7- Fluid Managment

Question 1

True False:

Females have more H2O by weight ?

Answer 1

False

Males= 60% H2O by weight

Females= 50% H2O by weight

Question 2

What are examples of hypovlemia?

Answer 2

Vomiting, bleeding, diarrhea, sepsis, trauma

Question 3

What are examples of hypervolemia?

Answer 3

CHF, renal impairment, weight gain

Question 4

What are labs seen with hypovolemia?

Answer 4

Increasing hematocrit (dehydration)

concentration alkalosis then metabolic acidosis

Urine specific gravity over 1.010

Urine sodium less 10

urine osm over 450

hypernatermia

BUN:Cr > 10:1

Question 5

what are labs seen with hypervolemia?

Answer 5

increased pulm vascular markings on chest xray

Question 6

What are the two most common crystalloids?

Answer 6

NS

LR

Question 7

What are the advantages of NS?

Answer 7

-preferred for diluting pRBCs due to no Ca2+ and no K+

-preferred in brain injuries

Question 8

What are the disadvantages of NS?

Answer 8

-Large volumes produces hyperchloremic metabolic acidosis

• Hyperchoremia -> low GFR

Question 9

What are advantages of LR?

Answer 9

-More physiologic

-Lactate is converted to HCO3- by liver

Question 10

What are the disadvantages of LR?

Answer 10

Watch K+ in rental patients

CA2+ may cause clotting with pRBCs

Question 11

What crystalloid does not have K+ and Ca2+?

Answer 11

NS

Question 12

What crystalloid is given for its buffer in trauma pts?

Answer 12

LR

Question 13

What is crystalloid is considered more acidic?

Answer 13

NS (PH: 5)

LR (PH: 6.6)

Question 14

intact capillary membranes that contain colloids such as albumin expand plasma volume rather than ICE volume due to?

Answer 14

Oncotic pressure

Question 15

In colloids, albumin concentration is, and how is it derived ?

Answer 15

5% or 25%

usually derived from pooled donated blood
Expensive

Question 16

What is the composition of Colloid (Hetastarch)?

Answer 16

6% hydroxyethyl starch, HES

which is a solution of highly branched glucose chains

Question 17

What is the down sides of using Hetastarch?

Answer 17

it can increase PTT (via factor VIII/ vWF) and clotting times

Anaphylactoid reactions with wheezing and urticaria may occur

may interfere with platelet function

Question 18

What are some contraindications of Hetastarch?

Answer 18

Coagulopathy

Heart faliure

Renal faliure

Question 19

In terms of fluid selection, what are the advantages and disadvantages of using a crystalloid?

Answer 19

Advantages:
-Lower cost
-Readily available

Disadvantages:
-Requires more volume for the same hemodynamic effect
-Shot IV t(1/2) (20-30 min)
-Dilutes plasma proteins-> peripheral/ pulmonary edema

Question 20

In terms of fluid selection, what are the advantages and disadvantages of using a Colloid?

Answer 20

Advantages:
-Restores IV volume and HD with less volume, less time
-Longer IV t(1/2)
-Maintains plasma oncotic pressure
-Less cerebral edema (in healthy brain tissue)
-Less intestinal edema

Disadvantages:
-Expensive
-Coagulopathy (dextran >HRS)
-Potential renal complications
-May cause cerebral edema (in areas of injured brain)

Question 21

How to calculate the fluid maintenance requirement?

Answer 21

4-2-1 Rule

-4ml/kg/hr for first 10kg
-2ml/kg/hr for next 10-20kg
-1ml/kg/hr for each additional kg (above 20kg)
* for pt over 20kg: add 40 to weight in kg

Question 22

How to calculate fluid deficit?

Answer 22

-Multiply maintenance requirement by # of hours NPO
-Give 1/2 over 1st hr, 1/4 over 2nd hour, and 1/4 over 3rd hour

Question 23

What are some ongoing losses to take into consideration when calculating for classical fluid losses?

Answer 23

• Evaporative & intestinal losses (capillary leak)
  -Blood loss
  -Urine output

Question 24

What is a balanced fluid therapy?

Answer 24

-Balanced crystalloid solution
-1-3 ml/kg/hr

Question 25

what is a goal directed fluid therapy?

Answer 25

-Use patient metrics to guide fluid titration

-Vitals (HR & BP trends), urine output, hematocrit, base deficit, serum lactate, response to fluid bolus, central venous variation, pulse pressure variation, respiratory variation of the a-line tracing, physical exam (i.e dry mucus membrane)