Fluid & Body Therapy Flashcards
(181 cards)
1
Q
Crystalliods vs Colloids
A
- When given in sufficient amounts, they can be just as effective as colloids in restoring intravascular volume.
- Generally requires 3 three times the volume needed than when using colloids.
- Most surgical patients have an extracellular fluid deficit that exceeds the intravascular deficit.
- Severe intravascular deficits can be rapidly corrected using colloids.
- Rapid infusion of crystalloids is frequently associated with significant tissue edema (third spacing).
2
Q
general info about Replacement type solutions
A
- Losses primarily due to both water and electrolyte deficits are replaced with Isotonic solutions.
- These are what we use in the OR
-These solutions are called
REPLACEMENT TYPE SOLUTIONS
3
Q
general info about Maintenance Type Solutions
A
- The IV fluids we generally use on the floor are hypotonic.
- Primarily used to replace water loss.
- These solutions are referred to as MAINTENANCE TYPE SOLUTIONS
4
Q
0.9% Normal Saline
A
- Isotonic
- 308 mOsm/L
- 154 mEq/L Na+
- 154 mEq/L Cl-
- Always used as your carrier fluid to transfuse blood (PRBC’s)
5
Q
Lactated Ringers
A
-Most commonly used in OR Isotonic -273 mOsm/L -130 mEq/L Na+ -109mEq/L Cl- -4mEq/L K+ -3mEq/L Ca++ -28mEq/L Lactate -The lactate in this soln is converted by the liver into bicarbonate.
6
Q
The lactate in this solution is converted by the liver into bicarbonate
A
Lactated Ringers
7
Q
Approximate distribution of electrolytes Extracellular Fluid (mEq/L)
A
NA: 140
K: 4.5
Mg: 2
Ca: 5
8
Q
Approximate distribution of electrolytes Intracellular Fluid (mEq/L)
A
Na 10
K: 150
Mg: 40
Ca: 1
9
Q
ECF vs ICF Na level
A
ECF: 140
ICF: 10
10
Q
ECF vs ICF K level
A
ECF: 4.5
ICF: 150
11
Q
ECF v ICF Mg level
A
ECF: 2
ICF: 40
12
Q
ECF vs ICF Ca level
A
ECF: 5
ICF: 1
13
Q
SODIUM
A
Sodium (135-145 mEq/L)
- The major cation in blood
- Excitable cells depend on it for depolarization
- HYPERNATREMIA (>145mEq/L) is usually due to a total body water deficit
14
Q
-HYPERNATREMIA
A
Na >145, usu due to total body water defecit
15
Q
Major cation in blood
A
Sodium
16
Q
Excitable cells depend on it for depolarization
A
Sodium 135-145
17
Q
HYPONATREMIA
A
(<135mEq/L) usually due to excess body water, or can be associated with burns, vomiting, diarrhea, etc.
18
Q
S & S of HYPOnatremia
A
Neurologic signs:
Confusion/restlessness/ aggitation
Blindness
Twitches/seizures
Lethargy/paralysis/ coma
Dilated/nonreactive pupils
Headache
Cerebral Edema
GI signs:
Anorexia
N/V
Muscular Manifestations
Cramps
Weakness
19
Q
Isotonic Hyponatremia
A
Pseudohyponatremia Serum Osmolality 280-285 Causes: Hyperlipidemia hyperproteinemia infusion of nonelectrolyic substances: glucose, mannitol, glycine
20
Q
Nonelectrolytic substances
A
glucose, mannitol, glycine
21
Q
Hypertonic HYPOnatremia
A
Serum Osmolality >285
Causes: Hyperglcemia, infusion of hypertonic nonelectrolyte solutions
22
Q
Which natremia has serum osmolality >285 and is often caused by hyperglycemia or infusion of hypertonic non-electrolyte solutions?
