1) Determinants of O₂ delivery to tissue

    a) Generation of flow (cardiac output)

    b) O₂ content of blood

    c) Preload and hemoglobin (Hb) are most often manipulated by intravascular fluid therapy (Fig. 25-1).

  i) A Key assumption is that the vascular system (i.e., vascular autoregulation and normal endothelial permeability) is intact.

2) Fluid compartments

    a) Circulating blood volume makes up a small percentage of body weight and total body water (Fig. 25-2).

  i) Yet, one should appreciate the profound influence this small fraction has on homeostasis.

    b) Estimated circulating blood volume should be compared with blood loss during surgery or trauma.

    c) The type and amount of fluid therapy used to treat blood/fluid loss have a greater physiologic effect as the proportion of fluid therapy to circulating blood volume increases.

1) Classical calculation of fluid requirements

    a) One common method of perioperative fluid management calculates the fluid requirement needed to meet estimated demands and losses (Table 25-2a and b).

  i) This method is often referred to as a “liberal” fluid management strategy.

(1) Calculated results often lead to greater volumes being infused than are actually lost during surgery.

(2) This approach can help one gain a sense of the magnitude of fluids needed during a case.

   (a) However, evidence from many different surgical populations suggests that following a “liberal” fluid infusion strategy may lead to higher cardiac, pulmonary, renal, gut, and wound complications than more “restrictive” fluid strategies (2).

   (b) Thus, the use of classical fluid management results should be done with caution.

4) Modern perioperative fluid management

    a) The current intraoperative environment requires a sophisticated, individualized approach to fluid management.

    b) Clear goals should be used to determine the type of fluid, the amount, and the method in which it should be given (Fig. 25-3 and Table 25-3).

    c) Fixed and dynamic variables influence fluid requirements and include:

  i) Patient

  ii) Anesthetic technique and intraoperative course

  iii) Type of surgery

    d) Different data streams should be used as necessary to gather information.

  i) Functional reserve

  ii) Tissue oxygenation

  iii) Fluid responsiveness

  iv) Other hemodynamic variables

    e) One must learn the strengths and weaknesses associated with each monitor.

  i) Avoid over reliance on any one.

    f) Taken together, “goal-directed,” patient and procedure-oriented fluid management approaches have been shown to decrease morbidity and mortality in a wide range of populations (2–6).

5) Types of IV fluids

    a) See next chapter “Crystalloids and Colloids”.

6) Pearls and pitfalls for select surgical populations

    a) Neonates

  i) Require dextrose (D5) and should go no more than 3 to 4 hours without fluids.

  ii) Monitor blood glucose levels.

  iii) Limit fluids with a mini-infusion device.

  iv) Remove all air bubbles from lines to prevent any possibility of air emboli.

    b) Preeclampsia

  i) Patients usually have notable fluid deficits and decreased uretoplacental blood flow (9).

  ii) Despite intravascular volume depletion, these patients are at risk for pulmonary edema.

  iii) Randomized-controlled trials to guide fluid management are lacking.

  iv) Most practitioners limit crystalloid administration to 1 to 2 L.

(1) Some use colloid prior to spinal anesthesia.

(2) Arterial BP monitoring should be considered in patients with severe preeclampsia.

(3) Other invasive monitoring (e.g. PA catheter, TEE) may be helpful to guide fluid management in patients with renal failure in the setting of severe preeclampsia.

    c) Cerebral edema and/or intracranial neurosurgical patients

  i) Dextrose containing fluids are contraindicated because of worse neurological outcome (10).

(1) Hyperglycemia and oxidative stress leads to increased glycolytic metabolism and toxic derivative production

(2) The optimal level of glucose is unknown, but it is generally accepted that values >180 mg/dL should be treated with insulin.

    d) Congestive heart failure (CHF)

  i) Judicious fluid management should be the rule in CHF patients.

  ii) Expect third space redistribution to stress the heart in the first 24 to 96 hours post surgery.

  iii) Consider invasive monitoring and Intensive Care Unit (ICU) post-operative care.

    e) Acute respiratory distress syndrome (ARDS)

  i) Patients with ARDS may need emergency surgical services.

  ii) Fluid restrictive therapy has been shown to reduce morbidity in these patients in the ICU setting (10). However, this study had goals of CVP < 4 mm Hg or PAOP < 8 mmHg, which may be difficult to achieve.

  iii) A fluid restrictive approach may be beneficial, but this may be complicated by other factors and conditions.

