Mar: Sem 3 - Principles I > Final- Perioperative Fluid Therapy > Flashcards

Final- Perioperative Fluid Therapy Flashcards

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1
Q

What percentage of total body weight is water?

A
  • 60%
  • Elderly and Obese patients will have lower percent of water in the body.
  • Pediatrics will have HIGHER percent of water in the body (Table 47.1)

S2

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2
Q

what perecent of water is in adipose tissue?

A

low percentage in adipose tissue

S2

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3
Q

What are the two main fluid compartments?

A
  • Intracellular Fluid (ICF) makes up two-thirds of total body water
  • Extracellular Fluid (ECF) makes up one-third of total body water

S2

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4
Q

What are the different compartments of the ECF?

A
  • Interstitial: lymphatics and protein-poor fluid around the cell.
  • Intravascular: plasma volume
  • Transcellular: GI Tract, Urine, CSF, Joint fluid, aqueous humor.

S2

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5
Q

List the different ways of fluid/electrolye movement

A
  • Diffusion
  • Osmosis
  • Osmolarity
  • Osmolality
  • Oncotic pressure

S3-7

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6
Q

What is diffusion?

A
  • Solute particles moving or filling solvent volume
  • High to Low concentration
  • Speed is proportional to the distance squared
  • Can occur across permeable membranes
  • Can relate to electrical gradients

S3

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7
Q

What are examples of the type of solutes that are in our body?

A
  • Glucose
  • Protein (Albumin)
  • Electrolytes

S3

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8
Q

What is the primary extracellular cation?

A
  • Sodium (Na+)

S3

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9
Q

What is the primary intracellular cation?

A
  • Potassium (K+)

S3

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10
Q

What is osmosis?

A
  • A semipermeable membrane that separates pure water from water with dissolved solute.
  • Osmosis is just the movement of WATER
  • Diffuses from low to high solute concentration

S4

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11
Q

What is osmotic pressure?

A
  • Pressure that resists the movement of water through osmosis

S4

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12
Q
  • What is osmotic pressure affected by?
A
  • Temperature
  • Number of Molecules
  • Volume

S4

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13
Q

What is the equation for osmotic pressure?

A

P = nRT/V
* V=volume
* N= number
* T=temperture

S4

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14
Q

What is osmolarity?

A
  • Number of osmotically active particles per L of solvent
  • Higher osmolarity, higher “pulling power”

S5

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15
Q

Patient A has serum glucose of 600mg/dl

Patient B has serum glucose of 250mg/dl

Who has higher osmolarity?

A
  • Patient A

Pt with glucose of 600 has more particles

S5

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16
Q

What is osmolality?

A
  • Number of osmotically active particles per Kg of solvent

S6

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17
Q

What is normal osmolality?

A
  • 280-290 mOsm

S6

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18
Q

What is oncotic pressure?

A
  • The component of total osmotic pressure due to colloids

S7

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19
Q

List examples of colloids

A
  • Albumin
  • Globulins
  • Fibrinogen

S7

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20
Q

What percentage of oncotic pressure is due to albumin?

A
  • 65-75%

S7

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21
Q

What makes up our daily fluid intake?

A
  • Solids (750 mL)
  • Liquids (1400 mL)
  • Metabolism (350 mL)

S8

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22
Q

What makes up our daily fluid output?

A
  • Insensible Loss (1000 mL)
  • GI loss (100 mL)
  • Urine output (0.5-1 mL/kg/hr)

S8

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23
Q

How do we regulate intake and output of fluid?

A
  • We are responsible for:
    • intake: oral fluids & food
    • Output: urinary secretion

S9

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24
Q

Urine secretion accounts for ____-% of daily water loss.