A
HYPERtonic HYPOnatremia
23
Q
HYPOtonic HYPOnatremia
A
Serum Osmolality <280
Hypovolemic hypotonic hyponatremia
Causes
diuretics
Salt-losing nephropathy
ketonuria
third-spacing
adrenal insufficiency
Vomiting/ diarrhea
ISOvolemic hypotonic hyponatremia
causes
SIADH
renal failure
hypothyroidism
drugs
water intoxication
drugs
24
Q
Hypovolemic hypotonic hyponatremia
A
Serum Osmolality < 280
Causes
diuretics
Salt-losing nephropathy
ketonuria
third-spacing
adrenal insufficiency
Vomiting/ diarrhea
25
ISOvolemic hypotonic hyponatremia
```
Serum Osmolality < 280
causes
SIADH
renal failure
hypothyroidism
drugs
water intoxication
drugs
```
26
which natremia has a serum Osm <280 and is often caused by SIADH, Renal Failure, HYPOThyroidism, water intoxication?
ISOvolemic hypotonic hyponatremia
27
Clinical manifestations of HYPERnatremia
```
Neuro:
thirst
weakness
seizure
coma
intracranial bleeding
disorientation
hallucinations
irritability
CV:
hypovolemia
Renal:
polyuria or oliguria
renal insufficiency
```
28
Potassium
(3.5-5.0 mEq/L)
Major intracellular cation
-Maintenance of cardiac rhythm
-Contribution to cellular energy production
-Deposition of glycogen by liver cells
-Transmission and conduction of nerve impulses
29
Which electrolyte is the major intracellular cation?
Potassium 3.5-5.0 mEq/L
30
which lyte helps with maintenance of cardiac rhythm?
Potassium
31
which lyte contributes to cellular energy production?
K+
32
which lyte is involved in transmission and conduction of nerve impulses?
K+
33
Hyperkalemia
>5.5
| increased total body K+
34
Hyperkalemia
Renal disease
Role of Succinylcholine
S/S of Hyperkalemia
Usually only occur with an acute increase
Many renal patients have elev. K+ chronically
MOST DETRIMENTAL is cardiac conduction defects
```
EKG:
Prolongation of the PR interval
Widening of the QRS complex
Peaking of the T wave
Treatment
Multiple treatments are available depending on severity and time frame
```
35
what drug are you concerned with using with HYPERkalemia?
Succinylcholine
36
EKG changes of Hyperkalemia
Prolongation of the PR interval
Widening of the QRS complex
Peaking of the T wave
37
Redistribution factors of Hyperkalemia
```
Acidosis
Hypertonicity
Hemolysis
Tissue necrosis
Rhabdomyolysis
```
38
Decreased renal Excretion causitive factors of Hyperkalemia
Renal insufficiency and failure
potassium sparing diuretics
hypoaldosteronsim
Drugs: NSAIDs, B-Blockers, ACE Inh
39
Excessive Potassium intake: causitive factors of hyperkalemia
IV/ PO supplementation
Excessive use of salt substitutes
Rapid transfusion of banked blood
40
clinical manifestations of hyperkalemia
```
CV:
Tall, peaked T waves
Widened QRS complex
Ventricular dysrhythmias
Cardiac Arrest
NEURO:
Muscle weakness
Confusion
Parathesias
```
41
Tx of Hyperkalemia (dose, mechanism, onset, duration): Calcium Gluconate
Calcium Gluconate 10-20 ml IV (10% solution)
Mechanism: Direct antagonism
Onset: Rapid
Duration: 15-30 min
42
Tx of Hyperkalemia (dose, mechanism, onset, duration): Hyperventilation
PaCO2 25-30 mmHg
Mech: shift intracellular
onset: rapid
duration: no data
43
Tx of Hyperkalemia (dose, mechanism, onset, duration): Hemodialysis
Mech: remove
Onset: Rapid
Duration: no data
44
Tx of Hyperkalemia (dose, mechanism, onset, duration): Sodium Bicarbonate
Sodium Bicarb 50-100 mEq IV
Mech: shift intracellular
Onset: 15-30 min
Duration: 3-6h
45
Tx of Hyperkalemia (dose, mechanism, onset, duration): Glucose+ insulin
Glucose 25-50g IV + Insulin 10-20 units IV
Mech: shift intracellular
Onset: 15-30 min
duration 3-6h
46
what are the rapid onset tx of hyperkalemia?
Calcium gluconate 10-20ml IV (10% solution)
| Hyperventilation PaCO2 25-30 mmHg
47
What is a direct antagonism tx of Hyperkalemia?