(1) For example, a septic patient with ARDS who needs an emergent exploratory laparotomy due to necrotic bowel may necessitate more fluid resusciation.

  iv) Invasive monitoring should be considered to guide fluid therapy.

    f) Lung resection

  i) Although multifactorial in origin, postpneumonectomy pulmonary edema (PPE) rates increase with excessive fluid therapy (3).

  ii) Minimize fluids to approximately 1.5 L for an entire case.

(1) Use vasopressors intraoperatively as needed.

  iii) Fluid restriction may also be beneficial during the first 72 hours post-operatively.

  iv) Blood transfusion should be avoided.

(1) It is linked to worse perioperative pulmonary inflammatory changes and increased risk for PPE (3).

    g) Anuric renal failure

  i) These patients are unable to compensate for fluid overload and are often challenging.

  ii) Consider invasive BP monitoring with an arterial line.

  iii) Central venous access

(1) If deemed necessary, consider consultation with a vascular surgeon before cannulating upper body central veins as these may be sites for future arteriovenous fistulae (AVF).

(2) No IV catheters or BP cuffs on should be placed on same side as an arteriovenous fistula unless absolutely necessary.

   (a) Every effort should be made to protect patients’ fistula when anesthetized.

    h) Liver failure/hepatic transplantation

  i) Patients often have multisystem organ dysfunction.

  ii) A wide variety of possible complications and comorbidities may be present (11).

(1) Cerebral edema

(2) Hyperdynamic ventricular function

(3) Cardiomyopathy

(4) Pulmonary hypertension

(5) Hepatopulmonary syndrome

(6) Hepatorenal syndrome

(7) Effective circulating volume depletion

(8) Electrolyte perturbations

(9) Anemia

(10) Coagulopathy

  i) Burns

  i) These patients often have massive fluid requirements due to widespread loss of epidermal barrier and circulating oncotically active proteins

  ii) The Parkland formula is frequently used as an initial guide for fluid requirements for burns >30% total body surface area:

(1) BSA (use % as whole number not as fraction) × wt (kg) × 4 = total mL over 24 hours.

   (a) Give ½ of volume over 8 hours and second ½ over next 16 hours.

(2) More importantly, titrate infusions to hemodynamic parameters or to a urine output of 0.5-1ml/kg/h or more.

  iii) Albumin is often given to replace large intravascular protein losses from injury after the first 24 hours.

(1) However, timing and amount vary widely among institutions.

    j) Liposuction

  i) The “tumescent technique” consists of infiltration of the surgical region with very dilute lidocaine (1 mg/ml) and very dilute epinephrine (1:1,000,000 = 1 mg/L) in large volumes of saline.

  ii) The area becomes swollen (tumescent) which helps minimize bleeding, decreases lidocaine absorption, and achieves effective local anesthesia in the surgical region.

  iii) Maximum lidocaine dose for this technique is up to 55 mg/kg versus 7 mg/kg maximum for 1% to 2% lidocaine with 1:100,000 epinephrine (12).

  iv) Minimize any additional fluids that may be given intravenously

  v) Cardiopulmonary complications may be increased when liposuction volumes exceed 5 L due to large fluid shifts.

    k) Laparoscopic gastric bypass surgery

  i) Transient intraoperative oliguria frequently develops due to increased SVR and compression of intra-abdominal renal cortices and the inferior vena cava secondary to pneumoperitoneum (13)

(1) Effects are reversed when pneumoperitoneum is abolished.

  ii) A liberal management strategy is often used for these patients. However, care must be taken to avoid perioperative cardiopulmonary complications.

    l) Massive trauma

  i) Patients require close attention in order to avoid the “Lethal Triad” of acidosis, hypothermia, and coagulopathy.

