F&E, Blood Products Class (3 per) - 3 PDF

1/22/25 Fluids & Electrolytes Blood Products & Transfusion Kelly Elmore, DNP, APRN-CRNA Mary Baldwin University NAP Advanced Pharmacology for Anesthesiology Practice I 1 Electrolytes & Minerals...

1/22/25 Fluids & Electrolytes Blood Products & Transfusion Kelly Elmore, DNP, APRN-CRNA Mary Baldwin University NAP Advanced Pharmacology for Anesthesiology Practice I 1 Electrolytes & Minerals Se e the Ele ctroly & M ine tes ral s Sp otl igh t!! 2 Sodium Majority in ECF 135 – 145 mEq/L Functions Water movement/balance, control of osmotic pressure Osmolality & volume of ECF Nerve impulse conduction Muscle contraction 3 1  1/22/25 Sodium Intake through diet, IV fluids Homeostasis Some Na loss through sweat, feces Kidneys primary determinant Reabsorbs vast majority of filtered Na RAAS, AD H, SN S (BP, intravascular volum e m anagem ent) Excretion stimulated by parathyroid hormone, natriuretic peptides 4 Sodium Alterations Hyponatremia Hypervolemic cause (eg, CHF, cirrhosis) Hypovolemic cause (eg, diarrhea, vomiting, diuretics) Salt wasting (eg, intracranial injury) Euvolemic cause (eg, adrenal insufficiency, polydipsia) Symptoms __________________________________________________________, confusion, coma N/V Muscle cramps Treatment depends on underlying cause h ttp s ://w w w.o s m o s is.o rg /le a rn /H y p o n a tre m ia 5 Sodium Alterations Hypernatremia Water loss (eg, fever, sweating, osmotic diuresis) Nephrogenic or central diabetes insipidus Excessive Na administration in IV fluids, dietary intake Symptoms Signs of dehydration or fluid excess (depends on cause) Cellular death Altered mental status, seizures, coma Treatment depends on underlying cause h ttp s ://w w w.o s m o s is.o rg /le a rn /H y p e rn a tre m ia 6 2  1/22/25 Potassium Majority intracellular (98%) 3.5 – 5.2 mEq/L Functions Cell membrane excitability (nerves, muscle, heart) Kidney function Endothelial-dependent vasodilator Inhibits thrombus formation, PLT activation Influences osmotic pressure 7 Potassium Homeostasis Kidneys primary determinant Hormones affecting secretion Aldosterone Glucocorticoids Catecholamines Arginine vasopressin ______________________________________________________ decreases K+ secretion ______________________________________________________ increases K+ secretion 8 Potassium Alterations Hypokalemia Diuretics*, beta agonists, insulin, antibiotics, catecholamines GI losses (eg, laxatives, bowel prep) Symptoms Skeletal muscle weakness, muscle cramps, rhabdomyolysis Ileus, N/V, abdominal distension Dysrhythmias Hyperpolarization, increased autom aticity & excitability T w ave inversion, U w ave Tachyarrhythm ias, torsades, AFib 9 3  1/22/25 Potassium Alterations Hypokalemia Treatment Determine cause K+ replacement in the setting of intracellular shifts may cause hyperkalemia PO or IV administration 10 mEq/hr peripheral IV 20 mEq/hr central line Diminished K+ regulation (eg, diabetes, renal failure) à high risk hyperkalemia 10 Potassium Alterations Hyperkalemia K+ redistribution or inhibition of secretion (eg, SCh, digitalis) Aldosterone antagonists, beta antagonists NSAIDs Chemotherapy (cellular lysis) PRBC transfusion Symptoms _________________________________________________________*, QRS widens, prolonged PR Cardiac conduction blockade, decreased automaticity, VF, asystole Paresthesias, skeletal muscle weakness 11 Potassium Alterations h ttp s ://litfl.c o m /h y p e rk a la e m ia -e c g -lib ra ry / 12 4  1/22/25 Potassium Alterations Hyperkalemia treatment Calcium IV Rapid repair of adverse cardiac conduction & contractility effects Does not significantly affect serum K+ concentration Sodium bicarbonate Alkalinization shifts K into cells, promotes secretion 0.5 – 1 mEq/kg IV 13 Potassium Alterations Hyperkalemia treatment Insulin + glucose 10 units insulin + 50 mL D50 Can decrease serum K by 1.5 – 2.5 mEq/L Kayexalate Beta agonists Loop diuretics 14 Magnesium Majority intracellular (bone, muscle, soft tissues) 1.7 – 2.4 mg/dL Ionized, protein-bound, complexed to anions Functions Protein synthesis, nucleic acid stability Neuromuscular function, muscle relaxation Antiarrhythmic Vasodilation Stabilization of BBB, limits cerebral edema Decrease anesthetic requirements 15 5  1/22/25 Magnesium Dietary intake, supplemental administration Homeostasis Kidneys regulate Vast majority reabsorbed by renal tubules Bone stores Mg and buffers plasma levels 16 Magnesium Alterations Hypomagnesemia Dietary deficiency, GI malabsorption (eg, alcoholism, vomiting, laxatives) Renal losses (eg, diuretics, nephropathy) __________________________________________________ binding in massive transfusion Symptoms Prolonged PR & QT, diminished T wave, torsades, arrhythmias Weakness, tetany, fasciculations Convulsions N/V 17 Magnesium Alterations Hypermagnesemia Excessive administration of supplemental Mg Symptoms QRS widens, conduction blockade, asystole HOTN Respiratory depression, muscle paralysis, diminished reflexes Narcosis Treatment ___________________________________________________________________________________________________ Diuretics or dialysis 18 6  1/22/25 Magnesium Administration Preeclampsia Pregnancy disorder of HTN, proteinuria, liver dysfunction Mechanism of action Systemic, vertebral, uterine ____________________________________________________________ Increased concentration of endogenous vasodilators (eg, CGRP) Attenuation of endogenous vasoconstrictors (eg, ET-1) Recommended dose 4 g loading + 1 g/hr IV (24 hrs) Placenta cross Neonatal lethargy, HOTN, respiratory depression 19 Magnesium Administration Dysrhythmias Tx polymorphic wide complex tachycardia, long QT syndrome Tx digoxin-induced tachyarrhythmias Use during CPB/CABG may decrease postop AFib Analgesia Antinociceptive effects, __________________________________________________ Conflicting data on routine analgesic use 20 Magnesium Administration Asthma Bronchodilation via inhibition of calcium, histamine, ACh IV Mg may improve bronchodilation when other therapies fail Pheochromocytoma Pheo patients undergoing tumor excision or catecholamine crisis Arterial smooth muscle relaxation Reduction in catecholamine release 21 7  1/22/25 Calcium More calcium than any other mineral à skeleton (> 99%)! 