Blood Products & TransfusionBlood Products & Transfusion Nutrition in SurgeryNutrition in Surgery

Water & Electrolyte BalanceWater & Electrolyte Balance

Dr.Ramesh ParajuliDr.Ramesh ParajuliMS (ORL-HNS)MS (ORL-HNS)

Chitwan Medical College Teaching Hospital, Bharatpur-10, chitwan, Nepal

Blood Transfusion:Blood Transfusion:

Blood Product :- Any Blood Product :- Any therapeutic substances therapeutic substances prepared from human prepared from human blood blood

Blood & Blood Products:Blood & Blood Products:

1.Whole Blood1.Whole Blood

2.Blood & Plasma 2.Blood & Plasma componentscomponents

3.Plasma Derivatives: 3.Plasma Derivatives: albumin, coagulation albumin, coagulation factors, immunoglobulinfactors, immunoglobulin

Human Blood GroupsHuman Blood Groups

23 human blood group systems23 human blood group systems

eg. ABO,MN, Duffy, Lewis, Kelleg. ABO,MN, Duffy, Lewis, Kell

ABO-most importantABO-most important

RBC Cell surface: A ,B,AB antigensRBC Cell surface: A ,B,AB antigens

Plasma : anti-B, anti-A, anti-A & anti-BPlasma : anti-B, anti-A, anti-A & anti-B

- IgM antibody- IgM antibody

HistoryHistory

1900- Karl Landsteiner discovered A,B,O1900- Karl Landsteiner discovered A,B,O

1902-Decastrello & Sturli discovered AB1902-Decastrello & Sturli discovered AB

1939-Levine & Stetson1939-Levine & Stetson

1940-Landsteiner & Weiner1940-Landsteiner & Weiner Rh system Rh system

Rh SystemRh System

Rh antigens-RBC membraneRh antigens-RBC membrane

About 15% population= Rh About 15% population= Rh NegativeNegative

Rh antibody=IgG antibodyRh antibody=IgG antibody

Anti-Rh antibody= ‘‘rhogam”Anti-Rh antibody= ‘‘rhogam”

Blood GroupingBlood Grouping

1.Before a person gets blood donation1.Before a person gets blood donation

2.Before a person donates blood2.Before a person donates blood

3.Before a person donates an organ for transplantation3.Before a person donates an organ for transplantation

4.Before surgery4.Before surgery

5.Women planning to become pregnant or has first becomes 5.Women planning to become pregnant or has first becomes pregnantpregnant

6.To show whether two people could be blood relatives6.To show whether two people could be blood relatives

7.To check identity of a person suspected of committing 7.To check identity of a person suspected of committing crimecrime

Who can receive blood from whom?Who can receive blood from whom?

Blood Blood groupgroup

AntigensAntigens AntibodieAntibodies s

Can give Can give blood toblood to

Can Can receive receive

blood fromblood from

AA A A anti-Banti-B A & ABA & AB A & OA & O

BB BB anti-Aanti-A B & AB B & AB B & OB & O

ABAB A & BA & B NONENONE ABAB AB,A,B,OAB,A,B,O

OO NONENONE A & BA & B AB,A,B AB,A,B & O& O

OO

Complications & Risks:Complications & Risks:For the Donor:For the Donor:

1.Vasovagal syncope1.Vasovagal syncope

2.Bruise at the needle site2.Bruise at the needle site

3.Hematoma at the needle site3.Hematoma at the needle site

4.Fatigue 4.Fatigue

5.Nausea & vomiting5.Nausea & vomiting

For the Patient:For the Patient:

1.Febrile non hemolytic reaction1.Febrile non hemolytic reaction

2.Vol.overload2.Vol.overload

3.Iron overload3.Iron overload

4.Graft vs host disease4.Graft vs host disease

5.Acute hemolytic reactions5.Acute hemolytic reactions

Donor unit-Donor unit-

Must be refrigerated to prevent bacterial growthMust be refrigerated to prevent bacterial growth

Must begin within 3o min after taking out of Must begin within 3o min after taking out of fridgefridge

Intravenously Intravenously

Personal details of the patients to be matched Personal details of the patients to be matched with the donorwith the donor to prevent transfusion to prevent transfusion reactionsreactions

Contraindications for being a Blood Contraindications for being a Blood DonorDonor

For Recipient SafetyFor Recipient Safety

1.Donor who recently received transfusion1.Donor who recently received transfusion2.Recent pregnancy2.Recent pregnancy3.History of cancer eg. leukemia, lymphoma3.History of cancer eg. leukemia, lymphoma

4.Current infection4.Current infection

For Donor SafetyFor Donor Safety

1.Donors not healthy enough1.Donors not healthy enough2.Nutritional status2.Nutritional status3.Age-17 to 70 yrs3.Age-17 to 70 yrs

Blood products

Platelet components

Red cell components

Plasma components &

derivatives

Apheresis

Red cell Red cell componentscomponents

Plasma Plasma componentscomponents

Plasma Plasma derivativesderivatives

Red cell Red cell concentrateconcentrate

Red cell Red cell suspension (red suspension (red cells + additive cells + additive solution)solution)

Buffy coat Buffy coat depleted red cellsdepleted red cells

Leukocyte-Leukocyte-depleted (filtered) depleted (filtered) red cellsred cells

Fresh frozen Fresh frozen plasmaplasma

Liquid plasmaLiquid plasma

Freeze-dried Freeze-dried plasmaplasma

Cryoprecipitate-Cryoprecipitate-depleted plasmadepleted plasma

Viral-inactivated Viral-inactivated plasmaplasma

CryoprecipitateCryoprecipitate

AlbuminAlbumin

Coagulation Coagulation factorsfactors

ImmunoglobulinImmunoglobulin

Centrifugation at different rpm and duration

PRP FFP Cold room

Definition :Definition : The transfusion of safe blood products to treat a condition The transfusion of safe blood products to treat a condition

leading to significant morbidity or mortality that can’t be leading to significant morbidity or mortality that can’t be prevented or managed effectively by other means.prevented or managed effectively by other means.

-Can save life-Can save life

-Improve health-Improve health

1.Homologous Transfusion1.Homologous Transfusion

2.Autologous Transfusion2.Autologous Transfusion

Blood TransfusionBlood Transfusion

Functions of anticoagulant-Functions of anticoagulant-preservativepreservativesolution in blood collection packsolution in blood collection packSolutionsSolutions FunctionsFunctions

CC Sodium citrateSodium citrate Binds with calcium ions in blood Binds with calcium ions in blood in exchange for the sodium salt in exchange for the sodium salt so the blood does not clotso the blood does not clot

PP PhosphatePhosphate Supports metabolism of the red Supports metabolism of the red cells during storage to ensure cells during storage to ensure they release oxygen readily at they release oxygen readily at tissue leveltissue level

DD DextroseDextrose Maintains the red cell Maintains the red cell membrane to increase storage membrane to increase storage lifelife

AA AdenineAdenine Provides energy sourceProvides energy source

Whole BloodWhole Blood::

1.Sterile, disposable plastic pack1.Sterile, disposable plastic pack

2.Anticoagulant-Preservative:-CPDA2.Anticoagulant-Preservative:-CPDA

3.Volume up to 510ml (63 ml anticoagulant,450ml blood)3.Volume up to 510ml (63 ml anticoagulant,450ml blood)

4.Hb-12gm/dl,Hct-35%4.Hb-12gm/dl,Hct-35%

5.No functional platelets5.No functional platelets

6.No labile coagulation factors (V & VIII)6.No labile coagulation factors (V & VIII)

Whole BloodWhole Blood

Indications Indications – Red cell replacement in acute blood loss with Red cell replacement in acute blood loss with

hypovolemiahypovolemia– Exchange transfusionExchange transfusion– Patients needing red cell transfusions where red Patients needing red cell transfusions where red

cell concentrates or suspensions are not availablecell concentrates or suspensions are not available

Contraindications Contraindications – (Risk of volume overload)– (Risk of volume overload)

– Chronic anemiaChronic anemia– Incipient cardiac failureIncipient cardiac failure

Effects of storage on whole bloodEffects of storage on whole blood

Reduction in the pHReduction in the pH

Rise in plasma potassium concentrationRise in plasma potassium concentration

Progressive reduction in the red cell content of 2,3 Progressive reduction in the red cell content of 2,3 diphosphoglycerate (2,3 DPG) diphosphoglycerate (2,3 DPG)

Loss of all platelet function in whole blood within 48 hours Loss of all platelet function in whole blood within 48 hours of donationof donation

Reduction in Factor VIII to 10–20% of normal within 48 Reduction in Factor VIII to 10–20% of normal within 48 hours of donation. Coagulation factors such as VII and IX hours of donation. Coagulation factors such as VII and IX are relatively stable in storageare relatively stable in storage

Administration Administration – Must be ABO and Rh compatible with the Must be ABO and Rh compatible with the

recipientrecipient– storage:2-6*Cstorage:2-6*C– Use within 35 days Use within 35 days – Transfuse within ½ hrs of removal from Transfuse within ½ hrs of removal from

refrigeratorrefrigerator– Complete transfusion within 4 hrs of Complete transfusion within 4 hrs of

commencementcommencement– Never add medication to a unit of bloodNever add medication to a unit of blood