References

1. Beekley AC. Damage control resuscitation: A sensible approach to the exsanguinating surgical patient. Crit Care Med 2008;36(7 Suppl):S267–S274.

2. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002;89:622–632.

3. Parquin F, Marchal M, Mehiri S, et al. Post-pneumonectomy pulmonary edema: analysis and risk factors. Eur J Cardiothorac Surg 1996;10:929–933.

4. Josh GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg 2005:101;601–605.

5. Rosenthal MH. Intraoperative fluid management—what and how much? Chest 1999;115:106S–112S.

6. Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354(24):2564–2567.

7. Michard F, Teboul JL. Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation. Crit Care 2000;4:282–289.

8. Desebbe O, Cannesson M. Using ventilation-induced plethysmographic variations to optimize patient fluid status. Curr Opin Anaesthesiol 2008;21(6):772–778.

9. Farragher R, Datta S. Recent advances in obstetric anesthesia. J Anesth 2003:17(1):30–41.

10. Prakash A, Matta BF. Hyperglycemia and neurological injury. Curr Opin Anaesthesiol 2008;21(5):565–569.

11. Ozer Y, Klink JR. Anesthetic management of hepatic transplantation. Curr Opin Anaesthesiol 2008;21:391–400.

12. Kacuera IJ, Lambert TJ, Klein JA, et al. Liposuction: contemporary issues for the anesthesiologist. J Clin Anesth 2006;18(5):379–387.

13. McGlinch BP, Que FG, Nelson JL. Perioperative care of patients undergoing bariatric surgery. Mayo Clinic Proc 2006;81(10 Suppl):S25–S33.

Crystalloids and Colloids

Tzevan Poon, MD

1) Crystalloids

    a) Crystalloids commonly used for resuscitation (Tables 26-1 and 26-2)

  i) Normal saline (NS)

(1) Lower pH, higher osmolarity, and higher chloride content than plasma

   (a) Large volume administration (>2 to 3 L) leads to hyperchloremic metabolic acidosis.

     (i) This can take hours to days to resolve in patients with acute and/or chronic renal failure.

     (ii) Lactated Ringers (LR) and Normosol cause less perturbation to chloride and acid-base homeostasis.

  ii) Lactated Ringers (LR)

(1) The lactate in LR is rapidly converted into pyruvate and shuttled into the Krebs cycle mostly by liver cells.

   (a) During severe liver failure or overwhelming lactic acidosis, net conversion is diminished.

(2) LR contains a small amount of potassium.

  iii) Normosol

(1) Currently, more expensive than other crystalloids but less expensive than colloids.

(2) A reasonable, balanced choice for resuscitation crystalloid for critically ill patients who have severely diminished compensatory mechanisms

(3) Normosol also contains a small amount of potassium.

  iv) Replacement of intravascular volume with crystalloid

(1) Classically, it has been taught that approximately three to four liters of crystalloid (versus only one liter of colloid) should be replaced for every liter of blood loss (1).

(2) Recent human data has shown that tissue equilibration may be slower than previously thought (20 to 30 minutes after infusion) and that this process is complex and dynamic (2).

(3) Furthermore, robust clinical trial data have shown that titrating crystalloids and colloids to similar hemodynamic goals leads to a crystalloid:colloid ratio of only 1.3 to 1.6:1.0.

   (a) This ratio is stable over hours to days (3,4)

    b) Additional forms of crystalloid are available and have a diverse array of uses.

  i) Various mixtures of ½ NS

(1) D5 or 20 mEq/L of KCl may be added.

(2) Used as maintenance fluids before and after surgery

(3) These hypotonic forms provide minimal intravascular volume effect and are usually not used intraoperatively

  ii) Isotonic sodium bicarbonate (300 mEq/L) in D5W plus n-acetylcysteine.