8.5 – 10.5 mg/dL (4.5 – 5.5 mEq/L) Plasma ionized calcium (51%) Produces physiologic effects Normal 2 – 2.5 mEq/L Dependent on pH à acidosis increases, alkalosis decreases Protein-bound calcium (40%) Albumin binds non-ionized Calcium may shift to storage sites in low albumin states 22 Calcium Functions Musculoskeletal strength, contraction Neuromuscular transmission Cardiac muscle contractility, relaxation, rhythm Vascular motor tone _______________________________________________________________________ Intracellular signaling Homeostasis Endocrine control through vitamin D, parathyroid hormone, calcitonin Regulate intestinal absorption, renal reabsorption, bone turnover Bone as reservoir helps maintain intra- & extracellular concentrations 23 Calcium Alterations Hypocalcemia Decreased albumin, vitamin D Disorders (eg, hypoparathyroidism, pancreatitis, chronic renal failure) Citrate binding in transfusion Symptoms Neuromuscular ___________________________________________ (eg, twitching, spasms, paresthesias, tetany) Seizures Dysrhythmias 24 8  1/22/25 Calcium Alterations Hypocalcemia treatment Calcium chloride 27 mg elemental calcium per mL Extravasation leads to subcutaneous irritation, necrosis, sloughing _________________________________________________________________________________ preferred Calcium gluconate 9 mg elemental calcium per mL Okay to give in peripheral veins Avoid rapid IVP Dose 0.5 – 2 g 25 Calcium Alterations Hypercalcemia Diosrders (eg, hyperparathyroidism*, parathyroid adenoma, malignancies, etc.) Excessive dietary supplementation Medication-induced (eg, diuretics, lithium) Symptoms GI smooth muscle relaxation (N/V, constipation) Decreased neuromuscular transmission (lethargy, hypotonia) Polyuria, dehydration, renal stones Shortened QT 26 Calcium Alterations Hypercalcemia treatment General goal to promote renal excretion of calcium IV fluids __________________________________________________________________________ Corticosteroids inhibit effects of vitamin D Hydrocortisone IV or prednisone PO Biophosphonates, calcitonin, gallium nitrate, mithramycin Hemodialysis for acute, severe, hypercalcemia 27 9  1/22/25 Phosphate Majority intracellular (bone*, soft tissue) 3 – 4.5 mg/dL Functions Energy metabolism Intracellular signaling (eg, cAMP) Immune system regulation Coagulation cascade regulation Buffer for acid-base balance 28 Phosphate Homeostasis Interplay of phosphate and calcium levels Vitamin D, parathyroid hormone (GI absorption), renal reabsorption, bone storage Hypophosphatemia Permits increase in serum calcium Decreased ATP and 2,3-DPG in erythrocytes Profound skeletal muscle weakness, hypoventilation CNS dysfunction Peripheral neuropathy 29 Physiology of Body Fluid Compartments 30 10  1/22/25 h ttp s ://w w w.le c tu rio.c o m /c o n c e p ts /b o d y -flu id -c o m p a rtm e n ts / 31 Body Fluid Compartments Intracellular 2/3 of total body fluid Rich in K*, Mg, Ca, Phos*, proteins Extracellular 1/3 of total body fluid Interstitial ~80% Plasma ~20% Transcellular - anatomically separate (CSF, GI, intraocular) Rich in Na*, Cl* 32 33 11  1/22/25 Plasma Composition 90% water Maintains volume, transports molecules 7 – 8% plasma proteins (albumins, globulins) Oncotic pressure, volume, transportation, pH, coagulation, etc. < 1% salts Osmotic pressure, pH, metabolism ___________________________________________________________________ Cellular respiration, metabolism 34 Plasma Composition Nutrients (lipids, glucose, amino acids) Feeds cells Nitrogenous wastes (uric acid, urea) Products for excretion Other (hormones, vitamins, etc.) Metabolism, regulatory functions Blood cells (red, white, platelets) Transport gases, infection, hemostasis, etc. h ttp s ://w w w.k h a n a c a d e m y.o rg /s c ie n c e /b io lo g y /h u m a n -b io lo g y /c irc u la to ry -p u lm o n a ry /a /c o m p o n e n ts -o f-th e -b lo o d 35 Compartmental Movement Small ions move freely between plasma & interstitium Proteins, large molecules prevented from free movement Vascular endothelial cell tight junctions Endothelial glycocalyx layer h ttp s ://a jp.a m jp a th o l.o rg /a rtic le /S 0 0 0 2 -9 4 4 0 % 2 8 2 0 % 2 9 3 0 0 7 3 -0 /fu llte xt 36 12  1/22/25 Compartmental Movement h ttp s ://w w w.m d p i.c o m /2 0 7 3 -4 4 0 9 /1 0 /1 0 /2 7 1 2 37 Compartmental Movement Inflammatory states Endothelial cell changes Increased number of capillary ___________________________________ Promotes protein, macromolecule movement into interstitial space Albumin movement can double in surgery (~10%), more in sepsis (~20%) h ttp s ://a jp.a m jp a th o l.o rg /a rtic le /S 0 0 0 2 -9 4 4 0 % 2 8 2 0 % 2 9 3 0 0 7 3 -0 /fu llte xt 38 Monitoring Intravascular Volume Status Standard monitors Noninvasive blood pressure Heart rate Invasive or advanced monitors Invasive blood pressure, arterial line CO, SV monitors Central line or pulmonary artery catheter with CVP 39 13  1/22/25 Monitoring Intravascular Volume Status Static parameters Monitoring of these alone may result in hypo or hypervolemia Reductions in tissue perfusion may go unrecognized BP, HR Responses unpredictable SNS & RAAS activation with release of vasoconstrictor hormones which