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APEX > Fluids & Blood > Flashcards

Fluids & Blood Flashcards

(129 cards)

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1
Q

Fluid Compartments

A

60% 70 kg
TBW 42L
1. Intracellular 40% 28L
2. Extracellular 20% 14L
a. Interstitial 15% 11L
b. Plasma 5% 3L

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2
Q

↑TBW

A

Neonates

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3
Q

↓TBW

A

Females
Elderly
Obese

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4
Q

Intracellular Ions

A

K+
Mg2+
Phosphate

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5
Q

Extracellular Ions

A

Na+
Ca2+
Cl¯
HCO3¯

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6
Q

Net Filtration Pressure

A

Starling forces
(Pc - Pif) - (πc - πif)

Pc = capillary hydrostatic
Pif = interstitial hydrostatic
πc = capillary oncotic
πif = interstitial oncotic

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7
Q

OsmolaRity

A

Osmoles per LiteR solution mOsm/L

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8
Q

OsmolaLity

A

Osmoles per kg solvent mOsm/kg H2O

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9
Q

Plasma Osmolarity

A

Normal 280-290 mOsm/L

= 2[Na+] + (Glucose/18) + (BUN/2.8)

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10
Q

NaCl 0.9%

A

ISOtonic
Hyperchloremic metabolic acidosis
Na+ 154 mEq/L
Cl¯ 154 mEq/L
↑Cl¯ load → kidneys excrete HCO3¯ to maintain electroneutrality → non-gap metabolic acidosis

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11
Q

IVF Na+ Concentration

A

NaCl 154 mEq/L
Plasmalyte 140 mEq/L
LR 130 mEq/L

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12
Q

Crystalloid Replacement

A

3:1 ratio
Plasma volume ↑20-30 minutes
Dilutional effects

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13
Q

Albumin

A

Only colloid derived from human blood products
1:1 ratio
Anti-inflammatory properties
Binds Ca2+ → hypocalcemia

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14
Q

Synthetic Colloids

A

*Renal injury risk (FDA black box warning)
Dextran 40
Hetastarch
Hextend
Voluven

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15
Q

Dextran 40

A

Synthetic colloid
↓blood viscosity → improves microcirculation
1° coagulopathy
Dextran > Hetastarch > Hextend
Anaphylaxis risk

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16
Q

Hetastarch

A

Synthetic colloid
2nd highest coagulopathy risk

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17
Q

Hextend

A

Synthetic colloid
Do NOT exceed 20 mL/kg
3rd highest coagulopathy risk

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18
Q

Hyperkalemia
Definition & Causes

A

K+ > 5.5 mEq/L
↑RMP (closer to threshold potential)
Causes include PRBCs, renal failure, NSAIDs, acidosis, Succinylcholine, β blockers, cellular injury (tumor lysis, hemolysis, burns, crush injury, & rhabdomyolysis )

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19
Q

Hyperkalemia
Cardiac Dysrhythmias S/S

A

5.5-6.5 peaked T waves
6.5-7.5 P wave flattening + PR prolongation
7.0-8.0 QRS prolongation
> 8.5 QRS → sine wave → Vfib

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20
Q

What is the most common electrolyte abnormality?

A

Hypokalemia
K+ < 3.5 mEq/L
Hyperpolarizes RMP

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21
Q

Hyperkalemia
Treatment

A

Ca2+ IV
- Central 20 mEq/hr
- Peripheral 10 mEq/hr
Insulin + D50
Hyperventilation
HCO3¯
β2 agonists
Elimination - diuretics, Kayexalate, & dialysis

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22
Q

Hypokalemia
Causes

A

GI loss - vomiting/diarrhea, NG suction, Zollinger-Ellison syndrome, JG bypass
Renal loss - diuretics or metabolic alkalosis
Redistribution into cells (hyperkalemia treatment)

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23
Q

Hypokalemia
S/S

A

Skeletal muscle cramps → weakness → paralysis
Worsens dig toxicity
EKG prolonged PR & QT intervals
Flat T wave
U wave present

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24
Q

What maintains the intracellular K+ distribution?