(1) May be used to prevent contrast-induced nephropathy

(2) May be superior to saline plus n-acetylcysteine (5).

  iii) Hypertonic 3% or 7.5% Saline

(1) Commonly administered to patients with brain injury to decrease intracranial pressure (ICP).

(2) Thought to osmotically promote outflow of brain interstitial fluid from the enclosed calvaria.

(3) May be more effective than mannitol and has a good safety profile (6).

   (a) Imaging and autopsy studies have not shown evidence of central pontine myelinolysis from this therapy (7,8).

(4) Hypertonic saline may be given through a central line as a 250 mL bolus every 6 hours as needed.

   (a) Gradually achieve a plasma sodium goal of 145 to 155 mEq/L and an osmolarity of 310 to 320 mOsm/L.

     (i) Increase plasma sodium no more than 10 to 20 mEq/L/24 h.

  iv) Highly concentrated 23.4% sodium chloride

(1) May emergently reverse transtentorial herniation and temporize the situation until more invasive interventions can be performed (e.g., craniectomy).

(2) Mechanism of action is similar to lower concentration hypertonic saline administration.

(3) May lead to transient hypotension after initial bolus (i.e., seconds to minutes).

   (a) However, heart rate, mean arterial pressure, and cerebral perfusion pressure generally remain stable.

   (b) ICP may continue to decrease for up to 24 hours (9).

(4) Given centrally in 30 or 60 mL boluses over 15 to 20 minutes.

2) Colloids

    a) Provides oncotic pressure effects in addition to volume

    b) Can be further classified as protein or nonprotein colloids

  i) Protein colloids

(1) Human serum albumin

(2) Modified gelatin solutions

  ii) Nonprotein colloids

(1) Dextrans

(2) Hydroxyethyl starches (HES)

    c) Colloids commonly used for resuscitation (Table 26-3)

  i) Albumin

(1) The most expensive resuscitation fluid with the exception of blood products.

(2) Well tolerated, and not associated with anaphylaxis, increased infection, or coagulopathy (aside from hemodilution effects) even at high volumes

  ii) Gelatins

(1) Not sold in the United States

(2) Similar in safety to albumin but with much shorter effects (3-6 hours) (10,11).

  iii) Dextrans

(1) Have plasma expanding volume effects.

   (a) Also have robust anticoagulant properties.

(2) They have a low but relatively higher association with anaphylactoid reactions than other colloids (12).

(3) Currently not used for resuscitation

(4) Dextrans may be used during vascular cases such as free muscle flap transfers to potentially improve perfusion and decrease risk of graft thrombosis.

  iv) Hydroxyethyl Starch

(1) Available in the United States as medium molecular weight pentastarch (200 kDa) and high molecular weight hetastarch (450 kDa).

(2) Pentastarch is less commonly available due to concerns regarding increased risk of acute kidney injury in diabetic patients (4).

(3) Hetastarch

   (a) Generally safe for most patients, although there have been some safety concerns

   (b) Clinically idiosyncratic anticoagulant effects may occur in some patients receiving hetastarch in doses >20 mL/kg/d (approximately 1.5 L for a 75 kg patient) (12, 13).

   (c) Hetastarch molecules are thought to bind to factor VIII, von Willebrand factor, and fibrinogen.

     (i) This leads to decreased function among these factors and a reduction in platelet aggregation

  v) Blood products

(1) Have oncotic effects that expand intravascular volume similar to colloids

    d) Possible benefits of colloids

  i) Require less volume than crystalloids to maintain the same effective arterial circulating volume.

  ii) Remain intravascularly for a much longer time period than crystalloids

  iii) May lead to less total body and organ edema

  iv) Possible greater improvement than crystalloids in myocardial contractility, tissue oxygen tension, and microcirculation in organs such as bowel after anastomosis (15,16).

  v) Possible better clinical outcomes during resuscitation, although demonstrating a beneficial effect of colloids on morbidity and mortality has proven difficult (11).

1) Crystalloids versus colloids in primary resuscitation

    a) Controversy and the emergence of meta-analyses

  i) Risk and benefit analyses regarding crystalloids vs. colloids are controversial despite more than sixty clinical trials over three decades (18).

  ii) Three issues stand out from the key meta-analyses of trial data (10–22).