increase BP Beta blockade may mask tachycardic response to hypovolemia CVP May be inadequate surrogate to determine preload, fluid responsiveness, pulmonary edema risk 40 Monitoring Intravascular Volume Status Static parameters Urine output Inhalation anesthetics, surgical stress may reduce UO in euvolemic patients Intraop oliguria (< 0.5 ml/kg/hr) does not predict acute kidney injury Mixed venous O2 saturation Intended to track global O2 delivery Proportional to CO, tissue perfusion & O2 delivery May not accurately reflect tissue perfusion changes when O2 consumption is variable 41 Monitoring Intravascular Volume Status Dynamic parameters Assess fluid responsiveness, guide goal-directed fluid therapy Beneficial in major invasive surgeries, large expected blood losses or fluid shifts Challenges with sensitivity & specificity Interpret with caution à consider entire clinical picture Visual estimation may be adequate (compared to computed indices) 42 14  1/22/25 Monitoring Intravascular Volume Status Dynamic parameters Respiratory variation in arterial waveform Variations in pulse pressure variation, stroke volume variation, systolic BP variation Controlled mechanical ventilation Requires vasomotor tone and cardiac function to remain constant Normal variations with respiration < 10 – 12% Greater than 10 – 12% suggests fluid responsiveness Lower than 10 – 12% suggests better response to ________________________________________ 43 h ttp s ://w w w.u p to d a te.c o m /c o n te n ts /in tra o p e ra tiv e -flu id - m a n a g e m e n t?s e a rc h = a n e s th e s ia % 2 0 flu id % 2 0 re p la c e m e n t& s o u rc e = s e a rc h _ re s u lt& s e le c te d T itle = 1 ~ 1 5 0 & u s a g e _ ty p e = d e fa u lt& d is p la y _ ra n k = 1 44 h ttp s ://w w w.u p to d a te.c o m /c o n te n ts /in tra o p e ra tiv e -flu id - m a n a g e m e n t?s e a rc h = a n e s th e s ia % 2 0 flu id % 2 0 re p la c e m e n t& s o u rc e = s e a rc h _ re s u lt& s e le c te d T itle = 1 ~ 1 5 0 & u s a g e _ ty p e = d e fa u lt& d is p la y _ ra n k = 1 45 15  1/22/25 Monitoring Intravascular Volume Status Limitations to respiratory variation May not be useful during: ____________________________________________________________________________ Low tidal volumes or high PEEP on mechanical vent Open thoracic surgery Elevated intra-abdominal pressure, tamponade, arrhythmias, right heart failure Vasoactive infusions 46 Monitoring Intravascular Volume Status Dynamic parameters End-expiratory occlusion test Use in ventilated patients with arrhythmias, spontaneous ventilation activity, low tidal volumes ___________________________ interruption in ventilation Assess for > 5% increase in pulse pressure or pulse contour CO High sensitivity, specificity h ttp s ://w w w.c n s y s te m s.c o m /te c h n o lo g y /c n a p -c a rd ia c -o u tp u t/ 47 Monitoring Intravascular Volume Status Dynamic parameters Ultrasound technologies Esophageal doppler: measure flow velocity in descending aorta to estimate SV Echocardiography: quick estimation of chamber size & function, intravascular volume status 48 16  1/22/25 Monitoring Intravascular Volume Status Dynamic parameters Noninvasive technologies Pleth variability index, pulse wave analysis, CO2 rebreathing, etc. Measure CO & assess fluid responsiveness May have significant CO measurement errors 49 Monitoring Intravascular Volume Status Dynamic parameters Lab values __________________________________________________ levels (> 1 – 2 mmol/L) or lactic acidosis Assessed on serial ABG intraop Indicator of reduced global tissue perfusion May not reflect acute changes 50 MemoryMaster Knowledge Check What is the total body water of a 70-kg adult? What percentage is extracellular vs intracellular? What are signs & symptoms of hyponatremia? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 51 17  1/22/25 MemoryMaster Knowledge Check What are the treatment options for hyperkalemia? Which of the above is the fastest way to correct hyperkalemia? Why is dextrose given with insulin for hyperkalemia? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 52 MemoryMaster Knowledge Check How does serum K+ change in acute acidosis and alkalosis? What are some of the physiologic functions of calcium? What are the neuromuscular effects of hypocalcemia? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 53 MemoryMaster Knowledge Check What major side effects accompany a serum Mg2+ below 1.2 mg/dL? Like Ca2+, magnesium is a membrane stabilizer. What is it used to treat? How much dextrose is in a 1-liter bag of D5W? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 54 18  1/22/25 MemoryMaster Knowledge Check What major side effects accompany a serum Mg2+ below 1.2 mg/dL? Like Ca2+, magnesium is a membrane stabilizer. What is it used to treat? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 55 Intravenous Fluids 56 Crystalloids Fluid solutions containing water-soluble electrolytes & low molecular weight molecules Lack proteins Classified by tonicity Effective osmolality or ability to alter water movement across cell membranes Isotonic = same osmolality (electrolyte, solute concentration) as plasma Hypertonic = greater osmolality Hypotonic = lower osmolality 57 19  1/22/25 Isotonic & ”Balanced” Crystalloids Composition Similar Na concentration as ECF Effective osmolality like the patient (270 – 310 mOsm/L) Contains various levels of other electrolytes (K, Mg, Cl, Mg) Contains organic anions (eg, lactate, gluconate, acetate) Contributes to strong ion difference (SID) Used to treat ECF deficits, administration of drugs and blood products Examples: 0.9% NaCl, Lactated Ringers, Plasmalyte, Normosol-R h ttp s ://w w w.le c tu rio.c o m /c o n c e p ts /in tra v e n o