Advantages:Advantages:

1.Requires only simple & inexpensive single collection pack1.Requires only simple & inexpensive single collection pack

2.Supplies all components & volume2.Supplies all components & volume

Disadvantages:Disadvantages:1.Risk of circulatory overload, transmitting infection1.Risk of circulatory overload, transmitting infection

2.No functional platelet or labile clotting factors2.No functional platelet or labile clotting factors

Production of Whole BloodProduction of Whole Blood

Donor –whole blood-ABO & RhD testingDonor –whole blood-ABO & RhD testing

II

Test for infectious diseases markersTest for infectious diseases markers

II

Negative positiveNegative positive

I II I

Quarentine refrigerator discardQuarentine refrigerator discard

II

releaserelease

II

Blood bank refrigeratorBlood bank refrigeratorcompatibility testcompatibility testcompatiblecompatible pts pts

Red cell Concentrate Red cell Concentrate (Packed Red cells)(Packed Red cells)

Prepared by allowing the blood to Prepared by allowing the blood to separate under gravity in refrigerator at separate under gravity in refrigerator at 2-6*C overnight2-6*C overnight

oror

By centrifugingBy centrifuging

Red Cell ConcentrateRed Cell Concentrate

150-200ml red cells150-200ml red cells

Hb approx. 20gm/dl(not<45gm per unit)Hb approx. 20gm/dl(not<45gm per unit)

Hct 55 -75%Hct 55 -75%

Indications Indications – Replacement of red cells in anemic patientsReplacement of red cells in anemic patients– Use with crystalloid replacement fluids or colloid Use with crystalloid replacement fluids or colloid

solution in acute blood losssolution in acute blood loss

Administration Administration – Same as whole bloodSame as whole blood– To improve transfusion flow, normal saline (50–To improve transfusion flow, normal saline (50–

100 ml) may be added using a Y-pattern infusion 100 ml) may be added using a Y-pattern infusion setset

Advantages:Advantages:

simple, cheapersimple, cheaper

Disadvantages:Disadvantages:

--Increases viscosityIncreases viscosity

-Febrile Non haemolytic Transfusion Reaction-Febrile Non haemolytic Transfusion Reaction

Red cell SuspensionRed cell Suspension

150–200 ml red cells with minimal residual plasma150–200 ml red cells with minimal residual plasma

110 ml normal saline, adenine, glucose, mannitol 110 ml normal saline, adenine, glucose, mannitol solution (SAG-M) or an equivalent red cell nutrient solution (SAG-M) or an equivalent red cell nutrient solution addedsolution added

Hb approximately 15 g/dL (not < 45 g per unit)Hb approximately 15 g/dL (not < 45 g per unit)

Hct – 50–70%Hct – 50–70%

Indications – Same as red cell concentrateIndications – Same as red cell concentrate

Contraindications – exchange transfusion of Contraindications – exchange transfusion of neonatesneonates

Administration Administration – Same as whole bloodSame as whole blood– Better flow rates than red cell concentrate Better flow rates than red cell concentrate

or whole bloodor whole blood

Advantages:Advantages:-Reduces viscosity-Reduces viscosity-Better preservation of the red cells-Better preservation of the red cells-Permits separated use of platelets & plasma-Permits separated use of platelets & plasma

Disadvantages:Disadvantages:-Cost a special blood collection set-Cost a special blood collection set-Expensive equipment (refrigerated centrifuge)-Expensive equipment (refrigerated centrifuge)

Red cell suspension or concentrate containing < 5 x 10Red cell suspension or concentrate containing < 5 x 1066 white cells per packwhite cells per pack

Preparation – filtration through a leucocyte-depleting filterPreparation – filtration through a leucocyte-depleting filter

Leucocyte depletion removes the risk of transmission of Leucocyte depletion removes the risk of transmission of cytomegalovirus (CMV)cytomegalovirus (CMV)

Leucocyte-Depleted (Filtered) Red cells Leucocyte-Depleted (Filtered) Red cells or Whole Bloodor Whole Blood

IndicationsIndications– Minimizes white cell immunization in Minimizes white cell immunization in

patients receiving repeated transfusionpatients receiving repeated transfusion– Reduces risk of CMV transmissionReduces risk of CMV transmission– Patients who have experienced two or Patients who have experienced two or

more previous febrile reactions to red cell more previous febrile reactions to red cell transfusiontransfusion

ContraindicationsContraindications– Will not prevent graft-vs-host diseaseWill not prevent graft-vs-host disease

Advantages:Advantages:

--Decreases development of immunity to Decreases development of immunity to white cellswhite cells

-Decreased transfusion reaction-Decreased transfusion reaction

-Decreases chance of transmitting viral -Decreases chance of transmitting viral infection eg; CMVinfection eg; CMV

Disadvantages:Disadvantages:

--Special instrument & blood pack neededSpecial instrument & blood pack needed

-Skilled & trained operator needed-Skilled & trained operator needed

Buffy Coat Depleted Red CellsBuffy Coat Depleted Red Cells

--White cells & platelets are removed by White cells & platelets are removed by controlled centrifugationcontrolled centrifugation

Advantages:Advantages:

-Red cells & only about 10% of the -Red cells & only about 10% of the white cells remains in concentratewhite cells remains in concentrate

-Use to prepare platelets concentrates-Use to prepare platelets concentrates

DisadvantagesDisadvantages

--Expensive procedureExpensive procedure

-More skilled manpower needed-More skilled manpower needed

Platelet ConcentratesPlatelet Concentrates

Single donor unit in a volume of 50–60 ml of Single donor unit in a volume of 50–60 ml of plasma should contain:plasma should contain:– At least 55 x 10At least 55 x 1099 platelets platelets– <1.2 x 10<1.2 x 1099 red cells red cells– <0.12 x 10<0.12 x 1099 leucocytes leucocytes

Single donor unit : platelets prepared from one Single donor unit : platelets prepared from one donationdonation

Pooled unit : platelets prepared from 4 to 6 donor Pooled unit : platelets prepared from 4 to 6 donor units ‘pooled’ into one pack to contain an adult units ‘pooled’ into one pack to contain an adult dose of at least 240 x 10dose of at least 240 x 1099 platelets platelets

Bacterial contamination affects about 1% of Bacterial contamination affects about 1% of pooled unitspooled units

Indications Indications

Treatment of bleeding due to:Treatment of bleeding due to:ThrombocytopeniaThrombocytopeniaPlatelet function defectsPlatelet function defectsPrevention of bleeding due to Prevention of bleeding due to thrombocytopenia, such as in bone marrow thrombocytopenia, such as in bone marrow failurefailure

Contraindications Contraindications

– Not generally indicated for prophylaxis of Not generally indicated for prophylaxis of bleeding in surgical patients, unless known bleeding in surgical patients, unless known to have significant pre-operative platelet to have significant pre-operative platelet deficiencydeficiency

– Not indicated in:Not indicated in:ITPITPTTPTTPDICDICThrombocytopenia associated with Thrombocytopenia associated with septicemia, until treatment has septicemia, until treatment has commenced or in cases of commenced or in cases of hypersplenismhypersplenism

DosageDosage– 1 unit of platelet concentrate/10 kg body 1 unit of platelet concentrate/10 kg body

weight : in a 60 or 70 kg adult, 4–6 single weight : in a 60 or 70 kg adult, 4–6 single donor units containing at least donor units containing at least 240 x 10240 x 1099 platelets should raise the platelet count by platelets should raise the platelet count by 20–40 x 1020–40 x 1099/L/L

– Increment will be less if there is:Increment will be less if there is:SplenomegalySplenomegalyDICDICSepticemiaSepticemia

Contd.

AdministrationAdministration

-After pooling, platelet concentrates should be -After pooling, platelet concentrates should be infused as infused as

soon as possible generally within 4 hourssoon as possible generally within 4 hours

– Must not be refrigerated before infusion as this Must not be refrigerated before infusion as this reduces platelet functionreduces platelet function

– 4–6 units of platelet concentrates should be 4–6 units of platelet concentrates should be infused through a fresh standard blood infused through a fresh standard blood administration setadministration set

– Special platelet infusion sets are not requiredSpecial platelet infusion sets are not required

– Platelet concentrates should be Platelet concentrates should be infused over about 30 minutesinfused over about 30 minutes

– Platelet concentrates prepared from Platelet concentrates prepared from Rh D positive donors should not be Rh D positive donors should not be given to a Rh D negative potential given to a Rh D negative potential child-bearing femalechild-bearing female

– Platelet concentrates that are ABO Platelet concentrates that are ABO compatible should be given compatible should be given whenever possiblewhenever possible

ComplicationsComplications

– Febrile Non-hemolytic ReactionsFebrile Non-hemolytic Reactions– Allergic Urticarial ReactionsAllergic Urticarial Reactions– Pooling increases transmission of infectionPooling increases transmission of infection

FRESH FROZEN PLASMAFRESH FROZEN PLASMA

Fresh Frozen PlasmaFresh Frozen Plasma

Pack containing the plasma separated from one Pack containing the plasma separated from one whole blood donation within 6 hours of collection and whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colderthen rapidly frozen to –25°C or colder

