Intravenous Fluid Therapy and Blood Component

MUHAMMAD ALAMSYAH

Fluid Compartments
Total body consists of 60% water by

weight in adults Body fluids divided into: Intracellular compartment Extracellular compartment, further divided into: Interstitial compartment Intravascular compartment

Fluid Compartments
Intracellular Fluid 2/3 Extracellular Fluid 1/3

Interstitial Fluid=75% Intracellular Fluid

Intravascular Fluid=25%

Intravascular compartement
Consists of:

Cellular components of blood Proteins Ions mainly sodium, chloride and bicarbonates Potassium only a small portion in plasma Normal blood volume is about 72 mL/kg of body weight

Interstitial compartement
Larger than intravascular compartment Water and electrolytes pass freely between blood

and interstitial spaces, which have similar ionic composition Plasma proteins are not free to pass out of the intravascular space unless there is damage to capillaries, e.g., septic shock or burns With fluid loss or fall in blood pressure, water and electrolytes pass from interstitial compartment into blood (intravascular) to maintain volume (physiologic priority)

Intracellular Compartement
Water within cells: Largest reservoir of body water Ionic composition different from extracellular fluid Contains high concentration of potassium ions and low sodium and chloride ions Normal saline given IV: Tends to remain in extracellular compartment Glucose solution gets distributed throughout all body compartments Pure water given IV: Causes massive hemolysis (dangerous)

Principles of Fluid Therapy

Fluid replacement should be as close as possible

in volume and composition to those fluids lost Acute losses should be replaced quickly Chronic lossesreplace with caution; rapid infusion may cause fluid overload and heart failure Better replaced by oral or rectal rehydration Mostly deficient in water: Do not overload with sodium

Fluid Therapy During Operation

Use salt solution Normal saline or Ringer s

lactate Preload 1 L before spinal anesthesia Ketamine anesthesia does not need preloading Maintenance fluid 4mL/kg/hour

Fluid Therapy During Operation

Replacement for the loss of fluid Blood loss replace with crystalloid 3 times the

volume of blood loss Blood loss more than 1 L consider giving blood Desirable to have a hemoglobin minimum 89 mg after surgery

Intravenous Fluid Therapy

Estimation of Blood Loss

Subjective Fully soaked and dripping mop approximately

100 mL Monitor heart rate, blood pressure throughout the operation Urine output 0.5 mL/kg/hr considered adequate fluid replacement

Types of IV Fluids
Crystolloids

5% dextrose in aqua 5% dextrose in NaCl Normal saline (NaCl) Hartman s solution Ringer s lactate solution Cholera saline Colloids Dextran 40, 70 Gelatin preparations e.g., Haemacel Hetastarch, Pentastarch

Intravenous Fluid Therapy

TRANSFUSI DARAH

Pemberian Transfusi Darah Pada Pasien

Nilai ulang: - check list pelaksanaan transfusi darah - golongan darah pasien = donor ? (tanyakan/peneng) - identitas pasien tepat ? - identitas donor dan golongan darah donor - awasi selama dan setelah transfusi (tanggung jawab dokter) - awasi reaksi transfusi darah

Table 1. Blood Components and Plasma Derivatives (1)

Component/Product Whole Blood Composition Volume Indications

RBCs (approx. Hct 40%); plasma; 500 ml Increase both cell mass & plasma WBCs; platelets volume (WBCs & platelets not functional; plasma deficient in labile clotting Factors V and VIII) RBC (approx. Hct 75%); reduced plasma, WBCs, and platelets 250 ml Increase red cell mass in symptom atic anemia (WBCs & platelets not functional) 225 ml Increased red cell mass; < 5 x 106 WBCs to decrease the likelihood of febrile reactions, immunization to leukocytes (HLA) antigens) of CMV transmission Increase red cell mass; reduced risk of allergic reactions to plasma proteins

Red Blood Cells

RBCs Leukocytes Reduced (prepared by filtration)

> 85% original volume of RBC; < 5 x 106 WBC; few platelets; minimal plasma

RBCs Washed

RBCs (approx, Hct 75%); < 5 x 108 WBCs; no plasma

180 ml

(Continued)

Table 1. Blood Components and Plasma Derivatives (1)

Component/Product Composition Platelets Platelets Pheresis Platelets (> 5.5 x 1010/unit); RBC; WBCs; plasma Platelets (> 3 x 1011); RBCs; WBCs; plasma Volume 300 ml 300 ml Indications Bleeding due to thrombocytopenia or thrombocytopathy Same as platelets;l sometimes HLA matched

FFP; FFP Donor Retested plasma; Solvent/detergentTreated plasma Cryoprecipitated AHF

Plasma; anticoagulation factors; complement (no platelets)

