Fluids

Question 1

what does a crystalloid solution contain?

Answer 1

water, electrolytes (like NaCl), small molecules like dextrose and buffers

Question 2

what are the main osmotically active particles?

Answer 2

electrolytes, glucose, urea (also ketones and mannitol)

Question 3

what is osmolarity?

Answer 3

the concentration of osmotically active particles in a solution, a function of the number of particles, NOT the size, molecular weight, or charge

Question 4

what is an isotonic crystalloid?

Answer 4

a fluid where the concntration of Na and Cl is close to what is in the blood, aka, the intravascular space

Question 5

what are the two scenarios you can use isotonic solutions in?

Answer 5

replacement for hypovolemia, or dehydration

Question 6

what happens when you give isotonic cystalloids?

Answer 6

there is an increase in intravascular volume, which corrects hypovolemia, and then after 45 minutes 75% of the volume will diffuse into the interstitial space and correct dehydration

Question 7

some of the ingredients in isotonic crystalloids are lactate, acetate, and gluconate. what do these do?

Answer 7

they are buffers and they absorb H+ ions to prevent acidosis

Question 8

why are buffers added to fluids?

Answer 8

• many patients are acidotic
• the buffering molecules will produce bicarbonate which will bind to H+ ions and limit a change in pH

Question 9

cystalloids with buffers are called what?

Answer 9

“balanced” crystalloids

Question 10

0.9% NaCl has no buffer. What is the consequece of this?

Answer 10

the increase in Cl- when given will cause a decrease in bicarb, which can cause some acidosis. therefore, not the best kind of fluid to treat shock unless the patient is in hypochloremic metabolic alkalyosis (basic blood)

Question 11

why is potassim added to fluid solutions? can you give potassium as a bolus?

Answer 11

it limits hypokalemia in the patient. it is usually added in amounts equal to the plasma. in small amounts it is okay to be given as a bolus, but if you need to supplement more for a maintenace infusion you can’t give it as a bolus because it will stop the heart

Question 12

why is calcium an ingredient in a cystalloid?

Answer 12

it may improve contractility and vascular tone

Question 13

what is the role of magnesium in a crystalloid?

Answer 13

it is an electrolyte that is commonly low in critical illness so this acts as a supplement to restore those levels

Question 14

what are two examples of ways in which the fluids you give are incompatible with some drugs?

Answer 14

blood products: calcium will precipitate with the citrate in the blood product
medications: potassim phosphate will precipitate with calcium, so you cannot give with ringer lactate

Question 15

what conditions can I treat with isotonic crystalloids?

Answer 15

hypovolemia (fluid remains in the IV space long enough to improve perfusion)
interstisial dehydration (equilibrates between IV and intersitial space within an hour)
NOT good for intracellular dehydration because there is no driving force to move fluids into this space

Question 16

what is a contraindication for giving isotonic cystalloids?

Answer 16

be careful with patients at risk for edema or that might die if edema worsens, for example:
- hypoalbuminemia patients
- patients with anuric renal failure (kidneys can’t excrete)
- patients with cardiac disease
- pulmonary contusions (bruise in the lungs, fluids can cause these to pop and bleed)
- patients with brain injury (can cause increase in intracranial pressure and swelling)
- sepsis (water gets in easier if the patient is in sepsis, increase in increased permeability)

Question 17

if you have to give isotonic fluids to a patient that may be at high risk (like a brain injury or CHF), how might you do this?

Answer 17

you can still give it, but you must do so slowly with very close monitoring

Question 18

can you give hypotonic crystalloids as a bolus? why or why not?

Answer 18

you should not because they can have high potassium content

Question 19

what is a maintenance fluid?

Answer 19

it is the volume and electroyte content that must be consumed to maintain the total body water and electroytes within normal limits

Question 20

what happens when you give hypotonic fluids?

Answer 20

it expands the IV space a little bit, but it very quickly diffuses into the intersitial space and into cells (remember it’s hypotonic, so there’s lots of water, and the osmolarity is higher in the intersitial space and in cells, so the water moves out of the vessels and into where it’s more salty)

Question 21

when should you give hypotonic fluids?

Answer 21

-when a patient needs fluid but they have cardiac disease (you want fluids with low sodium because this is less likely to cause edema, fluid wont stay in the vessels for very long and therefore will not overwhelm the heart)
- if you have a patient with hypernatremia ( provides free water to dilute the sodium)
- if the patient only requires fluid to compensate for normal physiologic losses like urination and panting (like if a dog is having surgery the next day and the dog can’t eat or drink anything but you need to restore these loses)

Question 22

list some advantages and disadvantages of hypotonic crystalloids?

