Bloedprodukten, hemodilutie, autologe en homologe transfusie
Bloedprodukten, hemodilutie, autologe en homologe transfusie
Bloedprodukten, hemodilutie, autologe en homologe transfusie
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<strong>Bloedprodukt<strong>en</strong></strong>,<br />
<strong>hemodilutie</strong>,<br />
<strong>autologe</strong> <strong>en</strong> <strong>homologe</strong> <strong>transfusie</strong><br />
Dr. Dirk Himpe<br />
ZNA MIDDELHEIM ZIEKENHUIS ANTWERPEN
perc<strong>en</strong>tage<br />
gewicht<br />
92%<br />
perc<strong>en</strong>tage<br />
volume<br />
plasma<br />
% gewicht<br />
7% proteine<br />
91% H20<br />
albumine<br />
58%<br />
globulin<strong>en</strong><br />
38%<br />
coagulatie<br />
protein<strong>en</strong> o<br />
4%<br />
bloed<br />
8%<br />
55% plasma<br />
45% cell<strong>en</strong><br />
2% solutes<br />
Cell<strong>en</strong> per mm 3<br />
ion<strong>en</strong>;<br />
nutri<strong>en</strong>t<strong>en</strong>;<br />
gas;<br />
buffers;<br />
Plaatjes 150 - 450 x 10 3<br />
Leucocyt<strong>en</strong> 4,5 – 9 x 10 3<br />
Erythrocyt<strong>en</strong> 4,2 – 6,2 x 10 6<br />
Premature<br />
Newborn<br />
Infant<br />
Adult male<br />
Adult female<br />
100-120 cc/Kg<br />
80-90 cc/Kg<br />
75-80 cc/Kg<br />
70 cc/Kg<br />
65 cc/Kg
Factor VII
POMP
(ρεοσ)<br />
reologie<br />
van bloed<br />
F = Δ p/R = Δp x 1/R<br />
F = Δ p x ( π) x (<br />
1<br />
) x (<br />
r<br />
4<br />
)<br />
8 η L<br />
Poiseuille-Hag<strong>en</strong>
F<br />
V<br />
F<br />
A<br />
v<br />
Y<br />
shear stress = F/A<br />
shear rate = Dv/ Dy = V/Y » flow velocity<br />
viscosity = _____________<br />
shear stress<br />
shear rate
"ketchup"<br />
f<strong>en</strong>ome<strong>en</strong><br />
niet-newtoniaans<br />
Hct 45<br />
newtoniaans<br />
<strong>hemodilutie</strong><br />
Hct 30<br />
postcapillaire<br />
v<strong>en</strong>ul<strong>en</strong><br />
shear rate (<br />
arteries<br />
& arteriol<strong>en</strong><br />
»<br />
flow velocity)
Hint H, AAB 2, p. 119-38 (1968)<br />
Hint H, AAB 2, p. 119-38 (1968)
<strong>hemodilutie</strong> & het hart<br />
maximale zuurstof extractie<br />
dilatatie coronair<strong>en</strong><br />
CAVE<br />
hypovolemie -> tachycardie<br />
infarct: Hct > 28%<br />
randdecomp<strong>en</strong>satie &<br />
globale dysfunctie: Hct>30%<br />
verminderd effect inotropica<br />
Hematocrit > 3O%<br />
Flow of blood<br />
Hematocrit < 25%<br />
Flow of blood<br />
Eberst and Berkowitz, Am J Med, 1994
1. voorkom<strong>en</strong> van bloedverlies:<br />
chirurgische hemostase<br />
medicatie<br />
on-line evaluatie van de stolling met TEG/Sonoclot<br />
patiënt<strong>en</strong> op antico of aspirine tracer<strong>en</strong><br />
techniek anesthesie (?)<br />
2. bloedverlies comp<strong>en</strong>ser<strong>en</strong> met plasma-substitut<strong>en</strong><br />
3. bloedverlies opvang<strong>en</strong> met autoloog bloed<br />
4. verder bloedverlies corriger<strong>en</strong><br />
met veilige <strong>homologe</strong> bloedproduct<strong>en</strong><br />
5. <strong>homologe</strong> <strong>transfusie</strong> (! belang van ‘<strong>transfusie</strong>trigger’)<br />
(6. synthetische zuurstofdragers, recombinant Hb,<br />
erythropoëtine...)<br />
Predeposit - predonatie<br />
Int<strong>en</strong>tionele normovolemische <strong>hemodilutie</strong><br />
Intra-operatieve <strong>hemodilutie</strong><br />
Intra- & postoperatieve bloedrecuperatie
int<strong>en</strong>tionele normovolemische <strong>hemodilutie</strong>
