Dr.U.P.

Rathnakar
MD.DIH.PGDHM

[Plasma expanders]
MBBS iii Sem. 15 NOV 12

Circulatory failure: oxygen delivery (DO2) fails to meet the metabolic requirements of the tissues

Shock

CO= 5L

Capacity= 5L

Blood volume= 5L

CO= ?3L

Volume failure
Capacity= 5L Blood volume= 3L

Hypovolemic shock

Hypovolemic shock

CO= ?3L
Volume failure

Capacity=5L
Volume=3L

Pump failure Capacity=5L Volume=5L

Cardiogenic shock

Hypovolemic shock

Cardiogenic shock

CO= 3L

Volume failure

Pump failure

Capacity=5L
Volume=3L

Capacity=5L
Volume=5L

Distribution failure

Capacity= 8L Blood volume= 5L

Distributive shock

Hypovolemic shock

Cardiogenic shock

Volume failure

Pump failure

Capacity=5L
Volume=3L

Capacity=5L
Volume=5L

CO= 3L

Distributive shock

Distribution failure

Capacity=5L
Volume=5L

Capacity=8L
Blood Volume=5L

Obstructive shock

Hypovolemic shock
Volume failure

Stages of shock
Non-progressive stage

Cardiogenic shock

Pump failure

Progressive stage
Distribution failure

Distributive shock

Refractory [irreversible] stage

Obstructive shock

Pharmacotherapy of shock
1. Managing specific causes

2. Managing associated

hemodynamic alterations 3. Undertaking life saving & life sustainable measures

Hypovolemic shock

Pump failure

Cardiogenic shock

Distribution failure

Distributive shock

Obstructive shock

Agents used to treat hemodynamic dysfunction: 1. Sympathomimetic amines [Dopamine, dobutamine etc.] 2. Glucocorticoids 3. Blood and plasma expanders

Dopamine Dose dependent action

2-5 ug/kg/min [D1]
D1 receptors-renal, mesenteric,

and cerebral circulations and increases blood flow

Increase in urinary sodium and

water excretion

5 to 10 [D1 &

1]

Stimulates 1-receptors in the

heart & increase in cardiac output.

Cardiac

11-20 [1]
More than 20 ug/kg/min[1

-receptors-progressive

vasoconstriction, and increase in ventricular afterload -limits the ability of dopamine to augment cardiac output.

Dobutamine
Cardioselective

Postive inotropic
1-10mcg/kg/min. i.v.

Nor-adrenaline
When dopamine & dobutamine fail
1-8mcg/min

Adrenaline
Anaphylactic shock

Glucocorticoids
Methyl prednisolone, dexamethasone
1

2
3 4

Other drugs used in shock

Oxygen

Naloxone [Opioid antagonist]

Vasoconstrictors Vasopressin

Volume replacements
1. Whole blood and plasma

2. Plasma expanders

a. Colloids

b. Crystalloids

Hydroxyethyl starch

Colloidal plasma expanders

Physiology of plasma expanders

Replace the lost volume. This way remaining RBCs can oxygenate body tissue. Normal human blood has a significant excess oxygen

transport capability, -Provided blood volume is maintained by volume expanders, Since the lost blood was replaced with a suitable fluid, the now diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is released to the tissues. Ultimately red blood cell levels drop too low for adequate tissue oxygenation, even if volume expanders maintain circulatory volume.

Plasma expanders[Colloidal]
Colloidal plasma expanders -Substances of high Mol.Wt. -Remain long time in blood stream -Augment the volume of circulating fluid -By increasing the osmotic pressure

Plasma expanders
Requirements of an ideal plasma expander: 1. Oncotic pressure comparable to plasma. 2. Remain in the circulation for an adequate period and 3. Disposed of either by metabolic degradation or by excretion. 4. Not antigenic or pyrogenic. 5. Not interfere with grouping and cross matching of blood.

Use of plasma expanders:

Hypovolemic shock. Burns. Severe trauma. Endotoxin shock. Severe anaemia. Cardiac failure. Pulmonary oedema. Renal insufficiency.

Contraindications:

Dextran
It is a Polysaccharide[ made of

many glucose molecules]. Dextran 70 (MW 70,000) & Dextran 40 ( MW 40,000). Oncotic pressure similar to plasma proteins and expands plasma volume for about 24 hours. Large doses do not induce antibody formation. They may interfere with coagulation and platelet function and also blood grouping.

Dextran 70:
Excreted very slowly by glomerular filtration

and some amount deposited in RE cells.

Reduces blood viscosity.

Dextran 40

Excreted through renal tubules and

occasionally may produce acute renal failure. Precautions should be taken.

Caution
Dextran does not provide necessary electrolytes

and can cause hyponatremia or other electrolyte disturbances

Dextran- other uses

Antithrombotic in microsurgeries

In some eye drops as a lubricant

To solubilize other factors, e.g. iron (=iron

dextran) Used in laboratory tests

Contraindications:
Allergy.

Heart failure.
Acute oliguric renal failure. Hypofibrinogenemia. Thrombocytopenia.

Hydroxyethyl starch[HES]:
Compared to dextrans Maintains blood volume longer. Does not cause acute renal failure or coagulation disturbances. Adverse effects: Anaphylactoid reactions Mild fever, Chilling, periorbital edema, urticaria, itching and chills.

Polyvinylpyrrolidone[PVP]:
Synthetic polymer,MW- 40,000.

Interferes with blood grouping and cross

matching. Releases histamine. Binds to penicillin and insulin.

Gelatin polymer[Haemaccel]:
Does not interfere with grouping and cross

matching. Expands plasma volume for about 12 hours. Not antigenic Hypersensitivity and hypotension can occur.

Crystalloids

Normal saline:
Very limited duration of action.
Dextrose: Osmolality is lower than serum. Useful when kidney function is impaired.

Human albumin:
Obtained from pooled human plasma.

Crystalloid solutions must be infused concurrently

for better action. Does not interfere with coagulation. Used as a vehicle for transfusing packed red cells.

Pharmacotherapy of shock
Drug therapy aims at: Managing specific causes

Volume,cardiac function,relieving obstruction etc. Managing associated hemodynamic alterations Dopamine or dobutamine, glucocorticoids, volume replacements &expanders Undertaking life saving & life sustainable measures

Shock & Plasma expanders

Enlist the principles of pharmacotherapy of shock

Enumerate plasma expanders

Indications and CIs of plasma expanders

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