Plasma and Colloids

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Plasma and Colloids Dr . Sarah.A.Abdelrazig December 2015

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DEFINITIONS Blood product Any therapeutic substance prepared from human blood Whole blood Unseparated blood collected into an approved container containing an anticoagulant-preservative solution Blood component 1- A constituent of blood, separated from whole blood, such as: Red cell concentrate Plasma Platelet concentrates

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2- Plasma or platelets collected by apheresis 3- Cryoprecipitate, prepared from fresh frozen plasma: rich in Factor VIII and fibrinogen Plasma derivative Human plasma proteins prepared under pharmaceutical manufacturing conditions, such as: Albumin Coagulation factor concentrates Immunoglobulins

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Note Apheresis : a method of collecting plasma or platelets directly from the donor, usually by a mechanical method Processes for heat treatment or chemical treatment of plasma derivatives to reduce the risk of transmitting viruses are currently very effective against viruses that have lipid envelopes: — HIV-1 and 2 — Hepatitis B and C — HTLV-I and II Inactivation of non-lipid-enveloped viruses such as hepatitis A and human parvovirus B19 is less effective.

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Intravenous replacement therapy The administration of intravenous fluids is one of the most common universal intervention in medicine. Colloids are an alternative to the frequently used crystalloids, with highly variable use depending on a myriad of clinical variables. Colloids are considered to have a greater intravascular persistence when compared to crystalloids.

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Colloid solutions A colloid is defined as a high MW substance that largely remain intravascular compartment. Mimic plasma proteins, thereby maintaining or raising the colloid osmotic pressure of blood Provide longer duration of plasma volume expansion than crystalloid solutions Require smaller infusion volumes.

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Colloids are of two types: Natural, i.e., human albumin. Artificial ,i.e. gelatin, dextran solutions & hydroxylethyl staches (HES). Colloids require smaller infusion volumes than crystalloids. They are usually given in a volume equal to the blood volume deficit

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Supplementary infusions will be needed to maintain blood volume in conditions such as: Trauma Acute and chronic sepsis Burns Snake bite.

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Plasma-derived (natural) colloid solutions Plasma-derived colloids are all prepared from donated blood or plasma. They include: Plasma Fresh frozen plasma Albumin These products should not be used simply as replacement fluids. They can carry a similar risk of transmitting infections, such as HIV and hepatitis, as whole blood. They are also generally more expensive than crystalloid or synthetic colloid fluids.

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FRESH FROZEN PLASMA Description Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin Factor VIII level at least 70% of normal fresh plasma level Unit of issue Usual volume of pack is 200–300 ml Smaller volume packs may be available for children

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Infection risk If untreated, same as whole blood Very low risk if treated with methylene blue/ultraviolet light inactivation. Storage At –25°C or colder for up to 1 year Before use, should be thawed in the blood bank in water which is between 30°C to 37°C. Higher temperatures will destroy clotting factors and proteins Once thawed, should be stored in a refrigerator at +2°C to +6°C

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Indications Replacement of multiple coagulation factor deficiencies: e.g. — Liver disease — Warfarin (anticoagulant) overdose — Depletion of coagulation factors in patients receiving large volume transfusions Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenic purpura (TTP)

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Precautions Acute allergic reactions are not uncommon, especially with rapid infusions Severe life-threatening anaphylactic reactions occasionally occur Hypovolaemia alone is not an indication for use Dosage Initial dose of 15 ml/kg

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Administration Must normally be ABO compatible to avoid risk of haemolysis in recipient No compatibility testing required Infuse using a standard blood administration set as soon as possible after thawing Labile coagulation factors rapidly degrade; use within 6 hours of thawing

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Plasma derivatives (Natural colloid) HUMAN ALBUMIN SOLUTIONS Description Prepared by fractionation of large pools of donated plasma Preparations Albumin 5%: contains 50 mg/ml of albumin Albumin 20%: contains 200 mg/ml of albumin Albumin 25%: contains 250 mg/ml of albumin Infection risk No risk of transmission of viral infections if correctly manufactured

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Indications Replacement fluid in therapeutic plasma exchange: use albumin 5% Treatment of diuretic- resistant oedema in hypoproteinaemic patients: e.g. nephrotic syndrome or ascites . Use albumin 20% with a diuretic Although 5% human albumin is currently licensed for a wide range of indications (e.g. volume replacement, burns and hypoalbuminaemia ), there is no evidence that it is superior to saline solution or other crystalloid replacement fluids for acute plasma volume replacement

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Precautions Administration of 20% albumin may cause acute expansion of intravascular volume with risk of pulmonary oedema Contraindications Do not use for IV nutrition: it is an expensive and inefficient source of essential amino acids Administration No compatibility testing required No filter needed

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Synthetic colloid solutions

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COMPOSITION OF COLLOID REPLACEMENT SOLUTIONS Colloid Osmotic pressure ( mmHg Base- mEq /L Cl - mmol /L Ca+2 mmol /L K + mmol /L Na+ mmol /L Fluid 27 Trace amount 145 6.25 5.1 145 Gelatin (urea linked): e.g. Haemaccel 34 Trace amount 125 <0.4 <0.4 154 Gelatin ( succinylated ): e.g. Gelofusine 58 0 154 0 0 154 Dextran 70 (6%) 22 30 110 2 4 130 Dextran 60 (3%) 28 0 154 0 0 154 Hydroxyethyl starch (6%) 27 V V V ( variabe ) <1 130-160 Albumin 5% 27 38-44 97-110 2.2-2.6 3.5-5.5 135-145 Ionic composition of normal plasma

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Key points Replacement fluids are used to replace abnormal losses of blood, plasma or other extracellular fluids by increasing the volume of the vascular compartment, principally in: Treatment of patients with established hypovolaemia : e.g. haemorrhagic shock Maintenance of normovolaemia in patients with ongoing fluid losses: e.g. surgical blood loss.

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Intravenous replacement fluids are the first-line treatment for hypovolaemia . Initial treatment with these fluids may be life-saving and provide some time to control bleeding and obtain blood for transfusion, if it becomes necessary. Crystalloid solutions with a similar concentration of sodium to plasma (normal saline or balanced salt solutions) are effective as replacement fluids. Dextrose (glucose) solutions do not contain sodium and are poor replacement fluids.

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Crystalloid replacement fluids should be infused in a volume at least three times the volume lost in order to correct hypovolaemia . All colloid solutions (albumin, dextrans , gelatins and hydroxyethyl starch solutions) are replacement fluids. However, they have not been shown to be superior to crystalloids in resuscitation. Colloid solutions should be infused in a volume equal to the blood volume deficit.

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Plasma should never be used as a replacement fluid. Plain water should never be infused intravenously. It will cause haemolysis and will probably be fatal.

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