A

Na-K+ ATPase pump

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25
K+ Supplementation
Do NOT administer > 0.5-1 mEq/kg/hr
26
Hypernatremia Causes
↓total body Na+ content Osmotic diuresis, N/V, adrenal insufficiency Normal Na+ DI, renal failure, diuretics ↑total body Na+ Hyperaldosteronism ↑Na+ intake
27
Hypernatremia S/S
Na+ > 145 mEq/L Based on serum osmolality normal range 280-290 mOsm/L 350-375 HE, agitation, confusion 376-400 weakness, tremors, ataxia 401-430 hyperreflexia & muscle twitching > 430 seizures, coma, death
28
Hyponatremia Causes
↓total body Na+ content Diuretics, salt-wasting, hypoaldosteronism Normal Na+ SIADH, hypothyroid, H2O intoxication, periop stress ↑total body Na+ CHF or cirrhosis
29
Hyponatremia S/S
Mild 125-129 N/V & malaise 115-124 HE, lethargy, & altered LOC < 115 seizures, coma, cerebral edema, & respiratory arrest
30
Hyper/hyponatremia Treatment
Dependent on cause* Na+ restriction IVF selection based on tonicity Diuretics
31
What mechanisms maintain Na+ homeostasis?
GFR, RAAS, & ANP (BNP)
32
Na+ Supplementation
NaCl 3% 1-2 mL/kg/hr ↑ < 1-2 mEq/L per hour
33
What occurs when hyponatremia corrected too quickly?
Osmotic demyelination syndrome or central pontine myelinolysis - Mental status changes - Seizures - Spastic quadriplegia - Pseudobulbar palsy - Encephalopathy - Coma & death
34
Calcium Normal Serum Levels
Total 8.5-10.5 mg/dL Ionized 4.6-5.2 mg/dL
35
What is the most abundant electrolyte?
Calcium 2nd messenger, neurotransmitter release, & muscle contraction
36
Hypercalcemia S/S
Nausea, abdominal pain, HTN, psychosis, mental status changes, seizures, & shortened QT interval
37
Hypercalcemia Treatment
NS Loop diuretic
38
Calcium Storage
1° bones Albumin = intravascular Ca2+ reservoir
39
Hypocalcemia Causes
Hypoparathyroidism Vitamin D deficiency Renal osteodystrophy Pancreatitis Sepsis
40
Hypocalcemia S/S
Skeletal muscle cramps Nerve irritability → paresthesia & tetany Laryngospasm Mental status changes → seizures Chvostek or Trousseau signs Prolonged QT interval
41
Hypocalcemia Treatment
Calcium Vitamin D
42
Chvostek Sign
Tapping on the jaw angle (facial nerve/masseter muscle) causes facial contraction on the ipsilateral side of the
43
Trousseau Sign
Upper extremity BP cuff inflated above SBP 3 minutes Hand & forearm muscle spasms
44
Magnesium
Normal plasma Mg2+ 1.7-2.4 mg/dL or 1.5-3 mEq/L Antagonizes Ca2+ effects
45
Parathyroid Hormone & Calcitonin
PTH ↑serum Ca2+ Parathyroid gland releases PTH → osteoclasts release Ca2+ from bone storage + ↑Ca2+ renal reabsorption & Ca2+ absorption in the small intestine Calcitonin ↓serum Ca2+ ↑Ca2+ → thyroid releases calcitonin → osteoclast activity inhibited + ↓Ca2+ reabsorption
46
Hypercalcemia Causes
Hyperparathyroid Cancer Thyrotoxicosis Thiazide diuretics Immobilization
47
Magnesium 1° Location
Muscle & bone 1% ECF 0.3% plasma
48
Where is Mg2+ reabsorbed?
Renal tubules
49
Magnesium Clinical Uses
Pre-E 4G load over 10-15 min then 1G/hr infusion Opioid-sparing techniques (ERAS) Acute bronchospasm Cardiac rhythm disturbances - symptomatic PVCs or Torsades de pointe
50
Hypermagnesemia Causes
Excessive admin Renal failure Adrenal insufficiency
51
Hypermagnesemia S/S
Not significant unless extremely high Heart block Potentiates NMBs (Succinylcholine & non-depolarizing)
52
No Hypermagnesemia S/S
2.5-5 mg/dL 2.1-4.2 mEq/L
53
What serum magnesium level are diminished deep tendon reflexes noted?