Contains normal plasma levels of stable Contains normal plasma levels of stable clotting clotting factors, albumin and immunoglobulinfactors, albumin and immunoglobulinFactor VIII level at least 70% of normal fresh plasma Factor VIII level at least 70% of normal fresh plasma levellevel

Usual volume of pack is 200–300 mlUsual volume of pack is 200–300 ml

Smaller volume packs may be available for childrenSmaller volume packs may be available for children

Very low risk of infection if treated with methylene Very low risk of infection if treated with methylene blue/ultraviolet light inactivationblue/ultraviolet light inactivation

IndicationsIndications

– Replacement of multiple coagulation factor Replacement of multiple coagulation factor deficiencies, e.g: -deficiencies, e.g: -

Liver diseaseLiver disease

Warfarin overdoseWarfarin overdose

Depletion of coagulation factors in pts Depletion of coagulation factors in pts receiving large volume transfusionsreceiving large volume transfusions

DICDIC

TTPTTP

Dosage – Dosage – Initial dose of 15 ml/kgInitial dose of 15 ml/kg

AdministrationAdministration --Must normally be ABO compatible to avoid risk of Must normally be ABO compatible to avoid risk of hemolysis in recipienthemolysis in recipient

– No cross matching neededNo cross matching needed– Before use, should be thawed in water which is Before use, should be thawed in water which is

between 30°C and 37°C.between 30°C and 37°C.– Higher temperatures will destroy clotting factors and Higher temperatures will destroy clotting factors and

proteinsproteins– Infuse using a standard blood infusion set as soon Infuse using a standard blood infusion set as soon

as possible after thawingas possible after thawing– Labile coagulation factors rapidly degrade; Labile coagulation factors rapidly degrade; use use

within 6 hours of thawingwithin 6 hours of thawing– Cant be refrozen for further storageCant be refrozen for further storage

CryoprecipitateCryoprecipitate

CryoprecipitateCryoprecipitate

Prepared from FFP by collecting the Prepared from FFP by collecting the precipitate formed during controlled thawing precipitate formed during controlled thawing and re suspending it in 10–20 ml plasmaand re suspending it in 10–20 ml plasma

Contains about half of the Factor VIII and Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. fibrinogen in the donated whole blood: e.g. Factor VIII: 80–100 I.U./pack; fibrinogen: Factor VIII: 80–100 I.U./pack; fibrinogen: 150–300 mg/pack150–300 mg/pack

Usually supplied as a single donor pack or a Usually supplied as a single donor pack or a pack of 6 or more single donor unitspack of 6 or more single donor units

CryoprecipitateCryoprecipitate

IndicationsIndications

– As an alternative to Factor VIII As an alternative to Factor VIII concentrate in the treatment of inherited concentrate in the treatment of inherited deficiencies of:deficiencies of:

Von Willebrand Factor (von Von Willebrand Factor (von Willebrand’s disease)Willebrand’s disease)

Factor VIII (haemophilia A)Factor VIII (haemophilia A)

Factor XIIIFactor XIII

As a source of fibrinogen in acquired As a source of fibrinogen in acquired coagulopathies: e.g. (DIC)coagulopathies: e.g. (DIC)

Factor VIII ConcentrateFactor VIII ConcentratePartially purified Factor VIII prepared from large Partially purified Factor VIII prepared from large pools of donor plasmapools of donor plasma

Vials of freeze-dried protein usually about 250 i.u. Vials of freeze-dried protein usually about 250 i.u. of Factor VIIIof Factor VIII

IndicationsIndications– Treatment of hemophilia ATreatment of hemophilia A– Treatment of von Willebrand’s diseaseTreatment of von Willebrand’s disease

Factor VIII prepared in vitro using recombinant Factor VIII prepared in vitro using recombinant DNA methods is commercially availableDNA methods is commercially available

Human Albumin SolutionsHuman Albumin SolutionsPrepared by fractionation of large pools of donated Prepared by fractionation of large pools of donated human plasmahuman plasma

PreparationsPreparations– Albumin 5%: contains 50 mg/ml of albuminAlbumin 5%: contains 50 mg/ml of albumin– Albumin 20%: contains 200 mg/ml of albuminAlbumin 20%: contains 200 mg/ml of albumin– Albumin 25%: contains 250 mg/ml of albuminAlbumin 25%: contains 250 mg/ml of albumin– Stable plasma protein solution (SPPS) and plasma Stable plasma protein solution (SPPS) and plasma

protein fraction (PPF): similar albumin content to protein fraction (PPF): similar albumin content to albumin 5%albumin 5%

IndicationsIndications– Replacement fluid in therapeutic plasma exchange Replacement fluid in therapeutic plasma exchange

ContraindicationsContraindications - Not for use as IV nutrition - Not for use as IV nutrition

Volume of Blood ProductsVolume of Blood Products

Blood productBlood product VolumeVolume

Whole blood (CPDA-1)Whole blood (CPDA-1) 350 ml350 ml

Whole blood for component Whole blood for component separationseparation

450 ml450 ml

Packed red blood cells (CPD)Packed red blood cells (CPD) 150-200 ml150-200 ml

Packed red blood cells (SAGM)Packed red blood cells (SAGM) 200-250 ml200-250 ml

Fresh frozen plasmaFresh frozen plasma 100-150 ml100-150 ml

Cryo poor plasmaCryo poor plasma 100-150 ml100-150 ml

Platelet rich plasmaPlatelet rich plasma 100-150 ml100-150 ml

Platelet concentratePlatelet concentrate 50-70 ml50-70 ml

CryoprecipitateCryoprecipitate 15-20 ml15-20 ml

Buffy coatBuffy coat 50-70 ml50-70 ml

Component StorageComponent StorageBlood & blood productsBlood & blood products Storage Temp.Storage Temp. Duration Duration

Whole blood (CPDA-1)Whole blood (CPDA-1) 2-62-600CC 35 days35 days

Packed red blood cells (CPD)Packed red blood cells (CPD) 2-62-600CC 28 days28 days

Packed red blood cells (CPDA-Packed red blood cells (CPDA-1)1)

2-62-600CC 35 days35 days

Washed red blood cellsWashed red blood cells 2-62-600CC 24 hrs24 hrs

Packed red blood cells Packed red blood cells (SAGM)(SAGM)

2-62-600CC 42 days42 days

Fresh frozen plasmaFresh frozen plasma -20-2000CC 3-6 mths3-6 mths

Fresh frozen plasmaFresh frozen plasma -30-3000CC 6-12 mths6-12 mths

Cryo poor plasmaCryo poor plasma -30-3000C or lessC or less 6-12 mths6-12 mths

Platelet concentratePlatelet concentrate 22-2422-2400CC 3 days 3 days

CryoprecipitateCryoprecipitate -30-3000CC 6-12 mths6-12 mths

Buffy coatBuffy coat 222200CC 4-6 hrs4-6 hrs

Transfusion ReactionsTransfusion ReactionsAcute complications of transfusionAcute complications of transfusion

Category 1: Mild reactionsCategory 1: Mild reactionsMild hypersensitivity: allergic, urticarial reactionsMild hypersensitivity: allergic, urticarial reactions

Category 2: Moderately severe reactionsCategory 2: Moderately severe reactionsModerate–severe hypersensitivity (severe urticarial reactions)Moderate–severe hypersensitivity (severe urticarial reactions)Febrile non-hemolytic reactions:Febrile non-hemolytic reactions:— — Antibodies to white cells, plateletsAntibodies to white cells, platelets— — Antibodies to proteins, including IgAAntibodies to proteins, including IgAPossible bacterial contamination (early signs)Possible bacterial contamination (early signs)PyrogensPyrogens

Category 3: Life-threatening reactionsCategory 3: Life-threatening reactionsAcute intravascular hemolysisAcute intravascular hemolysisBacterial contamination and septic shockBacterial contamination and septic shockFluid overloadFluid overloadAnaphylactic reactionsAnaphylactic reactionsTransfusion-associated Acute lung injury (TRALI)Transfusion-associated Acute lung injury (TRALI)

Delayed complications of transfusionDelayed complications of transfusion

Transfusion-transmitted infections :Transfusion-transmitted infections :HIV-1 and HIV-2HIV-1 and HIV-2HTLV-I and IIHTLV-I and IIViral hepatitis B and CViral hepatitis B and CSyphilisSyphilisChagas diseaseChagas diseaseMalariaMalariaCytomegalovirusCytomegalovirusOther rare infections: e.g. human parvovirus B19 and Other rare infections: e.g. human parvovirus B19 and

hepatitis Ahepatitis A

Other delayed complications of transfusion :Other delayed complications of transfusion :Delayed hemolytic reactionDelayed hemolytic reactionPost-transfusion PurpuraPost-transfusion PurpuraGraft-vs-host diseaseGraft-vs-host diseaseIron overload Iron overload

Management of Transfusion ReactionsManagement of Transfusion Reactions

CategoryCategory SignsSigns SymptomsSymptomsCategory 1: Category 1: Mild reactionsMild reactions

Localized cutaneousLocalized cutaneousreactions: Urticaria, Rashreactions: Urticaria, Rash

Pruritus (itching)Pruritus (itching)

Category 2: Category 2: Moderately Moderately severe severe reactionsreactions

FlushingFlushingUrticariaUrticariaRigorsRigorsFeverFeverRestlessnessRestlessnessTachycardiaTachycardia

AnxietyAnxietyPruritus (itching)Pruritus (itching)PalpitationsPalpitationsMild dyspnoeaMild dyspnoeaHeadacheHeadache

Category 3: Category 3: Life-Life-threatening threatening reactionsreactions

RigorsRigorsFeverFeverRestlessnessRestlessnessHypotension (fall of ≥20% in Hypotension (fall of ≥20% in SBP)SBP)Tachycardia (rise of ≥20% in HR)Tachycardia (rise of ≥20% in HR)Haemoglobinuria (red urine)Haemoglobinuria (red urine)Unexplained bleeding (DIC)Unexplained bleeding (DIC)

AnxietyAnxietyChest painChest painPain near infusion sitePain near infusion siteRespiratory Respiratory distress/SOBdistress/SOBLoin/back painLoin/back painHeadacheHeadacheDyspnoeaDyspnoea

CATEGORY 1: MILDCATEGORY 1: MILD1.Slow the transfusion1.Slow the transfusion

2.Administer antihistamine IM (e.g. 2.Administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or chlorpheniramine 0.1 mg/kg or equivalent).equivalent).