(1) The majority of trials available for analysis were of poor methodological quality. Most are underpowered, poorly randomized, lacking allocation concealment, and/or not double-blinded.

(2) A large percentage of trials analyzed from the literature were performed before 1980 and used outmoded fluid resuscitation strategies. For example, titrating albumin boluses to plasma albumin levels.

(3) Different meta-analyses authors reached different conclusions and recommendations despite overall similar findings.

4) The saline versus albumin fluid evaluation (SAFE) trial

    a) High quality, well powered, multicenter, double-blinded randomized, controlled study.

  i) Designed to address the safety of albumin administration (3).

  ii) Albumin did not confer overall mortality benefit or harm to a large representative group of critically ill patients.

(1) Did not increase or decrease the risk of organ failure, duration of mechanical ventilation, or duration of renal replacement therapy.

  iii) A statistically significant increase in mortality in traumatic brain injury patients was observed.

(1) An ad hoc follow-up study showed that this increase involved only the most severely injured (GCS 3-8) patients (23).

5) Rational use of crystalloids and colloids

    a) Crystalloids should usually be the initial fluids used for resuscitation.

  i) They are inexpensive, readily available, safe, and effective for intravascular volume replacement in a wide variety of surgical and critically ill populations.

    b) Nonprotein colloids may be considered second line volume agents due to cost and possible anticoagulant effects.

    c) Albumin may be considered a third-line agent.

    d) Despite being equivalent in terms of mortality and other major endpoints, there continues to be a large gap in our knowledge on what indication is best suited for colloid.

  i) Colloid may be considered if a large amount of crystalloid (>3 to 4 L) has already been given and the patient still appears intravascularly depleted.

  ii) Elderly or extremely frail patients (with plasma albumin <2.5 g/dL) might not tolerate large volumes of fluid resuscitation and may benefit from early colloid administration.

  iii) Giving albumin in special situations may provide benefits to certain patients such as:

(1) After paracentesis with >4 L of ascites removed.

(2) After plasmapheresis

(3) Resuscitation in the setting of nephrotic syndrome or severe diarrhea with albumin <2 g/dL

    e) The choice to give crystalloid or colloid is only one factor among many other considerations when administering fluid therapy.

References

1. Lamke LO, Liljedahl SO. Plasma volume changes after infusion of various plasma expanders. Resuscitation 1976;5:93–102.

2. Svensen CH, et al. Arteriovenous differences in plasma dilution and the distribution kinetics of lactated ringer’s solution. Anes Analg 2009;108:128–133.

3. The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247–2256.

4. Brunkhorst FM, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358(2):125–139.

5. Meier P, et al. Sodium bicarbonate-based hydration prevents contrast-induced nephropathy: a meta-analysis. BMC Med 2009;7:23.

6. Wakai A, Roberts IG, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev 2007;1:CD001049.

7. Khanna S, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med 2000;28: 1144–1151.

8. Peterson B, et al. Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients. Crit Care Med 2000;28:1136–1143.

9. Koenig MA, et al. Reversal of transtentorial herniation with hypertonic saline. Neurology 2008;70:1023–1029.

10. Perel P, Roberts IG. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2007;4:CD000567.

11. Rizoli SB. Crystalloids and colloids in trauma resuscitation: a brief overview of the current debate. J Trauma 2003;54:S82–S88.

12. Boldt J. Fluid choice for resuscitation of the trauma patient: a review of the physiological, pharmacological, and clinical evidence. Can J Anesth 2004;51(5):500–513.

13. Warren BB, Durieux ME. Hydroxyethyl starch: safe or not? Anesth Analg 1997;84:206–212.

14. Gan TJ, et al. Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Anesth Analg 1999;88:992–998.

15. Hankeln K, et al. Comparison of hydroxyethyl starch and lactated Ringer’s solution on hemodynamics and oxygen transport of critically ill patients in prospective crossover studies. Crit Care Med 1989;17:133–135.

