Fluid Therapy & Transfusions

By: Hisham MF Anwer, MD

Professor of Anaesthesia
Alexandria University
 Intravenous fluids (IVFs)
• Are the most commonly used drugs in
hospitalized patients.

• Intravenous fluids should be treated as any

other drug. (indication and duration of therapy)

• Isotonic saline (normal saline, 0.9% NS) is the

most utilized intravenous solution.
 Main Indications
• fluid resuscitation
• replacement
• maintenance
 Fluid Resuscitation Phases
1. Resuscitation
2. optimization
3. stabilization
4. de-escalation (or evacuation)
 4 D’s of IVF therapy
• drug selection
• dosing
• duration
• de-escalation
 Intravenous Fluids
• The proper use of IVFs in different clinical
scenarios is paramount.
• IVFs differ with regard to their half-life,
intravascular volume expansion, preparation,
and cost.
 Fluids include
• Whole blood
• Blood products
• Colloids
• Crystalloids
• Hypertonic Saline
• Fluids used for parentral nutrition
 Intravenous Fluids:

• Crystalloids
• Colloids
• Blood/blood products and blood
substitutes
 Crystalloids

Combination of water and electrolytes

– Isotonic,
– Hypertonic, or
– Hypotonic
(relative to the plasma)

“Tonicity is effective
osmolality”
 Tonicity - Osmolality
• Tonicity is effective osmolality

• An isotonic solution is a solution with the

same osmolality as body fluids.

• The normal range of plasma osmolarity in

adults is 280-295 mOsm/L.
 Question:

• Why 0.225% NaCl is given in 5% dextrose?

A significantly hypotonic IV solution can lead to lysis of red

blood cells
 Commonly used intravenous solutions
Crystalloid solutions Colloid solutions

Dextrose in water (5% or D5W, 10%) Human Albumin (4%, 5%, 20%, 25%)

Hydroxyethyl starch (HES) (Hetastarch 5%,

Sodium Chloride (NaCl) (0.45%, 0.9%, 3%)
6%)

NaCl and D5 solutions (D5 0.225 NaCl, D5

Dextran 40 and 70
0.45 NaCl, D5 0.9 NaCl),

Ringer’s lactate (LR)

Plasma-Lyte A
The composition of commonly used crystalloid solutions

Calculated
Solution Osmolarity Na+ Cl- K+ Ca2+ Lactate Glucose g/L
mOsm/L

D5W 278 0 0 0 0 0 50

0.9 NaCl 308 154 154 0 0 0 0

0.45 NaCl 154 77 77 0 0 0 0

D5 0.9 NaCl 586 154 154 0 0 0 50

3% NaCl 1026 513 513 0 0 0 0

Ringer’s Lactate 272 130 109 4 3 28 0

Plasma-Lyte A 294 140 98 5 0 * 0

 Composition
Fluid Osmo- Na Cl K
lality
D5W 278 0 0 0
0.9NS 308 154 154 0
LR 273 130 109 4.0
Plasma-lyte 294 140 98 5.0
Hespan 310 154 154 0
5% Albumin 308 145 145 0

3%Saline 1027 513 513 0

• Normal plasma sodium is around 140 mEq/L.
Since plasma is 93% water and 7% protein and
lipids, normal sodium in plasma water is 140/0.93
or approximately 151 mEq/L.
 normal saline
• Isotonic saline (normal saline, 0.9% NS) is the
most utilized intravenous solution.
• pH: 5.6
• One-quarter of the infusate goes intravascularly
• The remaining three-quarters go
into the interstitial space.
 normal saline
• Utilization of a large volume of isotonic saline
may lead to hypervolemia, hypernatremia,
hyperchloremia, metabolic acidosis, and
hypokalemia.
• With prolonged administration of isotonic saline,
other electrolytes such as magnesium, calcium,
and phosphate will need to be replaced.
• The use of balanced intravenous solutions has
been advocated to avoid these complications.
 Dextrose in Water
(5% solution (D5W))

• Its measured osmolarity is 278 mOsm/L

• Provides 170 kcal/L
• Metabolized into water and CO2.
• Its distribution matches the water distribution in
the ECF and intracellular fluid (ICF)
• Used to correct hypernatremia and hypoglycemia.
 Dextrose in Water
(5% solution (D5W))

