Nutrition, Fluids, Electrolytes,

Acid-Base, and blood trnsfusion

Residents lecture
Muhammad Al-Kofahi
 Nutrition
• 12 hrs after meal it will be totally absorbed.
• Then insulin decrease, glucagon increased
• Result in glycogenolysis from liver about 200 gm.
• Early obligatory glucose dependent organs: brain, WBCs, RBCs, renal
medulla.
• Muscle glycogen, 500 gm, converted to lactate then in cori cycle to
glucose.
• After 24 hrs gluconeogenesis from skeletal muscles.
• This reversed by glucose administration.
 Nutrition
• 48-72 hrs fat breakdown and ketoadaptation reduces muscle
breakdown.
• Decrease in conversion of T4 to T3, decreases basal metabolic rate.
• Still obligatory glucose requirements 100gm per day.
• Energy preservation mode in starvation, the problem in dieting
• Resting expenditure decreases from 25-30 kcal \ kg\day to 15-20.
 Response to sepsis or trauma
• Increase adrenalin, noradrenalin, cortisol, glucagon and GH.
• Increase energy expenditure to 40 kcal\kg\day.
• Increase nitrogen (protein) requirements.
• Insulin resistance, hyperglycemia.
• Increase gluconeogenesis from proteins.
• Loss of ketoadaptation.
 Nutritional assessment
• Lab. : not reliable.
• Weight : loss more than 10% over 6 months
• BMI less than 18.5
• BMI less than 15 indicates bad prognosis.
• Mid arm circumference and skin fold for follow up.
 Nutrition
• Entral is preferred over parenteral.
• If expected NPO for more than 5 days start parenteral.
• Parenteral : cannot have enteral or not benefitted or enough.
• Water,
• Macronutrients: carbs, fat, proteins.
• Micronutrients: vitamins, electrolytes, trace elements.
• Overfeeding is the commonest cause of complications.
• Energy: 1300-1800 daily, glucose and fat, no fixed percentages.
 Nutrition
• Enteral: sips, fine bore nasogastric or enteric, gastrostomy,
jejunostomy.
• Parenteral: peripherally inserted CVL for up to 2 weeks, or
classical CVL.
 Complications of parenteral nutrition
• Related to underfeeding, general or specific.
• Related to overfeeding.
• Related to catheter.
• Sepsis.
 Refeeding syndrom
• Sever fluid and electrolytes shift in malnourished patient
under nutritional therapy.
• More in parenteral nutrition.
• Decrease PO4, Ca, Mg.
• Myocardial, respiratory, liver, neurological dysfunction and
death.
• Prevention: increase calories slowly, give regular
supplements of electrolytes, vitamins and trace elements.
 Fluids and electrolytes
• Water losses
• Urine: 1500.
• Skin 600, increases in hot climate
• Lung 400 increases on dry air and tracheostomy,
• Feces 100.
• A minimum of 400cc urine daily is needed to excrete protein end
catabolites.
 Daily electrolyte requirements
• Na 1 – 1.5 mmol per kg
• K 1 mmol per kg
• Ca 5 mmol total ( 2.5 meq.).
• Mg 1 mmol.
• Body fluids: saliva high k low Na.
stomach high Cl
pancreas high in HCO3
 Fluids
• Body fluid compartments.
• Water content decreases with age.
• Water more in males.
• Pediatrics : 100, 50, 20
• Adults: 40cc \kg\day.
• Needs: maintenance+ dehydration + ongoing loss.
 Dehydration
• Mild: history of fluid loss, 3% of body wt.
• Moderate :> 2 signs except hemodynamic and neurological, 6%.
• Sever : hemodynamic or neurological signs, 9%.
• Na : mild 3, moderate 6, sever 9 mmol per kg.
• Cation = +ve charge, anion= -ve charge.
• Mole = number of avocado of molecules.
• Equivalent= mole by number of charges.
 Fluid and electrolytes
• Eg: 70 kg, Na 140, mild dehydration, NG tube
water maintenance 40x70 = 2800 cc
dehydration 3/100 x70 000 = 2100
total about 5 000cc
Na maintenance 100 meq
dehydration 3 x 70 = 210
total about 3000
obligatory glucose 100gm
• 2 L NS, 3 L GW 5%, plus NG replacement by ½ GS.
• If hyponatremia eg 125, add NaCl
135 – 125 = 10 x 0.6 ( volume of distribution) x 70 =420
420+300 = 720
5 L GS 0,9%.
• Another method
• Maintenance 1L NS, 2L GW 5%
• Replace deficit if isotonic by isotonic NS + ongoing loss
• In hypertonic dehydration initial resuscitation by NS, then ½ GS,
correction not exceeding 12 meq per 24 hours.
• NB: don’t give k in dehydrated patient and in the first 24 hours after
surgery.
 Acid-base balance
• pH 7.35 – 7.45
• PCO2 35 – 45 mmhg
• [HCO3] 20 -28 mmol/L
• Acidemia pH < 7.35, alkalemia pH > 7.45
• In metabolic imbalance, respiratory system responds to restore Ph in
12 to 24 hrs, but it will NEVER OVER CORRECT OR EVEN NORMALISE
the pH .
 Acid - Base
• Kidney compensates to respiratory acidosis by excreting H+, so
increasing HCO3.
• Kidney compensates for respiratory alkalosis by excreting HCO3.
