Fluid Management & Blood Therapy Flashcards
(186 cards)
1
Q
How much is TBW of lean body weight?
A
60% of lean body weight
2
Q
What is ICV of normal body weight?
A
40% body weight (2/3)
3
Q
What percentage is EVC of TBW?
A
20% body weight (1/3 TBW)
4
Q
What percent is plasma volume?
A
4% (1/4 of ECV)
5
Q
What percent is interstitial volume?
A
16% (3/4 of ECV)
6
Q
How many mL/kh/day necessary for homeostasis for health adult?
A
25-35 mL/kg/day (about 2-3 L)
7
Q
What is also contained in ECV in small amounts?
A
Trans cellular fluids, CSF, synovial fluid, GI secretions, intraocular fluid
8
Q
Normal Na in plasma?
A
142 mEq/L
9
Q
Normal Na in ICF?
A
10 mEq/L
10
Q
What is ECF Na amount?
A
140 mEq/L
11
Q
Normal K amount plasma
A
4 mEq/L
12
Q
Normal K amount intracellular fluid
A
150 mEq/l
13
Q
Normal K ECF?
A
4.5 mEq/L
14
Q
Normal Mg plasma?
A
2 mEq/L
15
Q
Normal Mg intracellular?
A
40 mEq/L
16
Q
Normal Mg ECF?
A
2 mEq/L
17
Q
Normal Ca plasma?
A
5 mEq/L
18
Q
Normal Ca ICF
A
1 mEq/L
19
Q
Normal Ca ECF?
A
5 mEq/L
20
Q
Normal Cl Plasma?
A
103 mEq/L
21
Q
Normal Cl ICF
A
103 mEq/L
22
Q
Normal Cl ECF?
A
117 mEq/L`
23
Q
Normal bicarb Plasma?
A
25 mEq/L
24
Q
Normal Bicab IF?
A
7 mEq/L
25
Normal Bicarb ECF?
28 mEq/L
26
Primary cation and anion ICF?
K (cation), phosphate (anion)
27
Primary cation and anion ECF?
Na (cation), Cl (anion)
28
Normal range K in plasma?
3.5-5.5 mEq/L
29
What is value for hypokalemia?
<3.5 mEq/L
30
Etiology of hypokalemia?
```
Poor intake: diet
GI loss (v/d/ NG sxn, kayexalate)
Renal loss: diuretics, metabolic alkalosis, licorice
```
Intracellular shift: beta2 agonist, insulin, alkalosis
31
Presentation of hypokalemia?
Skeletal muscle cramps--> weakness--> paralysis
Worsens dig toxicity
32
EKG findings for hypokalemia?
PR interval- short
QT- Long
T wave- flat
U wave
33
How to treat hypokalemia?
Potassium supplementation
34
Etiology of hyperkalemia
Poor excretion : renal failure, K sparing diuretics
Extracellular shift: acidosis
Iatrogenic: succ
Misc tumor lysis
35
Presentation of hyperkalemia?
Cardiac rhythm disturbances
36
Early EKG findings of hyperkalemia
PR long, T wave peaked, QT short
37
Middle stage EKG findings hyperkalemia?
P flat, QRS- wide
38
Late stage EKG findings hyperkalemia?
QRS- sine waves--> VF
39
Treatment for hyperkalemia?
```
Calcium FIRST to stabilize membrane (does not affect K directdly)
Insulin + D50
Hyperventilation
Bicarbonate
Albuterol
Potassium wasting diuretics
Dialysis
```
40
Normal range sodium level blood?
135-145 mEq/L
41
Etiology of hyponatremia
SIADH, CHF, cirrhosis, TURP sydrome, cushings
Need to evaluate plasma osm and ECF volume to determine cause
42
Presentation of hyponatremia
N/V
Skeletal muscle weakness
Mental status changes--> seziures--> coma
Cerebral edema (cell SWELLING)
43
Treatment of hyponatremia?