3.If no clinical improvement within 30 3.If no clinical improvement within 30 minutes or if signs and symptoms minutes or if signs and symptoms worsen, worsen, treat as Category 2.treat as Category 2.

CATEGORY 2: MODERATELY SEVERECATEGORY 2: MODERATELY SEVERE1. Stop the transfusion. Replace the infusion set and keep 1. Stop the transfusion. Replace the infusion set and keep

IV line open with normal salineIV line open with normal saline

2. Notify the doctor and the blood bank immediately.2. Notify the doctor and the blood bank immediately.

3. Send blood unit with infusion set, freshly collected urine 3. Send blood unit with infusion set, freshly collected urine and new blood samples (1 clotted and 1 anticoagulated) and new blood samples (1 clotted and 1 anticoagulated) from vein opposite infusion site to blood bank and from vein opposite infusion site to blood bank and laboratory for investigations.laboratory for investigations.

4. Administer antihistamine IM (e.g. chlorpheniramine 0.1 4. Administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or equivalent) and oral or rectal antipyretic (e.g. mg/kg or equivalent) and oral or rectal antipyretic (e.g. paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid aspirin.aspirin.

5.5. Give IV corticosteroids and bronchodilators if there are Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. bronchospasm, stridor).anaphylactoid features (e.g. bronchospasm, stridor).

6.6. Collect urine for next 24 hours for evidence of Collect urine for next 24 hours for evidence of hemolysis and send to laboratory.hemolysis and send to laboratory.

7.7. If clinical improvement, restart transfusion slowly with If clinical improvement, restart transfusion slowly with new blood unit and observe carefully.new blood unit and observe carefully.

8.8. If no clinical improvement within 15 minutes or if S/S If no clinical improvement within 15 minutes or if S/S worsen, worsen, treat as Category 3.treat as Category 3.

CATEGORY 3: LIFE-THREATENINGCATEGORY 3: LIFE-THREATENING1.1. Stop the transfusion. Replace the infusion set and keep Stop the transfusion. Replace the infusion set and keep

IV line openIV line open

2.2. Infuse NS (initially 20–30 ml/kg) to maintain SBP. If Infuse NS (initially 20–30 ml/kg) to maintain SBP. If hypotensive, give over 5 minutes and elevate patient’s hypotensive, give over 5 minutes and elevate patient’s legs.legs.

3.3. Maintain airway and give high flow oxygen by mask.Maintain airway and give high flow oxygen by mask.

4.4. Give adrenaline (as 1:1000 solution) 0.01 mg/kg body Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by slow intramuscular injection.weight by slow intramuscular injection.

5.5. Give IV corticosteroids and bronchodilators if there are Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. bronchospasm, stridor).anaphylactoid features (e.g. bronchospasm, stridor).

6.6. Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.

7.7. Notify the doctor and the blood bank immediately.Notify the doctor and the blood bank immediately.

8.8. Send blood unit with infusion set, fresh urine sample and Send blood unit with infusion set, fresh urine sample and new blood samples (1 clotted and 1 anticoagulated) from new blood samples (1 clotted and 1 anticoagulated) from vein opposite infusion site to blood bank and laboratory vein opposite infusion site to blood bank and laboratory for investigations.for investigations.

9.9. Check a fresh urine specimen visually for signs of Check a fresh urine specimen visually for signs of haemoglobinuria (red or pink urine)haemoglobinuria (red or pink urine)

10.10. Start a 24-hour urine collection and I/O charting. Maintain Start a 24-hour urine collection and I/O charting. Maintain fluid balance.fluid balance.

11.Assess for bleeding from puncture sites or wounds. If 11.Assess for bleeding from puncture sites or wounds. If there is evidence of DIC, give platelets (adult: 5–6 units) there is evidence of DIC, give platelets (adult: 5–6 units) and either cryoprecipitate (adult: 12 units) or FFP (adult: and either cryoprecipitate (adult: 12 units) or FFP (adult: 3 units). Use virally-inactivated plasma coagulation 3 units). Use virally-inactivated plasma coagulation products, wherever possible.products, wherever possible.

12.12. Reassess. If hypotensive:Reassess. If hypotensive:

Give further saline 20–30 ml/kg over 5 minutesGive further saline 20–30 ml/kg over 5 minutes

Give ionotrope, if availableGive ionotrope, if available

13.13. If urine output falling or laboratory evidence of acute If urine output falling or laboratory evidence of acute renal failure : renal failure :

Maintain fluid balance accuratelyMaintain fluid balance accurately

Give further frusemideGive further frusemide

Consider dopamine infusion, if availableConsider dopamine infusion, if available

Seek expert help: the patient may need renal dialysisSeek expert help: the patient may need renal dialysis

14.14. If bacteremia is suspected, start broad-spectrum If bacteremia is suspected, start broad-spectrum antibiotics IV, to cover pseudomonas and gram antibiotics IV, to cover pseudomonas and gram positives.positives.

Massive Blood TransfusionMassive Blood TransfusionDefined as the replacement of blood loss Defined as the replacement of blood loss equivalent to or greater than the patient’s total equivalent to or greater than the patient’s total blood volume with stored blood in < 24 hours blood volume with stored blood in < 24 hours (70 ml/kg in adults, 80–90 ml/kg in children or (70 ml/kg in adults, 80–90 ml/kg in children or infants)infants)

ComplicationsComplications– AcidosisAcidosis– HyperkalemiaHyperkalemia– Citrate toxicity and hypocalcaemiaCitrate toxicity and hypocalcaemia– Depletion of fibrinogen and coagulation factorsDepletion of fibrinogen and coagulation factors– Depletion of plateletsDepletion of platelets– DICDIC– HypothermiaHypothermia– Reduced 2,3 diphosphoglycerate (2,3 DPG)Reduced 2,3 diphosphoglycerate (2,3 DPG)– MicroaggregatesMicroaggregates

(1)Preoperative Blood Deposit (PAD)(1)Preoperative Blood Deposit (PAD)

(2)Acute Normovolaemic Haemodilution(2)Acute Normovolaemic Haemodilution

(3)Blood salvage(3)Blood salvage– Gauze filtrationGauze filtration– Simple suction collection systemsSimple suction collection systems– Automated suction collection systemsAutomated suction collection systems– Modified drain Modified drain

Autologous Blood TransfusionAutologous Blood Transfusion

Artificial Oxygen CarrierArtificial Oxygen Carrier

(1)Hemoglobin-based Oxygen Carriers (HBOC) (1)Hemoglobin-based Oxygen Carriers (HBOC)

(2)Products based on Perfluorocarbons (PF)(2)Products based on Perfluorocarbons (PF)

AdvantageAdvantage– Can be sterilizedCan be sterilized– Do not have any blood group Do not have any blood group – Could be stored for a long timeCould be stored for a long time

DisadvantageDisadvantage

-Very short half life=around 24 hrs-Very short half life=around 24 hrs

-High flow O2 required-High flow O2 required

Other Methods to Reduce Red Blood Cell Other Methods to Reduce Red Blood Cell TransfusionTransfusion

1.Recombinant Erythropoietin1.Recombinant Erythropoietin

2.Fibrin Glue:2.Fibrin Glue:

11stst Syringe-calcium & human thrombin Syringe-calcium & human thrombin

22ndnd Syringe- human fibrinogen Syringe- human fibrinogen

Injected simultaneously over the minor cutaneous bleeding Injected simultaneously over the minor cutaneous bleeding sitessitesfibrin clot(glue)fibrin clot(glue)hemostasishemostasis

3.Tranexamic acid3.Tranexamic acid

Transfusions of blood products Transfusions of blood products can save lives, but are not without can save lives, but are not without risks or costsrisks or costs

Safe blood is a scarce and Safe blood is a scarce and valuable resource that is valuable resource that is expensive to collect, process and expensive to collect, process and administeradminister

Limiting Transfusion to patientsLimiting Transfusion to patients

whose chance of survival or quality of life is whose chance of survival or quality of life is improved with blood will help to decrease improved with blood will help to decrease the high demand for blood products and the high demand for blood products and will reduce unnecessary exposure of will reduce unnecessary exposure of patients to the risks of transfusion.patients to the risks of transfusion.