A
  • 60%

S9

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25
What hormones regulate urine output?
* Antidiuretic hormone [ADH] * Atrial natriuretic peptide [ANP] * Aldosterone | S9
26
How does ADH regulate urine output?
* Renal H2O excretion in response to plasma tonicity *tonicity: a measure of effective osmolarity* | S9
27
How does ANP regulate urine output?
* ANP is activated by ↑ fluid volume * ↑ Atrial Stretch = ↑ Renal Excretion | S9 ## Footnote A&P: ANP/ANF talk to the kidney to increase prostaglandins [PG] production in the kidneys. -More PG result in increases RBF—> increases GFR —>increase UO to get rid of fluid and electrolytes to reduce strain/stretch on atria.
28
How does Aldosterone regulate urine output?
* Regulates sodium and potassium levels * Aldosterone is released if sodium and fluid volume decreases, causing sodium and water conservation. | S9
29
What are the sensors for fluid balance?
* Hypothalamic osmoreceptors * Low-pressure baroreceptors * large veins and RA) * High-pressure baroreceptors * carotid sinus and aortic arch | S10
30
What is the trigger for fluid balance?
* Increased thirst or increase ADH | S10
31
What are the compensatory mechanisms for acute disturbances in circulating volume?
* Venoconstriction * Mobilization of venous reservoir * Autotransfusion from ISF to plasma * Reduced urine production * Maintenance of CO…tachycardia, increased inotropy **happens in minutes to hours** | S11
32
For compensatory mechanisms to occurs for acute disturbances in circulating volume, what sensors must be present?
* low and high pressure baroreceptors * RAA Axis | S11
33
Overview of RAAS
* Renin relased * Angiotensinogen → Angiotension 1 * Angiotensin 1 → Angiotension 2 * Vasocontriction + aldosterone release
34
* Where is Renin released? * What does Renin do to angiotensinogen?
* Released from juxtaglomerular cells * Cleaves angiotensinogen to make angiotensin I | S12
35
When ANG I → ANG II, what will this cause?
* Vasoconstriction and aldosterone release | S12
36
Where is aldosterone released from and what does it cause?
* Aldosterone is released from the adrenal cortex * causes salt and water retention | S12
37
In the absence of ongoing fluid loss, volume loss is restored within how many hours?
* 12-72 hours | S12
38
In the absence of ongoing fluid loss, how is RBC restored? How long does this take?
* through erythropoiesis in 4-8 weeks | S12
39
What are the Electrolytes and Osmolarity of Normal Saline (0.9%)?
* Na+: 154 mEq/L * K: - * Chloride: 154 mEq/L * Osmolarity: 308 mOsm/L | S14
40
What are the Electrolytes and Osmolarity of LR?
* Na+: 130 mEq/L * K+: 4 mEq/L * Chloride: 109 mEq/L * Lactate: 28 mEq/L * Osmolarity: 274 mOsm/L | S14
41
What are the Electrolytes and Osmolarity of Plasmalyte?
* Na+: 140 mEq/L * K+: 5 mEq/L * Cl-: 98 mEq/L * Acetate: 27 mEq/L * Osmolarity: 295 mOsm/L | S14
42
What are the Electrolytes and Osmolarity of Albumin 5%?
* Na+: 145 +/- 15 mEq/L * K+: < 2.5 mEq/L * Cl-: 100 mEq/L * Osmolarity: 330 mOsm/L | S14
43
What are the Electrolytes and Osmolarity of Hetastarch 6%?
* Na+: 154 mEq/L * K: - * Cl-: 154 mEq/L * Osmolarity: 310 mOsm/L | S14
44
What are crystalloids?
* Isotonic * Solutions of electrolytes in water * The are called balanced solutions (not really though, misnomer) * *LR is probably considered the most "balanced" crystalloid* | S15
45
What are indications of using crystalloids?
* Replacement of free water and electrolytes * Volume expansion | S15
46
* With crystalloid administration and distribution throughout the EFC what percentage will be in the intravascular space: * after 20 minutes? * What about after 30 minutes?
* 70% in the intravascular space after 20 minutes * 50% in the intravascular space after 30 minutes | S16
47
What are the negative effects of crystalloids?
* Tissue Edema * Lungs, GI Tract, Soft Tissues * Hypercoagulability * Anticoagulant factors diluted * *micro emboli* | S16
48
List the different types crystalloids
* Normal saline (0.9%) * Hypertonic saline (3%) * Lactated Ringers * Dextrose solutions | S17-20