Depends on specific cause. Do slowly to prevent extreme shifts
Restore Na by manipulating serum Osm and fluid balance with H2O restriction
44
Etiology of hypernatremia?
DI, Impaired thirst, NaHCO3 administration
45
Presentation of hypernatremia?
```
Thirst
Mental status changes--> sz--> coma
Cerebral dehydration (cell shrinkage)
```
46
Treatment hypernatremia?
Depends on cause
Goal to restore Na by fluid balance and Na restriction
47
Normal range Ca in blood?
8.5 mg/dL- 10.5 mg/dL
48
Etiology of hypocalcemia?
```
Hypoparathyroidism ( i.e. parathyroidectomy)
Vitamin D def.
Renal osteodystrophy
Pancreatitis
Sepsis
```
Blood product adminEtio
49
Presentation of hypocalcemia?
Skeletal muscle cramps
Nerve irritability-- paresthesia and tetany (circumferential numbness/tingling)
Chvostek sign (tap face and twitch)
Trousseua sign (carpal spasm with BP cuff on)
Laryngospasm
Mental status changes--> sz
50
EKG findings of hypocalcemia?
QT LONG
51
Treatment of hypocalcemia?
Admin calcium
| Vit D
52
Etiology hypercalcemia
```
Hyperparathyroidism
Ca
Thyrotoxicosis
Thiazide diuretics
Immobilization
```
53
Presentation of Hypercalcemia
```
nausea
ABD pain
HTN
Psychosis
Mental status changes
```
54
EKG findings hypercalcemia
QT SHORT
55
Treatment of hypercalcemia
NS, furosemide
56
Normal range of Mg in blood?
1.3-2.5 mEq/L
57
Etiology hypomagensimia?
```
poor intake
Alcohol abuse
Diuretics
Critical illness
Commonly occurs with hypokalemia
```
58
Presentation of hypomagnesemia?
Skeletal muscle weakness
| Arrythmia (torsade to pointes)
59
EKG findings of hypomagnesemia?
Not very significant unless very low, then long QT
60
Treatment hypomagnesemia?
Mg sulfate
61
Etiology hypermagnesemia?
Excessive admin (iatrogenic)
Renal failure
Adrenal insufficiency
62
When do you lose deep tendon reflexes in hypermagnesemia?
4-6.5 mEq/L or 10-12 mg/dL
| lower levels of hypermagnesemia
63
When do you see respiratory depression in hypermagnesemia?
6.5-7.5 mEq/L or >18 mg/dL
64
When do you see cardiac arrest in hypermagnesemia?
>10 mEq/L or >25 mg/dL
65
Treatment for hypermagnesemia?
Calcium chloride
66
How is interstitial fluid pressure relative to atmospheric pressure?
Negative; believed to be due to contraction of lymphatic vessels
67
How does plasma communicate with interstiital fluid?
Capillary pores
68
What dictates fluid movement?
Osmotic forces and hydrostatic pressure
69
What is most important oncotically active constituent of ECF?
Albumin
70
What favors filtration of fluid into interstitial space?
Increases in capillary hydrostatic pressure and interstitial oncotic pressure
71
What favors absorption of fluid into intravascular space?
Increase in interstitial fluid hydrostatic pressure and plasma oncotic pressure.
72
What accounts for small amount of fluid diff b/w arteries and venous ends of capillary?
Lymph vessels absorb some fluid
73
What is the sum of filtration and absorption?
Net filtration pressure (NFP)
74
What is main determinant of extracellular osmotic pressure?
Na
75
What is main determinant of intracellular osmotic pressure?
K
76
What does positive net filtration favor?
Fluid exudation into tissue
77
What does negative net filtration favor?
Fluid absorption into vasculature
78
How much intravascular volume is constantly filtered into interstitial space?
2mL/min; returned to intravascular system via lympatic system
79
What is endothelial glycocalyx?
Gel layer in capillary epithelium that creates physiologically active barrier within vascular space.
