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Ch 29 Fluid Management & transfusion

Ch 29 Fluid Management & transfusion. R1 최 정 현. Evaluation of intravascular volume. Physical examination Most reliable preoperatively Hypovolemia Invaluable clues ( 표1). Evaluation of intravascular volume. Hypovolemia Intraoperatively 에서 자주 사용되는 sign Fullness of a pph. Pulse

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Ch 29 Fluid Management & transfusion

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  1. Ch 29Fluid Management & transfusion R1 최 정 현

  2. Evaluation of intravascular volume • Physical examination • Most reliable preoperatively • Hypovolemia • Invaluable clues • (표1)

  3. Evaluation of intravascular volume • Hypovolemia • Intraoperatively에서 자주 사용되는 sign • Fullness of a pph. Pulse • Urinary flow rate • Indirect sign • Positive pr. Ventilation에 대한 BP 변화 • Anesthetics의 vasodilating and negative inotropic effect • hypervolemia • Pitting edema • Presacral(bedridden), pretibial(ambulatory pt.) • Increased urinary flow • Late sings • Tachycardia, pulmonary crackles, wheezing, cyanosis, pink & frothy pulmonary secretion

  4. Evaluation of intravascular volume • Laboratory evaluation • Serial Hct. • Arterial blood pH • Urinary specific gravity or osmolality • Urinary sodium or chloride conc. • Serum sodium • Serum BUN/Cr ratio

  5. Evaluation of intravascular volume • Lab signs of dehydration • Rising Hct. • Progressive metabolic acidosis • Urinary specific gravity > 1.010 • Urinary sodium < 10 mEq/L • Urinary osmoloality > 450 mOsm/kg • Hypernatremia • BUN:Cr ratio > 10:1 • Radiologic sign • Increased pulmonary vascular and interstitial markings(Kerly B sign) • Diffuse alveolar infiltrate

  6. Evaluation of intravascular volume • Hemodynamic measurement • CVP • Hypovolemia의 다른 sing이 없다면 low values(<5 mmHg)는 보통 정상. • Response to a fluid bolus(250 mL) • Small elevation(1-2)  need for more fluid • Large increase(>5)  slow rate administration & reevaluation of volume status • 12 mmHg이상  hypervolemia • Pulmonary a. pr. • PAOP < 8 mmHg : hypovolemia • PAOP > 18 mmHg : left ventricular volume overload • Newer techniques • Transesophageal echocardiography • Radioisotopes  more accurate but not as widely available

  7. Intravenous fluid • Crystalloid solution • Low-molecular-weight ions(salt) with or without glucose • Colloid solutions • High-molecular-weight substances • Protein, large glucose polymers

  8. Intravenous fluid • Crystalloid solution • Initial resucitation fluid • 3~4 L 의 crystalloid로 hemodynamic reponse가 충분치 않으면 colloid added • Loss가 주로 water일 때  hypotonic solution replacement called maintenance-type solution • Both water and electrolyte  isotonic electrolyte solution  called replacement-type solutions

  9. Crystalloid solution • Lactated Ringer’s solution • m/c used fluid • Slightly hypotonic(sodium : 130 mEq/L) • Large volume이 필요한 경우 가장 physiologic solution • Lactate : liver에서 bicarbonate로 convert • 다량의 N/S주입으로 생길 수 있는 hyperchloremic acidosis시 bicarbonate가 chloride를 증가만큼 감소시킴. • Normal saline • Hypochloremic alkalosis시 preferrable • Diluting packed RBC시 • 5DW : pure water defic • Hypertonic 3% saline : severe symptomatic hyponatremia시 • 7.5% saline : hypovolemic shock pt.

  10. (표 2)

  11. Colloid solution • Intravascular half-lives  3~6 시간 • Crystalloid  20~30분 • Indication • Severe intravascular fluid deficit. patients(eg.hemorrhagic shock)의 fluid resuscitation시 transfusion을 위한 blood도착 전에 • Severe hypoalbuminemia • Burn가 같은 large protein loss시 • Many clinician들이 transfusion 전에 3-4L의 fluid replacement가 필요한 경우 crystalloid와 함께 사용함.

  12. Colloid solution • Blood derived colloid : Albumin, plasma protein fraction • 적어도 10시간 이상 60도 이상으로 가열하여야 hepatitis나 다른 virally transmitted disease를 최소화할 수 있음. • Synthetic colloid : dextrose starches, gelatins • Gelatin은 histamine-mediated allergic reaction으로 미국에선 사용되지 않음.

  13. Colloid solution • Dextran • Dextran 40, dextran 70 • 20 mL/kg이상 주입시 blood typing을 방해할 수 있으며, bleedign time연장시킬 수 있음. • Antigenic하기 때문에 dextran 1을 먼저 투여하여 anaphylactic reaction예방. • Hetastarch • Average molecular weight : 450,000 • Plasma expander로 highly effective하지만 albumin보다 less expensive • Nonantigenic하며 anaphylactoid reaction이 rare • 0.5~1 L주입시에는 Coagulation study, bleeding time에 별 영향 없음. • Pentastarch • Lower molecular weight • Adverse effect가 더 적어 hetastarch를 대체할 것.

