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Fluid Resuscitation and Massive Transfusion Lecture Overview
- 1. Fluid Resuscitation and Massive Transfusion Dalhousie Critical Care Lecture Series
- 6. Distribution of Different Fluids
- 11. Content LR NS Normosol Pentaspan Na + 130 154 140 154 K + 4.0 0 5.0 0 Cl - 109 154 98 154 pH 6.7 5.7 7.4 5.4 Buffer Lactate - Acetate/gluconate - osmo 273 308 295 326
- 16. … but no difference in need for renal replacement therapy
- 19. Class I ClassII Class III Class IV Clinical Correlates of Hemorrhage American College of Surgeons, 1989 Blood loss (mL) > 750 750 - 1500 1500 - 2000 > 2000 Blood loss (% total) > 15% 15 - 30% 30 - 40% > 40% Pulse rate < 100 > 100 > 120 > 140 Blood pressure Normal Normal ↓ ↓ Pulse pressure Normal or ↑ ↓ ↓ ↓ Orthostasis Absent Minimal Marked Marked Capillary refill Normal Delayed Delayed Delayed Resp rate 14 - 20 20 - 30 30 - 40 > 34 UO (mL/hr) > 30 20 - 30 5 - 15 < 5 CNS mental status Slight anxiety Mild anxiety Anxious/confused Confused/lethargic CI (L/min) ↓ 0-10% ↓ 20-50% ↓ 50-75% ↓ >75%
- 32. Thrombocytopenia
- 43. Infection Risk (blood products)
Notes de l'éditeur
- Transcellular includes pleural, peritoneal, aqueous humor, sweat, urine, lymph and csf
- i.e. NS 20 % is intravascular vs pentaspan 75-80% intravascular hence the volumes given
- Outcomes were death, number of organ systems failures, time in ICU/hospital, times on mechanical ventilation and days of dialysis Finally, at least for critically ill patients, with the publication of the Saline versus Albumin Evaluation (SAFE) study, we have conclusive evidence that in the short-term albumin is at least as safe as saline for resuscitation [ 14 ]. This large, randomized clinical trial included a heterogeneous population of nearly 7000 critically ill patients requiring intravascular fluid resuscitation. The Australian and New Zealand Intensive Care Society Clinical Trials Group set out to determine the safety of fluid resuscitation with 0.9% normal saline versus 4% human albumin on a number of patient outcomes. There were no significant differences between the groups with respect to 28-day mortality, incidence of organ failure, intensive care unit or hospital length of stay, or duration of mechanical ventilation or renal replacement therapy. These results were achieved in the albumin arm with significantly less fluid administration, in a ratio of 1:1.4 (albumin versus normal saline) over the first 4 days. However, various subgroup analyses did reveal interesting results. There was a trend towards decreased mortality in septic shock patients treated with albumin (relative risk for death, 0.87; 95% CI, 0.74–1.02). Increased mortality in trauma patients (relative risk, 1.36; 95% CI, 0.99–1.86), especially those with traumatic brain injury (relative risk, 1.62; 95% CI, 1.12–2.34), was observed in the albumin treatment group. There was no overall benefit associated with albumin use in the SAFE trial, although albumin use in septic shock patients may confer a survival advantage. Despite this interesting trend, it is worth noting that recent guidelines from the Surviving Sepsis Campaign and numerous professional critical care organizations advocate the equivalence of initial fluid resuscitation with either crystalloids or colloids (natural or artificial) in septic patients [ 15 ]. The biologic plausibility of improved outcome with albumin in sepsis has been examined in various in vitro and animal models, but the physiologic basis of this effect in vivo is not known [ 2 ]. The increased risk of mortality among trauma patients in the SAFE trial confirms a similar finding from a previous systematic review, where trauma patients who received crystalloids had a lower mortality rate than those who received colloids [ 13 ]. Interpretation of results from subgroup analyses requires caution and confirmation from properly designed clinical trials.
- Calcium in LR and magnesium in normosol
- PREVENTION OF FEBRILE TRANSFUSION REACTIONS,PREVENTION OF HLA-ALLOIMMUNIZATION AND PLT REFRACTORINESS,PREVENTION OF LEUKOCYTE-TRANSMITTED INFECTIONS (CMV, EBV, HTLV-1), PREVENTION OF BACTERIAL&PROTOZOAL INFECTIONS
- Hypocalcemia from dilution, binding to citrate and hypomagnesemia from dilution
- ACUTE FEBRILE HEMOLYTIC: The classic presenting triad of fever, flank pain, and red or brown urine (ie, hemoglobinuria) is rarely seen. Fever and chills may be the only manifestations and, in patients under anesthesia or in coma, DIC may be the presenting mode, with oozing of blood from puncture sites and hemoglobinuria.
- i.e. decreased natural killer cell activity, decreased monocyte activity, decreased B cell stimulation, Overload of RES,
- Sequential Organ Failure Assessment (SOFA) score