16. Kimberger O, et al. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology 2009;110:496–504.

17. Yim JM, et al. Albumin and nonprotein colloid solution use in US academic health centers. Arch Intern Med 1995;155:2450–2455.

18. Velanovich V. Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality. Surgery 1989;105:65–71.

19. Bisonni RS, Holtgrave DR, Lawler F, Marley DS. Colloids versus crystalloids in fluid resuscitation: an analysis of randomized controlled trials. J Fam Pract 1991;32:387–390.

20. Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998;316:961–964.

21. Choi PTL, et al. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med 1999;27(1):200–210.

22. Wilkes MM, Navickis RJ. Patient survival after human albumin administration: a meta-analysis of randomized, controlled trials. Ann Intern Med 2001;135:149–164.

23. Study Investigators. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007;357(9): 874–884.

Blood Component Therapy

Andrea J. Fuller, MD

1) Pretransfusion testing

    a) When preparing to transfuse blood, draw a blood sample from the patient and send it to the blood bank.

    b) Type and screen

  i) Determines the ABO type and Rhesus (Rh) factor and screen the sample for common antibodies.

  ii) ABO type

(1) Determined by cell surface glycoprotein antigens present on the RBC surface

(2) Patients may be type A, B, AB, or O.

(3) Type O patients lack type A and B antigens.

  iii) Rh factor

(1) 85% of patients have the D antigen from the Rh group and are Rh positive.

(2) Patients who are Rh negative are at risk of alloimmunization (synthesis of antibodies against foreign antigens) when exposed to the D antigen.

  iv) Antibody screen

(1) Commercially available RBC are mixed with the patient’s blood in order to detect antibodies with the potential to cause hemolysis.

    c) Type and cross

  i) Cross-matching the blood involves mimicking the transfusion by mixing the donor’s RBC with the recipient’s blood.

(1) Ensures compatibility of donor and recipient blood samples.

    d) Time to obtain blood

  i) Type and screen can usually be done within 45 minutes and the cross-match within an additional 15 minutes.

  ii) If antibodies are present, these steps can take much longer, especially if the antibodies are uncommon.

    e) Autologous blood donation

  i) If time permits, patients may donate their own blood preoperatively.

  ii) Patients who elect to do autologous blood donation may become anemic and require iron and erythropoeitic agents.

  iii) Autologous blood should be meticulously handled as human errors still occur with its administration.

    f) Directed donor blood donation

  i) A family member or friend may be designated by the patient to donate blood which may be used if needed, provided compatibility can be assured.

  ii) This technique does not decrease the incidence of transfusion-transmitted infection as the patient may not be aware of the donor’s infection status.

2) Packed red blood cells (PRBCs)

    a) The purpose of PRBC transfusion is to increase the O₂ carrying capacity of the blood.

    b) The decision whether to transfuse PRBC is multifactorial. The patient’s coexisting disease and risk of ongoing blood loss should be considered.

  i) For example, a patient with coronary artery disease will likely require transfusion at a lower threshold due to the need to maintain myocardial oxygen delivery.

    c) PRBC transfusion parameters

  i) There is no absolute laboratory value that necessitates blood transfusion.

  ii) Transfusion is rarely indicated for hemoglobin concentrations >10 g/dL (1).

  iii) Transfusion is usually indicated for hemoglobin concentrations <6 g/dL (1).

  iv) Within the range of 6 to 10 g/dL, the risk of ongoing blood loss and patient’s coexisting disease must be considered. For example, patients with coronary artery disease probably should be transfused at a higher hemoglobin than a young, healthy patient.

    d) In the absence of continued blood loss, one unit of PRBC should increase the hemoglobin concentration by 1 g/dL and the hematocrit by 3%.

    e) ABO compatibility

  i) ABO blood type is determined by the presence or absence of A and/or B antigens on the surface of the RBC.

(1) Patients who lack either antigen are Type O.

(2) Patients have circulating antibodies to RBC antigens that they lack.