49
NS 0.9% is the most commonly fluid, but what are the negative consequence of this fluid?
* Dilutes Hct and Albumin * Late onset of diuresis * Increase AKI and dialysis in ICU patients * Causes hyperchloremic metabolic acidosis if too much is given resulting in: * ↑ Cl- and K+ concentraions | S17
50
* How does hypertonic saline (3%) work? * What does it treat?
* pulls water out of ICF to ECF including plasma * Treats: * hypoosmolar hyponatremia * increased ICP * TURP | S18
51
In comparison to NS, what does the osmolarity, Na, and Cl look like in LR?
* lower osmotarity * lower Na+ * lower Cl- | S19
52
What is added to LR to act as a buffer?
* Lactate | S19
53
how does LR excreter excess water faster than NS?
suppresses ADH secretion which allows for diuresis | S19
54
Why would you not want to use LR on a liver pt?
* LR relies on hepatic metabolism * *This can cause an increase build of lactate in the patient.* | S19
55
What happens to dextrose solution when the glucose is metabolized?
* Dextrose becomes a hypotonic solution/a source of free water * Does not say in the vascular space * Water moves freely between all compartments | andy?
56
* What percent dextrose is a source of free water? * What is this not suitable for and why?
* D5 * not suitable for volume expansion bc water moves freely between all compartments | S20
57
What fluid could be used for caloric intake in diabetic patients?
* Dextrose 10% * Better options out there | S20
58
What are colloids?
* Large molecules of a homogeneous, non-crystalline substance * dispersed in a second substance (usually a balanced crystalloid). * Particles cannot be separated (through filtration or centrifuge) | S21
59
What are the two main types of colloids?
* Semisynthetic colloids (Starches) * Human plasma derivatives (FFP, Albumin) | S21
60
How do colloids work?
* Colloids work by increasing colloid oncotic pressure (pulling force), which increases potential plasma volume expansion | S22
61
What are the negative effects of colloids?
* Causes hemodilution * Decreases plasma viscosity * Inhibit RBC aggregation * Uncertain effect on immune, coag, and renal system (AKI) * maximum recommended dosages | S22
62
* What is hydroxyethyl starch? * where is is derived from? * what is it substituted on?
* modified natural polymers of amylopectin * dervied from potato or maize * substitution onto glucose *This is a man made colloid* | S23
63
The metabolism of hydroxyethyl starch is dependent on?
* Molecular weight of molecules (small, medium, large) * 70 to 80% of larger molecules are still in the intravascular space at 90 minutes. * Plasma volume effect last longer | S23
64
What are the S/E of Hydroxyethyl Starch r/t molecular weight?
* Coagulopathy through dilution effects, leading to reduction in VWF, Factor VIII, Clot Strength. * Renal Dysfunction | S23
65
Dextrans are a type of colloid. Where are the derive from?
* highly branched polysaccharide * produced by a bacteria called Leuconostoc Mesenteroides | S24
66
Describe the plasma volume of dextrans.
* Plasma volume similar to the starches * duration: 6-12 hours [stays in vascular space for a long time] | S24
67
What is Dextran-40 used for? Why? How?
* Microvascular Surgery (limb reattchement, breast flap) * Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation * Coats the RBC...may interfere with cross-matching | S24-lecture ## Footnote Dextran-40 will coat the RBC and may interfere with cross-matching
68
What are examples of human plasma derivative colloids?
* Albumin 5% * FFP * Immunoglobulin Solution | S25
69
Human plasma derivates: physiologic colloid oncotic pressure [COP]
* Volume replacement * trauma * sepsis * replacement following paracentesis | S25
70
Fluid alterations in the preoperative settings (long list, common sense).
* Na+ distribution disorder * Dialysis requirement * Chronic use of diuretics * Dx of HTN * Preop Fasting * Bowel Prep * Acute Hemorrhage * NVD, Suction * 3rd space redistribution | S26
71
