Is any one observing that intraoperatively patients are being given so much fluid that dilutional anemias are resulting? If so what kind of training do you give to the anesthesia department to be more conscious of fluid (especially crystalloids) volume?

In my experience it is the type of solution that is used that is more of the issue. Some contribute to anticoagulation issues more than others. But to answer more directly I guess it would have to be "education, education, education" and usually from published studies. Dilutional #'s can be up to 20% of your drop.

Gail:
We always have dilutional anemia unless the physician uses colloids and not crystalloids which usually does not happen. We just know that as long as it is not a large amount that it doesn't change what the hemoglobin really is. In other words if it is 9.0, it is 9.0 even though there is a large amount of fluid in it that is telling you the hgb is 8.0 or 7.0. The fluid does not change the red cell (RBC)count even when the RBC's have much fluid around them. The oxygenation of the patient also does not change unless there is just a large amount of fluid and the patient is fluid overloaded. Remember during anemia in the normal person, when the hgb drops the body automatically compensates by dumping more fluid into the vascular system thus changing the viscosity of the blood by making it less thick and that causes your RBC's to go to the microcirculation even faster thus oxygenating your patient even thought the hemoglobin is low. This is a good thing as long as it is not too much. Our cardiac surgeons are the ones most concerned about fluid overload and they are also the best when it comes to not having a large dilutional anemia post surgery. We wait until after the patient starts to diurese and as long as there is no cardiac problems or renal problems to prevent the diuiresis then we let it go.

__________________
Elora Thorpe RN BSN
Coordinator
Blood Conservation Program
St. Luke's Hospital of Kansas City
Kansas City, MO. 64111
816-932-6183

I think it would be a good idea to obtain a whole blood volume & red cell volume before and after surgery; so that there is no guess work. You will know whether there is dilutional anemia or tue anemia or even hypovolemia with red cell deficit.

If BVAGUY wants to get whole blood volumes before and after surgery, perhaps you should contact Daxor Corporation. They have a device for blood volume management. Contact Richard Loftus at 818 774-3268

Nanuke said:
"In my experience it is the type of solution that is used that is more of the issue. Some contribute to anticoagulation issues more than others. "
I would appreciate it if you would expand on this a little. What, in your experience, is used that causes or contributes to dilutional anaemia?
My son was given large amounts of colloids and crystaloids before his op to reduce fractures of the femur, tibia and fibula of his right leg.
He died following the surgery and the cause of death was given as Severe Dilutional Anaemia.
I am interested in learning whether the type of fluid given could have contributed to his death.

First I am truly sorry about your loss. Second there are a million different things that can contribute to "dilutional anemia adverse outcomes". The list is quite long. There is a reason that trauma and emergency care comes with a large amount of problematic areas. The literature is just starting to get more vigorous about looked at the type of fluid that is used in large quantity resuscitation efforts. You state "was given large amounts of colloids and crystaloids before his op to reduce fractures of the femur, tibia and fibula of his right leg". The cause of his demise was probably due to numerous issues secondary to his fractures. When a large bone fracture such as that occurs there is a large amount of blood loss. Therefore unfortunately since there are so many things that might have cause it, you would have to address all of them. There are many life threatening perioperative complications that come from that type of injury. Again I am sorry I can't assist you more, and sorry for your loss.

I am sorry about your loss. It is a fine balancing act with fluid resusitation. Recent journal articles have demonstrated their is no difference in mortality between the use of saline solution and albumin. I hope this will give you a measure of comfort. It sounds like the physicians were trying to keep his volume up which is very important. When the hemoglobin drops below 5 things can become very unstable. Was your son at an institution that had an active bloodless program? My first husband was killed by a drunk driver. It seemed I had to know every little detail. Perhaps it was a way of working though the stages of denial and guilt. So, a truly understand your search for answers. And, a sudden loss like this does set you up for more complicated grief. If you would like the reference for the trauma article please let me know. Wishing you a good support system. yvette bunch

Spartanburg Regional HealthCare System
Bloodless Medicine and Surgery
101 E. Wood Street 3N
Spartanburg, SC 29301

ybunch@srhs.com

__________________
Yvette Bunch

Thank you Trudi and Yvette. David died nearly ten years ago and there were many unresolved issues regarding the treatment he received in hospital. The reason why the fluid question is important is that David's Hb was 12 when he went into the hospital and all his other tests were well within the accepted parameters for a 17 year old. Between 9pm and 11pm he was given seven litres of fluids. His fractures were all closed fractures and so blood was lost internally in his leg. The surgeon estimated that he had lost two litres of blood by 11pm.
For some reason, no fluid balance chart was kept. (Or it "went missing" we are not sure which.) I would like to know how they knew how much fluid to give him, and why they gave someone with a Hb of 12 any fluids at all?

Blood pressure is a one of the key elements in fluid resuscitation. The
resuscitation fluid then has to be balanced with kidney output. Generally,
it is better to keep a patient "wet". It would be standard protocol to
start a trauma patient on fluids to try to prevent shock, which in itself is
life threatening. The average adult has 6 to 8L=1000 mL or 10 pints of
blood. So, he had lost a great deal of blood. Blood is so
complex--nutrients, hormones, proteins, electrolytes it is hard to know
exactly what happened. Did you have an autopsy performed? There could be
other unknown factors. I always hate those types of injuries, because they
are very unpredictable. Other factors like is the patient kept warm enough
also play a role. We now know that if a person is not kept warm enough,
they tend to bleed more. We have come a long way in the last 10 years in
blood management. However, that really does not help your heart. My
husband's name was also David. It means "beloved", which seems to fit your
David as well as mine. Hope this helps, at least some. yvette

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Yvette Bunch