  14. Perioperative fluid therapy 1. Replacement of preexisting fluid deficits 2. Normal losses ( maintenance requirement) 3. Surgical wound losses including blood loss

  15. Normal maintenance requirements • Urine formation • GI secretion • Sweating • Insensible loss from skin and lung (표3) • Preexisting deficit • Multiplying normal maintenance rate by the length of the fast

  16. Surgical fluid loss • Blood loss • Surgical suction container • Visually estimating blood on • surgical sponge  4*4 : 10 mL • and laparotomy pad  100-150 mL • Hct. : long procedure나 estimation이 어려울 때 유용 • Other fluid loss • Evaporation • Internal redistribution of body fluid  third spacing

  17. Intraoperative fluid replacement • Replacing blood loss • Anemia danger가 transfusion risk를 넘어서기 전까지는 crystalloid나 colloid로 replace하는 것이 좋음. • 보통 hemoglobin 7~8 g/dL(Hct. 21~24%) • Elderly, significant cardiac or pul. dis.  10 g/dL • Transfusion 전까지 blood loss의 • Lactated Ringer’s solution은 3-4배 • Colloid 는 1:1 ratio 로 given

  18. Allowable blood loss • Estimate blood volume • preopRBC volume estimation • Hematocrit 30%에서의 RBCV estimation • preopRBCV – 30% RBCV • 4.*3 • Other guidelines • RBC 1 unit  increase Hb. 1 g/dL(Hct 2-3%) • RBC 10 mL/kg  increase Hb 3 g/dL(Hct 10%)

  19. Replacing redistribution & evaporative losses

  20. Transfusion • Compatibility testing • ABO-Rh testing • Crossmatching • Confirm ABO and Rh typing • Other blood group system의 Ab. detect • 쉽게 agglutinate하지않거나 low titer Ab. detect • Antibody screen • Non-ABO hemolytic reaction을 일으키는 흔한 Ab.의 detection • Indirect Cooms test • Emergency transfusion  type O Rh-negative

  21. Blood bank practice • CPDA-1 : m/c used preservative-anticoagulant solution • Citrate : anticoagulant(by binding calcium) • Phosphate : buffer • Dextrose : red cell energy source • Adenosine : ATP synthesis의 precursor • 1 unit of blood • 250 ml of PRBC : 1~6 °C에 보관 • Platelet and plasma : 20~24 °C에 5일동안 보관 • Fresh frozen plasma : 200mL, high conc. of factor VIII and fibrinogen • Automated Plateletpheresis  한 사람에게서 6 unit 를 얻을 수 있음.

  22. Intraoperative transfusion practice • Packed RBC • Ideal for patient requiring red cells not volume replacement • Volume replacement를 위해 second line을 통해 crystalloid를 주입 • Transfusion전 blood bank slip과 recipiet’s identitybracelet확인 • Transfusion tubing은 clot, debris를 거르기 위한 170-um filter를 가지고 있어야 함 • 37 °C로 가온하여 주입 • Blood warmer : 150 mL/min에서까지 30 °C이상으로 유지할 수 있어야 함

  23. Intraoperative transfusion practice • Fresh frozen plasma • Contains all plasma protein(all clotting factor포함) • Indication • Treatment of isolated factor deficiencies • Reversal of warfarin therapy • Correction of coagulopathy associated with liver disease • 1 unit 는 각각의 clotting factor를 2~3% 증가시킴. • Initial therapeutic dose : 10-15 ml/kg • Goal : normal coagulation factor conc.의 30%도달. • Also used • Massive blood transfusion • Continue to bleed following platelet transfusion • Anti thrombin III deficiency • Thrombotic thrombocytopenic purpura

  24. Intraoperative transfusion practice • Platelet • Bleeding이 있으며 thrombocytopenia or dysfunctional platelet 환자에서 투여 • Prophylactic platelet transfusion • 10,000 – 20,000 * 109 /L 이하시 • 50,000 * 109 /L 이하시 surgery중 blood loss 증가함. • Thrombocytopenic patient  op전 100,000 * 109 /L 까지 증가시켜야 • 1 unit  10,000 -20,000 * 109 /L 증가시킴. • Granulocyte transfusion • In neutropenic patient with bacterial infections not responding to antibiotics • Irradiation으로 transfusion 부작용 줄일 수 • G-CSF, GM-CSF사용으로 granulocyte transfusion은 줄어들었음.

