1. Fluids, Blood, IV access
J Albrett

2. Introduction A very simple topic. BUT ALSO a very difficult topic!
Fluid composition.
Maintenance fluids.
Bolus fluids for hypovolaemia.
Blood products.
Transfusion triggers.

3. Simple If the patient looks dry they need a fluid challenge.
Skin tugor
Mucous membrane
Heart rate and blood pressure
Biochemical changes
Na+, Cl-, osmolality
Urea/Creatinine

4. Complex CVP, PCWP ITBI/GEDV CO response to fluid challenge
CO response to passive leg raise
IVC diameter on echo and collapse with sniff
Arterial line ‘swing’ PPV, SVV
Echo – LV looks empty, Kissing papillary muscle.

5. Even more complex Assessing fluid status in the failing heart
Haemorrhage
Concealed haemorrhage
Microvascular dysfunction
Can be grossly overloaded and hypovolemic in the vascular compartment (Severe sepsis/burns/capillary leak syndrome)

6. Who needs fluids? NBM or poor oral intake need maintenance fluids
Hypovolaemia, fluid responsive need bolus
Blood product requirements

7. Fluid composition Na K Cl Lactate Glucose Osm 150 300 75 30 40 282 50
0.9% Nacl
150
300
0.45% NaCl 75
Dextrose saline 30 40
282
D5W 50
278
CSL
129 5
109 29
274
Ca2+
Gelofusin
144
120
283
Albumin
Voluven
154
304
Pl 148 98
Acetate 27 Gluconate 23
294

8. Transfusion triggers
Reasonable to discuss with more senior member of your team
Hb > 70g/dL acceptable in stable patient without unstable cardiac disease. Many teams may want 80g/dL
Unstable cardiac disease Hb 80, 90 or 100g/dL should be threshold.
Ongoing haemorrhage often transfused more aggressively

9. Problems with RBC transfusion
Fever
Allergic reaction
Iron over load
Acute haemolysis
Delayed haemolysis
Graft Vs Host disease
TRALI
?Immune suppression/cancer risk/avoided prior to renal transplant
Infections
HIV — 1 in 2.3 million transfusions.
Human T-lymphotrophic virus — 1 of every 2 million transfusions.
Hepatitis B — 1 in 350,000 transfusions.
Hepatitis C affects — 1 in 2 million transfusions.
West Nile virus — 1 of every 350,000 units of blood in the United States.
Sepsis (bacterial infection of the blood) — 1 in 1 million transfusions.

10. Platelets
Bleeding rare with Plt >10x109/micromL afebrile or >20 febrile
For surgery Plt >50 or higher if neurosurgery (>100)
>80 for spinal/epidural
Care with TTP/ITP/HITS – talk to haematology
One bag of Plts will raise level 20-25
Only one bag in hospital so may need to warn blood bank if planned for the next day etc.

11. FFP Warfarin reversal Haemorrhage Liver disease Massive transfusion
Plasma exchange
10-15 mL/kg

12. Cryoprecipitate Bleeding and fibrinogen <1g/L DIC
Massive transfusion
1 bag / 30kg

13. Prothrombinex Warfarin reversal Sterile freeze dried powder
From donor plasma
High levels of II, IX and X and less so F VII, may need to transfuse some FFP for this.
Dose 25-50IU/kg

14. Lines
In general a large bore, short cannula will offer the least resistance.
Peripheral Vs Central.
Arterial Vs Venous.
Ezi-IO.

15. Scenario one ATSP on call Orthopaedic patient
68 years old, MBA yesterday. Awaiting rodding of fractured femur
Ward request review as he is tachycardic and he has not made any urine in the past 3 hours.
Think he needs a fluid assessment

16. Scenario two A 24 year old man is booked for an acute appendectomy.
He is febrile, tachycardic, tachypnoeic.
Asked to review as he has increasing abdominal pain and has vomited several times in the last hour.

17. Scenario three
A 79 year old lady with a repaired NOF # (hemiarthroplasty) looks pale and clammy.
Nurse suggests you review for need for a blood transfusion.
What is your trigger for transfusion
What is needed to facilitate the transfusion

18. Scenario four
A 68 year old man is one day post op after a hip revision.
He is only making 10 mLs/hour of urine for the past 4 hours so you have been asked to review.

19. Scenario 5 A 75 year old urology patient is six hours post TURP
He is on the ward and his family and nurses note he does not seem his normal self and is quite confused.

20. Scenario 6
A 15 year old girl has presented with a DKA, BSL 45, pH 7.1, and a sodium of 130.
She has represented six times in the past two months so has been sent straight through ED to ward 2.
What are your priorities?

21. Scenario 7
A 54 year old man has presented with renal colic. He is an ex IVDU, Hep C (+)ve and known to have very poor IV access.
How would you approach this?

22. Scenario 8 General surgical ERAS patient. First day post op.
Epidural at T8 in situ and working well.
Patient has become hypotensive despite a phenylephrine infusion.
What are your treatment options for hypotension?