Maximum Blood Ordering ScheduleMaximum Blood Ordering Schedule

Elective Surgical ProcedureElective Surgical Procedure

Agreement between Surgeons, Agreement between Surgeons, Anaesthesiologists & HaematologistsAnaesthesiologists & Haematologists

ProcedureProcedure Blood OrderBlood Order

Tumor of palateTumor of palate G & S G & S

LaryngectomyLaryngectomy 2 units2 units

RNDRND 2 units2 units

CommandoCommando 4 units4 units

Getting The Right Blood to the RightGetting The Right Blood to the RightPatient at the Right TimePatient at the Right Time

Nutrition in Nutrition in SurgerySurgery

30% – 50% of hospitalized patients – malnourished30% – 50% of hospitalized patients – malnourished

Malnutrition a/w increased morbidity and mortalityMalnutrition a/w increased morbidity and mortality

Most healthy patients can tolerate 7 days of starvation (with Most healthy patients can tolerate 7 days of starvation (with adequate glucose and fluid replacement)adequate glucose and fluid replacement)

Preoperative nutritional support can significantly reduce Preoperative nutritional support can significantly reduce perioperative morbidity and mortality in patients with severe perioperative morbidity and mortality in patients with severe malnutrition malnutrition

Protein RequirementsProtein Requirements– Avg. healthy adult : approximately Avg. healthy adult : approximately 0.8 g/kg 0.8 g/kg

body weightbody weight– Physiologically stressed : Physiologically stressed : 1.2 – 2.5 g/kg/day1.2 – 2.5 g/kg/day– protein intake of 6.25 g equivalent to 1 g of protein intake of 6.25 g equivalent to 1 g of

nitrogennitrogen– 15% of normal energy expenditure15% of normal energy expenditure– 1 gm of protein = 4 kcal1 gm of protein = 4 kcal

Carbohydrate RequirementsCarbohydrate Requirements– 40-60 % of normal energy expenditure40-60 % of normal energy expenditure– 400 kcal of CHO/day minimizes protein 400 kcal of CHO/day minimizes protein

breakdown, particularly after adaptation to breakdown, particularly after adaptation to starvationstarvation

– 1 gm of Enteral CHO = 4 kcal & 1 gm of Enteral CHO = 4 kcal &

1gm of Parenteral CHO = 3.4 kcal/g1gm of Parenteral CHO = 3.4 kcal/g

Lipid Requirements :Lipid Requirements :– 25% to 45% of normal energy expenditure25% to 45% of normal energy expenditure– 1 gm of lipid = 9 kcal1 gm of lipid = 9 kcal

Daily Vitamins RequirementsDaily Vitamins Requirements

Daily Trace elements RequirementsDaily Trace elements Requirements

The The MetabolicMetabolic Response to Critical Response to Critical IllnessIllness

Nutritional AssessmentNutritional AssessmentHistory History – Weight fluctuation or a change in dietary habitsWeight fluctuation or a change in dietary habits– Recent weight lossRecent weight loss

5% in the last month5% in the last month10% over 6 months10% over 6 monthsCurrent body weight of 80% to 85% (or less) Current body weight of 80% to 85% (or less) of ideal body weightof ideal body weight

Physical ExaminationPhysical Examination– Muscle wasting (especially thenar, temporal & Muscle wasting (especially thenar, temporal &

gluteal muscles)gluteal muscles)– Loose or flabby skinLoose or flabby skin– Peripheral edema and/or ascitesPeripheral edema and/or ascites– Skin rash, pallor, glossitis, gingival lesions, hair Skin rash, pallor, glossitis, gingival lesions, hair

changes, hepatomegaly, neuropathy, and changes, hepatomegaly, neuropathy, and dementia dementia

Anthropometric measurementsAnthropometric measurements– Triceps skinfold thicknessTriceps skinfold thickness– Mid-upper arm circumferenceMid-upper arm circumference– BMIBMI

Laboratory testsLaboratory tests– Serum albumin < 3.5 g/dL Serum albumin < 3.5 g/dL – Half-life is 14 to 20 days.Half-life is 14 to 20 days.– Serum Prealbumin (indicator of acute changes) : Serum Prealbumin (indicator of acute changes) :

10 to 17 mg/dL – mild depletion10 to 17 mg/dL – mild depletion5 to 10 mg/dL – moderate depletion5 to 10 mg/dL – moderate depletion< 5 mg/dL – severe depletion < 5 mg/dL – severe depletion half-life is 2 to 3 days.half-life is 2 to 3 days.

– Serum transferrin < 200 mg/dLSerum transferrin < 200 mg/dLhalf-life is 8 to 10 days.half-life is 8 to 10 days.

Immune FunctionImmune Function– Delayed-type hypersensitivity (anergy Delayed-type hypersensitivity (anergy

to common skin antigens)to common skin antigens)– Total lymphocyte count (TLC)Total lymphocyte count (TLC)

1,500 to 1,800/mm1,500 to 1,800/mm33 – mild – mild depletiondepletion

900 to 1,500/mm900 to 1,500/mm33 – moderate – moderate depletiondepletion

< 900/mm< 900/mm33 – severe depletion – severe depletion

Nutritional IndicesNutritional Indices

Body Mass Index (BMI)Body Mass Index (BMI)BMI = weight (kg)/[height (m)]BMI = weight (kg)/[height (m)]22 BMI: Normal 18.5–24.9BMI: Normal 18.5–24.9 Overweight 25–29.9Overweight 25–29.9 Obese 30–40Obese 30–40 Morbid Obesity >40Morbid Obesity >40Prognostic Nutritional Index (PNI)Prognostic Nutritional Index (PNI)PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)DH: >5 mm induration = 2; 1–5 mm induration = 1; anergy DH: >5 mm induration = 2; 1–5 mm induration = 1; anergy = 0= 0PNI: >50% = high risk for complicationsPNI: >50% = high risk for complications 40%–49% = intermediate risk40%–49% = intermediate risk <40% = low risk<40% = low risk

Alb, albumin (g/dL); DH, delayed cutaneous hypersensitivity; TFN, transferrin (mg/dL); TSF, triceps skinfold thickness (mm); UUN, 24-hr urine urea nitrogen excretion (g)

Estimation of Caloric Estimation of Caloric RequirementsRequirements

TEE = BEE + EEA + EETTEE = BEE + EEA + EET

TEE : Total Daily Energy ExpenditureTEE : Total Daily Energy Expenditure

BEE : Basal Energy ExpenditureBEE : Basal Energy Expenditure

EEA : Energy Expenditure of Activity (25 %)EEA : Energy Expenditure of Activity (25 %)

EET : Energy Expenditure of Thermogenesis (10%)EET : Energy Expenditure of Thermogenesis (10%)

Calculating BEECalculating BEE : :Harris - Benedict EquationHarris - Benedict Equation

Men:Men:BEE= BEE= 66.5 + [13.75 x weight(kg)] + [5 x height(cm)] –[6.78 x 66.5 + [13.75 x weight(kg)] + [5 x height(cm)] –[6.78 x

age(yrs)]age(yrs)]WomenWomen::

BEE= BEE= 65.5 + [9.56 x weight(kg)] + [1.85 x height(cm)] – 65.5 + [9.56 x weight(kg)] + [1.85 x height(cm)] –

[4.68xage(yrs)][4.68xage(yrs)]– 25 kCal/kg – 35kCal/kg25 kCal/kg – 35kCal/kg

TEE = BEE x specific stress factorsTEE = BEE x specific stress factors

StarvationStarvation 0.80–1.000.80–1.00

Elective operationElective operation 1.00–1.101.00–1.10

Adult respiratory distress syndrome or Adult respiratory distress syndrome or sepsissepsis

1.30–1.351.30–1.35

Caloric requirements may be 150% more than the basal Caloric requirements may be 150% more than the basal energy expenditure in pts undergoing major surgeryenergy expenditure in pts undergoing major surgery

Phases following SurgeryPhases following Surgery(1)Phase I: Catabolic phase lasting 3-7 days, increased (1)Phase I: Catabolic phase lasting 3-7 days, increased

protein consumptionprotein consumption

(2)Phase II: Protein consumption & production are equal(2)Phase II: Protein consumption & production are equal

(3)Phase III: Anabolic phase, protein production exceeds (3)Phase III: Anabolic phase, protein production exceeds consumptionconsumption

(4)Phase IV: Restoration of lipid stores(4)Phase IV: Restoration of lipid stores

Pre-operative PreparationPre-operative Preparation

In patients with severe nutritional risk, start nutrition In patients with severe nutritional risk, start nutrition supplement 2 wks prior to surgerysupplement 2 wks prior to surgery

Solid foods allowed up to 6 hrsSolid foods allowed up to 6 hrs

Liquid foods allowed up to 4hrsLiquid foods allowed up to 4hrs

Clear liquid allowed up to 2 hrsClear liquid allowed up to 2 hrs

Preoperative carbohydrate loading, the night before and Preoperative carbohydrate loading, the night before and 2 hr before surgery recommended2 hr before surgery recommended