• A poor choice for fluid resuscitation for

hypotension or hypovolemic shock.
• Avoid in patients with hyponatremia.
• Aggravate ischemic brain injury
 Dextrose 5%

Disadvantages:
-enhance CO2 production
-enhance lactate production
 Dextrose in Water
(10% & 50% solution (D5W))
• Used in the management of severe
hypoglycemia.
 0.45 Saline (0.45% NaCl, Half-Normal Saline)

• Inappropriate for initial resuscitation

• Helpful in the management of hypernatremia
 Ringer’s Lactate (Lactated Ringer, LR)

• A balanced electrolyte solution

• A buffered crystalloid solution
• It contains a buffer (lactate), potassium, and
calcium
• should be used with caution in patients with
hepatic failure
• Isotonic saline is preferred in the management
of hyponatremia, chloride-sensitive metabolic
alkalosis, and in patients with hyperkalemia.
 Crystalloids Advantages
Balanced electrolyte solutions
-

-Buffering capacity (Lactate)

-Easy to administer

-No risk of adverse reactions

-No disturbance of hemostasis

-Promote diuresis

-Inexpensive
 Crystalloids Disadvantages

-Poor plasma volume support

-Large quantities needed

-Risk of Hypothermia

-Reduced plasma COP

-Risk of edema
 The half-life
• The half-life of crystalloid intravenous solutions
is 20-40 minutes in conscious humans.
• In the presence of dehydration or preoperative
stress, such half-life may become 80 minutes or
longer

• Albumin has a half-life of 16-24 hours.

• Hydroxyethyl Starch (HES) has half-life of 50 hours.
 Hypertonic Solutions
• Fluids containing sodium concentrations greater
than normal saline.
• Available in 1.8%, 2.7%, 3%, 5%, 7.5%, 10%
solutions.
• Hyperosmolarity creates a gradient that draws
water out of cells; therefore, cellular dehydration
is a potential problem.
 Hypertonic saline
Advantages:
-Small volume for resuscitation.
-Osmotic effect
-Inotropic effect
-Direct vasodilator effect
-Increase MAP, CO
-Increase renal, mesenteric,splanchnic, coronary blood
flow.
Disadvantages:
increase hemorrhage from open vessels. Hypernatremia
Hyperchloremia. Metabolic acidosis.
 Colloids

• Colloids are large molecules that increase

the plasma oncotic pressure and remain in
the intravascular compartment
• Examples: Human albumin (5%, 20%, and
25%), and hetastarch (6% hydroxyethyl
starch) and dextran.
Crystalloids/Colloids
 Colloids
• Fluids containing molecules sufficiently large
enough to prevent transfer across capillary
membranes.
• Solutions stay in the space into which they are
infused.
• Examples: hetastarch (Hespan), albumin,
dextran.
The composition of commonly used colloid solutions

Calculated
Albumin
Solution Osmolarity Na+ Cl- HES g/L
g/L
mOsm/L

Albumin
308 154 154 50 0
5%

Albumin
308 154 154 250 0
25%

Hetastarch
310 154 154 0 60
6%
 Colloids
Advantages:
--Prolonged plasma volume support
-Moderate volume needed
-minimal risk of tissue edema
-enhances microvascular flow
 Colloids
Disadvantages:
Risk of volume overload
Adverse effect on hemostasis
Adverse effect on renal function
Anaphylactic reaction
Expensive
 Dextran 40 & Dextran 70
• Dextrans are polysaccharides of high molecular
weight.

• rarely associated with anaphylactoid reactions

• Inhibit platelet aggregation
 Human Albumin
• Available : Albumin 5%, 20%, 25% and also 4%
• Human albumin 20%, is a low-salt albumin
(contains 125 mEq of sodium/L vs. 154 mEq sodium/L for other albumin
solutions).

