Behandeling van ernstig perioperatief bloedverlies

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1 Behandeling van ernstig perioperatief bloedverlies Jente Grietens Promotor: Dr. J. Lauweryns

2 Stolling Vorming van een bloedplaatjesprop Verderzetting van de klontervorming door de stollingscascade Stopzetting van klontervorming door antitrombotische factoren Fibrinolyse van de klonter

3 Stolling Kumar and Clark. In: Clinical Medicine, 7th, Kumar and Clark, Edinburgh 2009; 431:434

4 Stolling Kumar and Clark. In: Clinical Medicine, 7th, Kumar and Clark, Edinburgh 2009; 431:434

5 Coagulatie beïnvloedende factoren Hypothermie ph

6 Circulerend volume Leeftijdsgroep Prematuur Neonaat Zuigeling Kleuter Adolescent Volwassen man Volwassen vrouw Obesitas Circulerend volume ml/kg ml/kg ml/kg 70 ml/kg 70 ml/kg ml/kg ml/kg ml/kg

7 Herstel circulerend volume Eerste uur: 25 ml/kg bij kinderen jonger dan 3 jaar 15 ml/kg bij kinderen ouder dan 4 jaar Volgende uren: Onderhoudsvloeistof + trauma = hoeveelheid vloeistof per uur Onderhoudsvolume = 4 ml/kg/u Onderhoudsvloeistof + mild trauma = 6 ml/kg/u Onderhoudsvloeistof + gemiddeld trauma = 8 ml/kg/u Onderhoudsvloeistof + ernstig trauma = 10 ml/kg/u Vervanging van bloed = 1:1 bij colloïden en 3:1 bij kristaloïden Arya VK. Basics of fluid and blood transfusion therapy in paediatric surgical patients. Indian J Anaesth Sep;56(5):

8 Massieve Transfusie Kinderen: Vervangen circulerend volume over 24u Vervangen helft circulerend volume over 12u Volwassenen: Toedienen van 10 PC over 24u Toedienen van 5 PC over 12u

9 Colloïden vs kristalloïden HES zorgt voor verminderde stolling bij massieve transfusie SOPP heeft minder effect op de stolling Colloïden goed om initieel bloedverlies op te vangen Kristalloïden eerste keus bij vochtresuscitatie

10 Packed cells Kinderen: o Vanaf 15% verlies circulerend volume o Daling van hematocriet onder 24% -> 10 ml/kg PC Volwassenen: o Altijd bij Hb <6 o Grijze zone: 6-10 Hangt af van comorbiditeiten van patiënt (O2 transport, cardiovasculair, bloedverlies, )

11 Fresh frozen plasma Vanaf PT of aptt 1,5x verhoogd Fibrinogeenconcentratie < 1 g/l Massieve transfusie PC -> verhouding 1:1 nastreven Kinderen: ml/kg Volwassenen: fibrinogeenconcentratie 1-2 g/l of normalisatie van TEG

12 Bloedplaatjes Trigger zelfde kinderen als volwassenen: o < 50x10 9 /l Kinderen < 4 maanden: o 5-10 ml/kg -> stijging van x10 9 /l Kinderen > 10kg en volwassenen o 1 unit BP -> evaluatie van bloedplaatjes

13 Novoseven Recombinant geactiveerd factor VII Laatste redmiddel 40 mcg/kg Bij vermoeden van ontwikkelen ernstige coagulopathie Goed alternatief bij patiënten die bloedtransfusies weigeren (vb geloofsovertuiging)

14 Exacyl Antifibrinolyticum Mortaliteit door bloedingscomplicaties daalt Geen verhoogde kans op morbiditeit of mortaliteit door klontervorming 1 g over 10 min en daarna 1 g over 8u

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