Ch 29 Fluid Management & transfusion

1. Ch 29Fluid Management & transfusion 성 준 경

2. A. Evaluation of intravascular volume 1. Physical examination • Most reliable preoperatively • Hypovolemia • Invaluable clues

3. A. Evaluation of intravascular volume • Hypervolemia • Pitting edema • Presacral(bedridden), pretibial(ambulatory pt.) • Increased urinary flow • Late sings • tachycardia • pulmonary crackles • wheezing • cyanosis • pink & frothy pulmonary secretion

4. A. Evaluation of intravascular volume 2. Laboratory evaluation • Serial Hct. • Arterial blood pH • Urinary specific gravity or osmolality • Urinary sodium or chloride conc. • Serum sodium • Serum BUN/Cr ratio

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

6. A. Evaluation of intravascular volume 3. Hemodynamic measurement • CVP • low values(<5 mmHg) • Hypovolemia의 다른 sing이 없다면 는 보통 정상 • Response to a fluid bolus(250 mL) • Small elevation(1-2)  need for more fluid • Large increase(>5)  slow rate administration & re-evaluation 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. B. Intravenous fluid • Crystalloid solution • Low-molecular-weight ions(salt) with or without glucose • Colloid solutions • High-molecular-weight substances (Protein, large glucose polymers) < General facts > • Crystalloid is effective ascolloid with sufficient volume • Colloid 에 비해 3~4배의 양이 필요 • Colloid를 사용해 혈관내액을 보충하게 되면 더 빠른 교정이 가능 • 4~5L이상의 crystalloid 투여는 tissue edema를 더 쉽게 유발 < Severe tissue edema > • 산소운반을 방해 • 조직회복을 더디게 함 • bowel function이 돌아오는데 더 많은 시간 필요

8. B. Intravenous fluid1. Crystalloid solution • Initial resucitation fluid • 3~4 L 의 crystalloid로 hemodynamic reponse가 충분치 않으면 colloid added • Mainly freewater loss  hypotonic solution replacement (=maintenance-type solution) • Both water and electrolyte loss  isotonic electrolyte solution (=called replacement-type solutions)

9. B. Intravenous fluid1. 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 • Normal saline • Dilutional hyperchloremic acidosis (Choride 농도 증가  Bicarbonate농도 감소) • Hypochloremic alkalosis시 preferrable • Diluting packed RBC during transfusion • 5DW : pure water deficit , Na restriction • Hypertonic 3% saline : severe symptomatic hyponatremia시 • 3 ~ 7.5% saline : hypovolemic shock pt.

10. B. Intravenous fluid1. Crystalloid solution • (표 2)

11. B. Intravenous fluid2. 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. B. Intravenous fluid2. Colloid solution • Blood derived colloid : Albumin, plasma protein fraction • 적어도 10시간 이상 60도 이상으로 가열하여야 hepatitis나 다른 virally transmitted disease를 최소화할 수 있음 • Plasma protein fraction • Hypotensive reaction • Allergic in nature

13. B. Intravenous fluid2. Colloid solution • Synthetic colloid : dextran, gelatins, Hetastarch, pentastarch • Gelatin은 histamine-mediated allergic reaction으로 미국에선 사용되지 않음 • Dextran 40, dextran 70 • Improves blood flow through microcirculation – lowers blood viscosity • 20 mL/kg이상 주입시 blood typing을 방해할 수 있으며, bleedign time연장시킬 수 있음. • Antigenic하기 때문에 dextran 1을 먼저 투여하여 anaphylactic reaction예방 • Hetastarch (Hydoxyethyl starch)  Voluven • Plasma expander로 highly effective하지만 albumin보다 less expensive • Nonantigenic하며 anaphylactoid reaction이 rare • 0.5~1 L주입시에는 Coagulation study, bleeding time에 별 영향 없음 • Pentastarch  Pentaspan • Lower molecular weight • Adverse effect가 적어 hetastarch 대체 가능

14. C. Perioperative fluid therapy • Normal maintenance requirement • Preexisting fluid deficits • Surgical wound losses

15. C. Perioperative fluid therapy 1. Normal maintenance requirements • Urine formation • GI secretion • Sweating • Insensible loss from skin and lung