• Essentially remains in the intravascular

compartment
• Has a half-life of 16-24 hours.
 Human Albumin
• Albumin administration results in an oncotic
action attracting 18 ml of water per 1 g of
albumin

• A 100 ml vial of 25% albumin can expand the

intravascular compartment by approximately
450 ml, which is equivalent to 1.8 L of isotonic
saline or LR.
 Human Albumin
• Normally, 12.5-25 g (250-500 ml) of 5%
albumin are given over 30 minutes, while 25 g
(100 ml) of 25% albumin are given over 2
hours.
 Human Albumin
Recommend in:
• Hepatorenal syndrome
• Spontaneous bacterial peritonitis
• Post large-volume paracentesis
• Decompensated cirrhosis

Should be avoided in:

• Traumatic brain injury
 Albumins
 Heat treated preparation of human serum
5% (50g/l), 25% (250g/l)
 Half of infused volume will stay intravascular
 COP=20mmHg=plasma
 25%, COP=70mmHg, it will expand the vascular
space by 4-5 times the volume infused
 25% used only in case of hypoalbuminemia
 Hydroxyethyl Starch (HES)
• A synthetic colloid
• Has been associated with anaphylactoid
reactions
• Osmolarity around 310 mOsm/L
• A long half-life of 50 hours.
• Its maximum volume expansion is 100-200%
 Hetastarch 6%

Composition: synthetic colloid, 6% preparation in

isotonic saline MW 240,000 D- DS 0.7
Advantages: low cost, more potent than 5% albumin
(COP 30)

Disadvantages: Hyperamylesemia, allergy,

coagulopathy
Dose: 15-30ml/kg/day
The US Food and Drug Administration (FDA) warned
against the use of HES in critically ill patients due to
an increased risk of AKI and death.
 Pentastarch 10%

-MW: 200,000 D- DS 0.5

-Low cost
-Extensive clinical use in sepsis, burns..
-Low permeability index
-Good clinical safety
-Decreases PMN-EC activation
-Potential to diminish vascular permeability and
reduces
tissue edema
 Crystalloids OR Colloids
replace each ml of blood loss with 3 ml of
crystalloid fluid. 3 for 1 rule.
 Crystalloids vs Colloids

Crystalloids Colloids
Hemod Stability Transient Prolong
Infusate volume Large Moderate
Plasma COP Reduced Maintain
Tissue edema Obvious Insignific
Anaphylaxis Non-exist low-mod
Cost Inexpensive Expensive
 Clinical Evaluation of Fluid
Replacement
1. Urine Output: at least 1.0 ml/kg/hr
2. Vital Signs: BP and HR normal (How is the patient
doing?)
3. Physical Assessment: Skin and mucous
membranes no dry; no thirst in an awake patient
4. Invasive monitoring; CVP or PCWP may be used as
a guide
5. Laboratory tests: periodic monitoring of
hemoglobin and hematocrit
 Proper choice for fluid resuscitation
• Isotonic saline or Ringer’s lactate (lactated Ringer, LR) is
usually the first choice in patients with volume depletion
who are normo-natremic.
• Patients who are volume-depleted and hypernatremic
are given hypotonic solutions such as half-normal saline
(0.45% NS) or 5% dextrose in water (D5W).
• Hypotensive patients are resuscitated with isotonic saline
or LR irrespective of their sodium, then they are changed
to hypotonic solutions once extracellular fluid (ECF)
volume is restored and blood pressure (BP) is normalized.
 Proper choice
• The use of a large volume of isotonic saline in
the resuscitation of critically ill patients should
be avoided unless there is a clear indication
such as chloride-sensitive metabolic alkalosis
or hyponatremia.
 Proper choice
• balanced intravenous solutions in the
resuscitation of ED, and critically ill patients
especially with sepsis may prevent or mitigate
AKI.
 Proper choice

• HES preparations should be avoided in

critically ill patients due to increased mortality
and incidence of AKI.
• Isotonic albumin is safe for the resuscitation
but should be avoided in patients with
traumatic brain injury.
 Transfusion Therapy

- 60% of transfusions occur perioperatively.