Calcium Gluconate 10-20 ml IV (10% solution)
Mechanism: Direct antagonism
Onset: Rapid
Duration: 15-30 min
48
Hypokalemia
```
(<3.5mEq/L)
Diuretics
Nausea, Vomiting, Diarrhea
NG Suction
Maldistribution (Alkalosis)
Stress induced catacholamines
```
49
Adverse effects of hypokalemia
```
Decreased myocardial contractility
Skeletal muscle weakness
Increased automaticity in the atria
Prolongation of PR interval, QT interval
Flattening of the T wave
```
50
What lyte imbalance can cause decreased myocardial contractility, increased automaticity in the atria, prolongation of PR interval/ QT interval, flattening of the T wave?
Hypokalemia
51
why is NaCl preferred to LR with brain injury, hypochloremic metabolic acidosis, or hyponatremia?
LR contains a hypotonic concentration of sodium
52
why do many patients with hyperkalemia, including renal failure pts, routinely receive NaCl?
because it contains no K+
53
why is NaCl ideal for dilution of PRBCs
because it is nearly isotonic
54
Tx of hypokalemia
Oral replacement in chronic hypokalemia questionably effective
IV replacement slow and carefully with cardiac monitoring
55
Surgical implications of hypokalemia
Debate as to whether or not to do elective surgery of K+ <3.5mEq/L. Most will go at 3.0mEq/L
56
What organ is the main rregulator of magnesium?
Kidney (proximal tubule)
57
Magnesium
```
(1.5-2.5mEq/L)
Intracellular cation
Enzyme activity
Essential fro protein synthesis
Neurochemical transmission
Muscular excitability
```
58
Which Lyte is essential to protein synthesis?
Magnessium
59
Which Lyte is incolved in muscular excitability?
Mg
60
Is Mg ECF or ICF Cation?
ICF
61
Hypermagnesemia
(>2.5mEq/L)
Laxative abuse, Antacid abuse
CNS depression, decreased myocardial contractility
Skeletal muscle weakness
Treatment includes antagonism with Calcium
Establish diuresis
IV fluid dilution
62
Hypomagnesemia
(<1.5mEq/L)
Chronic alcoholism, protracted nausea
Diarrhea
S/S mirror hypocalcemia
63
hypo states of these two Lytes mirror each other in S & S
Mg & Ca
64
Calcium
```
(4.5-5.5 mEq/L, 9-11mg/dL)
Extracellular and intracellular functions
Formation of bones and teeth
Transmission of nerve impulses
Contraction of muscles
COAGULATION
Maintenance of cellular permeability
Cardiac action potential and pacemaker activity
```
65
This lyte has ECF & ICF functions
Calcium
66
This lyte is essential in formation of bones and teeth
Calcium
67
THis lyte is involved in contraction of muscles
Ca
68
this lyte is involved in Coagulation
Ca
69
this lyte is involved in maintenance of cellular permeability
Ca
70
This Lyte is involved in cardiac action potential and pacemaker activity
Ca
71
Hypercalcemia
```
(>5.5mEq/L)
Hyperparathyroidism
Neoplastic disorders with bone mets
S/S include
Prolonged PR interval
Widened QRS complex
Shortened QT interval
Hydration and Urinary output important
```
72
This lyte imbalance is seen in Neoplastic disorders with bone mets
Hypercalcemia
73
this lyte imbalance is seen in hyperparathyroidism
Hypercalcemia
74
Hypocalcemia
```
(< 4.5 mEq/L)
Decreased serum albumin
Hypoparathyroidism
Pancreatitis
Renal failure
S/S include
Skeletal muscle spasm
Laryngospasm
Respiratory alkalosis can further decrease Ca++ levels
```
75
This lyte imbalance can have Laryngospasm as a S & S
HYPOcalcemia
76
Respiratory alkalosis can further decrease this lytes levels
Ca++
77
Metabolic effects of fasting
To withstand fasting and the catabolic effects of surgery, the body must mobilize nutrients from it fuel stores
Glycogen
First to go, but cannot maintain the body for more than 1 day
Fats
Mobilized and converted to glucose
Protein
Ketones and fatty acids, packed with energy, but there is a price to pay!