5-7 mg/dL 4.2-5.8 mEq/L Lethargy, drowsiness, flushing, N/V
54
When are deep tendon reflexes lost?
Serum Mg2+ 7-12 mg/dL 5.8-10 mEq/L HoTN, EKG changes, somnolence
55
When does respiratory depression occur?
Serum Mg2+ > 12 mg/dL > 10 mEq/L Apnea, complete heart block, cardiac arrest, coma, paralysis
56
Hypermagnesemia Treatment
Calcium chloride or gluconate
57
Hypomagnesemia Causes
Poor intake, alcohol abuse, diuretics, critical illness, hypokalemia
58
Hypomagnesemia S/S
Not significant unless extremely low Prolonged QT
59
Mg2+ level when tetany & dysrhythmias present
< 1.2 mg/dL < 1 mEq/L Tetany, seizures, dysrhythmias
60
Mg2+ level when neuromuscular irritability present
1.2-1.8 mg/dL 1-1.5 mEq/L Neuromuscular irritability, hypokalemia, hypocalcemia
61
Hypomagnesemia Treatment
Magnesium sulfate supplementation
62
Acid-Base Respiratory Compensation
CO2 = volatile acid
63
Acid-Base Renal Compensation
Reabsorb filtered HCO3¯ Remove titratable acids (non-volatile) Ammonia formation
64
Acidosis CNS/Pulmonary/Cardiac Effects
↑CBF/ICP ↑PVR ↑P50 (R shift) ↑SNS tone ↑dysrhythmias risk ↓contractility Hyperkalemia H+/K+ pump
65
Alkalosis CNS/Pulmonary/Cardiac Effects
↓CBF/ICP ↓PVR ↓P50 (L shift) ↓Coronary blood flow ↑dysrhythmias risk Hypokalemia ↓ionized Ca2+
66
Respiratory Acidosis Causes
↑CO2 production ↓CO2 elimination ↑Vd Rebreathing
67
What is the most common respiratory acidosis cause?
Hypoventilation
68
ACUTE Respiratory Acidosis
Every 10 mmHg > 40 ↓pH 0.08
69
Chronic Respiratory Acidosis
Every 10 mmHg > 40 ↓pH 0.03
70
What causes non-anion gap acidosis?
Metabolic acidosis Normal anion gap 8-12 mEq/L HCO3¯ loss HARDUP - Hypoaldosteronism - Acetazolamide - Renal tubular acidosis - Diarrhea - Uretosigmoid fistula - Pancreatic fistula
71
Non-Anion Gap Acidosis Treatment
Admin sodium bicarbonate
72
What causes an anion gap acidosis?
Metabolic acidosis Add +acid Anion gap > 12 mEq/L MUDPILES - Methanol - Uremia - DKA - Paraldehyde - Isoniazid - Lactate ↓DO2, sepsis, cyanide poison - Ethanol or ethylene glycol - Salicylates → inhibit Krebs cycle
73
Anion Gap Acidosis Treatment
Lactic acidosis = IVF, O2, cardiopulmonary support DKA = IVF + insulin Uremia or drug-induced = dialysis
74
Metabolic Acidosis Respiratory Compensation
↑minute ventilation ↓PaCO2 PaCO2 ↓1-1.5 mmHg ↓HCO3¯ 1 mEq/L
75
What causes metabolic alkalosis?
HCO3¯ addition = massive transfusion Loss non-volatile acid = NG suction, vomiting, loop diuretics, acid loss via urine, ECF depletion ↑Na+ reabsorption H+/K+ excretion to maintain electroneutrality Antacids ↑mineralocorticoid activity = Cushing or hyperaldosteronism
76
Metabolic Alkalosis Respiratory Compensation
↓minute ventilation ↑PaCO2 PaCO2 ↑0.5-1 mmHg ↑HCO3¯ 1 mEq/L
77
Shock Stage I
Blood loss < 15% or < 750 mL Pulse < 100 BP normal Pulse pressure normal RR 14-20 UOP > 30 mL/hr Fluid management = crystalloid
78
Shock Stage II
Blood loss 15-30% or 750-1,500 mL Pulse 100-120 BP normal ↓pulse pressure RR 20-30 UOP 20-30 mL/hr Fluid management = crystalloid
79
Shock Stage III
Blood loss 30-40% or 1,500-2,000 mL Pulse 120-140 ↓BP ↓pulse pressure RR 30-40 UOP 5-15 mL/hr Fluid management = crystalloid + blood
80
Shock Stage IV
Blood loss > 40% or > 2L Pulse > 140 ↓BP ↓pulse pressure RR > 40 Minimal/absent UOP Fluid management = crystalloid + blood
81
Universal Donor
RBCs O ¯ Plasma AB +
82
Universal Recipient
RBCs AB + Plasma O ¯