- responsibility of transfusing perioperatively is
with the anesthesiologist.
 Blood Transfusion
Why?
-Improvement of oxygen transport
-Restoration of red cell mass
-Correction of bleeding caused by platelet
dysfunction
-Correction of bleeding caused by factor
deficiencies
(up to 30% of blood volume can be treated with crystalloids)
 Blood Components
• Prepared from Whole blood collection
• Whole blood is separated by differential
centrifugation
– Red Blood Cells (RBC’s)
– Platelets
– Plasma
• Cryoprecipitate
• Others
• Others include Plasma proteins—IVIg, Coagulation
Factors, albumin, Anti-D, Growth Factors, Colloid
volume expanders
 Whole Blood
• Storage
– 4° for up to 35 days
• Indications
– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations
– Use filter as platelets and coagulation factors will not be
active after 3-5 days
– Donor and recipient must be ABO identical
 Component Therapy
• A unit of whole blood is divided into components; Allows
prolonged storage and specific treatment of underlying
problem with increased efficiency:
- packed red blood cells (pRBC’s)
- platelet concentrate
- fresh frozen plasma (contains all clotting factors)
- cryoprecipitate (contains factors VIII and fibrinogen; used in
Von Willebrand’s disease)
- albumin
- plasma protein fraction
- leukocyte poor blood
- factor VIII
- antibody concentrates
 Packed Red Blood Cells

• 1 unit = 250 ml. Hct. = 70-80%.

• 1 unit pRBC’s raises Hgb 1 gm/dL.
• Mixed with saline: LR has Calcium which
may cause clotting if mixed with pRBC’s.
 Packed Red Blood Cells
• Are prepared from whole blood by removing
approximately 250 mL of plasma.
• One unit of packed RBCs should increase levels of
hemoglobin by 1 g per dL and hematocrit by 3
percent.
• In most areas, packed RBC units are filtered to
reduce leukocytes before storage, which limits
febrile nonhemolytic transfusion reactions
(FNHTRs), and are considered cytomegalovirus safe
 Red blood cell transfusions
• Red blood cell transfusions are used to treat
hemorrhage and to improve oxygen delivery
to tissues.
• Transfusion of red blood cells should be based
on the patient's clinical condition.
 Indications for transfusion include
• symptomatic anemia (causing shortness of
breath, dizziness, congestive heart failure, and
decreased exercise tolerance)
• acute sickle cell crisis
• acute blood loss of more than 1,500 mL or
30% of blood volume.
 Indications for transfusion include
• Patients with symptomatic anemia should be
transfused if they cannot function without
treating the anemia. Symptoms of anemia
may include fatigue, weakness, dizziness,
reduced exercise tolerance, shortness of
breath, changes in mental status, muscle
cramps, and angina or severe congestive heart
failure.
 until the 1980s
• The 10/30 rule—transfusion when a patient
has a hemoglobin level less than or equal to
10 g per dL (100 g per L) and a hematocrit
level less than or equal to 30 percent—was
used as the trigger to transfuse, regardless of
the patient's clinical presentation
 transfusion strategy
• The threshold for transfusion of red blood cells
should be a hemoglobin level of 7 g per dL (70
g per L) in adults and most children.

• A restrictive transfusion strategy (hemoglobin

level of 7 to 9 g per dL [70 to 90 g per L]) should
not be used in preterm infants or children with
cyanotic heart disease, severe hypoxemia,
active blood loss, or hemodynamic instability.
 Restrictive transfusion practices
• A recently updated Cochrane review supports
the use of restrictive transfusion triggers in
patients who do not have cardiac disease

• Restrictive transfusion practices resulted in a

54 percent relative decrease in the number of
units transfused and a reduction in the 30-day
mortality rate.
 RBC Transfusions
Administration
• Dose
– Usual dose of 10 cc/kg infused over 2-4 hours
– Maximum dose 15-20 cc/kg can be given to hemodynamically stable
patient
• Procedure
– May need Premedication (Tylenol and/or Benadryl)
– Filter use—routinely leukodepleted
– Monitoring—VS q 15 minutes, clinical status
– Do NOT mix with medications
• Complications
– Rapid infusion may result in Pulmonary edema
– Transfusion Reaction
 Platelet Concentrate
• Storage
– Up to 5 days at 20-24°
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations
– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by 50,000
– Donor and Recipient must be ABO identical
 Platelet transfusion
• Platelet transfusion is indicated to prevent
hemorrhage in patients with
thrombocytopenia or platelet function
defects.
• Platelets should not be transfused in patients
with thrombotic thrombocytopenic purpura or
heparin-induced thrombocytopenia unless a
life-threatening hemorrhage has occurred.
(can result in further thrombosis)
 Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml)
• Storage
– FFP--12 months at –18 degrees or colder
• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion
• Considerations
– Plasma should be recipient RBC ABO compatible
– In children, should also be Rh compatible
– Usual dose is 20 cc/kg to raise coagulation factors approx 20%
• Fresh frozen plasma infusion can be used for
reversal of anticoagulant effects.
• Cryoprecipitate is used in cases of
hypofibrinogenemia, which most often occurs
in the setting of massive hemorrhage or
consumptive coagulopathy.
 Plasma Transfusion
• Transfusion of plasma should be considered in
a patient who has an International Normalized
Ratio (INR) greater than 1.6 with active
bleeding, or in a patient receiving
anticoagulant therapy before an invasive
procedure.
 Not an indication
• Plasma is often inappropriately transfused for
correction of a high INR when there is no
bleeding.