78
In healthy adults undergoing elective surgery, the following must be taken into consideration:
NPO loss
Insensible loss
EBL Replacement
Maintenance
79
The predicted daily maintenance fluid requirements for healthy adults may exceed
2500ml/day including 20 mEq/L Sodium and 15-20mEq/L Potassium
80
Insensible loss may exceed?
(diaphoresis, respiration, etc.) may exceed 1000ml/day
81
Urinary losses to maintain renal function average
1000ml/day
82
GI losses avg
200ml/day
83
Normal daily Losses
| Urinary, Resp-sweat, GI
Urinary 1000-1500 ml/day
Respiratory-sweat: 500-1000 ml/day
GI: 100-200 ml/day
84
Total maintenance requirement for a 70kg male
2500ml/day
85
Crystalloid replacement scheme
```
Maintenance hourly
NPO deficit as follows
½ 1st hour
¼ 2nd hour
¼ 3rd hour
Insensible loss (Replacement)
4cc/kg minimal trauma
6cc/kg moderate trauma
8cc/kg extensive trauma
```
86
NPO deficit crystalloid replacement scheme
1/2 in 1st hour
1/4 in 2nd hour
1/4 in 3rd hour
87
Minimal trauma insensible loss replacement
4cc/kg
88
moderate trauma insensible loss replacement
6 cc/kg
89
extensive trauma insensible loss replacement
8cc/ kg
90
The following is an accepted example of “third space” replacement (insensible)
Minor trauma 4 ml/kg/hr
Moderate trauma 6ml/kg/hr
Extensive trauma 8ml/kg/hr
91
What fluid may be required if EBL is extensive?
Colloids
92
4-2-1 RULE
4cc/kg for the 1st 10kg of body weight
2cc/kg for the next 10kg of body weight
1cc/kg for the rest of the body weight
This formula works for children and adults
In an adult weighing over 30kg, just add 40 to the weight to find the maintenance rate
93
Intraoperative fluid replacement
| Maintenance fluid
Maintained with isotonic solution
4-2-1 RULE
4cc/kg for the 1st 10kg of body weight
2cc/kg for the next 10kg of body weight
1cc/kg for the rest of the body weight
This formula works for children and adults
In an adult weighing over 30kg, just add 40 to the weight to find the maintenance rate
94
What are the maintenance fluid requirements for a 25kg child?
For the first 10kg 4ml/hr = 40cc/hr
For the second 10kg 2ml/hr = 20cc/hr
For each kg above 20 1ml/hr= 5cc/hr
_______
Answer 65cc/hr
95
70 kg man has a maintenance rate of
110 cc/hr
96
Deficit is described as the ?
Maintenance rate x hours NPO
Example – 70 kg man has a maintenance rate of 110cc/hr. If he was NPO after midnight at his surgical procedure is to begin at 0800 (8hrs), then his deficit is 880ml.
Give ½ in the first hour (440cc), ¼ in the second hour (220cc), and ¼ in the third hour (220cc).
It is OK to give it faster, if needed
97
Abnormal fluid losses
```
Hemorrhage
Sweating
Diarrhea
Vomiting
NG Suction
Pre-op Bowel Prep
Bowel Obstruction w/edema
Ascites
Sepsis
```
- Difficult to calculate
- must use clinical evaluation
- entail more than just water loss
- may require replacement
98
Surgical losses other than blood
3rd space losses
evaporation
serous fluid loss
99
3rd space losses
Fluid moves into the interstitial, intracellular, space and are functionally not available to intravascular space.
Amount depends on degree of surgical trauma
- Minimal 2 ml/kg/hr
- Major 4-6 ml/kg/hr
Replace with crystalloid
Post-op days 1-3, fluid moves back to the intravascular space and is renally excreted if excess water is present.
100
COLLOIDS
The osmotic activity of the high molecular weight substances in colloids tends to maintain these solutions intravascularly.
While the intravascular half-life of a crystalloid solution is 20-30 minutes, most colloid solutions have intravascular half-lives between 3 and 6 hours.
101
Intravascular half-life of crystalloids
20-30 minutes
102
Intravascular half life of colloids
3-6 hours
103
The osmotic activity of the high molecular weight substances in (BLANK) tends to maintain these solutions intravascularly.