Fluid alterations in the intraoperative settings (alterations caused by CRNA).
* Vasodilation from anesthetics * Sympathetic blockade (narcotics) * Autoregulatory response * Acute Hemorrhage * Insensible Loss * Inflammation related redistribution | S26
72
Assessment of Low Intravascular Volume
* **Signs of Hypovolemia** - ↑HR, ↓Pulse Pressure, ↓BP, ↓Cap Refill (25% of volume must be lost) * **Decreased Urine Output** * inadequate as end-organ d/t RAA * **CVP** * measures central venous volume but venous system distensible * **Tissue Perfusion**: Lactate, Mixed venous O2 | S27
73
What are the signs of hypovolemia for low intravascular volume? how much volume must be lost for these s/sx to occur
* ↑HR * ↓Pulse Pressure * ↓BP * ↓Cap Refill * 25% of volume must be lost
74
What factors do you need to consider as a CRNA when assessing urine output for intravascular volume?
* Low UO can be d/t stress hormone release from anesthetic * Low UO can be d/t low intravascular volume and inadequate perfusion to the kidney * Low UO can be d/t the patient's position, Steep Trendelenburg | S27 lecture
75
Assessment of High Intravascular Volume
* Increase capillary hydrostatic pressure * Excess fluids in lungs (Crackles/edema), bowels, muscle * Decreased gut motility * Reduced tissue oxygenation * Poor wound healing * Hypo/Hyper Coagulation If he is fluid overloaded, HE DRIP | S28
76
A study of 13 patients (11 adults and 2 peds) all died from what? Why?
post-op pulmonary edema -we give way too much volume in surgery historically speaking | S28
77
what is the 4-2-1 plan? What does it take into account?
* it is the "classic" fluid therapy Takes into account: * NPO deficit * ongoing maintenance (hourly) * anticipated surgical loss (blood & insensible) | S29
78
NPO Status: * Clear Liquids * Breast Milk * Infant Formula * Light Meal * Meal/Fatty, Fried
* Clear Liquids: 2 hours * Breast Milk: 4 hours * Infant Formula: 6 hours * Light Meal: 6 hours * Meal/Fatty, Fried: 8 hours | S30
79
How is ERAS protocol changing NPO status?
* Maintain homeostasis by allowing NPO status to be delayed * Can have carbohydrated 2 hours before surgery. | S30-lecture
80
# Classic approach for **NPO/MAINTENANCE** Formula for Classic Fluid Therapy.
* 1st 10 kg = 4 mL/kg/hr * 2nd 10kg = 2 mL/kg/hr * Each kg over 20 kg = 1 mL/kg/hr | S31
81
Mr. Cartman's Weight is 80 kg. Calculate Total NPO deficit for 8 hours using the classic fluid therapy.
Cartman is 80kg, using the 4-2-1 Rule. 4 mL/kg for 1st 10 kg = 40 mL 2 mL/kg for 2nd 10 kg= 20 mL 1 mL/kg for last 60 kg = 60 mL 120 mL/ hr x 8 hours = 960 mL deficit | S32
82
How do we replace the deficit in the OR? Mr. Cartman's has a 960 ml deficit. How would you replace this?
* ½ in the 1st hour of surgery * *480 m*l * ¼ in the 2nd hour. * 240 ml * ¼ in the 3rd hour. * 240 ml | S33
83
If Cartman's fluid deficit is 960 mL and fluid maintenance is 120 mL/hour, what is the fluid plan for this patient? | S33/34
Add blood loss...could easily exceed 1L in the 1st hour | S34-36
84
How much blood would the following hold when estimating blood loss in surgery: Suction: Lap Sponge: Raytech: 4x4 Gauze:
* **Suction**: be sure to subtract the irrigation fluids * **Lap Sponge (packs of 5)**: 100 mL * **Raytech** (pack of 10): 20 mL * **4x4 Gauze**: 10 mL | S37 ## Footnote dont argue with what the surgeon says the blood loss is...just chart what you know!
85
How much fluid can be loss with a bowel prep?
* 2000 mL | Andy?
86
What is the fluid deficit for a fever?
* 10% fluid deficit for every 1 degree Celsius above 38C | andy?
87
What are the different categories of evaporative/ redistribution losses?
* **Minimal**: 0-2 mL/kg/hr * (robotics case, sinus) * **Moderate**: 2-4 mL/kg/hr * **Severe**: 4-8 mL/kg/hr * (open belly, bowel) | S38, lecture ## Footnote **controversial**
88
The parkland formula is based on what? what is it adusted due o?
* Rule of 9's * 20% TBSA of 2nd/3rd degree burns * Adjusted due to: * obesity * kids | S39
89
What is the Parkland Burn Formula?