u s -flu id s / 58 Strong Ion Difference Difference between completely dissociated cations and anions in plasma “Apparent” SID = (Na + K + Ca + Mg) – (Cl – lactate) Normal ~40 mEq/L Not all strong anions can be measured Affects pH following metabolism of most organic anions Increases in SID, increase pH Decreases in SID, decrease pH Lactic acidosis or hyperchlorem ic m etabolic acidosis (excessive 0.9% N S infusion) “Effective” SID also takes into account bicarb and the anion equivalent of albumin & phosphate 59 Isotonic Crystalloid Volume Kinetics Variable distribution influenced by: Physiological status Degree of dehydration Surgery & anesthesia Changes in vascular permeability, oncotic/osmotic pressures, extracellular matrix Healthy patients… Volume of distribution approximates relative size of intravascular & interstitial compartments 20 – 25% remains intravascular Nearly 50% of infused volume (and effect) can be lost in ~30 min. 60 20  1/22/25 Hypotonic Crystalloids Lower effective osmolality than the patient _______________________________________________________ of the ECF H2O will redistribute into the intracellular compartment Used as maintenance fluids, treat solute-free water deficits, administration of drugs Examples: 0.45% NaCl, 5% Dextrose in water, Plasma-Lyte 56 (5% dex) h ttp s ://w w w.le c tu rio.c o m /c o n c e p ts /in tra v e n o u s -flu id s / 61 Hypertonic Crystalloids Greater effective osmolality than the patient ______________________________________________________ of the ECF H2O will redistribute out of the intracellular compartment Used to target a desired solute concentration (eg, sodium) or to promote fluid redistribution Examples: Dextrose 5% in NS, 3 – 7.5% Saline h ttp s ://w w w.le c tu rio.c o m /c o n c e p ts /in tra v e n o u s -flu id s / 62 Crystalloids 63 21  1/22/25 Perioperative Crystalloid Administration Indication: replace water & electrolyte losses in the fasting patient Liberal vs. restrictive ASA recommends ”moderately liberal” administration Goal overall positive fluid balance __________________________________ at end of surgery Minimize preoperative fasting time Hemodynamic monitoring to guide fluid volume resuscitation 64 Perioperative Crystalloid Administration NS vs. Balanced crystalloid Mixed results on renal dysfunction and mortality Balanced crystalloid favored over NS for resuscitation Normal saline Large volumes risk hyperchloremic metabolic acidosis Balanced salt solutions Large volumes risk hyperlactatemia, metabolic alkalosis, hypotonicity Ca2+ containing solutions risk microthrombi formation when infused with citrate-containing blood products 65 Colloids Fluid solutions containing large molecular weight particles suspended in a crystalloid solution Contains macromolecules such as plant or animal polypeptides (proteins), starches Categorized by natural vs. synthetic Natural Whole blood, plasma, concentrated albumin solutions Semisynthetic/synthetic Gelatins, hydroxyethyl starch (HES) solutions, dextrans, polysaccharides 66 22  1/22/25 Albumin (5, 25%) Produced from human blood, suspended in saline Increases serum albumin and colloid osmotic pressure More expensive compared to semisynthetic colloids & crystalloids Pasteurized to reduce risk of __________________________________________________________ Anaphylactoid reactions rare Clinical trials show mixed results regarding morbidity/mortality related to albumin vs crystalloid 67 Hydroxyethyl Starches Variety of solutions with different concentrations, molecular weights, crystalloid carriers Affects osmotic pressure, half-life, coagulation effects Chemical alteration of starches such as maize or potatoes Black box warning Critically ill, sepsis patients Renal dysfunction or signs of renal injury after HES infusion Open heart surgery with CPB Signs of coagulopathy after HES infusion 68 HES Pharmacokinetics Dose Max 20 – 50 ml/kg/day Varies based on solution and ability to hydrolyze starches Redistribution Leaves plasma Temporary storage in skin, liver, kidneys Trace amounts of HES detectable up to 6 months later 69 23  1/22/25 HES Pharmacokinetics Renal excretion Immediate glomerular filtration of smaller molecular weight polymers __________________________________________ of larger molecules following metabolism Hydrolysis in the plasma by alpha-amylase Hydroxyethyl groups can slow the process of hydrolysis Prolonged circulation in plasma 70 HES Pharmacokinetics Adverse effects Decreases factor VIII, von Willebrand factor ___________________________________________________________________ Impaired renal function (renal injury) Anaphylactoid reactions rare 71 © 2 0 2 3 U p T o D a te , In c. a n d /o r its a ffilia te s. A ll R ig h ts R e s e r v e d. C o p y rig h ts a p p ly 72 24  1/22/25 Choosing Intraoperative IV Fluids Crystalloids Routine perioperative fluid administration Replacement of sensible & insensible fluid losses May be used to replace blood loss until transfusion thresholds meet Optimize intravascular volume in volume responsive ___________________________________________________________ solutions generally preferred NS may be used in renal patients Avoid large volume NS Dextrose-containing solutions generally avoided d/t hyperglycemia risks 73 Choosing Intraoperative IV Fluids Colloids Used to expand microvascular volume with minimal capillary leakage in fluid responsive May be used to replace blood loss until transfusion thresholds meet Preferable in patients with ________________________________________________________ Minimizes quantity of administered fluid Reduced edema risks Minimal evidence that administration of colloids superior to balanced crystalloid $$ 74 Intraoperative Fluid Management Hypovolemia Preoperative