-Creates barrier between vessel and blood
- Plays role in transcapillary fluid excahnge, microcirculatory flow, blood component rheology, plasma oncotic pressure, signal transduction, immune modulation and vascular tone (GEEZ)
- Composed glycoproteins, polysaccharides, hyaluronic acid
80
How does EGL preserve oncotic pressure and decrease capillary permeability to water?
Binds to circulating plasma albumin
81
What is also contained in EGL?
inflammatory mediators, free radical scavenging, activation of anticoag factors
82
What can destory EGL?
Hyperglycemia
| Stress, critical illness
83
How does EGL contribute to laminar blood flow?
dyanmic barrier repels negatively charged polar compounds in addition to blood components.
-This prevents blood component adhesion to vascular wall
84
What are some neurohormonal influences in fluid dynamics (general overview)
RAAS- reabsoprtion of sodium and water
ADH- hold onto water
ANP-- inhibit renin and ADH when atria stretch receptors stimulated
85
Why might intraoperative UOP not be a good indicator of fluid status?
Stress causes increase in ADH
- Increased abd pressure from lap surgery can also release ADH
May see abrupt drop in UOP even in health, euvolemic patients
86
Normal pH ABG
7.35-7.45
87
Normal CO2 ABG
35-45
88
Normal bicarb ABG
22-26
89
Cardiac effects acidosis?
Increased p50 (right release o2)
Decreased contractility
Increased SNS tone
Increased risk of dysrhythmia
90
CNS effect of acidosis?
Increased CBF
| Increased ICP
91
Pulmonary effects acidosis?
Increased PVR
92
Other effect acidosis?
Hyperkalemia
93
Cardiac effects of alkalosis?
Decreased p50 (left= love, holding onto o2)
Decreased coronary blood flow
Increased risk dysrhythmia
94
CNS Effect alkalosis
Decreased CBF
| Decreased ICP
95
Other effects alkalosis?
Hypokalemia
| Decreased ionized calcium
96
What do we use hypotonic solutions for?
Replaces water loss
called MAINTENANCE fluids
ex: D5W
97
What do we use iotonic? What Osm is considered isotonic?
REPLACEMENT fluids
Replaces water and electrolyte loss
Ex: LR, NS
(275-295 mOsm/L)
98
What do we use hypertonic fluids for?
Hyponatremia, shocks
D5 1/2NS (405 mOsm/L) , 3% NS (1026 mOSM/L)
99
Why might crystalloids be preferred for fluid restoration?
- Lack of allergenic potential
- Ease of metabolism and renal clearance (compared to colloids)
- Preservation of electolyte balance despite active intraoperative plasma losses
100
What is consequence of low molecular weight of crystalloid?
Crystalloid solutions contribute to hemodilution of plasma proteins and loss of capillary oncotic pressure. This causes filtration of 75-80% of volumes into interstitial space.
Ability of crystalloids to expand plasma volume is transient
101
What are hypotnic solutions and their osmolarity?
NaCl 0.45%- 154
| D5W- 253
102
What are isotonic solutions (crystalloid and colloid) and OsM
NaCl 0.9%- 308
LR- 273
Plasmalyte A- 294
Colloids:
- Albumin 5%- 300
Voluven 6%- 296
Hespan 6%- 309
103
What are hypertonic solutions and Osm
```
Crys:
NaCl 3%- 1026
D5 NaCl 0.9%- 560
D5 NaCl 0.45%- 405
D5 LR- 525
```
Colloid:
Dextran 10%- 350
104
Which solutions will cause cells to swell?
Hypotonic
105
Which solutions cause cell to shrink?
Hypertonic
106
What is plasmalyte/normosl/isolyte composed of? OsM?
Na, K, Cl, phosphat,e Mg, acetate, gluonate
OsM- 294-295
107
What is LR composed of? OsM?
```
Na
K
Cl
Calcium
Lactate
OSM- 275
```
108
What is 0.9% NS composed of? OsM
Na, Cl
Osm- 310
109
What crystalloids cannot be used with blood products?