* 4 mL x kg x % BSA burn (whole number) = Fluids to replaced * 1/2 over the first 8 hours * 1/2 over the next 16 hours *Formula adjusted for obese patients and children* | S39
90
What is the percent body surface area of the following: (front and back of body) * front/back of head: * Each arm * Each leg * Chest: * Abdomen: * Groin:
* Front/back of head: 9% * Chest: 18% * Each arm: 9 % * Each leg: 18% * Abdomen: 18% * Groin: 1% | S39
91
What is the percent body surface area of the anterior trunk? (includes upper and lower) Posterior trunk?
* 18% * 18% | S39
92
What fluid is used to replace burn patients?
* Lactated Ringers | S39
93
When is the Parkland Burn formula used?
* 20% of TBSA is burned * 2nd and 3rd degree burns only | S39
94
If an 80kg patient has 40% of their TBSA burned, what would be the total fluid needed to be replaced in this patient?
* 4mL x kg x TBSA (%) * 4 x 80kg x 40 =12800 mL total * 6400 mL replaced in the first 8 hours * 6400 mL replaced in the next 16 hours | S39 lecture
95
4-2-1 is an old estimation for fluid replacement. What is goal directed theraphy and fluid administration is based on?
* Goal: keep CO at a level that delivers appropriate amounts of oxygen to the tissues **Fluid administration based on**: * CVP- not specific * CO * **SV** -determines if they are fluid responsive * **SVV** -determines if they are fluid responsive * SWAN- use declining * SVO2- measures O2 extraction * TEE- quantify LV cavity size/EF (not a standard of care) * lactate levels: decreasing level signals successful resuscitation *Patient will either be fluid responsive or unresponsive. If fluid responsive, a bolus will be administered. Fluid replacement is individualized.* | S40
96
What are the reasons for using GDT (goal directed therapy)?
Allows decisions to use: * more fluid * vasopressors * inotropes * blood products | S41
97
What have studies shown about the results of goal directed therapy?
* Less AKI * Less Respiratory Failure * Decrease Wound Infection * Decrease Mortality | S41
98
What is the maintenance dose for goal directed therapy?
* 1-3 mL/kg/hr of crystalloid | S42
99
For goal directed therapy, a fluid challenge of ___________ mL will be used to increase SV.
* 250 mL | S42
100
What is used in goal directed therapy with blood loss or blood products?
* Colloids 1:1 (1 colloid for every blood product) * *Did 3:1 in the past* | S42
101
What are the LIMITS to arterial waveform pressure monitoring (SVV Monitoring)?
* **L**ow HR/RR * **I**rregular rhythms * **M**echanical Ventilation w/ Low Vt * **I**ncreased Abdominal Pressure * **T**horax Open * **S**pontaneous Breathing *Any of these factors will result in an inaccurate reading on the monitor. Need normal on all of these factors to have SVV* | S43 ## Footnote its ironic that patients we would need to measure this on are the patients that this information will not be accurate with, haha
102
What are the 3 different types of monitoring using an aterial line for fluid responsiveness?
* Systolic Pressure Variation * Pulse Pressure Variation: * Stroke Volume Variation | S44 and lecture
103
How do you utilize Systolic Pressure Variation
* Max systolic pressure -min systolic pressure * during one cycle of mechanical breath *Normal: 7-10 mmhg* *Increase: volume responsive or have residual prelaod reserve* | S44
104
How do you utilize pulse pressure variation?
* **The difference between the lowest systolic pressure and the highest diastolic pressure** * *Over entire RR cycle* * *Normal <13-17%* * *>13-17% = positive respone to volume expanson*
105
How do you utilize stroke Volume Variation?
* variation of SV in 30 seconds * The area under the "curve" (*still highest and lowest values)*
106
What is normal Stroke Volume Variance (SVV)?
* 10-15% (erikson: 10-13%) | S44
107
* For SVV, what do you do if its >15%? * What do you do if pt is hypotensive but SVV is normal or low?
* If >15%, patient will be responsive to fluid (give fluid bolus) * Pt will not be fluid responsive. Give ionotrpes | S44 lecture
Mar: Sem 3 - Principles I
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