factors increase risk of significant HOTN during induction Fasting Studies investigating overnight N PO did not find significant reductions in intravascular volum e Fasting reduced to avoid dehydration, m orbidity Bowel preparation with GI tract fluid losses Medications such as diuretic use preop Inflammatory disorders or presence of interstitial edema Active hemorrhage 75 25  1/22/25 Intraoperative Fluid Management W hat bolus dose might you start Hypovolemia with to treat Surgical factors hypovolemia? Bleeding Coagulopathy r/t hemodilution, hypothermia Decreases in venous return (positional, abdominal insufflation, compression of vena cava) Positive pressure mechanical ventilation (large TV, high PEEP, lung recruitment) Evaporative, insensible fluid losses from prolonged surgery Decreases cardiac output, tissue perfusion Risks shock, organ ischemia/failure 76 Intraoperative Fluid Management Hypervolemia Excessive volume administration Care when treating hemodynamic instability Surgery factors Treatment of bleeding Excess crystalloid, colloid, PRBCs dilutes coagulation factors à exacerbation of bleeding Patient factors CHF with compensatory fluid retention Renal insufficiency 77 Intraoperative Fluid Management Hypervolemia Anesthesia factors General anesthetics à dose-dependent vasodilation, myocardial depression, HOTN Neuraxial anesthesia sympathetic blockade with overload of IVF Failure to measure and identify appropriate volume infusion to replace surgical losses & maintenance 78 26  1/22/25 Intraoperative Fluid Management Hypervolemia Fluid overload risks Reduced tissue perfusion r/t tissue edema Impaired O2 exchange and respiratory dysfunction GI edema, decreased motility or ileus, ascites __________________________________________________________________ 79 Goal-Directed Fluid Therapy Fluid administration strategy to achieve pre-specified goal Typically based on one or more dynamic parameters ERAS use Major invasive surgery with expected large blood loss and/or fluid shifts Ensures intravascular volume status optimal prior to vasopressors 80 Goal-Directed Fluid Therapy Fluid administration strategy to achieve pre-specified goal Mixed study results on superiority May be beneficial compared to traditional liberal and fixed-volume approaches Example: _____________________________________ crystalloid to support fluid losses and metabolic rate 250 ml boluses crystalloid/colloid for respiratory variations > 10 - 12% 81 27  1/22/25 MemoryMaster Knowledge Check What electrolyte is not found in Normosol & Plasma-Lyte? Which isotonic crystalloid solution does not contain potassium? How much dextrose is in a 1-liter bag of D5W? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 82 MemoryMaster Knowledge Check What are the concentrations of Na, Cl, K, and Ca in lactated Ringer’s? What is the maximum daily dose of hetastarch? What IV fluids are typically used in patients losing large volumes of blood? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 83 Blood Physiology & Transfusion 84 28  1/22/25 Composition of Blood Cells, hematocrit (~45%) RBCs, WBCs, PLTs Plasma (55%) H2O Proteins Nutrients Electrolytes Hormones 85 Function of Blood Homeostasis, defense Transport O2 Nutrients Waste Hormones Heat exchange – core to extremities 86 Blood Cell Sources Bone marrow** Red marrow of sternum, ribs, vertebrae, skull Femur, tibia Primary source as well in pediatrics Liver, spleen Liver key in early fetal development Stem cell proliferation h ttp s ://w w w.o s m o s is.o rg /le a rn /B lo o d _ c o m p o n e n ts 87 29  1/22/25 White Blood Cells Leukocytes Granulocytes Agranulocytes Defense against foreign cells, infection Non-specific and acquired immune responses, inflammation ____________________________________________* h ttp s ://m y.c le v e la n d c lin ic.o rg /h e a lth /b o d y /2 1 8 7 1 -w h ite -b lo o d -c e lls Lymphocytes from lymphatic organs (lymph nodes, thymus) 88 Red Blood Cells Shape flexible Hemoglobin = O2 binding protein Determinant of O 2 carrying capacity Role of erythropoietin Destruction of aged RBCs ___________________________________________________________________________ ~ 4 months Heme breakdown into iron and bilirubin (recycled or excreted) 89 h ttp s ://ib.b io n in ja.c o m.a u /o p tio n s /o p tio n -d -h u m a n -p h y s io lo g y /d 3 -fu n c tio n s -o f-th e -liv e r/e ry th ro c y te -re c y c lin g.h tm l 90 30  1/22/25 Anemia Reduction in RBCs or Hemoglobin Hemorrhage, bone marrow failure, etc. Types Dietary deficiency – folic acid, iron, vitamin B12 Kidney disease, nephrectomy Sickle cell – hemolysis & destruction of RBCs 91 Iron Absorbed in diet from small intestine Increased by vitamin C Bound to transferrin in plasma 80% enters bone marrow à incorporated into new erythrocytes Also incorporated into reticuloendothelial cells in liver, spleen Hemoglobin synthesis* mobilizes release of tissue iron stores Essential component of enzymes necessary for energy transfer Plasma concentration 50 – 150 mcg/dL 92 Iron Deficiency Incidence up to 40% of menstruating females Causes Inadequate dietary intake Increased requirements due to pregnancy or blood loss Interference with GI absorption Iron deficiency anemia Iron supplementation increases rate of erythrocyte production, Hgb concentration Rise within 3 days to 3 weeks PO, IM, IV supplementation 93 31  1/22/25 Agglutination Agglutinogen = an antigen which stimulates formation of agglutinin Agglutinin = antibody or other blood substance that causes particle aggregation Transfusion risk Type A and B antigens Rh factor Agglutination reaction in Rh negative recipient after exposure to agglutinogen-D from Rh positive blood 94 h ttp s ://e n.w ik ip e d ia.o rg /w ik i/B lo o d _ ty p