• Supportive care can decrease high-normal to

slightly elevated INRs (1.3 to 1.6) without
transfusion of plasma.
 Cryoprecipitate
• Prepared by thawing fresh frozen plasma and
collecting the precipitate.
• Contains high concentrations of factor VIII and
fibrinogen
• Used in cases of hypofibrinogenemia, which
most often occurs in the setting of massive
hemorrhage or consumptive coagulopathy
 Cryoprecipitate
• Each unit will raise the fibrinogen level by 5 to
10 mg per dL, with the goal of maintaining a
fibrinogen level of at least 100 mg per dL

• The usual dose in adults is 10 units of pooled

cryoprecipitate
 Transfusion Complications
• Acute Transfusion Reactions (ATR’s)
• Chronic Transfusion Reactions
• Transfusion related infections
 Transfusion Complications
• Transfusion-related complications can be
categorized as acute or delayed, which can be
divided further into the categories of
noninfectious and infectious
 Transfusion-related complications

• Acute complications occur within minutes to

24 hours of the transfusion

• Delayed complications may develop days,

months, or even years later.
 Transfusion-related complications

• Transfusion-related infections are less

common than noninfectious complications.

• All noninfectious complications of transfusion

are classified as noninfectious serious hazards
of transfusion.
• Transfusion-related infections are less
common because of advances in the blood
screening process

• The risk of contracting an infection from

transfusion has decreased 10,000-fold since
the 1980s.

• Noninfectious serious hazards of transfusion

are up to 1,000 times more likely than an
infectious complication.
 noninfectious serious hazards

• However, there has been no progress in

preventing noninfectious serious hazards of
transfusion
 Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• Transf Related Acute Lung Injury
• Coagulopathy with Massive transfusions
• Bacteremia
 ACUTE HEMOLYTIC REACTIONS
• Caused by immune destruction of transfused
RBCs, which are attacked by the recipient's
antibodies.
• The incidence of acute hemolytic reactions is
approximately one to five per 50,000
transfusions
• Two categories: acute and delayed.
 Nonimmune acute reactions
• Include bacterial overgrowth, improper
storing, infusion with incompatible
medications, and infusion of blood through
lines containing hypotonic solutions or small-
bore intravenous tubes.
Acute Hemolytic Transfusion Reactions
• There is a destruction of the donor's RBCs within
24 hours of transfusion
• Hemolysis may be intravascular or extravascular.
• The most common type is extravascular
hemolysis, which occurs when donor RBCs
coated with immunoglobulin G (IgG) or
complement are attacked in the liver or spleen
• Intravascular hemolysis is a severe form of
hemolysis caused by ABO antibodies
 Symptoms of acute hemolytic transfusion
reactions
• Fever, chills, rigors, nausea, vomiting, dyspnea,
hypotension, diffuse bleeding, hemoglobinuria,
oliguria, anuria, pain at the infusion site; and
chest, back, and abdominal pain.
• Associated complications are clinically significant
anemia, acute or exacerbated renal failure,
disseminated intravascular coagulation, need for
dialysis, and death secondary to complications.
 ALLERGIC REACTIONS
• From mild (urticarial) to life threatening
(anaphylactic).
• To the soluble antigens in the donor unit
• dose-dependent
• occur in 1 to 3 percent of transfusions
• anaphylactic reactions: hives, hypotension,
bronchospasm, stridor, and gastrointestinal
symptoms
• anaphylactic reactions are estimated to occur in one
in 20,000 to 50,000 transfusions.
TRANSFUSION-RELATED ACUTE LUNG INJURY

