to discontinue

55. Fluid and Blood Therapy Transfusion reactions in the OR Hemolytic Administration of incompatible blood type Intravascular hemolysis Spontaneous hemorrhage If awake, lumbar and sternal pain, fever, chills, dyspnea, skin flushing All of the above can be masked by GA Acute renal Failure secondary top breakdown products of RBCs

56. Fluid and Blood Therapy Transfusion reactions in the OR Hemolytic Discontinue transfusion Maintain urinary output with crystalloids, mannitol, and/or furosemide NaHCO3 may help to alkalinize the urine and theoretically improve solubility of hemoglobin degradation products Corticosteroids are controversial

57. Fluid and Blood Therapy Albumin 5% and 25% concentrations 5% Isotonic for rapid expansion of intravascular fluid volume 25% indicated in hypoalbuminemia Does not provide clotting factors Increased mortality when administered to critically ill patients Heat treated to eliminate risk of infection

58. Fluid and Blood Therapy Colloid alternatives Hespan (Hetastarch) Increases total plasma osmolality Indicated in coagulopathies Should never exceed 1000ml or 20% of EBV, whichever is greater Can support bacterial growth, so handle carefully

59. Fluid and Blood Therapy Blood Alternatives Perfluorocarbon Emulsion that carries O2 and gives it up at the cellular level Limited O2 carrying ability Short intervascular persistence Poor shelf life Temperature instability Disruption of pulmonary surfactant mechanism

60. Fluid and Blood Therapy Stroma free Hemoglobin Made from outdated blood Hemoglobin that is suspended in an isotonic medium Improved O2 carrying capacity Quickly metabolized to nonuseful metabolites by the body Rapidly cleared from the circulation