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A
,
B|BRAUN
B|BRAUN
100% = 600 / = 60%
~ 1/3
~15%
~ 2/3
~5%
B|BRAUN
+
.
~1-3%
Mo
0.1 nm
1 nm
10 nm
: 25-50
nm
100 nm 1 m
10 m
100 m 1 mm
: 3 nm
B|BRAUN
(posm)
, ,
(
)
,
.
B|BRAUN
(posm)
posm
B|BRAUN
(pcop)
:
( )
,
,
.
B|BRAUN
(pcop)
pcop
B|BRAUN
=
=
B|BRAUN
-( )
(mm Hg)
300
200
()
100
RV
~ 60 ml
SV
~ 70 ml
50
SV
~ 90 ml
RV
~ 90 ml
0
100
150
200 (ml)
B|BRAUN
B|BRAUN
Co
(mmol/l)
(mmol/l)
(mmol/l)
Ma
(mmol/l)
(mmol/l)
(mmol/l)
(mmol/l)
pH
(mOsm/l)
O (mm Hg)
COP
e
141
4
2.5
1
103
1
25
7.4
280
25
143
4
1.3
0.7
115
1
28
7.4
280
4
B|BRAUN
10
155
<0.001
15
8
65
10
7.2
280
?
: -
: -
B|BRAUN
To
B|BRAUN
,
,
280 mOsm/l
B|BRAUN
Na
( Na )
( )
( Na )
B|BRAUN
Na
( Na )
B|BRAUN
B|BRAUN
5%,10%,20%
(,
,
,
-
(,
,
)
(
,
,
,
,
,
(,
,
)
VIII
,
(,
(,
(,
)
(,
)
B|BRAUN
G
()
B|BRAUN
B|BRAUN
~ 130-155 mmol/l
~ 20%
~ 30 min
B|BRAUN
30%, 5
30%,
.
12
10
8
6
4
10
20
30
40
50
60
70 (%)
B|BRAUN
B|BRAUN
B|BRAUN
> 15%
B|BRAUN
~ 130-155 mmol/l
B|BRAUN
, ,
, ,
(. )
(.
)
-
B|BRAUN
69 000 Dalton
: 14.1 x 4.2 nm
~ 50 g/l (~ 60% of plasma protein) but
~ 22 mm Hg (~ 80% of COP)
,
(. ,
)
B|BRAUN
0.2 /
2.0 /
0.2 /
1.5 /
1.5 /
B|BRAUN
(. )
B|BRAUN
B|BRAUN
.
:
,
(:
)
- (:)
( )
B|BRAUN
"leuconostoc mesenteroides"
40 000 70 000 Dalton
1000
B|BRAUN
()
C2, C3, C6
a-
B|BRAUN
R1 =
-CH2- CH2-OH
6
CH2-O-R1
H
4
R2-O
R2 =
O-CH2- CH2-OH H
2
H
O-R2
O-CH2- CH2-OH
B|BRAUN
(M)
()
M = 6/10 = 0.6
-CH2- CH2-OH
B|BRAUN
= 5/10 = 0.5
1.9
33.3
0
2.0
28.5
<5
2.0
29.0
0
B|BRAUN
2.1
45.6
0
Rheomacrodex
Macrodex
Company
Concentratio (g/l)
n
(Dalton)
Mw
40 000
70 000
(Dalton)
27 000
35 000
1.5
2.0
Mn
Mw/Mn
100
60
Na+
(mmol/l)
154
154
Cl-
(mmol/l)
154
154
5.0 + 0.5
5.0 + 0.5
300
315
4.4
2.7
90
55
pH
Osmolarity
(mOsm/l)
Relative viscosity
CO
P
(mm Hg)
B|BRAUN
Rheohes
B. Braun
(g/l)
(Dalton)
(Dalton)
Mw/Mn
60/100
Elohes
Freseniu
s 60
70 000
40 000
200 000
1.75
60
Hemohes
B. Braun
100
60
200 000
250 000
450 000
80 000
60 000
63 000
71 000
2.50
3.33
3.97
6.34
0.45
0.70 0.80
0.54
MS
DS
0.5
0.5
3.2 : 1
4.5 : 1
9.0 : 1
0.5
C2/C6 ratio
Pentaspa Hespan
n Pont
Du
Du Pont
Na+
(mmol/l)
154
154
154
154
154
Cl-
(mmol/l)
154
154
154
154
154
pH
Osmolarity
6.0 + 1.0
(mOsm/l)
5.5 + 1.5
6.0 + 1.0
5.5+ 1.5
7.3 + 0.3
320
310
308
310
310
Relative viscosity
1.5
1.9/3.7
2.0
COP
24
25 - 30 (6%)
60 - 80 (10%)
25 - 30
70 - 80
25
(mm Hg)
B|BRAUN
3.5 %
~70%
3-4% .