Colloids
104
The osmotic activity of the high molecular weight substances in colloids tends to maintain these solutions (BLANK)
Intravascularly
105
The osmotic activity of the high molecular weight substances in (BLANK) tends to maintain these solutions BLANK.
Colloids
| Intravascularly
106
All colloids are derived from (blank) or (Blank)
Plasma proteins or synthetic glucose polymers are are supplied in isotonic electrolyte solutions
107
all colloids are supplied in (blank) electrolyte solutions
Isotonic
108
Blood Derived colloids include
albumin, which are supplied in 5% or 25 % solutions
109
Synthetic colloids include
dextrose starches and gelatins. Gelatins are not available in the US as they are associated with histamine-mediated allergic reactions.
110
which synthetic colloid is associated with histamine-mediated allergic reactions?
Gelatins. they are not available in the US
111
Hetastarch
Hetastarch (hydroxyethyl starch) is available as a 6% solution.
Hetastarch is a highly effective plasma expander and is less expensive than albumin.
Hetastarch is non-antigenic and anaphylactoid reactions are rare.
Hetastarch (hydroxyethyl starch) is available as a 6% solution.
Hetastarch is a highly effective plasma expander and is less expensive than albumin.
Hetastarch is non-antigenic and anaphylactoid reactions are rare.
112
which colloid is non-antigenic and anaphylactoid reactions are rare
Hetastarch
113
Pentastarch
Pentastarch is a lower molecular weight starch solution and is less likely to cause adverse reactions.
Pentastarch may eventually replace hetastarch.
Voluven ( remains intravascularly 4-6 hours, hetastarch 1.5 hours).
114
Voluven ramains intravascular for x?
4-6 hours
115
Hetastarch remains intravascular for x?
1.5 hours
116
BLOOD
A viscous fluid composed of platelets, leukocytes, red blood cells, and plasma.
Plasma is part of the extracellular fluid.
Platelets form the primary hemostatic plug and are important in hemostasis.
Leukocytes (white blood cells) are comprised of neutrophils and basophils and are a rapid and potent defense against infection.
117
Plasma is part of the ? ECF or ICF
ECF
118
this forms the primary hemostatic plug and is important in hemostatis
Platelets
119
This allows specefic treatment of thrombocytopenia
platlets
120
What is the platelet count when platelet infusion is indicated?
platelet count <50,000 cells/mm3
121
how much does one unit of platelets increase the count?
one unit = 5-10k increase
122
The fluid portion obtained from a single unit of whole blood that is frozen within 6hrs of collecton
FFP (fresh frozen plasma)
123
this fluid is used in tx of hemorrhage
FFP
124
FFP is not needed unless PT and/or PTT is ?
>1.5times normal
125
fluid used in urgent reversal of Warfarin (Coumadin)
FFP
126
Cryoprecipitate
The fraction of plasma that precipitates when FFP is thawed.
Useful in treating hemophilia A (high conc. of factor VIII in a small volume).
Contains more fibrinogen that FFP.
127
This fluid is useful in tx of hemophilia A
Cryoprecipitate
128
what is hemophilia A
high concentration of factor VIII in a small volume
129
what fluid contains more fibrinogen than FFP?
Cryoprecipitate
130
These cells provide 70% of the body's acid base-buffering capacity
RBC's
131
This cells membrane has specific proteins (antigens) that are an integral part of the body’s immune system
RBC's
132
the antigens of these cells help the body identify foreign cells
RBC's
133
These antigens are inherited and are used as the basis for the ABO and Rh classification system
RBC's
134
ABO blood group highest frequency white US population
O
135
ABO blood group highest frequency Black US population
O
136
ABO blood group highest frequency Asian US population
O
137
rarest ABO US population
AB
138
2nd highest ABO US population
A
139
AB blood type RBC antigens
A, B
140
B blood type RBC antigens
B
141
O blood type RBC antigens
none
142
AB blood types can receive
A, B, AB, O
| "universal recipient"
143
Universal donor?
O
144
B type can receive?
B, O
145
A type can receive?
A, O
146
O type can receive?
O "universal Door"
147
Universal recipient?