• Is noncardiogenic pulmonary edema causing

acute hypoxemia that occurs within six hours
of a transfusion
• recipient's immune system is activated,
resulting in massive pulmonary edema.
• TRALI was the leading cause of transfusion-
related mortality, contributing to 50.7% of
transfusion-related deaths.
 FEBRILE NONHEMOLYTIC TRANSFUSION
REACTIONS
• Defined as a rise in body temperature of at
least 1.8°F (1°C) above 98.6°F (37°C) within 24
hours after a transfusion
• May involve rigors, chills, and discomfort
• occurs more often in patients who have been
transfused repeatedly and in patients who
have been pregnant
 FEBRILE NONHEMOLYTIC TRANSFUSION
REACTIONS
• Leukoreduction, which is the removal or
filtration of white blood cells from donor
blood, has decreased FNHTR rates
• Caused by platelet transfusions more often
than RBC transfusions
• Incidence that ranges from less than 1 percent
to more than 35 percent.
TRANSFUSION-ASSOCIATED CIRCULATORY
OVERLOAD
• The result of a rapid transfusion of a blood
volume
• At highest risk: recipients with underlying
cardiopulmonary compromise, renal failure, or
chronic anemia, and infants or older patients.
Signs and symptoms of TA Cir Overload
• include tachycardia, cough, dyspnea,
hypertension, elevated central venous
pressure, elevated pulmonary wedge
pressure, and widened pulse pressure
• Cardiomegaly and pulmonary edema are often
seen on chest radiography
• The treatment is diuresis
 Delayed Transfusion Reactions
TRANSFUSION-ASSOCIATED GRAFT-VERSUS-
HOST DISEASE
• An immune attack against the recipient's
tissues
• It is fatal in more than 90 percent of cases.
• Patients vulnerable to this condition are those
who are immunocompromised
• Symptoms include rash, fever, diarrhea, liver
dysfunction, and pancytopenia occurring one
to six weeks after transfusion.
Complications of Blood Therapy (cont.)

• Hemolytic:
- Wrong blood type administered (oops).
- Activation of complement system leads to intravascular
hemolysis, spontaneous hemorrhage.
Signs:
hypotension,
fever, chills
dyspnea, skin flushing,
substernal pain , Back/abdominal pain
Oliguria Dark urine Pallor
Complications of Blood Therapy (cont.)
Signs are easily masked by general anesthesia.
- Free Hgb in plasma or urine
- Acute renal failure
- Disseminated Intravascular Coagulation (DIC)
Complications of Blood Therapy (cont.)
Signs are easily masked by general anesthesia.
- Free Hgb in plasma or urine
- Acute renal failure
- Disseminated Intravascular Coagulation (DIC)
 Complications (cont.)
• Transmission of Viral Diseases:
- Hepatitis C; 1:30,000 per unit
- Hepatitis B; 1:200,000 per unit
- HIV; 1:450,000-1:600,000 per unit
- 22 day window for HIV infection and test
detection
- CMV may be the most common agent transmitted,
but only effects immuno-compromised patients
- Parasitic and bacterial transmission very low
 Other Complications
- Decreased 2,3-DPG with storage: ? Significance
- Citrate: metabolism to bicarbonate; Calcium
binding
- Microaggregates (platelets, leukocytes): micropore
filters controversial
- Hypothermia: warmers used to prevent
- Coagulation disorders: massive transfusion (>10
units) may lead to dilution of platelets and factor V
and VIII.
- DIC: uncontrolled activation of coagulation system
 Treatment of Acute Hemolytic
Reactions

• Immediate discontinuation of blood

products and send blood bags to lab.
• Maintenance of urine output with
crystalloid infusions
• Administration of mannitol or Furosemide
for diuretic effect
 Massive Transfusion (MT)
an important life-saving intervention for patients with massive acute blood loss.

