Fluid and Blood Therapy - Hooge slides Flashcards
(173 cards)
1
Q
What is the purpose of parenteral fluid therapy
A
Maintenance fluids
Replacement of fluids lost as a result of surgery/anesthesia
Correction of electrolyte disturbances
2
Q
What is the main concern with NS
A
Hyperchloremic metabolic acidosis
3
Q
What are the main concerns with LR
A
Metabolic alkalosis
Potassium accumulation in patients with renal failure
4
Q
Where does albumin come from
A
Pooled donor plasma
5
Q
What are the indications for albumin
A
Shock d/t loss of plasma, acute burns, fluid resuscitation, hypo-albuminemia, following paracentesis, liver transplantation
6
Q
Adverse reactions of albumin
A
Pruritis, fever, rash, N&V, tachycardia
7
Q
DOA of albumin
A
16-24 hours
8
Q
What is Plasmanate
A
A protein-containing colloid
9
Q
When do you use plasmanate
A
Hypovolemic shock - especially burn shock, hypoproteinia (low protein state)
10
Q
Adverse reactions of plasmanate
A
Chills, fever, urticaria, N&V
11
Q
How is albumin supplied
A
5% and 25% solutions
12
Q
How is plasmanate supplied
A
5% in 250ml or 500ml
13
Q
DOA of plasmanate
A
24-36 hours
14
Q
What is Dextran
A
An artificial colloid - polysaccharides molecule
15
Q
When do you use dextran
A
Improve micro circulatory flow in micro surgeries, extracorporeal circulation during cardio pulm bypass
16
Q
Adverse reactions of dextran
A
Anaphylaxis, coagulation abnormalities, interference with cross-match blood, precipitation of acute renal failure
17
Q
Dextran supplied as
A
Dextran 70 - 6% solution with avg mw 70,000
Dextran 40 - 10% solution with avg mw 40,000
18
Q
DOA of dextran
A
6-12 hours
19
Q
What is hetastarch
A
Synthetic colloid made from plant starch
20
Q
Indication for hetastarch
A
Hypovolemia
21
Q
Max dose of hetastarch
A
20ml/kg
22
Q
Hetastarch adverse reactions
A
Hypersensitivity, coagulopathy, hemodilution, circulatory overload, and metabolic acidosis
23
Q
How is hetastarch supplied
A
Hespan 6% solution in NS
24
Q
DOA hetastarch
A
24-36 hours
25
What is hextend
It is 6% hetastarch in a buffered solution including lactate buffer, balanced electrolytes, and physiologic glucose
26
What is a benefit of hextend over hetastarch
Studies show that you can give more than 20ml/kg without coagulopathy issues
27
What is voluven
It’s another plant-derived colloid with smaller molecules than other HES solutions
28
What is the benefit of voluven over other HES colloids
Less plasma accumulation, safer in patients with renal impairment, comparable effects on volume expansion and hemodynamics, fewer coagulation affects
**acceptable alternative to albumin
29
Why would we move from fluid therapy to blood component therapy
Necessary to increase oxygen carrying capacity while also increasing intravascular volume and restoring homeostasis
30
What are the transfusion triggers
```
Perioperative blood loss
Clinical condition of patient
Patient-specific blood volume
Calculation of allowable blood loss
Access to patient blood type
Patient preferences
```
31
What are the benefits and risks of blood component therapy
Benefits = increased oxygen carrying capacity & improved coagulation
Risks = infection and incompatibility
32
How do we estimate blood loss
Subjective - measuring net suction volume and counting or weighting sponges (usually underestimated)
Objective - sodium fluroescein dye
POCT - hgb/hct (this does not measure blood loss)
33
What are the clinical condition triggers of patient to consider giving product
Tachycardia
Decreased mixed venous o2 saturation
Measurement of systemic o2 delivery (DO2)
34
What is the equation for DO2
CO X CaO2
35
How do you calculate CaO2?
1.34 X hgb X spo2
36
What is the estimated blood vol of a full term infant?
80-90 ml/kg
37
What is the equation for maximum allowable blood loss?