e h ttp s ://w w w.p in te re s t.c o m /p in /8 5 7 0 9 1 9 9 1 3 3 0 7 5 7 5 2 / 95 RBC Storage Biochemical changes as RBCs age Depletion of ATP and 2,3-DPG Shape changes, fragile state impairs flow in microcirculation Promotes ______________________________________________________________________ Risk transfusion related acute lung injury Decreased O2 delivery Increased hemolysis 96 32  1/22/25 RBC Storage Biochemical changes as RBCs age Risk adverse events > 14 – 21 days RBC fragments Impaired NO scavenging Reduced NOS (dysfunctional endothelial cells) ____________________________________________________________ à potassium leak Mixed evidence 97 RBC Transfusion Minimum acceptable hgb is patient-specific Acute anemia à compensatory increase CO, oxygen transport Limited compensation in HF, flow restriction Considerations Intravascular volume Active bleeding (& control) Oxygen carrying capacity needs, signs of ischemia or other risk factors Risks of transfusion 98 One unit PRBCs RBC Transfusion increases H/H by approx. how much? Ensure adequate IV access Dedicated line preferred Large-bore PIV associated with fewer complications Single-lumen, large-bore CVC System checks followed to avoid transfusion errors Filters 170 – 260 micron Removes clots, aggregates Leukoreduction if not performed at time of collection 99 33  1/22/25 RBC Transfusion Refrigeration Kept cold until decision to transfuse Previously thawed blood products should be warmed Use of blood warmer during administration Reduces hypothermia Reduces risk of coagulopathy, adverse events Return Never leave to warm up to room temperature for prolonged periods Blood bank returned products should be noted with non-refrigerated duration 100 RBC Transfusion Compatible fluids _________________________________________ recommended for dilution NS, albumin, plasma often co-administered Isotonic crystalloids have been used without adverse events (eg, LR, Normosol, Plasmalyte) D5 or hypotonic avoided à RBC lysis Administer other blood products (eg, PLTs, cryo) via separate tubing or alone 101 Plasma, Fresh Frozen Plasma Whole blood removal of RBCs, PLTs, coagulation factors, fibrinogen, plasma proteins FFP = plasma frozen within 8 – 24 hours of collection Cryo can be obtained from FFP Can be transfused interchangeably with thawed plasma Should be transfused within 24 hrs once thawed Storage reduces factors __________________________________________________ 102 34  1/22/25 Plasma Transfusion Solvent/detergent-treated Kills some viruses, removes cellular debris, lipid contaminants Indications Replace volume & coagulation factors in massive transfusion Treat or prevent bleeding PTT, PT/INR > 1.5x normal Reverse warfarin anticoagulation Treat coagulation factor abnormalities 103 Plasma Transfusion Dose calculation 10 – 15 ml/kg Achieve ~30% increase in plasma factor concentration Administration Thawed products should be refrigerated, kept cold until decision to transfuse Use of blood warmer Avoid hypothermia Avoid coagulopathy, adverse effects 104 Cryoprecipitate Formed from slow thaw of frozen plasma (1 – 10 ℃) Residual volume refrozen & stored up to 3 years Rich in Fibrinogen (Factor I) Factor VIII Factor XIII Contains other factors Indications Restore fibrinogen depleted from massive hemorrhage or coagulopathy Treat hemophilia A, factor XIII deficiency 105 35  1/22/25 Cryoprecipitate Transfusion Administration Transfuse within ________________________________________________ 1 unit per 10 kg weight Increases FGN ~_____________________________________________________ Minimum FGN level for hemostasis ~100 mg/dl Blood warmer not necessary but preferable in hypothermia Administer PLTs separately 106 Platelets Average life span 8 – 12 days Spleen ~ 33% 150,000 – 400,000/microL Hemostasis Thrombus formation PLT, WBC recruitment 107 Platelet Transfusion Preparations Whole blood pooled, random-donor Single-donor apheresis (4 – 6 pooled units) Leukoreduced (removal of WBCs) Minimizes sensitization & antibody reactions Reduces risk of HLA alloimmunization, platelet refractoriness, transmission of viruses (eg, CMV) Administration Each dose increases ~ ________________________________________________________/microL Stored at 22℃ à risks bacterial growth 108 36  1/22/25 Platelet Transfusion Graft versus host disease Graft’s immune cells recognize the host as foreign and attacks recipient’s cells Graft = transplanted, donated tissue Risk in cancer patients, immunocompromised, pediatric populations Common after bone marrow, stem cell transplant Platelet transfusions with viable WBCs creating inflammatory response Platelets __________________________________________________________ for certain populations, indications 109 Platelet Transfusion Minimum acceptable PLT count may be patient & situation specific Surgical patients generally > 50,000 – 100,000/microL PLT count does not provide information on PLT quality, function Medications, sepsis, malignancy, trauma/injury, eclampsia, CPB, hepatic/renal failure Unknown threshold for prophylactic & therapeutic transfusion Consider prophylactic administration in massive transfusion coagulopathy, closed surgical procedures with high risks associated with hemorrhage 110 Pediatrics 1-2 u/10 kg h ttp s ://a n e s th e s ia.u c s f.e d u /s ite s /a n e s th e s ia.u c s f.e d u /file s /w y s iw y g /p d fs /P e d iR e fC a rd.p d f 111 37  1/22/25 Transfusion Adverse Effects Acute inflammatory response, immunomodulation Allogeneic blood with bioactive substances Immunomodulatory, immunosuppressive effects Febrile reaction Release of inflammatory mediators, neutrophil activation Neutrophil activation Risks ________________________________________________________________ Transfusion-transmissible