16. C. Perioperative fluid therapy2. Preexisting deficit • ( Normal maintenance rate x length of the fast ) • In reality, this deficit will be somewhat less as a result of renal conversion • Abnormal fluid losses • Bleeding, vomiting, diuresis, diarrhea • Occult losses (redistribution) • Traumatized tissue • Infected tissue • Ascites • Fever, sweating, hyperventilation  Can be overlooked

17. C. Perioperative fluid therapy3. Surgical fluid loss a. Blood loss (1) Surgical suction container (2) Visually estimating blood on - surgical sponge  4*4 : 10 mL - laparotomy pad  100-150 mL (3) Hct. : long procedure나 estimation이 어려울 때 유용 b. Other fluid loss (1) Evaporation (2) Internal redistribution of body fluid(=third spacing) - traumatized, inflamed, infected tissue - cellular dysfunction - loss of lymphatic fluid

18. C. Perioperative fluid therapy 4. Intraoperative fluid replacement • Maintenance + preexisting dehydration + intraop loss • Minimal bleeding & water loss  maintenance solution • 그 외 모든 수술  lactated Ringer’s solution a. 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

19. C. Perioperative fluid therapy 4. Intraoperative fluid replacement Determining transfusion point Allowable blood loss 1. Estimate blood volume 2. preopRBC volume estimation 3. Hematocrit 30%에서의 RBCV estimation 4. preopRBCV – 30% RBCV 5. (4.)x3 Other guidelines • RBC 1 unit  increase Hb. 1 g/dL(Hct 2-3%) • RBC 10 mL/kg  increase Hb 3 g/dL(Hct 10%) Ex) 85kg 술전 Hct 35% 총혈액량 85 x 65 = 55225 RBC vol 35% = 5525 x 35% = 1934 RBC vol 30% = 5525 x 30% = 1658 RBC loss at 30% = 276 Allowable blood loss 276 x 3 = 828

20. C. Perioperative fluid therapy 4. Intraoperative fluid replacement b. Replacing redistribution & evaporative losses

21. D. TransfusionCompatibility 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 Coombs test • Emergency transfusion  type O Rh-negative

22. D. TransfusionBlood 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

23. D. Transfusion 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 recipient’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 • Warming failure  hypothermia • Stored RBBC 의 low 2,3-DPG conc. • Hb-Oxygen curve의 Lt shift • Tissue hypoxia

24. D. Transfusion 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

25. D. Transfusion 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.

26. E. Complication of blood transfusionImmune Cx: Hemolytic Reaction 1.Hemolytic reaction - 보통 recipient’s Ab.에 의해 transfused red cell의 specific destruction과 연관됨. Acute : intravascular Delayed : extravascular

27. E. Complication of blood transfusionImmune Cx: Hemolytic Reaction • 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.

28. E. Complication of blood transfusionImmune Cx: Hemolytic Reaction • 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

29. E. Complication of blood transfusionImmune Cx: Hemolytic Reaction 2. 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

30. E. Complication of blood transfusionImmune Cx: Nonhemolytic 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

31. E. Complication of blood transfusionImmune Cx: Nonhemolytic 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

32. E. Complication of blood transfusionInfectious complication • Viral infection • Hepatitis • AIDS • CMV • 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.

33. E. Complication of blood transfusionMassive 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 (rare) • Hepatic disease pt.는 calcium infusion고려

34. E. Complication of blood transfusionMassive transfusion • Complication • Hypothermia • 30°C에 가까워지면 ventricular arrhythmia에서 fibrillation으로 진행이 자주 발생 • Acid-base balance • Acidosis: uncommon • M/c abnormality : postoperative metabolic alkalosis(citrate and lactate가 liver에서 bicarbonate로 converted) • Serum potassium conc. • Stored blood는 시간이 지남에 따라 K+증가 • Hyperkalemia: rate > 100mL/min • Hypokalemia는 postop metabolic alkalosis와 관련

35. F. Alternative strategies for management of blood loss during surgery • Autologous transfusion • 보통 수술 4-5주전 시행 • Hct 최소 34%이상, Hb 11 g/dL이상 되어야 함 • 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