  25. Complication of blood transfusion • Immune reaction 1.Hemolytic reaction - 보통 recipient’s Ab.에 의해 transfused red cell의 specific destruction과 연관됨. Acute : intravascular Delayed : extravascular

  26. Acute hemolytic reaction • 보통 ABO blood incompatibility에 의함 • Frequency ; 1:38,000 transfusion • M/c cause : misidentification • Symptom • In awake : chill, fever, nausea, chest &flank pain • In anesthetized : rise in temperature, unexplained tachycardia, hypotension, hemoglobinuria, diffuse oozing in the surgical field •  DIC, shock, renal shutdown으로 빠르게 진행될 수 있음 • Severity는 주입된 blood 양과 관계 있으며 10-15 mL만 들어가도 severe Sx.을 일으킬 수 있음.

  27. Management of hemolytic reaction • Hemolytic reaction이 의심되면 transfusion을 즉시 중지 • Blood slip과 patient’s identity bracelet을 recheck • Identifying Hb. in plasma, repeat compatibility testing, coagulation studies and platelet count을 위한 blood 채취. • Urinary catheter삽입하여 urine의 Hb. Check • Mannitol과 IV fluid로 osmotic diuresis • Rapid blood loss시 platelet, FFP투여

  28. Delayed hemolytic reactions • Extravascular hemolysis, 보통 mild함. • Caused by • Non-D antigens of Rh system • Other system : Kell, Duffy, Kidd antigens • Ab.가 형성될 chance : 1-1.6% • Reexposure시 anamnestic Ab. Reaction을 trigger : Kidd Ag. System에서 잘 발생 • Symptom • Malaise, jaundice, fever • Diagnosis : direct Coombs test • Tx. : supportive • Frequency : 1:12,000 transfusion

  29. 2. Nonhemolytic immune reaction • Due to sensitization to donor’s white cell, platelet, plasma protein • Febrile reaction • White cell or platelet에 의함 • 1-3% of transfusion • Tx. : White cell-poor RBC 사용 • Urticarial reaction • Plasma protein에 의함 • 1% of transfusion • Tx. : antihistamine and steroid • Anaphylactic reaction • Rare : 1 in 150,000 transfusion • 주로 IgA-deficienct patients with anti-IgA Ab.가 IgA-containing blood를 transfusion받았을 때 생김. • Tx. : epinephrine, fluids, corticosteroid, H1 and H2 blocker

  30. 2. Nonhemolytic immune reaction • Noncardiogenic pulmonary edema • TRALI : transfusion-related acute lung injury • < 1:10,000 • Initial Tx.는 ARDS와 비슷 • Graft-versus-Host disease • Immune-compromised patient에서 보임 • Blood product의 Lymphocyte에 의해 • Filter와 irradiation으로 lymphocyte를 inactivate • Posttransfusion purpura • Due to platelet alloantibody • Tx. : plasmapheresis • Immune suppression • Leukocyte-containing blood product시 immunosuppressive함. : renal transplant recipients가 preop. transfusion시 graft survival이 향상됨. • Blood transfusion은 surgery, trauma후 serious infection incidence가 증가

  31. Infectious complication • Viral infection • Hepatitis • AIDS • CMV, EBV, HTLV-1,HTLV-2, Parvovirus • Parasitic infection • Malaria, toxoplasmosis, Chagas’ disease • Very rare • Bacterial infection • 2nd leading cause of transfusion-associated death • Prevalence • Platelet product  1/2000 ,pRBC  1/250,000 • Contamination피하기 위해 4시간 안에 주입되어야 함. • Syphilis, brucellosis, salmonellosis, yersiniosis, rickettsioses

  32. Massive transfusion • Patient blood volume의 1-2배 수혈시를 말함.(대부분 성인의 경우 10-20unit에 해당) • Complication • Coagulopathy • M/c cause : dilutional thrombocytopenia • Platelet, FFP • Citrate toxicity • Hypocalcemia, cardiac depression • Hepatic disease pt.는 calcium infusion고려

  33. Massive transfusion • Complication • Hypothermia • 30°C에 가까워지면 ventricular arrhythmia에서 fibrillation으로 진행이 자주 발생 • Rapid infusion device with efficient heat transfer사용으로 현저히 감소하였음. • Acid-base balance • M/c abnormality : metabolic alkalosis(citrate and lactate가 liver에서 bicarbonate로 converted) • Serum potassium conc. • Stored blood는 시간이 지남에 따라 K+증가 • Hypokalemia는 postop metabolic alkalosis와 관련

  34. Alternative strategies for management of blood loss during surgery • Autologous transfusion • 보통 수술 4-5주전 시행 • Hct 최소 34%이상, Hb 11 g/dL이상되어야 • Plasma volume이 normal로 돌아오는데는 최소 72시간이 걸림 • Blood salvage & reinfusion • Contraindication : septic contamination of wound, malignant tumor • Normovolemic hemodilution • 술전 blood를 빼놓고 crystalloid와 colloid로 보충해준 다음 술후에 stored blood를 given back • Donor-directed transfusion

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