• Mixed acid base disturbance
Eg 1 : patient with COPD and heart failure, has respiratory acidosis from
his lung problem and metabolic alkalosis from use of furosemide, but
either acidemia or alkalemia.
Eg 2 : patient sever pneumonia and septic shock may have both
metabolic and respiratory acidosis .
 Compensation
• Metabolic acidosis: decrease PCO2
PCO2 = 1.5 x [HCO3]+8
• Metabolic alkalosis : increase PCO2 by 7 mmHg for each 10 meq/L
increase in [ HCO3].
• Acute respiratory acidosis: increase [ HCO3] by 1 mmol/L for each
10mmHg increase in PCO2.
• Chronic respiratory acidosis: increase [HCO3] by 3.5 mmol /L for each
10 mmHg increase in PCO2.
 Compensation
• Acute respiratory alkalosis: decrease [HCO3] by 2 mmol/L for each 10
mmHg decrease in PCO2.
• Chronic respiratory alkalosis: decrease [HCO3] by 4 mmol/L for each
10 mmHg decrease in PCO2.
 Acid- Base
• Anion gap= [Na]- [Cl]- [HCO3]
• Normal range 4 – 11 mmol/L
• It is the difference between the unmeasured cations( K, Mg, Ca) and
unmeasured anions ( phosphate, nitrate, sulphate, proteins).
• When other anions present, or the unmeasured increase wide anion
gap appears.
• Eg: lactic acidosis, ketoacidosis, alcohol toxicity, salicylic acid
overdose.
 Causes of metabolic acidosis
• Loss of bicarbonates: diarrhea, pancreatic fistula.
• Exogenous acids: methanol and drug toxicity.
• Endogenous acids: lactic acidosis, ketoacidosis.
• Impaired renal acid excretion: renal tubular acidosis, urinary diversion
to GIT.
 Autologous blood donation
• Same person
• Preoperative: starting donation 40 days prior to scheduled operation
and donates every 3 to 4 days up to 5 units.
Hb should be at least 11gm /dL.
Recombinant erythropoietin can be used.
• Intraoperative: blood collected in a cell saver, washed and retranfused
Contraindicated in malignancy, field contamination or sepsis
 Allogenic blood donation
• Relative or a friend.
• Therapeutic donation.
• General donor.
 Contraindications for blood donation
• Hb < 12 gm/dL.
• Age below 18 or above 65 years (relative)
• Malignancy except BCC or cured for 5 years.
• Sepsis or TB.
• Medical illnesses that prevent donation as ischemic heart disease.
• Specific infections.
• Pregnancy.
 Indications for blood transfusion
• Improving oxygen carrying capacity
Note decrease 2,3 DPG and deformed RBCs.
• Treatment of anemia, if Hb < 7gm/dL.
Higher level for patients with ischemic heart disease or failure.
• Volume replacement.
• FFP and others to provide clotting factors and proteins.
• WBC and platelets for deficiencies>
 Blood transfusion
• 1 unit of whole blood up to 450cc.
• Each unit screened for hepatitis B and C, HIV1, HIV2, syphilis.
• Blood depleted from WBCs as a precaution against Creutzfeldt-Jacob
disease.
• ABO and Rhesus D groups identified.
• Whole blood: now is rarely used in civilian practice, shelf life 42 days.
 Packed RBCs
• Each unit about 330cc.
• Hematocrit 50 – 70%.
• Stored with SAG-M ( saline, adenin, glycin, mannitol).
• Shelf life 5 wks.
• Stored at 2 to 6 C.
• Leukocyte reduced RBCs: 99.9% of WBCs and platelets removed.
• Leukocyte reduced washed RBCs: additional washing with saline
To reduce transfusion reaction and alloimmunization for HLA type1
antigens, and CMV transmission.
 FFP
• Stored at -40 to -50 C.
• Shelf life 2 years.
• Rh D +ve FFP can be given to Rh D –ve patients, but in large amounts
may cause seroconversion.
• It is the usual source of vit. K dependent clotting factors.
• It is the only source of factor V.
• Thawed FFP can be used up to 5 days.
 Blood products
• Cryoprecipitate: it is the supernatant of FFP.
Rich in factor VIII
Stored at -30, shelf life 2 years.
• Platelets concentrates: Pooled concentrates, about 50 cc
Each contains 250 000 000 000 platelets.
Stored at 20 – 24 C, so may transmit bacterial infection.
Indications: sever thrombocytopenia or platelets dysfunction.
 Blood products
• Prothrombin complex concentrates
Highly purified prepared from pooled plasma.
Factors II, VII, IX, X.
Indicated for emergency reversal of warfarin toxicity.
• Recombinant DNA clotting factors
Don’t transmit infections
Complications of single unit blood transfusion
• Incompatibility: acute hemolytic reaction.
• Delayed hemolytic reaction.
• Febrile reaction.
• Allergic reaction.
• Infections: bacterial, hepatitis, HIV, other viruses, malaria.
• Air embolism.
• Thrombophlebitis.
• Transfusion related acute lung injury, usually from FFP.
 Complications of massive transfusion
• Coagulopathy.
• Hypocalcemia.
• Hyperkalemia.
• Hypothermia
• Iron over load in chronic repeated transfusions.
 Blood transfusion
• Massive transfusion protocols, no definite consensus, but 1 :1:1
PRBC: FFP: Platelets may be acceptable.
• Blood substituents: either biomemitic hemoglobin based or abiotic
perflurocarbone based.
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