MABL = /starting hematocrit
38
Normal hgb range for men
13.2-16.6 g/dL
39
Normal hgb range for women
11.6-15 g/dL
40
Normal hct range for men
42-52%
41
Normal hct range for women
37-47%
42
Hgb and hct level considerations for transfusion
Hgb: 7-10 g/dL
Hct: 21-30%
43
Estimated blood volume of infants
80 ml/kg
44
Estimated blood volume of adults
65-75 ml/kg
45
Estimated blood volume of obese adults
50 ml/kg
46
Blood group A can receive which blood groups
A, O
47
Blood group B can receive which blood groups
B, O
48
Blood group AB can receive which blood groups?
A, B, AB, O
49
Blood group O can receive which blood groups?
O only
50
Rh + can receive which blood groups
Rh +/-
51
Rh - can receive which blood groups?
Rh -
52
Which blood group is the universal recipient?
AB +
53
Which blood type is the universal donor
O -
54
Why give RBCs?
Hemorrhage and improve o2 delivery to tissues
- symptomatic anemia
- Acute blood loss > 30% blood volume
- hemodynamically unstable
55
Why give FFP?
Reversal of anticoagulant effects
56
Why give platelets?
Prevent hemorrhage in patients with thrombocytopenia or platelet function deficits
57
Why give cryo?
Hypofibrinogenemia (setting of massive hemorrhage or consumptive coagulopathy)
58
What are the changes in banked blood?
```
Less DPG
Less ATP
Oxidative damage
Increased adhesion to endothelium
Acidosis
Change in shape/decreased flexibility of RBC
Microaggregates
Hyperkalemia
Absence of viable platelets once refrigerated for 2 days
Absence of factor V and VIII
Hemolysis
Accumulation of pro inflammatory metabolic and breakdown products
```
59
What level of hgb indicates significant mortality
Hgb < 5 g/dl
60
What is the record survival of hgb of jehovah witness
1.8 g/dl
61
Most common surgical procedures requiring transfusion
```
Ortho
Colorectal
Cardiac
Major vascular
Liver transplant
Trauma
```
62
What are the thre components of the strategy to reduce unnecessary transfusions and maximize patient outcomes
1. Optimize patients own RBC mass
2. Minimized blood loss
3. Optimize patients physiologic tolerance of anemia
63
Preop strategies for blood therapy
Screen and treat for anemia, iron deciency and administer erythropoiesis stimulating agents as indicated
ID and manage any bleeding risks (i.e. meds)
Assess pt reserve and optimized patient specific tolerable blood loss
Have an evidence based plan
Preop autologous blood donation in select situations
- may need to come 30 days preop to accommodate
64
Intraop strategies for blood therapy
Perform surgery when optimized
Use blood-sparing techniques
Continually measure and assess hgb/hct
Plan/optimize fluid management of nonblood products
Optimize CO, oxygen delivery, and ventilation
Use blood salvage and autologous transfusion when possible
65
Post op strategies for blood therapy
Treat anemia/iron deficiency with erythropoiesis stimulating agents
Vigilant monitoring/mgmt of post op bleeding
Normothermia to minimize o2 consumption
Avoid/treat infections promptly
Manage anticoags
66
Class 1 hemorrhage characteristics and Tx indication
Reduction of volume < 15%
Blood loss <750 ml
Hgb >10
RBC tx not necessary if no preexisting anemia
67
Class 2 hemorrhage characteristics and blood tx indication
Reduction of volume 15-30%
Blood loss 750-1500ml
Hgb 8-10
RBC tx not necessary unless preexisting anemia or cardiopulmonary disease
68
Class 3 hemorrhage characteristics and indicator for blood tx
Reduction of volume 30-40%
Blood loss 1500-2000ml
Hemoglobin 6-8
RBC tx probably necessary
69
Class 4 hemorrhage characteristics and indications for RBC
Reduction of volume > 40%
Blood loss > 2000ml
Hgb < 6
Necessary RBC tx
70
Definition of RBC transfusion
1. Replacement of estimated blood volume within 24 hours
2. >10 units of RBCs over 25 hours
3. 50% of blood volume within 3 hours or less
71
What are the major concerns for massive transfusion
Dilutional coagulopathy or dilution all thrombocytopenia
Banked blood anticoagulated with sodium citrate, which binds calcium and inhibits coagulation
Rapid infusion can decrease ionized calcium (aka citrate intoxication)
72
What is the blood component of choice for improving oxygen carrying capacity
PRBCs
73
What is the administration ratio of PRBCs?
1:2 because RBCs have a higher HCT
74
How much dose one unit of PRBCs increase Hgb and HCt
Hgb: 1g/do
Hct: 2-3%
75
Which blood component contains all of the coagulation factors?