   (a) For example, Type O patients have circulating anti-A and anti-B antigens and Type A patients have anti-B antibodies.

(3) Type specific transfusion is essential. This is because ABO incompatility leads to immediate and potentially life-threatening hemolysis.

   (a) Type AB patients are universal recipients, and type O donors are universal donors (2).

   (b) If type specific blood is not available, Type O, usually Rh negative, blood may be given.

1) Fresh frozen plasma (FFP)

    a) FFP contains all plasma proteins and clotting factors.

    b) Stored at -18°C to -30°C and must be thawed prior to administration

    c) Indications for FFP

  i) Rapid reversal of warfarin therapy

  ii) Correction of known coagulation factor deficiencies when factor concentrates are unavailable

  iii) Antithrombin III deficiency in patients receiving heparin

  iv) Correction of microvascular bleeding in patients who have been transfused greater than one blood volume

  v) Correction of microvascular bleeding in patients with abnormal coagulation parameters (PT > 1.5 times normal, INR > 2.0, aPTT > 2 times normal) (1)

    d) Recent studies in trauma patients who require massive transfusion have shown decreased morbidity and mortality with earlier administration of FFP (3).

    e) The goal of FFP administration is to achieve 30% of clotting factor concentration. The starting dose is 10-15 mL/kg.

    f) ABO compatibility

  i) Compatibility requirements are different than with RBC because the plasma contains anti-A and/or anti-B antibodies in patients who lack these antigens.

  ii) FFP should be ABO compatible.

  iii) For instance, a patient with type AB blood should receive only type AB plasma, but a patient with type O blood can receive types O, A, B, or AB plasma (2).

4) Platelets

    a) Platelets are usually available in 6 to 9 unit equivalents from pooled donors or from apheresis from a single donor.

    b) Must be stored at room temperature, which increases the likelihood of bacterial contamination and decreases shelf life

    c) One unit usually increases the patient’s platelet count by 5 to 10,000 cells/mm³, while one single donor aphoresis unit increases the platelet count by 30 to 60,000 cells/mm³ in the absence of platelet destruction (4).

    d) Indications

  i) Platelets are rarely indicated if a patient’s platelet count exceeds 100,000 cells/mm³.

  ii) Platelet transfusion should be considered in the presence of excessive microvascular bleeding with platelet counts <50,000 cells/mm (1,4).

  iii) May also be necessary in the presence of platelet dysfunction (anti-platelet therapy, uremia, post-cardiopulmonary bypass) and microvascular bleeding.

  iv) ABO compatibility

(1) Although you can transfuse ABO-incompatible platelets, these cells may have a shorter lifespan than ABO-compatible platelets (2).

5) Cryoprecipitate

    a) Made from slowly thawing FFP

    b) Contains high levels of Factor VIII, von Willebrand factor, and fibrinogen

    c) Indications

  i) Treatment of microvascular bleeding in the presence of fibrinogen deficiency, which most commonly occurs due to disseminated intravascular coagulation (DIC) or massive transfusion

  ii) Treatment of congenital fibrinogen deficiencies or bleeding in patients with Von Willebrand disease, where factor concentrates are unavailable (1)

  iii) Ideally, a fibrinogen level should be obtained before administering cryoprecipitate.

(1) Patients whose fibrinogen concentrations exceed 150 mg/dL usually do not require cryoprecipitate.

(2) When fibrinogen concentrations are <80 to 100 mg/dL, cryoprecipitate is usually indicated (1).

    d) ABO compatibility

  i) Because cryoprecipitate has only a small amount of plasma, ABO compatibility is not necessary (2).

6) Complications of transfusion

    a) Human error

  i) Due to recent advances in detecting potentially infectious agents, complications due to human error are significantly more common than transfusion-related infections.

  ii) Catastrophic outcomes during blood product administration are usually associated with multiple errors during the process (5,6).

  iii) In order to prevent errors, it is critical that all persons involved in administering blood products exercise extreme caution, including verifying blood samples sent to the lab against a patient’s armband and verifying blood prior to transfusion.

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