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Anaethetics 2 > Fluid Management And Blood Transfusions > Flashcards

Fluid Management And Blood Transfusions Flashcards

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1
Q

What else stimulates the release of ADH?

A

Stress and pain

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2
Q

How is ADH regulated in the heart?

A

By stretch receptors in low-pressure system of the heart and great vessels = baroreceptors

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3
Q

How do baroreceptors work?

A

Tonic firing from these receptors inhibit ADH release. In response to a decrease in filling of the RA, the rate of firing decreases =increasing ADH

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4
Q

What is ANP, and what role does it play?

A

Stretch of the right artrium releases atrial natriuretic peptide (ANP), which stimulates the excretion of sodium in the kidney. Fall in atrial filling inhibits release of ANP

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5
Q

What is the thirst mechanism?

A

Osmoreceptors sense an alter in osmotic concentration of the plasma and trigger the thirst mechanism releasing ADH from the post pituitary.

This stimulates water intake and re-absorption of water in the kidney

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6
Q

What is the circulatory response?

A

Central catecholamine release due to sympathetic stimulation in BRAINSTEM, and inhibition of parasympathetic response.

Increased HR and maintained BP(with decreased blood vol)

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7
Q

What does adrenaline do? And which organs are involved?

A

It had dominant B-agonist effects on CO and vasodilation of blood vessels in heart and skeletal mm

Brain heart and skeletal mm are predominately responsive to B-adrenergic stimulation

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8
Q

What does noradrenaline do?

A

Vasoconstriction via alpha agonist effect in all organs expect fight or flight

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9
Q

How is the kidney involved in shock?

A

Increased sympathetic tone reduced global renal blood flow, and redistributes plasma flow from cortical to JM nephrons

  • retention of Na and H2O
  • reduced ruins output
  • decreased urea clearance
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10
Q

Why are Juxtamedullary nephrons at high risk of renal tubular ischaemia, ATN, and AKI?

A

They have a tenuous oxygen supply and reductions in renal plasma flow puts them at risk

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11
Q

What is the diabetes of trauma?

A

Hormones released during shock = catecholamines, glucocorticoids, thyroid hormone and growth hormone. All anti- insulin hormones (insulin secretion and response is inhibited).

This causes increased glucose from liver
First glycogen breakdown
Gluconeogenesis

Suppression of insulin limited glucose use to fight/flight organs. Other organs are fat-adopted.
Rely on FFA and ketones for energy
In an inactive patient the metabolic response is inappropriate and results in elevated blood sugar

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12
Q

What are the fluid consequences of shock?

A

Maximal Na and water retention, dilutions like hyponatraemia, hypokalamia (Met. Alkalosis) diminished blood flow- risk of renal failure and hyperglycemia

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13
Q

What is the objective of fluid therapy?

A

Early and complete restoration of tissue blood flow and O2 supplies, reducing biochem disturbance and preservation of organ function (kidney and gut) and avoidance of transfusion complications

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14
Q

What are fluids used for?

A

Replacement of pre-operative losses
in-theatre resus
postop maintenance

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15
Q

Purpose of intra-operation fluids?

A

Rehydration
Maintenance
Replacement

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16
Q

What is the fluid replacement of pre-operative starvation losses according to normal hourly maintenance rate?

A

1-2ml kg hr

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17
Q

What should rehydration and maintenance fluids be replaced with?

A

Crystalloid solutions

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18
Q

Maintenance for adults?

A

1-2ml kg hr

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19
Q

How is blood loss replaced?

A

Isotonic crystalloid initially but once it exceeds 1litre all further replacement should be with colloids and then blood to maintain the appropriate haematocrit

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20
Q

Why should high sodium containing solutions be used?

A

To avoid hyponatraemia that results from the retention of water in excess sodium as part of the stress response

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21
Q

Should one use glucose containing products and why?

A

No, physiological response will ensure that blood sugar rises regardless of glucose admin and they are hypotonic not isotonic (don’t expand intravasculature space)

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22
Q

Where do crystalloid expand to and what is its consequences?

A

They expand the ECF and are redistributed between the intravascular as extracellular compartments in a 1:4 ration (1ml intravascular and 4ml in the ECF)

Consequently, full volume expansion after blood loss requires 3-4times the volume lost to be replaced

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23
Q

What is the ideal crystalloid resus solution?

A

One that resembles the electrolyte content of the plasma

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24
Q

What does normal saline contain that make it slightly hypertonic?

A

High levels of Na and Cl (154mmol). Osmolality is 308mosml
High levels of Cl can cause a metabolic acidosis

USE WITH CAUTION!