6% 200/0.5
~ 100%
6% 70
6% 200/0.62 and 450/0.7
10% 200/0.45 and 0.5
~ 145%
10% 40
~ 170%
(%)
0
50
100
150
B|BRAUN
200
3.5 %
~ 1-2 h
3-4% .
6% and 10% 200/0.45 and 0.5
10% 40
~ 3-4 h
6% 70
~ 5-6 h
~ 6-8 h
(h)
0
B|BRAUN
( )
,
,
450/0.7
B|BRAUN
(~ 95%)
(~5%),
2/3
,
1/3
( 40)
(70)
B|BRAUN
, ,
.
,
,
, .
.
These effects are stronger with dextrans than with HES
Interference with blood typing and crossmatching is
possible with dextrans and with HES 450/0.7
B|BRAUN
Gelatins
HES 200/0.5
HES 450/0.7
Dextran 40
Dextran 70
B|BRAUN
Synthetic
Dose of colloid
colloidal volume on 1st day of
replace-ment fluid therapy
Dextran 40
Dextran 70
HES 200/0.5
HES 450/0.7
Gelatins
Dose of colloid
on consecutive
days of therapy
0.6 g/kg bw and
day
0.6 g/kg bw and
day
2.0 g/kg bw and
day
1.2 g/kg bw and
day
no limit
B|BRAUN
B|BRAUN
75 + 25
= 100%
1/3 = 33%
Na+ ~ 0 mmol/l
25 +
2/3 = 66% = 33%
66%
B|BRAUN
(%)
100
Plasma
50
Buffy coat
B|BRAUN
B|BRAUN
Blood flow
Depends on heart function, blood pressure, volaemia, and
blood viscosity. Its is specially important that blood flow is
maintained in the capillaries (microcirculation)
B|BRAUN
O2
O2
O2
SvO2 = 75%
D02 ~ SV x HR x caO2
SaO2 = 100%
O2
O2
O2
O2
B|BRAUN
Body tissue
OER = 25%
O2
O2
O2
O2
O2
O2
SvO2 = 75%
D02
~ SV x HR
Body tissue
OER = 25%
x c a O2
SaO2 = 100%
O2
O2
O2
O2
O2
O2
O2
O2
B|BRAUN
120
100
80
60
40
20
0
0
10
20
30
40
50
60
70
80
(%)
B|BRAUN
Haematocrit
(%)
Change
CO ( = SV x HR )
150
HR
100
SvO
2
50
(g/dl)
7.5
Haemoglobin
15
B|BRAUN
Relative viscosity
10
9
8
Normal blood
7
6
5
4
Plasma
3
2
1
Water
0
10
20
30
40
50
60
70 (%) Haematocrit
B|BRAUN
Relative
viscosity
103
Haematocri
t
25%
102
40%
101
60%
100
0.01
0.1
10
100 x 10-5
(N/cm2)
B|BRAUN
Shear stress
Haemodilution
Haematocrit
Stroke
volume
DO2
Blood
viscosity
Cardiac
output
SV
Cardiac
preload
Oxygen
delivery
HR
B|BRAUN
c a O2
O2
O2
O2
SvO2 = 75%
D02
~ SV
x HR
x c a O2
SaO2 = 100%
O2
O2
O2
O2
B|BRAUN
Body tissue
OER = 25%
B|BRAUN
Hypovolaemia
Condition of lack of fluid in the vascular system
Absolute hypovolaemia
Relative hypovolaemia
B|BRAUN
Shock
Condition of profound haemodynamic and metabolic disturbance characterised
by failure of the circulatory system to maintain adequate perfusion of vital
organs
Cardiogenic
shock
Acute ventricular
insufficiency
Increased capacity
of vascular system
B|BRAUN
Hypovolaemic shock
with absolute
hypovolaemia
Haemorrhagic