Anything with Ca (LR)
110
Which crystalloids can be used to admin blood products?
Plasamalyte, NS
111
Key points for NS?
Isotonic (308 mOsM/L) (but least physiologic)
- in large volumes, can increase Cl content in blood. Causes hyperchloremic acidosis
- Typical solution for diluting PRBC
112
Hazrds with NS?
- Hyperchloremic acidosis- high amount of Cl contribute to acid-base imbalance
- Studies show does-dependent association with renal impairment and postop bowel dysmotility- effects more pronounced in pt with preexisting renal dx
113
Key points LR?
- NS with electolyes (K, Ca) and buffer (lactate)
- 273 mOsM/L, provides 100 cc free water/L, tends to lower Na
- Considered isotonic but actually slightly hypotonic
- Lactate can convert to bicarb, cause slight met. alkalosis
114
Cautions of LR?
Limit in ESRD since contains K
Avoid large volume in diabetic
-byproduct of hepatic metabolism of lactate is gluconeogenic\
-Don't mix with prbc
115
When is LR contraindicated?
Patient with TBI or other neurovascular insults.
Avoid use in any pt at increased risk for cerebral edema
116
Which is more effective in preserving intravascular volume, LR or NS?
LR
117
Key points D5W?
Hypotonic 260mOsM/L
- little place perioperatively (except neonates and pt receiving IV insulin)
Provides 170-200 cal/L
118
Caution in D5W?
Free water intoxication
| hyponatremia
119
Key points 3% and 5%
3% Na/Cl 513 mEq
5% 856 mEq
Used for low volume resuscitation(rarely)
Main use os txmt of hyponatremia
120
Risk of 3% and 5%
```
Hyperchloremia, hypernatremia
Cellular dehydration (generally wanted in head-injured pt)
```
121
What can happen if hypertonic solution infused too fast?
Sudden fluid shifts into intravascular space can cause dehydration of neural cells leading to osmotic demyelination syndrome
122
Half life of colloid solutions?
In circulation 16 hours but can be 2-3 hours
123
How do colloid solutions produce volume expansion?
Increasing plasma oncotic pressure and interacting with endothelial glycocalyx to decrease transcapillary filtration
124
What is only naturally occuring colloid solution available?
Albumin
125
What is dextran?
Synthetic colloid solution made from bacterial metabolism of sucrose. Hyperosmolar
1/2 life 6-12 hours
Largely abondoned use
126
Side effects dextran?
ACUTE RENAL FAILUR
- Anaphylactoid rection
- PLT inhibition (was used to small antithrombotic effects)
- Noncardic pulmonary edema
- Interference with crossmatching from biding to RBC and changing morphology
127
What is hespan?
-Synthetically derived form starchy plants (potatoes)
128
Side effects hespan?
- Huge allergy risk
- Coaguloathy
- Pruritis
- BLACK BOX for nephrotoxicity
MAX DOSE <20 mL/kg/day<
129
What is difference between different generations of synthetic collods?
Molecular weight gets lighter. Lighter molecular weight has slightly less side effects
130
What is albumin?
Colloid derived from pooled human plasma
| - heat treated to eliminate risk of disease transmission
131
What is critical to consider when considering administering albumin?
If EGL is intact or not. Only increase in pulmonary edem and end-organ complications with damaged EGL.
Colloid solutions should be avoided in patient with hyperglycemia or sepsis. Cochrane review"Cannot justify cost in crtiically ill patient." However, use of albumin in small allotments is warranted in goal-directed admin in volume-responsive patients
132
Propoenents of crystalloids say...
- cryst equally as effective as colloid in restoring intravascular volume
- support u/o better
- less likely to cause pulmonary edema
- inexpensive
133
Proponents of colloids say...