Access- Possibilities for Nutrition

Nasogastric tube

Whole food by mouth

Gastrostomy tube

Jejunostomy tube

Nasoduodenal tube

Nasojejunal tube

PPN

TPN

Intravenous Alimentation

Preferred over the Parenteral routePreferred over the Parenteral route

Simple, physiologic, relatively inexpensive, and well Simple, physiologic, relatively inexpensive, and well tolerated by most patientstolerated by most patients

Maintains the GI tract cytoarchitecture and mucosal integrity Maintains the GI tract cytoarchitecture and mucosal integrity (via trophic effects), absorptive function, and normal (via trophic effects), absorptive function, and normal microbial flora microbial flora

IndicationsIndications : patients who have a functional GI tract but are : patients who have a functional GI tract but are unable to sustain an adequate oral dietunable to sustain an adequate oral diet

ContraindicationsContraindications : intestinal obstruction, ileus, GI : intestinal obstruction, ileus, GI bleeding, severe diarrhea, vomiting, enterocolitis, or a high-bleeding, severe diarrhea, vomiting, enterocolitis, or a high-output enterocutaneous fistulaoutput enterocutaneous fistula

Enteral NutritionEnteral Nutrition

Enteral Feeding ProductsEnteral Feeding Products

– Standard Solutions – 1 kcal/mlStandard Solutions – 1 kcal/ml

- Calorically concentrated solutions – >1 kcal/ml- Calorically concentrated solutions – >1 kcal/ml

-Dietary Formulations -Dietary Formulations

Nutritionally complete formulas (standard Nutritionally complete formulas (standard enteral diets)enteral diets)

Chemically defined formulas (elemental Chemically defined formulas (elemental diets)diets)

Modular formulations (in specific clinical Modular formulations (in specific clinical situations)situations)

Bolus FeedingsBolus Feedings– Reserved for patients with nasogastric or gastrostomy Reserved for patients with nasogastric or gastrostomy

feeding tubesfeeding tubes– Administered by gravityAdministered by gravity– Begin at 50 to 100 mL every 4 hours, and increased in Begin at 50 to 100 mL every 4 hours, and increased in

50-mL increments until goal intake reached (usually 240 50-mL increments until goal intake reached (usually 240 to 360 mL every 4 hours)to 360 mL every 4 hours)

– Tracheobronchial aspiration is a potentially serious Tracheobronchial aspiration is a potentially serious complicationcomplication

Enteral Feeding Protocols

Continuous InfusionContinuous Infusion

– Administered by a pumpAdministered by a pump

– Generally required for nasojejunal, gastrojejunal, Generally required for nasojejunal, gastrojejunal, or jejunal tubesor jejunal tubes

– Initiated at 20 mL/hour and increased in 10 to Initiated at 20 mL/hour and increased in 10 to 20mL/hour increments every 4 to 6 hours until 20mL/hour increments every 4 to 6 hours until the desired goal reachedthe desired goal reached

– Can be infused over 8 to 12 hours at nightCan be infused over 8 to 12 hours at night

Conversion to Oral FeedingConversion to Oral Feeding– Resumed graduallyResumed gradually– Enteral Feeding modified asEnteral Feeding modified as

Providing fewer feedingsProviding fewer feedings

Holding daytime feedingsHolding daytime feedings

Decreasing the volume of feedingsDecreasing the volume of feedings

When oral intake provides approximately 75% of When oral intake provides approximately 75% of the required calories, tube feedings can be the required calories, tube feedings can be stoppedstopped

Administration of medicationsAdministration of medications– Many oral medications can be administeredMany oral medications can be administered– Not suitable for administration through a feeding Not suitable for administration through a feeding

tube includetube include

Enteric-coated medicationsEnteric-coated medications

Drugs in gelatinous capsulesDrugs in gelatinous capsules

Medications that are designed for sublingual Medications that are designed for sublingual useuse

Most sustained-release medicationsMost sustained-release medications

Complications of Enteral Complications of Enteral NutritionNutrition

Metabolic ComplicationsMetabolic Complications

Clogging Clogging (prevented by careful routine flushing of the (prevented by careful routine flushing of the feeding tube)feeding tube)

Tracheobronchial AspirationTracheobronchial Aspiration

High Gastric ResidualsHigh Gastric Residuals

DiarrheaDiarrhea

Parenteral NutritionParenteral Nutrition

Indicated for patients Indicated for patients – Who cannot meet their needs through oral intake Who cannot meet their needs through oral intake – Enteral feeding is contraindicated or not toleratedEnteral feeding is contraindicated or not tolerated

Peripheral parenteral nutrition (PPN)Peripheral parenteral nutrition (PPN)– Osmolarity of PPN solutions limited to 1,000 mOsm Osmolarity of PPN solutions limited to 1,000 mOsm

(approximately 12% dextrose solution)(approximately 12% dextrose solution) to avoid phlebitis to avoid phlebitis– Unacceptably large volumes (>2,500 ml) necessaryUnacceptably large volumes (>2,500 ml) necessary– Temporary nutritional supplementationTemporary nutritional supplementation

Total parenteral nutrition (TPN)Total parenteral nutrition (TPN)– Complete nutritional support Complete nutritional support – Central venous catheter requiredCentral venous catheter required– Replaced for unexplained fever or bacteremiaReplaced for unexplained fever or bacteremia

TPN SolutionsTPN Solutions

– 3-in-1 admixture3-in-1 admixture

Protein, as amino acids (10%; 4 kcal/g)Protein, as amino acids (10%; 4 kcal/g)

Carbohydrate, as dextrose (70%; 3.4 kcal/g)Carbohydrate, as dextrose (70%; 3.4 kcal/g)

Fat, as a lipid emulsion of soybean or safflower oil Fat, as a lipid emulsion of soybean or safflower oil (20%; 9 kcal/g)(20%; 9 kcal/g)

– Alternatively, the lipid emulsion can be administered Alternatively, the lipid emulsion can be administered as a separate intravenous infusionas a separate intravenous infusion

– Standard preparations availableStandard preparations available

AdditivesAdditives– Electrolytes : sodium, potassium, chloride, acetate, Electrolytes : sodium, potassium, chloride, acetate,

calcium, magnesium, phosphate adjusted dailycalcium, magnesium, phosphate adjusted daily– Number of cations and anions must balanceNumber of cations and anions must balance– Calcium : Phosphate ratio must be monitored to Calcium : Phosphate ratio must be monitored to

prevent salt precipitationprevent salt precipitation

Medications Medications

– Albumin, HAlbumin, H22-receptor antagonists, heparin, iron, -receptor antagonists, heparin, iron,

dextran, insulin, and Metoclopramidedextran, insulin, and Metoclopramide– Regular Insulin after adjusting doseRegular Insulin after adjusting dose

Other additivesOther additives– Trace elements added daily eg. commercially Trace elements added daily eg. commercially

prepared mixtureprepared mixture– Multivitamins generally added daily using a Multivitamins generally added daily using a

commercially prepared mixture commercially prepared mixture (e.g., 10 mL MVI-12)(e.g., 10 mL MVI-12)– Vitamin K not included in most multivitamin mixtures Vitamin K not included in most multivitamin mixtures

and must be added separately and must be added separately (10 mg once a week)(10 mg once a week)– Vitamins A and C and zinc essential for proper wound Vitamins A and C and zinc essential for proper wound

healing.healing.

Routine Physiologic and Laboratory MonitoringRoutine Physiologic and Laboratory Monitoring– On a scheduled basisOn a scheduled basis

– More frequently whose postoperative course has not More frequently whose postoperative course has not stabilizedstabilized

– Vital signs and serum glucose Vital signs and serum glucose every 6 hoursevery 6 hours

– Weight, serum electrolytes, and blood urea nitrogen Weight, serum electrolytes, and blood urea nitrogen dailydaily

– Triglycerides, CBC, PT, liver enzymes, and bilirubin Triglycerides, CBC, PT, liver enzymes, and bilirubin weeklyweekly

Administration of TPNAdministration of TPNIntroduction of TPNIntroduction of TPN– Gradual. e.g. approximately 1,000 kcal in 1Gradual. e.g. approximately 1,000 kcal in 1stst day day– Caloric goal achieved over 1 to 2 daysCaloric goal achieved over 1 to 2 days

TPN solutionsTPN solutions– Continuous infusionContinuous infusion

Cyclic administration of TPN solutionsCyclic administration of TPN solutions– Useful for selected patientsUseful for selected patients

Discontinuation of TPNDiscontinuation of TPN– Satisfies 75% of his or her caloric and protein needs Satisfies 75% of his or her caloric and protein needs

with oral intake or enteral feedingwith oral intake or enteral feeding

Complications Associated Complications Associated with TPNwith TPN

Catheter-Related ComplicationsCatheter-Related Complications

Metabolic Complications – Na overload, CHF, Metabolic Complications – Na overload, CHF, electrolyte imbalance, hyperglycemia and electrolyte imbalance, hyperglycemia and hyperosmolarity hyperosmolarity

(hyperglycemia may be the first indication of occult (hyperglycemia may be the first indication of occult infection)infection)

Refeeding Syndrome – in severely malnourished Refeeding Syndrome – in severely malnourished patientpatient

Hepatic Dysfunction – steatosis, raised AST, Hepatic Dysfunction – steatosis, raised AST, ALT, ALP & Bil. finally cirrhosisALT, ALP & Bil. finally cirrhosis

Cholecystitis – Acalculous type d/t CholestasisCholecystitis – Acalculous type d/t Cholestasis

Adverse Effects and RisksAdverse Effects and Risks

Parenteral NutritionParenteral Nutrition

OverfeedingOverfeeding

HyperglycemiaHyperglycemia

Infectious ComplicationsInfectious Complications

Gut Mucosal Atrophy?Gut Mucosal Atrophy?