shock
Traumatic
shock
Visible blood
losses through
wounds
Invisible internal
blood losses after
trauma
Shock after
burns
Plasma losses into
burn blisters
B|BRAUN
Shock from
dehydration
Losses of water
and electrolytes
with diarrhoea,
vomiting or fistulae
Hypovolaemic shock
with relative
hypovolaemia
Septic
shock
Anaphylactic
shock
Vasodilation as a
consequence of
sepsis
Vasodilation as a
consequence of
anaphylaxis
Neurogenic
shock
Vasodilation due to irreversible interruption of the regulation of intravascular
tone by the central nervous system after
cerebral or spinal trauma
B|BRAUN
Hypovolaemia
Blood
pressure
Venous
return
Cardiac
output
Sympathetic
activity
Vasoconstriction
Decreased perfusion
in stomach,
intestine, liver,
kidneys, muscle and
skin
Maintained perfusion
in brain, heart and
lung
B|BRAUN
Activation of
renin-angiotensin-aldosterone-system
Reduced blood
flow with rouleau
formation in the
capillaries
Uncompensated
hypovolaemia
Hypoxia, specially
in areas with
reduced perfusion
Acidosis and
endothelial
damage
Activation of
blood coagulation
Further
deterioration of
microcirculation
Multiple organ
failure and death
B|BRAUN
( Committee on Trauma American College of
Surgerions W B Saunders 1982)
15
II
20 - 25
III
-
,
(<400/)
30 -40
IV
40
B|BRAUN
Clas
s
I
II
III
IV
Blood
loss
< 15%
BP
HR
sys dia (per min)
n
0.75-1.5 l
30-40%
1.5-2.0 l
> 40%
> 2.0 l
Cap
. ref.
Respiration
Urine prod.
(ml/min)
80-100
~ 0.8
> 30
100-120
~ 1.0
> 2s
30-20
120
~ 1.1
> 2s
> 20/min
20-10
< 0.75 l
15-30%
SI
> 120
~ 1.5
B|BRAUN
10-0
Clas
s
Blood
loss
< 15%
< 0.75 l
Extremitie
s
Complexion
Mental
status
normal colour
normal colour
alert
II
1530%
0.75-1.5
l
pale
pale
III
3040% l
1.5-2.0
pale
pale
ashen
IV
> 40%
> 2.0 l
anxious and
aggressive
anxious and aggressive
or sleepy
sleepy, confused or
unconscious
B|BRAUN
Critical value
up to
15%
I
up to
30%
up to
40%
up to
60%
None. Compensation
normally possible
Volaemia
< 90% of normal
II
III
Colloidosmotic
pressure
< 20 mm Hg
Consequen
ce
None or transient
hypotension
Reduced cardiac
output
Insufficient oxygen
transport capacity
Risk of pulmonary
oedema
Coagulation factors
up to
80%
Disturbances of blood
coagulation
more
than
Platelets
< 50.000/mm3
80%
B|BRAUN
Problem
I
up to
30%
Measure
up to
40%
up to
60%
II
III
Total protein
< 50 g/l
I I + improve colloidosmotic
pressure with colloids
(human albumin ?)