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25
What does Ringer's lactate contain?
Higher Cl (115) the Na is lower than plasma but still high (131) and osmolality is 273mosml
26
That does the lactate in ringer's lactate result in and what is the consequences thereof?
Lactate is metabolized to CO2 and water and leads to metabolic alkalosis even though pH is 6,5 Compensatory Respiratory acidosis and post-op resp depression
27
What should be avoided when in diabetics on metformin?
Ringer's lactate
28
What is modified RL and what can it be used for?
Similar to RL with no Ca and can be used in blood transfusions
29
What solution is better for maintenance?
Hypotonic crystalloid as with much slower sodium concentrations
30
Hypotonic fluids have very ....... And therefore must NEVER be used in resus
Potassium
31
What is half normal saline and what is it used for?
0,45% saline, and is hypotonic compared to plasma and can rehydrate with "free water" components, which will move into all intracellular and extracellular compartments depleted by dehydration
32
What is half normal saline used for?
To correct hypernatramia associated with decreased total body water
33
What is rehydration fluids?
Half-normal saline with 5% dextrose
34
Rehydration fluid is ..... Compared to plasma once ...... Is metabolized
Hypotonic | Dextrose
35
In which patient s is it useful as maintenance solution?
Patient with high K. Renal failure, it is K free
36
General maintenance solution, when is it used?
2-3l supplies daily water and electrolyte requirements (daily total 78mmol of Na and K) Used when patients are nil per os Has high K
37
What is Maintelyte?
Similar electrolyte component to GMS, with a larger 10% dextrose
38
What is a good balance to fluid management?
Colloids for haemodynamic stability Crystalloid for maintenance
39
Blood loss should be replaced with?
Colloids on a volume to volume basis
40
What are synthetic colloids?
Small gelatinous particles suspended or dispersed in a medium. They do not dissolve readily, nor do they settle out under gravity They have a high capacity for binding with water and other substances and don't pass easily through cell membranes
41
Due to their ......., ..... Produce a faster plasma volume expansion and better initial resus than .......
Unique properties Colloids Crystalloids
42
What is rheology
The study of flow of a matter
43
What do colloids not resus?
The intracellular and interstitial fluid volume and may cause renal failure as a result of used alone
44
What interferes with coagulation?
Colloids to some degree
45
In what are most synthetic colloids suspended in?
0,9% saline and have high Cl
46
What are gelatins?
Synthetic colloids that is effective but relatively short acting because they are so rapidly excreted in the kidney where they exert osmotic diuresis Have the least effect on coagulation, but highest risk allergic reactions
47
What is the problem with Dextrans?
Have a good duration of effect with good theological properties, but they impair coagulation, interfere with cross matching techniques and significant allergic risk
48
How do Dextrans affect coagulation?
They bind to Von Willebrand factor/factor 8complex and impair coagulation. Similar effect to subcut heparin
49
How do Starches (Voluven) affect coagulation?
Good duration of action but high molecular weight starches impair coagulation
50
Whole blood properties?
Donations screened for hep B, C, HIV1&2 and syphilis | Used as raw material for numerous blood components-packed RBCs, plts, FFP and clothing factors
51
What is the volume, hct, shelf life and preservatives of whole blood
550ml 35 35 days at 4 degrees CPD-A ( citrate, phosphate, dextrose and adenine)
52
Indications for whole blood?
Massive hge Hypovol shock Burns
53
RBC?
Plasma (can be used to prep FFP and clothing factors) and anticoagulant are removed from whole blood
54
What are RBC suspended in?
Small volume of nutrient fluid, SAGM (saline, adenosine, glucose and mannitol)
55
What is a volume, hct, and shelf life of RBCs?
300ml 60% 42 days at 4degrees
56
Indications for RBCs?
Ongoing hge, where initial volume resus was carried out with crystalloid or colloid solutions Normovolaemic for non-elective surgery. 4mlkg of packed RBCs raises the Hb level by 1gdl
57
What is fresh frozen plasma and what is it used for?
FFP is extracted from freshly donated whole blood and frozen to preserve clothing factor Used to replace deficient clothing factors in patients who also need plasma volume support Higher risk of transfusion-related acute lung injury (TRALI)
58
What are the 3 types of cross matches?
Routine- complete cross match done Asap- full cross match, available in 30min-1hr STAT-incomplete screen, group specific blood to be issued within 5mins
59
What is the most common cause of transfusion reaction?
Clerical error
60
How is stored blood kept?
In 2-10 degrees Warm before use to 37 (higher risk harmony sis) NEVER rewarm!
61
What should not be used with citrates whole blood and why?
Calcium containing fluids, can cause clothing in tubing
62
What is the pilot tube used for?
It contains residual blood that is used for investigation for the transfused blood in event of patient reaction
63
What are immune complications of blood transfusions?
Hemolytic: Early-ABO incompatibility Late- rhesus ``` Non-haemolytic: Fever Urticaria Purpura TRALI Anaphylaxis Immune suppression Graft vs host disease ```
64
Non-immune complications of BT?
``` Infectious: Viral Bacterial Parasitical Prions ``` ``` Massive blood transfusions Hypothermia Hyperkalemia (early) Hypocalcemia Citrate toxicity DIC A-B changes Fluid over load ```
65
Clinical signs of transfusion reactions?
``` Restlessness, anxiety Nausea and vomiting Back, flank or praecordial pain Facial flushing, sweating and itching Abnormal bleeding- oozing from drip site Pyrexia Tachycardia or bradycardia Tachypnoea it bronchospasm Haemoglobinuria Jaundice Coma or death ```
66
Management of a transfusion reaction?
``` STOP TRANSFUSION! ABC - increase O2 -vasopressors if necessary Antihistamines and/ or steroids Encourage good urine flow Bloods Fbc: Hb, clothing profiles, DIC, U&E for renal failure Inform blood bank And send to blood bank: All units of blood and giving sets Post transfusion specimens of blood (clotted and EDTA) Urine sample Completed untoward reaction report form ```
67
What is a massive blood transfusion?
More than 10units in adult or total blood volume in less than 1 hour
68
Consequences of giving large amounts of stored blood?
-Dilution all thrombocytopenia- after 24 hr few plts -"" coagulopathy- reduced clothing factors (5 and 8) -Reduced pH initially followed by alkalosis- raised lactate, but citrate is converted to HCO3 by liver causing met alkalosis -Reduced 2,3 DPG, shifts curve to the left, reducing O2 availability to tissues -reduced temp, shifts curve to left and inhibits coagulation -reduced WBC -hyperkalemia initially, followed by hypokalamia -Citrate toxicity -increased extracellular Hb in plasma dude to decreased RBC survival Exacerbated by pressures infusions and renal impairment -microemboli

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