Bacterial translocation?Bacterial translocation?

Early Enteral NutritionEarly Enteral Nutrition

Procedure-related Procedure-related complications complications High gastric residualsHigh gastric residualsBacterial colonization of Bacterial colonization of the stomachthe stomachAspiration PneumoniaAspiration Pneumonia

Water & Electrolyte BalanceWater & Electrolyte Balance

Body Fluid CompartmentsBody Fluid Compartments

K+, Mg+, PO4

-, Proteins

Na+, Cl-,

HCO3-

Male – 60 %Female – 50

%

Principles of Fluid Principles of Fluid ManagementManagement

2,000-2,500 ml daily requirement2,000-2,500 ml daily requirement

Daily water losses Daily water losses – 1,000-1,500 ml in urine 1,000-1,500 ml in urine (minimum UO to excrete (minimum UO to excrete

catabolic end products of metabolism – 400 ml)catabolic end products of metabolism – 400 ml)– 250 ml in stool250 ml in stool– 750 ml insensible loss 750 ml insensible loss (increase with hypermetabolism, (increase with hypermetabolism,

fever & hyperventilation)fever & hyperventilation)

MaintenanceMaintenance– Maintain urine output of 0.5 to 1 ml/kg/hour in Maintain urine output of 0.5 to 1 ml/kg/hour in

adult & 1 to 2 ml/kg/hr in childrenadult & 1 to 2 ml/kg/hr in children

eg. in adult UO at least 30 ml/hreg. in adult UO at least 30 ml/hr

– Estimation of Maintenance FluidEstimation of Maintenance FluidFirst 10 kg – 100 ml/kg/day First 10 kg – 100 ml/kg/day

Second 10 kg – 50 ml/kg/daySecond 10 kg – 50 ml/kg/day

Then for subsequent kg – 20 ml/kg/dayThen for subsequent kg – 20 ml/kg/day

NaNa++ - 1 to 2 mmol/kg/day - 1 to 2 mmol/kg/day

KK++ - 0.5 to 1 mmol/kg/day - 0.5 to 1 mmol/kg/day

Maintenance Fluid formula:-Maintenance Fluid formula:-

4 ml/kg/h for the first 10 kg4 ml/kg/h for the first 10 kg

2 ml/kg/h for the next 10 kg2 ml/kg/h for the next 10 kg

1 ml/kg/h for every kg over 20 kg1 ml/kg/h for every kg over 20 kg

Therefore a 70 kg patient using the calculation:Therefore a 70 kg patient using the calculation:

40+20+50=11040+20+50=110

will require 110 ml/hwill require 110 ml/h

Preoperative managementPreoperative management

Intraoperative fluid managementIntraoperative fluid management– duration of the caseduration of the case– hemorrhagehemorrhage– third-space lossesthird-space losses

Estimation of Intraoperative Fluid Loss and Guide for Estimation of Intraoperative Fluid Loss and Guide for ReplacementReplacement

Preoperative deficitPreoperative deficit Maintenance IVF × hr NPO, plus Maintenance IVF × hr NPO, plus preexisting deficit related to preexisting deficit related to disease statedisease state

Maintenance fluidsMaintenance fluids Maintenance IVF × duration of Maintenance IVF × duration of casecase

Third-space and Third-space and insensible lossesinsensible losses

1–3 mL/kg/hr for minor procedure 1–3 mL/kg/hr for minor procedure (small incision)(small incision)3–7 mL/kg/hr for moderate 3–7 mL/kg/hr for moderate procedure (medium incision)procedure (medium incision)9–11 mL/kg/hr for extensive 9–11 mL/kg/hr for extensive procedure (large incision)procedure (large incision)

Blood lossBlood loss 1 mL blood or colloid per 1 mL 1 mL blood or colloid per 1 mL blood loss, or 3 mL crystalloid per blood loss, or 3 mL crystalloid per 1 mL blood loss1 mL blood loss

Postoperative Fluid Postoperative Fluid ManagementManagement

– Sequestration of ECF can continue for > 12 Sequestration of ECF can continue for > 12 hours after operationhours after operation

– Maintain Urine OutputMaintain Urine Output– GI lossesGI losses from NG or Gastrostomy tube suction from NG or Gastrostomy tube suction

Replaced with an equal volume ofReplaced with an equal volume of CrystalloidCrystalloid– Mobilization of Peri-operative third-space fluid Mobilization of Peri-operative third-space fluid

losses typically begins 2 to 3 days after losses typically begins 2 to 3 days after operationoperation

Commonly Used Parenteral SolutionsCommonly Used Parenteral Solutions

IV IV solutionsolution

Osmolality Osmolality (mOsm/L)(mOsm/L)

[Glucose] [Glucose] (g/L)(g/L)

[Na[Na++] ] (mEq/L)(mEq/L)

[Cl[Cl--] ] (mEq/L)(mEq/L)

[HCO[HCO33--] ]

equivalents equivalents (mEq/L)(mEq/L)

DD55WW 278278 5050 00 00 00

DD1010WW 556556 100100 00 00 00

DD5050WW 27782778 500500 00 00 00

0.225% 0.225% NaClNaCl

7777 00 38.538.5 38.538.5 00

0.45% NaCl0.45% NaCl 154154 00 7777 7777 00

0.9% NaCl0.9% NaCl 308308 00 154154 154154 00

3% NaCl3% NaCl 10261026 00 513513 513513 00

Lactated* Lactated* Ringer'sRinger's

274274 00 130130 109109 2828

*Also contains 4 mEq/l K+, 1.5 mEq/l Ca++, and 28 mEq/l lactate.

IV solutionIV solution Osmolality Osmolality (mOsm/L)(mOsm/L)

[Glucose] [Glucose] (g/L)(g/L)

[Na[Na++] ] (mEq/L)(mEq/L)

[Cl[Cl--] ] (mEq/L)(mEq/L)

HCOHCO33--

equivalentequivalents (mEq/L)s (mEq/L)

6% 6% hetastarchhetastarch

310310 00 154154 154154 00

10% 10% dextran-40dextran-40

300300 50/050/0** 0/1540/154** 0/1540/154** 00

6% 6% dextran-70dextran-70

300300 50/050/0** 0/1540/154** 0/1540/154** 00

5% albumin5% albumin$$ 330330 00 130–160130–160 130–160130–160 00

25% 25% albuminalbumin$$

330330 00 130–160130–160 130–160130–160 00

*Dextran solutions available in 5% dextrose or 0.9% NaCl$< 2.5 mmol/L K+

Composition of Gastrointestinal SecretionsComposition of Gastrointestinal Secretions

SourceSource Volume Volume (mL/24 hr)(mL/24 hr)

NaNa++ (mmol/L)(mmol/L) KK++ (mmol/L) (mmol/L) ClCl-- (mmol/L) (mmol/L)

HCOHCO33--

(mmol/L)(mmol/L)

SalivarySalivary 1,500 1,500 (500–2,000)(500–2,000)

10 10 (2–10)(2–10)

26 26 (20–30)(20–30)

10 10 (8–18)(8–18)

3030

StomachStomach 1,500 1,500 (100–4,000)(100–4,000)

60 60 (9–116)(9–116)

10 10 (0–32)(0–32)

130 130 (8–154)(8–154)

00

DuodenumDuodenum (100–2,000)(100–2,000) 140140 55 8080 00

IleumIleum 3,0003,000 140 140 (80–150)(80–150)

5 5 (2–8)(2–8)

104 104 (43–137)(43–137)

3030

ColonColon (100–9,000)(100–9,000) 6060 3030 4040 00

PancreasPancreas (100–800)(100–800) 140 140 (113–185)(113–185)

5 5 (3–7)(3–7)

75 75 (54–95)(54–95)

115115

BileBile (50–800)(50–800) 145 145 (131–164)(131–164)

5 5 (312)(312)

100 100 (89–180)(89–180)

3535

SodiumSodium

Serum conc. – 135 to 145 mmol/LSerum conc. – 135 to 145 mmol/L

Potential sources of significant NaPotential sources of significant Na++ loss – sweat, urine, loss – sweat, urine, and GI secretionsand GI secretions

PPosmosm – 290 to 310 mOsm/L – 290 to 310 mOsm/L

• Hyponatremia – [Na+] <135 mEq/L• Hypernatremia – [Na+] >145 mEq/L

HyponatremiaHyponatremia

C/F :C/F :

– Predominantly Neurologic Predominantly Neurologic – Lethargy, confusion, nausea, vomiting, seizures, and Lethargy, confusion, nausea, vomiting, seizures, and

comacoma– Chronic hyponatremia often asymptomatic until serum Chronic hyponatremia often asymptomatic until serum

NaNa++ concentration < 110 to 120 mEq/L concentration < 110 to 120 mEq/LRx :Rx :