Coagulation factors
I I + coagulation factors
(fresh frozen plasma)
up to
80%
more
than
80%
Platelets
< 50.000/mm3
I I + coagulation factors
(fresh frozen plasma) +
platelets or fresh blood ( 48
h old)
B|BRAUN
B|BRAUN
Definition :
Intravenous administration of liquid suitable for the
replacement of intravascular fluid
Aims :
To prevent or treat hypovolaemia in order to avoid its clinical
consequences
B|BRAUN
B|BRAUN
B|BRAUN
Volume replacement a)
Blood losses
Class
% of total blood
approx. in l
e. g. with Gelofusine
< 15 %
< 0.75 l
0.5 - 1.0 l
II
15 % - 30 %
0.8 - 1.5 l
1.0 - 2.0 l
III
30 % - 40 %
1.5 - 2.0 l
2.0 - 2.5 l
IV
> 40 %
> 2.0 l
> 2.5 l
B|BRAUN
(mm Hg) or
(beats x min1)
140
The normalisation of
systolic blood pressure
and heart rate, as shown
here, is found normally
when blood losses are
less than 20% of total
blood volume, and the
patient is no longer
actively bleeding
BPsys and HR
120
100
80
60
40
20
Systolic BP
0
0
60 min
B|BRAUN
Heart rate
(mm Hg) or
(beats x min1)
140
Typical behaviour of
systolic blood pressure
and heart rate after
volume replacement in
patients with blood
losses of more than
20% of blood volume
and still actively
bleeding
BPsys and HR
120
100
80
60
40
20
Systolic BP
0
0
60 min
B|BRAUN
Heart rate
(mm Hg) or
(beats x min1)
140
Typical behaviour of
systolic blood pressure
and heart rate after
insufficient volume
replacement, our in
patients bleeding more
quickly than volume
replacement fluids can
be administered
BPsys and HR
120
100
80
60
40
20
Systolic BP
0
0
60 min
B|BRAUN
Heart rate
2a
Blood-saving techniques
Intentional normovolaemic haemodilution
B|BRAUN
B|BRAUN
B|BRAUN
Haemodilution
Reduction of haematocrit with increase of the
liquid phase of blood
Hypovolaemic
haemodilution
Normovolaemic
haemodilution
Hypervolaemic
haemodilution
Reduced volaemia
Maintained volaemia
Increased volaemia
B|BRAUN
Vdraw =
B|BRAUN
B|BRAUN
preoperative haemodilution
500
ml
blood
Out
operation
500
ml
blood
Monitor.
0
In
10
20
500
ml
coll.
30
40
50
500
ml
coll.
60
70
(min)
Coll. if
required
B|BRAUN
Colloids and
PRBC as
required
Fluid balance
Y. J. Mortelmans et al., Anesth. Analg. 81 (1995) 1235-1242
B|BRAUN
2b
Blood-saving techniques
Tailored haemotherapy
B|BRAUN
Problem
I
up to
30%
Measure
up to
40%
up to
60%
II
III
Total protein
< 50 g/l
I I + improve colloidosmotic
pressure with colloids
(human albumin ?)
Coagulation factors
I I + coagulation factors
(fresh frozen plasma)
up to
80%
more
than
80%
Platelets
< 50.000/mm3
I I + coagulation factors
(fresh frozen plasma) +
platelets or fresh blood ( 48
h old)
B|BRAUN
<15
(0.75l)
FFP
PP
Ia 1-2 l
15-30
( 0.75
-1.5 l)
30-40
(1.5
-2.0 l)
Ib
1-2 l
1-2 l
II
1-2 l
1-2 l
1u
III
1-2 l
1-2 l
1-3 u
IV
1-2 l
1-2 l
3-6 u
1u
1-2 l
1-2 l
7-X u
2-X u
40-60
(2.0
-3.0 l)
(1 u)
60-80
(3.0
-4.0 l)
> 80
(> 4.0 l)
Control : Hc = 25-30%,
Hb = 7.5-10g/dl,
B|BRAUN
As
required
1 u = 250 ml
B|BRAUN
B|BRAUN
B|BRAUN
Origin
Periodical or continuous invasion of pathogenic bacteria or
their toxins, coming from a septic focus, into blood stream
Characteristics
Increased CI and VO2 , except in the final stage
Reduced vascular resistance
Disturbance of the regulation of microcirculation
Disturbance of oxygen extraction
B|BRAUN
Grade
II
III
HR
MAP
PAP
PAOP
SVR
CI
Oxygen extraction
Lactate in serum
B|BRAUN
IV
B|BRAUN
yes
Opt. goals
Re-evaluate
and recycle
no
2 PAOP > 20
no
4
no
yes
Lasix, PEEP, stop fluids
PAOP > 20
Blood or PRBC
5
CI, DO2
yes
Hct < 33
yes
Cardiac
consult
yes
Titrate fluids (15 < PAOP < 20)
no
Fluids
6
no
no
7
70 < MAP < 100
yes
Inotrope
8
CI , DO2
yes
no
no
10
yes
Vasodilator
no
13
MAP < 70
no
yes
Vasopressor
yes
yes
Opt. goals
9
yes
Opt. goals
no
B|BRAUN
29%
16%
0
p < 0.05
B|BRAUN
B|BRAUN
B|BRAUN
B|BRAUN
B|BRAUN
B|BRAUN
B|BRAUN