Answer 22

adv: can be used to treat hypernatremia or intracellular water deficits, it is balanced to replace daily metabolic losses, the low sodium decreases risk of volume overload in dehydrated patients with heart disease, compatable with most drugs/solutions for example there is no calcium for things to percipitate out

disadv: cannot use to treat shock, it leaves the IV space too quickly to treat shock

Question 23

what is the effect of giving dextrose IV?

Answer 23

dextrose is immediately taken up by the cells shortly after delivery, leaving pure water to equilibrate between body compartments. therefore, it is considered equivalent to pure water

Question 24

if giving dextrose is the same as giving pure water, why not just give pure water? why bother with the dextrose?

Answer 24

dextrose is added to provide osmolarity

Question 25

can you give IV dextrose in a bolus?

Answer 25

NO! the RBCs will explode from water shifting inside them when given as a bolus/given too quickly

Question 26

can you give dextrose to a hypoglycemic patient?

Answer 26

yes, you can treat the initial hypoglycemia event with a bolus of dextrose 50% and you give this quickly

Question 27

what happens when you give hypertonic fluids?

Answer 27

rapid and significant expansion of the intravascular space. within 45 minutes, 75% of the water will diffuse BACK into the interstitial space

Question 28

what are indications for using hypertonic crystallids?

Answer 28

• hypovolemia
• cerebral edema ( suck all the water out of the brain cells and increase IV volume to prefuse organs elsewhere)

Question 29

what are contraindications for giving hypertonic crystalloids?

Answer 29

• not good for intersitial dehydration (because the water comes from cells and interstitial space)
• not good for intracellular dehydration

Question 30

what are the 5 electrolytes in crystalloids?

Answer 30

sodium, chloride, potassium, calcium, magnesium

Question 31

what is a colloid?

Answer 31

fluid which cntains BOTH large organic macromolecules

Question 32

give examples of natural colloids and synthetic colloids

Answer 32

natural: albumin, fresh frozen and frozen plasma
synthetic: hydroxyl ethyl starch, dextran, gelatin

Question 33

what are some advntages and disadvantages of synthetic colloids?

Answer 33

adv: rapid volume expansion, can be used to treat hypovolemia since the water stays in the IV space longer, can theoretically be used to treat hypoalbuminemia

disadv: causes coagulation issues, causes renal injury, increased morbidity and mortality, concern with dehydration

Question 34

colloids can be used for short term ________ support in anesthesia

Answer 34

blood pressure

Question 35

which is better, 0.9% NaCl or balanced crystalloids?

Answer 35

generally balanced crystalloids are better; NaCl has no buffers so may cause metabolic acidosis

Question 36

what is an indication for using NaCl over a balanced crysalloids?

Answer 36

in hypochloremic metabolic alkalosis

Question 37

what are iogenic osmoles?

Answer 37

they are made by the cells ans contribute to the cellular osmolarity to maintain water content within the cell (keep drawing in water, maintain osmolarity). It takes 24 hours for the body to produce these

Question 38

in cases of water toxicity/severe hyponatremia before the 24 hour mark, did the body have enough time to make intracellular iogenic osmoles?

Answer 38

no, so in these cases you can restore concentration with fluids quickly and not have to worry

Question 39

what happens if you correct chronic (more than 24 hours or unknown) hyponatremia too quickly?

Answer 39

there is a rapid increase in IV osmolarity and it rapidly diffuses into the interstitial space, so there is a shift of water from inside the cells to the interstitial space. this can cause pontine demyelinatin which is irreversible and it is VERY BAD

Question 40

you cannot change sodium concentration more than _______ in a case of chronic hyponatremia

Answer 40

0.5-1mmol/L/hour

Question 41

what happens if you correct chronic hypernatremia too quickly?

Answer 41

it will cause brain cellular edema and neurological signs

Question 42

what is the rate at which you can safely correct chronic sodium disorders (either hypo or hyper)

Answer 42

no more than 0.5 to 1mmol/L/hour

Question 43

if a patient has more than 5-6% dehydration present, can you correct this with SC fluids?

Answer 43

NO!

Question 44

when you’re giving SC fluids, you can give _____ the maintenance requirements at a time

Answer 44

half

Question 45

true or false: you can’t correct more than 5% AND provide 50% maintenance with a single SQ dose

Answer 45

true

Question 46

can you use SC fluids to treat shock?

Answer 46

NO