FFP
76
What are the indications for giving FFP
Deficiency of coagulation factors with abnormal coag tests in the presence of active bleeding
Planned surgery in the presence of abnormal coag tests
Reversal of warfarin
Warfarin-related intracranial hemorrhage
Planned procedure when vit K is inadequate to reverse the warfarin effect, thrombocytopenia thrombocytopenia purpura, and congenital or acquired factor deficiency with no alternative therapy
Trauma patients requiring massive transfusion
77
Platelets indication
Prevent bleeding or stop ongoing bleeding in patients with low platelet count or functional platelet disorders
78
What is a normal platelet count
150,000-450,000 cells /mcL
79
When to transfuse platelets in bleeding patients
<50,000 cells in severe bleeding including DIC
<30,000 cells when bleeding, not life-threatening or considered not severe
<100,000 cells for bleeding in multiple trauma patients or patients with intracranial bleed
80
When to prophylactically transfusion threshold
Before neuro or ocular surgery = <100,000
Before epidural = < 80,000
Before major surgery or in DIC = < 50,000
Vaginal delivery = < 30,000 and when traumatic delivery < 50,000
Before central line < 20,000
81
What is cryoprecipitate
Contains factor VIII (von Wille brands) and fibrinogen
82
When do you administer cryo?
Patients with von willebrands or patients with probable or documented deficits in fibrinogen (<80-100 mg/dL)
83
How should you administer cryo?
As rapidly as possible - at least 200ml/hr
84
What is the most common and serious blood transfusion complication
Incompatibility
85
What happens in incompatibility
An immune reaction with risk of an acute hemolytic reaction
86
What causes half of all deaths of blood transfusions
Incompatibility r/t procedural or administrative error
87
How does GA complicate blood transfusion incompatibility
GA can obscure the symptoms associated with a hemolytic reaction
88
Transfusion associated graft vs host disease
Results when donor lymphocytes incorporate themselves into the tissues of the recipient, leading the recipients immune system to attack the embedded recipient tissues
S&S = rash, leukopenia, thrombocytopenia
Sepsis and death usually occur
89
TRALI
Transfusion related acute lung injury
ALI occurring within 6 hours of transfusion in patients previously free of ALI
Occurs as frequently as 1:432 units of platelets or as infrequently as 1:7900 units of FFP
Likely underreported
90
TRIM
Transfusion related immunomodulation
Presence of leukocytes in allogenic blood
Homologous transfusions, which invariably contain some leukocytes, have been implicated in immunosuppresion of recipients, leading to unexpectedly early recurrences of cancer and higher than expected rates of post op infection
91
Nonhemolytic transfusion reactions
Occur in 1-5% of all transfusions
S&S = fever, chills, urticaria
92
Leukoreduction
Use of filters to reduce the level of WBCs - proven to be effective in reducing the incidence of non hemolytic transfusion reactions and is likely to be effective in the reduction of TRIM
93
What do leukocytes do to the blood product recipient?
Leukocytes exert a variety of immunomodulatory effects on the recipient in a magnitude that is proportional to the length of time the donor unit is stored
94
Donor directed blood transfusion
Homologous blood transfusion from a donor selected by the recipient and believed by some to decrease the risk of transmission of disease
95
What are the types of autologous blood transfusion
Intraoperative and postoperative blood salvage
Preop blood donation
Acute normovolemic hemodilution
96
Cell salvage
Aspiration of blood shed into the surgical field which is washed to remove debris and then reinfused
97
What are contraindications of cell salvage
Surgery involving wounds contaminated by bacteria, sepsis, bowel contents, amniotic fluid, or malignant cells
98
What cases are most likely to use cell salvage
Cardiac, orthopedic, radial prostatectomy, nephrectomy, AAA, aneurysm
99
How does preop blood donation work
Collection and storage of a recipients own blood for reinfusion at a later date
100
What are the risk of preop blood donation
Preop anemia and resultant MI
Bacterial contamination
Clerical error - administration of wrong blood
101
How much preop blood donation is wasted
1/2
102
What is acute normovolemic hemodilution
Transfusion alternative involving the removal of whole blood from a patient immediately before or after the initiation of anesthesia and surgery and replacing volume with crystalloid or colloid
Blood lost during surgery will have a low hct
Reinfusion of the whole blood with normal hct and clotting factors is initiated when Intraoperative loss of blood has stopped or earlier if the patients condition warrants it
103
What is the role of fluids in a human body
Transport - oxygen and nutrients to cells and remove waste
Temp regulation - blood circulation to sling and sweating increase heat dissipation helping to keep body at constant temp
Maintain internal environment - maintain metabolism
104
What is the percentage of total body fluid for a newborn, toddler, child, man, woman, senior
```
Newborn - 80%
Toddler - 70%
Child - 65%
Man - 60%
Woman - 55%
Senior 50-55%
```
105
What proportion of TBW is intracellular fluid
2/3
106
What proportion of TBW is extracellular fluid?