Definition:
Transfusion of at least one blood volume or 10 units of
packed red blood cells (PRBCs) in a 24 hr period
Surgery is the most common use of major transfusion
protocols (MTPs)
3% to 5% of civilian trauma patients and 10% of
military trauma patients will receive a massive
transfusion.

patients requiring massive transfusions have a high

mortality.
 mimicking whole blood during massive
transfusion
• packed red blood cells (PRBCs), platelets, and
fresh frozen plasma (FFP),
• experts advocate for a [Link] ratio
• Lower ratios of platelets and FFP have been
used
• tranexamic acid (TXA) can reduce
coagulopathy and increase survival
 Targets of resuscitation in the setting of
massive transfusion
• Mean arterial pressure (MAP) of 60 to 65 mm Hg
• Hemoglobin 7 to 9 g/dL
• INR less than 1.5
• Fibrinogen greater than 1.5 to 2 g/L
• Platelets greater than 50 times 10/L
• pH 7.35 to 7.45
• Core temperature greater than 35 C
 Potential Complications
• metabolic alkalosis from sodium citrate and citric acid
• hypocalcaemia from sodium citrate and citric acid
• Hypothermia stored at 4 C

• hyperkalemia. long-term storage

 Autologous Blood
• Pre-donation of patient’s own blood prior to
elective surgery
• 1 unit donated every 4 days (up to 3 units)
• Last unit donated at least 72 hrs prior to
surgery
• Reduces chance of hemolytic reactions and
transmission of blood-bourne diseases
• Not desirable for compromised patients
Alternatives to Blood Products

• Autotransfusion
• Blood substitutes
 Autotransfusion

• Commonly known as “Cell-saver”

• Allows collection of blood during surgery
for re-administration
• RBC’s centrifuged from plasma
• Effective when > 1000ml are collected
 Blood Substitutes
• Experimental oxygen-carrying solutions:
developed to decrease dependence on human
blood products
• Military battlefield usage initial goal
• Multiple approaches:
- Outdated human Hgb reconstituted in solution
- Genetically engineered/bovine Hgb in solution
- Liposome-encapsulated Hgb
- Perflurocarbons
 Blood Substitutes (cont.)
• Potential Advantages:
- No cross-match requirements
- Long-term shelf storage
- No blood-bourne transmission
- Rapid restoration of oxygen delivery in
traumatized patients
- Easy access to product (available on
ambulances, field hospitals, hospital ships)
 Blood Substitutes (cont.)
• Potential Disadvantages:
- Undesirable hemodynamic effects:
• Mean arterial pressure and pulmonary artery
pressure increases
- Short half-life in bloodstream (24 hrs)
- Still in clinical trials, unproven efficacy
- High cost
 Transfusion Therapy Summary

• Decision to transfuse involves many factors

• Availability of component factors allows
treatment of specific deficiency
• Risks of transfusion must be understood and
explained to patients and patient should be
consented
• Vigilance necessary when transfusing any blood
product
 What to do?
If an AHTR occurs
• STOP TRANSFUSION
• ABC’s
• Maintain IV access and run IVF (NS or LR)
• Monitor and maintain BP/pulse
• Give diuretic
• Obtain blood and urine for transfusion reaction
workup
• Send remaining blood back to Blood Bank
 Monitoring in AHTR
• Monitor patient clinical status and vital signs
• Monitor renal status (BUN, creatinine)
• Monitor coagulation status (DIC panel–
PT/PTT, fibrinogen, D-dimer/FDP, Plt,
Antithrombin-III)
• Monitor for signs of hemolysis (LDH, bili,
haptoglobin)
 Fluid Therapy in Surgical Patient
Goals:
• Normo-volaemia: to normal COP & O2 del
• Normal electrolyte conc.
• Normo-glycaemia.
 Final Goals of Fluid resuscitation
• - Achievement of normovolemia& hemodynamic
stability
• -Correction of major acid-base disturbances
• -Compensation of internal fluid fluxes
• -Maintain an adequate gradient between COP&PCWP
• -Improvement of microvascular blood flow
• -Prevention of cascade system activation
• -Normalization of O2 delivery
• -Prevention of reperfusion cellular injury
• -Achievement of adequate urine output
 Preoperative Evaluation
of Fluid Status
• Factors to Assess:
- h/o intake and output
- blood pressure: supine and standing
- heart rate
- skin turgor
- urinary output
- serum electrolytes/osmolarity
- mental status
 Orthostatic Hypotension
• Systolic blood pressure decrease of greater than
20mmHg from supine to standing