infections (bacterial, viral, parasitic) 112 Transfusion-Associated Circulatory Overload (TACO) Volume overload r/t blood product transfusion Overloads poor cardiovascular status (eg, HF) Symptoms Acute onset dyspnea, tachypnea HTN Tachycardia HF exacerbation Pulmonary edema Echocardiography à ventricular & valvular dysfunction Brain-type natriuretic peptide elevated 113 Transfusion-Related Acute Lung Injury (TRALI) New acute lung injury within 6 hrs of transfusion Neutrophil and/or endothelial activation in the lungs Pulmonary vascular injury Pulmonary edema Symptoms Acute-onset ________________________________________ (< 90% on RA, PaO 2/FiO 2 < 300 mmHg) Bilateral pulmonary infiltrates No evidence of heart failure, volume overload 114 38  1/22/25 TRALI Related factors Initiating inflammatory event _______________________________________________________________ from stored blood Viral infection Cardiopulmonary bypass Secondary transfusion event triggers further inflammation, injury Other factors Antibody specificity Patient’s underlying condition 115 h ttp s ://w w w.s e m a n tic s c h o la r.o rg /p a p e r/T ra n s fu s io n -a s s o c ia te d -c irc u la to ry -o v e rlo a d -(T A C O )% 3 A -R o u b in ia n -M u rp h y /e a 3 5 b b d 7 5 a 8 5 e 8 7 3 4 7 7 4 4 7 1 1 4 5 1 d 1 7 4 6 4 b c 1 2 f3 2 116 MemoryMaster Knowledge Check Below what approximate Hgb level is transfusion indicated? What electrolyte is present in LR minimizing its usefulness during transfusion? What is the function of citrate in stored blood? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 117 39  1/22/25 MemoryMaster Knowledge Check Which blood product contains the greatest concentration of fibrinogen? What is the threshold for fibrinogen replacement? Which factors are reduced from the storage of plasma? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 118 Massive Transfusion 119 Surgical & Traumatic Hemorrhage Life-threatening, uncontrolled bleeding Massive transfusion coagulopathy Trauma-induced coagulopathy Extensive vascular, tissue injury Endothelial cell damage (endotheliopathy) Loss of vascular regulation, physiologic hemostatic response 120 40  1/22/25 Pathophysiology Coagulopathy Thawed Plasma: Inflammation Restores endothelial tight junctions Vascular permeability Proteins à osmotic maintenance Tissue edema Anti-inflammatory Multi-organ dysfunction Endotheliopathy 121 Associated Pathologic Effects Coagulopathy Depletion or decreased function of clotting factors Depletion or decreased function of platelets Accelerated clot breakdown Lost balance between physiologic anti- and pro-coagulant effects Worsened by hypothermia, acidosis __________________________________________________________________________ Volume resuscitation with crystalloid, colloid, RBCs, cell salvage Blood loss 122 Associated Pathologic Effects Fibrinolysis Excessive in trauma patients – can increase bleeding Hypofibrinogenemia Excess reduction in fibrinogen (~ 80 – 100 mg/dL) Prolongs PT/PTT Not corrected by FFP; use cryoprecipitate, fibrinogen concentrate 123 41  1/22/25 Associated Pathologic Effects _____________________________________________________ from citrate toxicity Hyperkalemia Potassium leakage during RBC blood product storage Risk arrhythmias esp. in ECMO, heart-lung machine use, older blood Hypothermia Chilled units reduce core temperature abruptly Ten units can reduce body temperature ~ 3℃ Use of blood warmer for massive transfusion Risks exacerbation of hemorrhage, arrhythmias, other complications 124 125 Laboratory Monitoring PT/aPTT Coagulopathy during massive transfusion PT à loss of factors, hemodilution No evaluation of bleeding, PLT function, clotting factor interactions TEG/TEM Diagnose, manage coagulopathy Goal-directed management Info on clot formation, strength, and firmness, fibrin polymerization, coagulopathy 126 42  1/22/25 h ttp s ://w w w.u p to d a te.c o m /c o n te n ts /in tra o p e ra tiv e -tra n s fu s io n -a n d - a d m in is tra tio n -o f-c lo ttin g - fa c to rs ?s e a rc h = in tra o p e ra tiv e % 2 0 tra n s fu s io n & s o u rc e = s e a rc h _ re s u lt& s e le c te d T itle = 1 ~ 1 5 0 & u s a g e _ ty p e = d e fa u lt& d is p la y _ ra n k= 1 127 Massive Transfusion > 10 units RBCs in 24 hrs May be associated with higher mortality Indicative of severity of injury Protocol/system to rapidly secure blood products Ideal transfusion ratio? 128 1:1:1 Ratio 1 unit frozen plasma, thawed plasma, or other plasma product Volume ~200 – 300 ml 1 unit apheresis platelets Contains ~ 300 billion PLTs ~25% of normal amount circulating PLTs Only 50% of transfused PLTs typically circulate 1 unit pRBCs Volume ~325 ml 129 43  1/22/25 Coagulopathy Management Plasma Clotting factor replacement Goal: PT < 18, aPTT < 35, ACT > 128 Cryoprecipitate for goal fibrinogen > 180 PLTs PLT replacement (goal: > 150,000) No clear data on threshold for replacement Difficulty assessing function 130 Coagulopathy Management RBCs Critical role in hemostasis RBCs release ADP (activates PLTs) Goal: Hgb > 8 – 10 g/dL Antifibrinolytic agents Preservation of clot formation Indication based on TEG (LY30 value) 131 Coagulopathy Management Hypocalcemia Citrate toxicity Depletes serum free calcium (________________________________________) concentration Risk paresthesias, arrhythmias Higher risk in hepatic dysfunction (underlying disease or ischemia-induced) Calcium chloride vs gluconate Chloride does not require normal liver function 10% calcium chloride – 2 – 5 ml per blood unit 10% calcium gluconate – 10 – 20 ml per blood unit 132 44  1/22/25 Risks of Aggressive Crystalloid Resuscitation Consider complex physiologic relationships in massive hemorrhage Maintenance of cardiac