1/3
107
What percentage of extracellular fluid is plasma and what percentage is interstitial fluid?
75% ISF
| 25% plasma
108
Which electrolytes predominate intracellularly
Potassium
Mag
Phosphate
Proteins
109
Which electrolytes predominate extracellularly
```
Sodium
Chloride
Calcium
Glucose
Bicarbonate
```
110
Osmolality definition
Number of osmoles of solute in a kg of solvent
111
Osmolarity definition
Number of osmoles of solute in liter of solution
112
What is normal plasma osmolality
290 mOsm/L
113
Hypertonic definition
Increases plasma osmolality above 295mOsm/L
114
Isotonic
Normal plasma osmolality = 290 mOsm/L
115
Hypotonic
Decreased plasma osmolality below the normal level <275mosm/L
116
Isotonic loss of fluid
Example: hemorrhage
Clinically: ECF volume depletion
Serum sodium and osmolality = normal
ICF = normal
117
Signs and symptoms of isotonic loss of fluid
Increased HR
decreased BP, cap refill, and UO
Vasoconstriction
Inadequate tissue/organ perfusion
118
How to treat isotonic loss of fluid
Administer isotonic fluid
119
Isotonic gain of fluid
Example: excessive LR administration
Clinically ECF volume overload
Serum Na and osmolality = normal
ICF volume = normal
120
Signs and symptoms of isotonic gain of fluid
Increased HR, BP, body weight
Dependent pitting edema
Inadequate tissue/organ perfusion
121
Treatment of isotonic gain of fluids
Restrict fluids
| Diuretics
122
Definition of hypotonic fluid disorders
Plasma osmolality is low caused by a low serum sodium = osmotic gradient = water shifts from ECF to ICF = ICF volume expansion
123
Hypertonic loss of Na
Example: diuretics, decreased aldosterone (addisons, 21 hydroxylase definicency)
ECF volume depletion
Serum sodium and osmolality decreased
Increased ICF volume d/t gradient
124
Signs and symptoms of hypertonic loss of Na
Increased HR
Decreased BP, cap refill, UOP
Confusion, mental status change
125
Treatment of hypertonic loss of sodium
Administer isotonic fluid
126
gain of pure water
Increased ECF,
Decreased serum sodium and osmolality
Increased ICF volume
127
Signs and symptoms of gain of pure water
Confusion, drowsiness, mental status change
128
Treatment of gain of pure water
Restrict water, treat underlying problem
129
Gain of hypotonic solution
“Hypervolemic hypernatremia”
Ex: absorption of electrolyte free irrigation solution - as in TURP
Increased ECF
Decreased serum sodium and osmolality
Increased ICF d/t gradient
130
Clincical signs of gain of hypotonic solution
Seizure, pulmonary edema, difficulty ventilating, cerebral edema
131
Treatment of gain of hypotonic solution
Diuresis
| 3% NS
132
Hypotonic gain of sodium
Example overload states - cirrhosis, nephrotic, CHF
“Hypervolemic hyponatremia”
Increased ECF
Decreased serum sodium and osmolality
Increased ICF d/t gradient
133
Clinical S&S of hypotonic gain of sodium
Dependent edema, cavity effusions, SOB, increased body weight, mental status change
134
Treatment of hypotonic gain of sodium
Restrict salt and water
| Diuretics
135
Hypertonic fluid disorders
Plasma osmolality is high caused by a high serum sodium or glucose = osmotic gradient = water shifts from ICF to ECF = ICF contracts (cell shrinks)
136
Hypotonic loss of sodium
“Hypovolemic hypernatremia”
Example: sweating (marathon), osmotic diarrhea/diuresis, vomiting
Decreased ECF, increased serum sodium and osmolality, decreased ICF
137
S&S hypotonic loss of sodium
Dry skin and mucous membranes, dizzy, confusion, mental status change, increased HR
138
Treatment of hypotonic loss of sodium
Administer isotonic fluid then switch to hypotonic fluid
139
Loss of pure water
“Euvolemic hypernatremia”
Example: DI, excessive water evaporation off the skin surface (fever, burn, insensible loss)