• Indicates fluid deficit of 6-8% body weight

- Heart rate should increase as a compensatory measure
- If no increase in heart rate, may indicate autonomic
dysfunction or antihypertensive drug therapy
Perioperative Fluid Requirements

The following factors must be taken into

account:
1- Maintenance fluid requirements
2- NPO and other deficits: NG suction, bowel
prep
3- Third space losses
4- Replacement of blood loss
5- Special additional losses: diarrhea
1- Maintenance Fluid Requirements
• Insensible losses such as evaporation of water
from respiratory tract, sweat, feces, urinary
excretion. Occurs continually.
• Adults: approximately 1.5 ml/kg/hr
• “4-2-1 Rule”
- 4 ml/kg/hr for the first 10 kg of body weight
- 2 ml/kg/hr for the second 10 kg body weight
- 1 ml/kg/hr subsequent kg body weight
- Extra fluid for fever, tracheotomy, denuded surfaces
 2- NPO and other deficits

• NPO deficit = number of hours NPO x

maintenance fluid requirement.
• Bowel prep may result in up to 1 L fluid loss.
• Measurable fluid losses, e.g. NG suctioning,
vomiting, ostomy output, biliary fistula and
tube.
 3- Third Space Losses

• Isotonic transfer of ECF from functional body

fluid compartments to non-functional
compartments.
• Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient
temperature, room ventilation.
 Functional classification system
• The First space : Intravascular space (within
vessels)
• The Second space: the extravascular space (the
interstitial and intracellular spaces)
• The Third space: does not normally collect in
large amounts
Ex: the peritoneal cavity and pleural cavity.
• Fluid in the second space is physiologically more
active with the intravascular ("first") space than
third space fluid is.

• Fluid in the second space is more readily

available for the body to use (such as for the
correction of ionic imbalances in other
compartments) than fluid in the third space.

• Third space: where any significant fluid

collection is physiologically nonfunctional .
 Third space loss
• Clinically, its actual volume of fluid is difficult to
accurately quantify.
• In long extensive operations is accounted by tissue
edema and evaporation.
• Also can refer to ascites and pleural effusions.
• In severe burns: fluids may pool on the burn site
(lying outside of the interstitial tissue) exposed to
evaporation.
• With pancreatitis or ileus, fluids may "leak out" into
the peritoneal cavity.
 Replacing Third Space Losses

• Superficial surgical trauma: 1-2 ml/kg/hr

• Minimal Surgical Trauma: 3-4 ml/kg/hr
- head and neck, hernia, knee surgery
• Moderate Surgical Trauma: 5-6 ml/kg/hr
- hysterectomy, chest surgery
• Severe surgical trauma: 8-10 ml/kg/hr (or
more)
- AAA repair, nehprectomy
 4- Blood Loss

• Replace 3 cc of crystalloid solution per cc of

blood loss (crystalloid solutions leave the
intravascular space)
• When using blood products or colloids
replace blood loss volume per volume
 5- Other additional losses
• Ongoing fluid losses from other sites:
- gastric drainage
- ostomy output
- diarrhea
• Replace volume per volume with crystalloid
solutions
 Example

• 62 y/o male, 80 kg, for hemicolectomy

• NPO after 2200, surgery at 0800
• 3 hr. procedure, 500 cc blood loss
• What are his estimated intraoperative fluid
requirements?
 Example (cont.)
• Fluid deficit (NPO): 1.5 ml/kg/hr x 10 hrs = 1200
ml total deficit: (Replace 1/2 first hr, 1/4 2nd hr,
1/4 3rd hour).
• Maintenance: 1.5 ml/kg/hr x 3hrs = 360mls
• Third Space Losses: 6 ml/kg/hr x 3 hrs =1440 mls
• Blood Loss: 500ml x 3 = 1500ml
• Total = 1200+360+1440+1500=4500mls
 Summary
• Fluid therapy is critically important during the
perioperative period.
• The most important goal is to maintain
hemodynamic stability and protect vital organs
from hypoperfusion (heart, liver, brain, kidneys).
• All sources of fluid losses must be accounted for.
• Good fluid management goes a long way toward
preventing problems.