output, O 2-carrying capacity, hemostasis Crystalloid volume expansion Adequate for mild – moderate illness or injury Large volume resuscitation in severe trauma risks: Dilutional coagulopathy Severe edema Lung stiffness Abdominal compartment syndrome 133 Massive Transfusion Uses Trauma Risks highest in Hypotensive, tachycardic Penetrating injury, major fractures Fluid in body cavities Trauma-associated coagulopathy Widely adopted 1:1:1 ratio “Damage control resuscitation” Associated with reduced blood use and mortality Limits crystalloid use 134 Massive Transfusion Uses Liver patients Reduced production normal coagulation factors Dysfunction of vitamin-K dependent factors and fibrinogen Reduced hepatic clearance coagulation factor fragments Often recommend 1:1:1 ratio Consider increased blood volume risks on portal circulation 135 45  1/22/25 Massive Transfusion Uses Cardiac surgery Hemostasis & reversal of anticoagulation after weaning from CPB Reports of improved outcomes (survival, organ function) with 1:1:1 ratio Obstetrics Hypercoagulable state with compensatory increase in fibrinolysis Postpartum hemorrhage* Goal maintenance of fibrinogen _______________________________________________ Expert opinion recommends use of 1:1:1 ratio 136 Postpartum Hemorrhage > 500 ml (vaginal) or > 1000 ml (C-section) with ongoing excessive bleeding “Early” PPH meets or exceeds 1000 ml or symptomatic hypovolemia within 24 hours Potential causes: Uterine atony Placental retention Uterine abnormalities or inversion Lacerations Coagulopathies 137 PPH Management Antifibrinolytics Tranexamic acid 1 gram over 10 – 20 min. Repeat dose after 30 min. if needed Uterotonics Oxytocin – stimulant which increases intracellular calcium for uterine contractions 10 – 40 units IM or IV diluted and infused at a rate “necessary to control atony” Adverse effects include maternal arrhythmias, HTN/HOTN, cerebral edema, convulsions 138 46  1/22/25 PPH Management Uterotonics M ethylergonovine (Methergine - ergot derivative) – potent vasoconstrictor that increases strength & frequency of uterine contraction 0.2 mg IM dose every 2 – 4 hours Alternative if oxytocin, TXA are ineffective Contraindicated in HTN, cardiovascular disease, preeclampsia Carboprost (Hemabate, prostaglandin F2a) – stimulates uterine smooth muscle contraction 250 mcg IM or directly into uterine muscle Adverse effects: nausea, bronchospasm, increased pulmonary vascular resistance 139 Review Multimodal resuscitation Early use of plasma, platelets, RBCs (cross-matched ASAP) Minimize crystalloid Resuscitate for hypotension Active warming Correct acidosis Calcium replacement Tranexamic acid, procoagulants (factor concentrates), drugs to control cause 140 MemoryMaster Knowledge Check When blood type is unknown, what blood type should be transfused? Transfusion of how many units of whole blood is considered massive? Bleeding following massive transfusion of PRBCs and FFP is likely due to what? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 141 47  1/22/25 MemoryMaster Knowledge Check A single unit of platelets increases the count by approximately how much? What symptoms characterize TRALI? What is the approximate volume and hematocrit of one unit of PRBCs? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 142 MemoryMaster Knowledge Check What is the therapeutic action of oxytocin? What are adverse effects of oxytocin? Valley Anesthesia.(2023). Memory Master: Questions and answers for the student nurse anesthetist (33rd ed.). pp.99-101 143 References https://www.openanesthesia.org/keywords/acid-base-balance-strong-ion- difference/#:~:text=Derangements%20that%20increase%20the%20strong,i.e.%20decreased%20SID%20%3 D%20acidosis https://www.uptodate.com/contents/intraoperative-fluid- management?search=anesthesia%20fluid%20replacement&source=search_result&selectedTitle=1~150&usa ge_type=default&display_rank=1 https://www.cnsystems.com/technology/cnap-cardiac-output/ https://journals.lww.com/cjasn/fulltext/2022/04000/in_defense_of_normal_saline__our_perspective.20.aspx Flood et al. (2022). Stoelting’s pharmacology & physiology in anesthetic practice (6th ed.). Wolters Kluwer Health: Philadelphia, PA. https://www.osmosis.org/learn/Hyponatremia https://www.osmosis.org/learn/Hypernatremia 144 48  1/22/25 References https://ib.bioninja.com.au/options/option-d-human-physiology/d3-functions-of-the-liver/erythrocyte- recycling.html https://en.wikipedia.org/wiki/Blood_type https://www.uptodate.com/contents/intraoperative-transfusion-and-administration-of-clotting- factors?search=intraoperative%20transfusion&source=search_result&selectedTitle=1~150&usage_type=defa ult&display_rank=1 https://my.clevelandclinic.org/health/body/21871-white-blood-cells https://www.osmosis.org/learn/Blood_components https://www.semanticscholar.org/paper/Transfusion-associated-circulatory-overload-(TACO)%3A-Roubinian- Murphy/ea35bbd75a85e87347744711451d17464bc12f32 https://www.uptodate.com/contents/massive-blood- transfusion?search=massive%20transfusion%20protocol&source=search_result&selectedTitle=1~113&usage _type=default&display_rank=1 145 References https://www.lecturio.com/concepts/body-fluid-compartments/ https://www.khanacademy.org/science/biology/human-biology/circulatory- pulmonary/a/components-of-the-blood https://link.springer.com/chapter/10.1007/978-3-319-96445-4_2 https://www.mdpi.com/2073-4409/10/10/2712 https://ajp.amjpathol.org/article/S0002-9440%2820%2930073-0/fulltext https://www.cdc.gov/dengue/training/cme/ccm/page70749.html#:~:text=Crystalloid%20sol utions%2C%20which%20contain%20water,of%20electrolytes%20as%20the%20plasma. https://www.lecturio.com/concepts/intravenous-fluids/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044465/ 146 49