intra-operatieve <strong>hemodilutie</strong><br />
normo/hyper volemie<br />
plasmasubstituut
intra-operatieve <strong>hemodilutie</strong><br />
normo/hyper volemie<br />
plasmasubstituut<br />
ev<strong>en</strong>tueel auto<strong>transfusie</strong><br />
via container of cell-saver<br />
of<br />
compon<strong>en</strong>ttherapie<br />
cell saver
Kwaliteit van auto<strong>transfusie</strong>bloed<br />
overleving:<br />
7-15 d (10)<br />
normaal bloed<br />
overleving 30 d<br />
bloed na auto<strong>transfusie</strong><br />
bankbloed na 10 d<br />
Blood-saving<br />
strategy (HD)<br />
Allog<strong>en</strong>eic transfusion<br />
YES<br />
NO<br />
YES<br />
a<br />
b<br />
NO<br />
Relative Risk:<br />
c<br />
d<br />
Incid<strong>en</strong>ce allog<strong>en</strong>eic transfusion<br />
with a blood saving strategy<br />
Incid<strong>en</strong>ce allog<strong>en</strong>eic transfusion<br />
without a blood saving strategy<br />
a/(a+b)<br />
c/(c+d)<br />
a(c+d)<br />
= 1 1<br />
c(a+b)<br />
Odds Ratio:<br />
ad<br />
bc
Preoperative autologous donation decreases allog<strong>en</strong>eic<br />
transfusion:<br />
results of a meta-analysis.<br />
International Study of Perioperative Transfusion (ISPOT)<br />
Investigators.<br />
n = 933<br />
odds ratio 0.17 (0.08-0.32)<br />
0 0.5 1<br />
Forgie MA et al. Arch Intern Med 1998 23;158(6):610<br />
Does acute normovolemic hemodilution reduce<br />
perioperative allog<strong>en</strong>eic transfusion? A meta-analysis.<br />
International Study of<br />
Perioperative Transfusion (ISPOT) Investigators.<br />
odds ratio 0.31(0.15, 0.62)<br />
24 trials (n=1218)<br />
0 1<br />
Bryson GL et al. Anesth Analg 1998 86(1):9-15
Karl Landsteiner:<br />
(Blood-groups 1901 - Noble-Prize 1930)<br />
“One should never<br />
order or prescribe a transfusion,<br />
unless it is worth the risks...”<br />
Engor<strong>en</strong> et al. Ann Thorac Surg 2002; 74:1 180-6
Bloedcompon<strong>en</strong>t “Therapie”<br />
Bloed -> compon<strong>en</strong>t<strong>en</strong> -> product<strong>en</strong> -> indicaties ?<br />
Product<br />
Volume<br />
Compon<strong>en</strong>t<br />
Indication/<br />
Utility<br />
Whole blood<br />
450-500 cc<br />
Hct. 36-44%<br />
1u =1g/dl Hb<br />
PRBC<br />
200-250 cc<br />
Hct. 70-80%<br />
1u = 1g/dl Hb<br />
Platelets<br />
30-50cc<br />
Platelets<br />
WBC Ag<br />
1u = 5000uL<br />
FFP<br />
100cc<br />
Fibrinog<strong>en</strong>,<br />
clotting<br />
factors<br />
PT, PTT> 1.5<br />
x nl, INR ><br />
1.6<br />
Cryo<br />
precipitate<br />
50-75cc<br />
Factor 8c,<br />
VW factor<br />
Fibrinog<strong>en</strong><br />
Fibrinog<strong>en</strong><br />
replacem<strong>en</strong>t
Definitie<br />
massieve <strong>transfusie</strong><br />
‣ Vervanging totaal bloedvolume in minder<br />
dan 24 uur;<br />
‣ volw: 10-20 units;<br />
‣ acute toedi<strong>en</strong>ing van meer dan de helft<br />
van het geëstimeerd bloedvolume per<br />
uur<br />
1) Hb (O- bloed steeds in stock op OK);<br />
2) Stolling (labo klinisch) -> TEG, Sonoclot;<br />
3) Homeostase (zuur-base, electroliet<strong>en</strong>, COD ...)<br />
POINT-of<br />
of-CARE labo in OK
“synthetic” or “artificial” colloids<br />
Hydrolysis<br />
animal collag<strong>en</strong><br />
Acidhydrolysis and<br />
ethyl<strong>en</strong>oxid treatm<strong>en</strong>t<br />
of corn<br />
B. Leuconostoc<br />
Mes<strong>en</strong>teroides B512<br />
polypeptides<br />
polysaccharides
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