220 ml

Treatment of some coagulation

Fibrinogen; Factors VIII and XIII; 15 ml von Willebrand factor

Deficiency of fibrinogen; Factor XIII; second choice in treatment of hemophilia A, von Willebrand s disease

(Continued)

Transfusi Trombosit
Trombosit disimpan dalam kondisi digoyang terus (Reciprocal agitator), pada suhu kamar (20C) Harus segera diberikan (tidak boleh disimpan di kulkas/ di ruangan) Kecepatan cepat Gunakan infus set khusus (jangan menggunakan set transfusi darah merah)

Kebutuhan Trombosit
Trombosit: - dosis umumnya: 1 unit per 10 kg BB (5-7 unit untuk orang dewasa) - 1 unit meningkatkan 5000/mm3 (dewasa 70 kg) - ABO-Rh typing saja, tak perlu cross match, kecuali pada keadaan tertentu

Transfusi Plasma / FFP KEBUTUHAN PLASMA/FFP

Dosis bergantung kondisi klinis dan penyakit dasarnya Coagulation factor replacement: 10 20 ml/kg BB (= 4-6 unit pd dewasa) Dosis ini diharapkan dapat meningkatkan faktor koagulasi 20 % segera setelah transfusi Plasma yang dicairkan (suhu 30 - 37 C) harus segera ditransfusikan ABO-Rh typing saja (tak perlu cross match)

KEBUTUHAN Transfusi KRIOPRESIPITAT Kriopresipitat

Diencerkan pada suhu 30 37 C 1 unit akan meningkatkan fibrinogen 5 mg/dl pada dewasa Target hemostasis level: fibrinogen > 100 mg % Segera transfusikan dalam 4 jam

REAKSI REAKSI Reaksi Transfusi Darah TRANSFUSI DARAH

Bila dilaksanakan pemeriksaan laboratorium sebelum pemberian transfusi darah, mayoritas transfusi darah tidak memberikan efek samping kepada pasien Namun, kadang-kadang timbul reaksi pada pasien, walaupun pemeriksaan laboratorium pratransfusi darah telah dilaksanakan dan hasilnya COMPATIBLE (= cocok antara darah resipien dan donor) Reaksi: reaksi RINGAN (suhu meningkat, sakit kepala) s/d BERAT (reaksi hemolisis), bahkan dapat meninggal

KOMPLIKASI TRANSFUSI Komplikasi Transfusi Darah DARAH

Komplikasi LOKAL: - kegagalan memperoleh akses vena - fiksasi vena tidak baik - masalah ditempat tusukan - vena pecah saat ditusuk, dll Komplikasi UMUM: - reaksi reaksi transfusi - penularan/transmisi penyakit infeksi - sensitisasi imunologis - kemokromatosis

REAKSI TRANSFUSI TRANSFUSI DARAH REAKSI DARAH

Reaksi Tranfusi Darah AKUT: hemolitik, panas, alergi, hipervolume, sepsis bakteria, lung injury, dll Reaksi Transfusi Darah LAMBAT

REAKSI REAKSI REAKSI TRANSFUSI DARAH TRANSFUSI DARAH

Yang paling sering timbul: - reaksi febris - reaksi alergi - reaksi hemolitik

REAKSI FEBRIS REAKSI FEBRIS

Nyeri kepala menggigil dan gemetar tiba tiba suhu meningkat Reaksi jarang berat Berespon terhadap pengobatan

REAKSI ALERGI REAKSI ALERGI

Reaksi alergi berat (anafilaksis): jarang Urtikaria kulit, bronkospasme moderat, edema larings: respon cepat terhadap pengobatan

REAKSI HEMOLITIK REAKSI HEMOLITIK

REAKSI YANG PALING BERAT Diawali oleh reaksi: - antibodi dalam serum pasien >< antigen corresponding pada eritrosit donor - antibodi dalam plasma donor >< antigen corresponding pada eritrosit pasien Reaksi hemolitik: - intravaskular - ekstravaskular

REAKSI HEMOLITIK REAKSI HEMOLITIK

REAKSI INTRAVASKULAR: - hemolisis dalam sirkulasi darah - jaundice dan hemogolobinemia - antibodi IgM - paling bahaya anti-A dan anti-B spesifik dari sistem ABO - fatal akibat perdarahan tidak terkontrol dan gagal ginjal

REAKSI HEMOLITIK REAKSI HEMOLITIK

REAKSI EKSTRAVASKULAR: - jarang sehebat reaksi intravaskular - reaksi fatal jarang - disebabkan antibodi IgG destruksi eritrosit via makrofag - menimbulkan penurunan tiba triba kadar Hb s/d 10 hari pasca transfusi