– Correct the underlying disorderCorrect the underlying disorder– Fluid Restriction (1,000 mL/day)Fluid Restriction (1,000 mL/day)– Hypovolemic hyponatremia – administer 0.9% NaCl to Hypovolemic hyponatremia – administer 0.9% NaCl to

correct volume deficits and replace ongoing losses.correct volume deficits and replace ongoing losses.Rapid correction should be avoidedRapid correction should be avoided

HypernatremiaHypernatremia

C/F :C/F :– Primarily NeurologicPrimarily Neurologic– Lethargy, weakness, & irritabilityLethargy, weakness, & irritability– Fasciculations, seizures, coma, & irreversible Fasciculations, seizures, coma, & irreversible

neurologic damageneurologic damage

Rx :Rx :– Water deficit (L) = 0.60 × total body weight (kg) × Water deficit (L) = 0.60 × total body weight (kg) ×

[(serum Na[(serum Na++ in mmol/L/140) – 1] in mmol/L/140) – 1]– Gradual correction Gradual correction – Treat specific causeTreat specific cause

PotassiumPotassium

Serum conc. – 3.5 to 5 mmol/LSerum conc. – 3.5 to 5 mmol/L

90 % of K90 % of K++ excreted renally, remainder in stools excreted renally, remainder in stools

HypokalemiaHypokalemia – – [K[K++] <3.5 mEq/L] <3.5 mEq/L

Hyperkalemia – [KHyperkalemia – [K++] >5.0 mEq/L] >5.0 mEq/L

Causes :Causes :– Inadequate intake Inadequate intake

– GI losses (e.g., diarrhea, persistent vomiting, GI losses (e.g., diarrhea, persistent vomiting, Nasogastric suctioning)Nasogastric suctioning)

– Renal losses (e.g., diuretics, fluid mobilization)Renal losses (e.g., diuretics, fluid mobilization)– Cutaneous losses (e.g., burns)Cutaneous losses (e.g., burns)

– Acute intracellular KAcute intracellular K++ uptake (insulin excess, metabolic uptake (insulin excess, metabolic alkalosis, hypothermia, theophylline toxicity)alkalosis, hypothermia, theophylline toxicity)

– Refeeding Syndrome – in malnourished patient after Refeeding Syndrome – in malnourished patient after initiation of TPNinitiation of TPN

HypokalemiaHypokalemia

C/F :C/F :– Mild hypokalemia [KMild hypokalemia [K++ >3 mmol/L] generally >3 mmol/L] generally

asymptomaticasymptomatic– Severe KSevere K++ deficiency [K deficiency [K++ <3 mmol/L] – primarily <3 mmol/L] – primarily

cardiovascular cardiovascular (ECG manifestations – ectopy, T-wave (ECG manifestations – ectopy, T-wave depression, and prominent U waves)depression, and prominent U waves)

– Fatigue, myalgias, and muscular weakness or cramps Fatigue, myalgias, and muscular weakness or cramps of the lower extremitiesof the lower extremities

– Constipation ,paralytic ileusConstipation ,paralytic ileus– Complete paralysis, hypoventilation, or Complete paralysis, hypoventilation, or

rhabdomyolysisrhabdomyolysisRx :Rx :– Oral replacement (40 to 100 mmol)Oral replacement (40 to 100 mmol)– Parenteral therapy (not exceeding 40 mmol/L & not Parenteral therapy (not exceeding 40 mmol/L & not

exceeding 20 mmol/hour)exceeding 20 mmol/hour)

HyperkalemiaHyperkalemia

Causes :Causes :– PseudohyperkalemiaPseudohyperkalemia– Abnormal redistribution of KAbnormal redistribution of K++

Insulin deficiencyInsulin deficiency

β-β-adrenergic receptor blockadeadrenergic receptor blockade

Acute acidosisAcute acidosis

RhabdomyolysisRhabdomyolysis

Cell lysis (after chemotherapy)Cell lysis (after chemotherapy)

Digitalis intoxicationDigitalis intoxication

Reperfusion of ischemic limbsReperfusion of ischemic limbs

Succinylcholine Succinylcholine

C/F :C/F :– Mild Hyperkalemia [KMild Hyperkalemia [K++ = 5 to 6 mmol/L] generally = 5 to 6 mmol/L] generally

asymptomaticasymptomatic– Severe Hyperkalemia [KSevere Hyperkalemia [K++ >6.5 mmol/L] – arrhythmia >6.5 mmol/L] – arrhythmia

(ECG abnormalities : symmetric peaking of T waves, (ECG abnormalities : symmetric peaking of T waves, reduced P-wave voltage, and widening of the QRS reduced P-wave voltage, and widening of the QRS complex, ultimately sinusoidal ECG pattern)complex, ultimately sinusoidal ECG pattern)

– Weakness, flaccid paralysis & hypoventilationWeakness, flaccid paralysis & hypoventilation

Rx :Rx :– Mild Hyperkalemia :Mild Hyperkalemia :

Reduction of daily KReduction of daily K++ intake intake

Loop diureticLoop diuretic

Withdrawal of drugs impairing KWithdrawal of drugs impairing K++ homeostasis homeostasis

-Severe Hyperkalemia-Severe HyperkalemiaTemporizing MeasuresTemporizing Measures

– Calcium gluconateCalcium gluconate– Insulin with dextroseInsulin with dextrose

– Inhaled βInhaled β22-agonists-agonists

– NaHCONaHCO33

Therapeutic MeasuresTherapeutic Measures– Sodium polystyrene sulfonate (Kayexalate), a Sodium polystyrene sulfonate (Kayexalate), a

NaNa++-K-K++ exchange resin exchange resin– Hydration in combination with a loop diuretic Hydration in combination with a loop diuretic – DialysisDialysis

CalciumCalcium

Serum Calcium – 2.23 to 2.57 mmol/L (8.9 to 10.3 Serum Calcium – 2.23 to 2.57 mmol/L (8.9 to 10.3 mg/dL), exists in three formsmg/dL), exists in three forms– Ionized (45%)Ionized (45%)– Protein bound (40%)Protein bound (40%)– Complexed to freely diffusible compounds (15%)Complexed to freely diffusible compounds (15%)

Free ionized CaFree ionized Ca2+2+ (4.6 to 5.1 mg/dL) is physiologically (4.6 to 5.1 mg/dL) is physiologically activeactive

Calcium Homeostasis – PTH, Vit. D & CalcitoninCalcium Homeostasis – PTH, Vit. D & Calcitonin

HypocalcemiaHypocalcemia

Serum Calcium <8.4 mg/dL with a normal serum albumin Serum Calcium <8.4 mg/dL with a normal serum albumin or an ionized calcium <4.2 mg/dLor an ionized calcium <4.2 mg/dL

Causes :Causes :– Calcium sequestration (acute pancreatitis, Calcium sequestration (acute pancreatitis,

rhabdomyolysis, or rapid administration of blood)rhabdomyolysis, or rapid administration of blood)– Vitamin D deficiencyVitamin D deficiency– Total thyroidectomy Total thyroidectomy – Parathyroidectomy Parathyroidectomy – Acute alkalemiaAcute alkalemia

C/F :C/F :– Perioral Numbness and TinglingPerioral Numbness and Tingling– TetanyTetanyECG - QT-interval prolongation and ventricular ECG - QT-interval prolongation and ventricular

arrhythmiasarrhythmias

Rx :Rx :– Parenteral therapy (overt tetany, laryngeal spasm, or Parenteral therapy (overt tetany, laryngeal spasm, or

seizures)seizures)– Oral therapy (Ca & vit. D)Oral therapy (Ca & vit. D)

HypercalcemiaHypercalcemia

Serum Calcium >10.3 mg/dl with a normal serum albumin Serum Calcium >10.3 mg/dl with a normal serum albumin or an ionized calcium >5.2 mg/dl or an ionized calcium >5.2 mg/dl

Causes :Causes :– MalignancyMalignancy– HyperparathyroidismHyperparathyroidism– HyperthyroidismHyperthyroidism– Vitamin D intoxicationVitamin D intoxication– ImmobilizationImmobilization– Long-term total parenteral nutritionLong-term total parenteral nutrition– Thiazide diureticsThiazide diuretics– Granulomatous diseaseGranulomatous disease

C/F :C/F :– Mild Hypercalcemia (Calcium <12 mg/dl) is generally Mild Hypercalcemia (Calcium <12 mg/dl) is generally

asymptomaticasymptomatic– Altered mental status, diffuse weakness, dehydration, Altered mental status, diffuse weakness, dehydration,

adynamic ileus, nausea, vomiting, and severe adynamic ileus, nausea, vomiting, and severe constipationconstipation

– Hypercalcemia of hyperparathyroidism –associated Hypercalcemia of hyperparathyroidism –associated infrequently with classic parathyroid bone disease and infrequently with classic parathyroid bone disease and nephrolithiasis.nephrolithiasis.

ECG - QT-interval shortening and arrhythmiasECG - QT-interval shortening and arrhythmias

Rx :Rx :– NaCl 0.9% and loop diuretics mayNaCl 0.9% and loop diuretics may– Salmon calcitoninSalmon calcitonin– Pamidronate disodiumPamidronate disodium

Thank youThank you

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