Decreased ECF, increased serum sodium and osmolality, decreased ICF
140
Signs and symptoms loss of pure water
Confusion, drowsiness, mental status change
141
Treatment of loss of pure water
Administer D5W, treat underlying problem
Give arginine vasopressin to replace missing ADH if pt has DI
142
Hypertonic gain of sodium
Hypervolemic hypernatremia
Example: NaHCO3 infusion, hypertonic saline, antibiotics that contain Na, sodium modeling in hemodialysis
Increased ECF, increased serum sodium and osmolality, decreased ICF
143
S&S hypertonic gain of Na
Mental status change
144
Treatment of hypertonic caring of Na
Stop the infusion
145
Hyperglycemia
Hypovolemic hyponatremia
Ex: DKA, hyperosmolar non-ketotic coma
Decreased ECF
Decreased serum sodium
Increased serum osmolality
Decreased ICF
146
Clinical sings and symptoms of hyperglycemia fluid shifting
Mental status change, diabetic coma
BG is like 600
147
What are the anesthesia factors that alter fluid balance
Vasodilation
Releases of ADH
Increase evaporative loss from ventilation
Mobilization of third space fluids on POD 3
148
Anti-diuretic hormone
Aka ADH, vasopressin, arginine vasopressin
Nonapeptide synthesized in the hypothalamus and release in response to stress
Causes reabsorption on the collecting duct in kidneys = water retention
149
What is a positive of ADH?
Can potentially offset the hypovolemic effect of fasting
150
Is uop a valid indicator of volume status
No - it’s effected by too many things
Isolated low UOP should not trigger fluid therapy and extensive diagnostic efforts
151
Goal directed fluid therapy goal
To maximize cardiac flow parameters as a Surrogate for oxygen delivery
To improve outcomes
Part of ERAS
152
What is a fluid challenge
Give 250-500 cc fluid - if CO increases, they are fluid responsive
153
Bioimpedance sensing
A non-invasive and powerful technique used to assess human physiological signals due to its deep penetration into the tissues, leveraging its electrical nature
154
4:2:1 method
Method for calculating hourly fluid maintenance requirements
4 mg/kg/hr - 0-10 kg
2 mg/kg/hr - 11-20 kg
1 mg/kg/hr - 21+ kg
155
NPO deficit calculation
Hourly maintenance requirement x # of hours NPO
Replaced over 3 hours
Hour 1 - half the volume
Hour 2 - quarter the volume
Hour 3 - quarter the volume
156
How much surgical loss is expected with a minimal invasive surgery
0-2 ml/kg
157
How much surgical loss is expected moderate invasive
2-4 ml/kg
158
How much surgical loss is expected severe invasive
4-8 ml/kg
159
Fluid replacement consists of
NPO deficit, maintenance, and surgical loss
160
Ph of LR
6.5
161
Osmolarity of LR
273
162
Composition of LR
```
Sodium (130)
Chloride (109)
Lactate (28)
Potassium (4)
Calcium (2.7)
```
163
Ph NS
5
164
Osmolarity NS
308
165
Composition NS
154 mM Na + Cl
166
Adavantages of crystalloid over colloid
Inexpensive, promotes urinary flow, restores third space loss, used for ECF replacement, used for initial resuscitation
167
Disadvantages of crystalloid vs colloid
Dilutes plasma proteins, reduces cap osmotic pressure, peripheral edema, transient, potential for pulm edema, osmotic diuresis, impaired immune response
168
Advantages of colloid over crystalloid
Sustained increase in intravascular volume
Requires smaller volume for resuscitation
Less peripheral edema
More rapid resuscitation
169
Disadvantages of colloid vs crystalloid
Can cause coagulopathy
Anaphylactic reaction
Decreases calcium
Can cause renal failure
170
Which colloid causes the most coagulopathy
Dextran>hetastarch>hextend
171
Which colloid is most risk for anaphylaxis
Dextran
172
Which colloid decreases calcium
Albumin
173
Which colloid is most risk to cause renal failure
Dextran