- prolonged increase in plasma volume by maintaining plasma oncotic pressure
- half life 3-5 hr colloid vs 20-30 min cryst
- fluid of choice with hypoporteinemia
- less tissue edema
- less volume infused
134
What is impact on vascular flow and organ perfusion during surgery and anesthesia
- Stress activates hypothalamus-pituitary release cortisol
- release of catecholamines- increased HR, increased SVR, vasoconstriction, release ADH, reabsoprtion water
-Damages EGL, and impairs wound healing, contributes to osmotic diuresis
135
Why are historical intraoperative fluid management requirements antiquated?
- Leads to substantial disruption of EGL and leads to pathologic fluid overload
136
What are the 4 step components of traiditonal fluid replacment?
1) Find baseline maintenance (wt- 20 )+60= ?mL/hr
2) Find fasting NPO def (maintenance dose from #1 x hours NPO)
replace 1/2 in 1st hour
replace 1/4 in 2nd
replace 1/4 in 3rd hr
3) Replacement of blood loss (starts hours 2)
3: 1 crystalloid of 1:1 colloid
4) evaporative losses (based on invasiveness sx)
137
What is formula for fluid replacmeent?
Holiday-Segar 4:2:1
<10 kg- 4mL/kg
11-20kg 40 + next 10kg@ 2mL/kg
>20 60 mL +anything over 20kg @1mL/kg
Quick way wt-20 + 60
138
When should you treat fluid deficit from preop NPo status
If prolonged i.e. kid vomiting 3 days prior to intussiception sx
139
How is NPo deficit replaced in sx?
1/2 in 1st hour
1/4 in 2nd hour
1/4 in 3rd hr
140
How much blood can soaked gauze hold (4x4)
10 cc
141
HOw much can soak lap pads hold?
100-150 cc blood
142
How do you find estimated blood volume in adults?
70 mL/kg
Wt * 70= EBV in adults
143
How do you find allowable blood loss?
EBV x (starting hgb-target hgb)/ starting hgb
Can replace HGB with HCT and find target HCT for transfusion
144
What is evaporative loss for superficial trauma (simple sx)
1-2 mL/kg/hr
145
Evaporative estimate for minimal trauma (minor sx)
2-4 mL/kg/hr
146
Evaporative loss for moderate trauma (non major abd sx, lap sx)
4-6 mL/kg/hr
147
Evaporative loss for major surgery?
6-8mL/kg/hr
148
What is ratio for blood loss replacement?
3: 1 crystalloid
1: 1 colloid
149
What is ERAS and goal directed fluid therapy (GDFT)
"Utilize individualized hemodynamic end points to support oxygen transport blanace by minimizing oxygen demand and optimnizing CO, tissue oxygenation, capillary and macrovascular flow, oxygen and nutrient deliver, end organ perfusion"
- MAP , CVP, UOP do not have good predictive value for fluid responsiveness
150
Consequences of too little volume resus?
```
Hypovolemia
Decreased O2 delivery
Decreased organ perfusion
Hemoconcentration (increased blood viscosity)
MI
Renal impairment
PONV
```
151
Too much volume resus consequences?
```
Hypervolemia
Decreased O2 deliver (microvascular congestion)
IMpaired glycocalyx
Hemodilution (hgb, coag factors, plasma proteins)
impaired wound healing
increased extravascular lung water
VAP
ABD compartment syndrome
liver congestion
```
152
At what point on frank starling curve will patient be responive to fluid?
Steep slope
153
At the plateau of frank starling curve, will pt be fluid responsive?
No
154
What is frank starling curve based on?
Length-tension relationship of sarcomeres
155
What is preload dependence?
When patient is on lower-end of frank starling curve and needs more sarcomere stretch in order to achieve more contraction
Sarcomeres are too tight together, need more volume to "stretch" sarcomeres and allow stronger contraction
156
What is preload independence?
Plateau of frank starling curve that suggest optimal balance between ciruclating volume and myocardial performance.
- additional fluids would not improve hemodynamics or oxygen delivery
157
What is overshoot on frank starling curve?