AB
148
Positive blood types can receive
rH negative and positive
149
negative blood tyoes can receive
RH negative only
150
ALL BLOOD TYPES CAN RECEIVE THIS ABO & RH
O-
151
Hemolytic disease of the newborn
Rh negative mother delivering an Rh positive baby.
IgG molecule of the mother passes through the placenta.
Among these antibodies are some that attack the red blood cells of the fetus.
Fetus can develop reticulocytosis and anemia
Rhogam IM at 28 weeks and within 72 hours after delivery. Prevents sensitization of the maternal immune system to Rh D in the current or subsequent pregnancies
152
Rh (blank) mother delivering Rh (blank) baby = hemolytic disease
negative mother and positive baby
| remember that negative blood types can only handle negative blood
153
Acute blood loss of Xml exceed the ability of crystalloids to replace without jeopardizing O2 carrying capacity of the blood
1500-2000ml (or approx 30% of EBV)
154
compensatory mechanisms maintain homeostasis until what EBL?
>1500-2000ml or 30% EBL
155
Blood loss continuously replaced with what ratio?
3: 1 with crystalloids
1: 1 with colloids
156
Intraoperative assessment of blood loss
```
Visual estimation
Sponges
Laps
Drapes
Suction
Most tend to underestimate
Urinary output is a good indicator
Tachycardia and hypotension also important
```
157
Surgical sponge (4X4) soaked = X EBL
10ml
158
Lap pad soaked = x ebl
100-150ml
159
Calculating Estimated Blood Volume (EBV) and Allowable Blood loss ABL
```
Blood Volume as a function of total body water composition decreases with age
Premature 100-120cc/kg
Newborn 80-90cc/kg
Infant (age 3-12 months) 75-80cc/kg
Adult male 70cc/kg
Adult female 65cc/kg
```
160
Adult male EBV
80kg
70ml/kg
80x70 = 5600ml
161
Adult female EBV
65ml/kg
65kg pt
65x65 = 4225ml
162
Calculating allowable blood loss
Hematocrit
If you know what the preoperative HCT is, you can calculate MABL this way:
ABL = EBV x (Starting HCT – Target HCT
/ Starting HCT
163
Guidelines for EBL & Transfusion
Some schools of thought propose not transfusing until the Hct reaches 24 or Hgb 8 but you have to consider how fast is blood being lost, co-morbidities, and oxygenation.
One unit of PRBC’s will increase Hgb by 1 g/dl and Hct 2-3%
A 10ml/kg transfusion of PRBC’s will increase Hgb by 3g/dl and the Hct by 10%
164
1 unit PRBC increase Hgn by x and Hct by X
Hgb 1g/dl
| Hct 2-3%
165
a 10ml/kg transfusion of PRBCs will increase Hgb by x and Hct by x
Hgb 3g/dl
| Hct 10%
166
Goals of fluid management
Adequate oxygen delivery: organ perfusion & RBCs
Norm electrolyte concentration
Normal glucose concentrations
167
Compensatory IV volume
Must be administered to expand blood volume
5-7 ml/kg prior to induction
Some practitioners give ½ calculated fluid deficit prior to induction
168
These surgeries get LESS compensatory IV fluid
Neurosurgery, CHF, Thoracic Surgery
169
These surgeries get MORE compensatory IV fluid
Preload, ABD surgeries, Hypovolemia
170
Maintenance type solutions are for X and replaced with x
losses primarily due to water loss
| generally replaced with hypotonic solutions
171
3rd space losses: amount by surgery
Minimal 2ml/kg/hr
| Major 4-6ml/kg/hr
172
3rd space losses are replaced with what type of fluid?
Crystalloids
173
what organ regulates Ca?
Parathyroid
174
Where in the clotting cascade does Ca play a role
Factor IV
175
what ingredients in antacids can affect Mg levels with abuse?
Aluminum, Ca
176
what 3 nutrients will the body use when fasting?
Glycogen
Fats
Protein
177
when is the 4-2-1 rule used?
Maintenance fluid
178
what product contains all coag factors but platlets
FFP
179
premature infant EBV
100-120ml/kg
180
newborn EBV
80-90ml/kg
181
Hct should be X times the Hgb
3 times
if Hgb is 10 Hct should be 30