Impaired myocardial performance, placing pt at risk of pulmonary edema and CHF
158
Where do we want our patients to stay in frank starling curve?
Top left quadrant= "safe quadrant"
159
How is pulse contour analysis used for GDFT?
<9% SVV non responsive to fluid
9-13%- gray zone
>13% responsive to fluid
160
Hemodynamic factors to guide GDFT?
Dilution techniques- thermodilution (invasive)
Pulse contour
ECHO, TEE (gold standard)
Tissue oxygenation
161
When are pulse contour readings inaccurate?
- Spontaneous ventilation
- Small TV <8mL/kg
- Open chest
- Sustained arrhyhtmia
- High level PEEP
- Right heart dysfunction
May be able to trend, but can't take absolute value
162
Goal Directed Fluid protocls want what preop, intraop and postop?
Preop- limit NPO time (2hr clear liquid)
Intraop- baseline assessment of target hemodynamic. Small boluses to assess responsiveness
vasopressors and inotropes as needed
Post op- quick discontinuation of IV fluids and encouraging PO intake
163
Recommendation for transfusion based on HGB?
>10 g/dL- not recommended
<6 always recommended
6-10- depends on patients risk for complication and inadequate oxygenation
Single transfusion trigger not recommended
164
What is purpose of crossmatch?
Evaluate patient's blood response to specific unit of blood
165
How much will 1 unit increase hgb/hct
Increase Hgb 1 gm/dL
HCT 2-3%
HCT 65-70%/unit
166
What preservatives are in PRBC?
Citrate
Dextrose (substrate for glycolysis)
Phosphate (buffers combats acidosis)
Adenine (helps RBC synthesize ATP)
167
What is citrate toxicity?
Causes hypocalcemia
| Monitor ionized Ca
168
Universal donor, recipient?
O- donor
| AB+ recipient
169
What does irradiation of PRBC prevent?
Graft vs host dx
170
What does leukocyte reduced blood do?
Decrease rate of complications and HLA alloimmunization
171
When do we see more complications with blood storage?
>14 DAYS
```
We start to see:
- decrease 2,3 DPG
- Depletion ATP
-oxidative damage
-Increased adhesion to human vascular endothelium
- acidosis
-altered morphologyRBC
-hyperkalemia
- absence viable plt
-absence factor V and VIII
hemokylsis
```
172
Potential complications of autologous blood transfusion?
- Anemia
- Preop MI
- Admin wrong unit
- Need for more frequent blood transfusion
- febrile/allergic reaction
173
When can we not use cell save
Sx with wounds with bacteria, amniotic fluid, malignant cells or patient with sepsis, chemical contaminants
174
What is acute normovolemic hemodilution?
Remove blood from pt
- Replace BV with crystalloid/colloid
- After sx blood loss slowed/stopped, blood transfused back to pt
175
What composes bag of platelets?
Either multi donor pooling (6-10)
| or single donor aphersis units<
176
Shelf life plt?
5 days
HIGH bacterial contamination risk 1:12,000
177
How much should PLT increase after transfusion?
7,000-10,000 one hour after transfusion
178
Uses for plt?
- Thrombocytopenia
- Dysfunctional plt
- Active bleeding
- PLT count <50,000 for low, mod risk
- Plt count <100,000 for high risk
179
What is contained in FFP?
Clotting factors (no plt)
180
How long can we store FFP?
Frozen for up to 1 yr
181
Volume of FFP?
200-250 CC
182
Use of FFP?
- Reversal warfarin
- Known coag factor deficiency
- microvascular bleed in presence of increased PT or PTT
183
What is cryoprecipitate?
Derived from precipitate remaining after FFP thawed
184
What does cryo contain?
Factor VIII
- XIII
- Fibrinogen
- von willebrand
- plasma
- fibronectin
185
Most common risk of transfuion?
CMV 1-3% of transfusions
186
Risk for TRALI? Product at highest risk?
1:8000
| FFP/PLT highest risk