83
O ¯
Contains NO RBC antigens Anti-A & anti-B plasma antibodies
84
O +
85% population Rh-D positive (+) O + an acceptable emergency transfusion RBC type when patient NOT childbearing age & has not received a previous transfusion
85
Rh
Rh+ RBC antigen D present No plasma antibodies Rh+ able to receive (+) OR (-) Patient w/ Rh¯ + exposure to Rh+ blood → develops antibodies to Rh antigen (anti-D)
86
Rh & Pregnancy
Fetus receives Rh+ antigen from father Maternal Rh¯& fetal blood Rh+ do not mix during pregnancy Rh+ antigen able to cross the placenta during delivery Mother sensitized when Rh+ antigen crosses the placenta during delivery Develops antibodies to Rh+ antigen (anti-D) Subsequent pregnancy w/ Rh+ fetus → erythroblastosis fetalis
87
Erythroblastosis Fetalis
Hemolytic disease that affects the newborn d/t Rh incompatibility
88
Who & when to administer Rhogam?
Rh immune globulin Pregnant Rh¯ mothers Starting at 28 weeks gestation to prevent sensitization Protects the fetus during delivery
89
Type
Determines ABO & Rh-D antigens in the recipients blood 5 minutes 0.2% probability incompatibility reaction
90
Screen
Determines most clinically significant antibodies present 45 minutes 0.06% probability incompatibility reaction
91
Crossmatch
Provides the most accurate compatibility Mixes the recipient plasma w/ blood in the actual unit to be transfused 45 minutes 0.05% probability incompatibility reaction
92
Emergency PRBCs Transfusion
1. Type-specific partially crossmatched blood 2. Type-specific uncrossmatched blood 3. Type O ¯ uncrossmatched blood *After 2 units type O blood transfused must continue to use type O despite patient's blood type!
93
PRBCs
Hgb 6-10 g/dL ? Hgb < 6 g/dL TRANSFUSE ↑CaO2 1 unit 300 mL Hct 70% ↑Hgb 1 g/dL or Hct 2-3%
94
Platelets
1 pack per 10 kg Do NOT use filter or warm Stored at room temp 5 days ↑bacterial contamination risk → sepsis
95
FFP
All coagulation factors, fibrinogen, & plasma proteins ↑factor concentration 20-30% Factor VII 1/2 life 3-6 hours Complete infusion w/in 24 hours thawing
96
FFP Indications
Coagulopathy 10-20 mL/kg Warfarin reversal 5-8 mL/kg Antithrombin deficiency Massive transfusion DIC C1 esterase deficiency Hereditary angioedema
97
Cryo
Contains fibrinogen, factor VIII & XIII, vWF Dose 5 bag pool ↑fibrinogen 50 mg/dL Complete infusion w/in 6 hours thawing
98
EBVs
Adult 70 mL/kg Child 70 mL/kg Infant 75-80 mL/kg Full term 80-90 mL/kg Premature 90-100 mL/kg
99
Stored Blood Additives
Citrate (anticoagulant) inhibits Ca2+ → hypocalcemia Phosphate (buffer combats acidosis) → alkalosis Dextrose (1° glycolysis substrate) → hyperglycemia Adenine (substrate helps RBCs re-synthesize ATP) extends storage 21 → 35 days
100
What temperature is blood stored at?
1-6° C Extents lifespan via slowing glycolysis
101
RBC Storage Lesion
↓2,3 DPG → shifts oxyhemoglobin curve L ↓ATP ↓pH ↑lactic acid ↑K+ Impaired ability to change shape → impacts capillary flow Hemolysis ↑proinflammatory mediators production
102
Leukoreduction
Removes WBCs Leukocytes (WBCs) responsible HLA alloimmunization, febrile non-hemolytic transfusion reactions, & CMV transmission
103
HLA Alloimmunization
Body develops antibodies against non-self antigens (human leukocyte antigens) The body attacks HLA proteins present on the platelet surface Most common cause platelet refractoriness
104
Washing
Washing blood products w/ saline removes any plasma & antigens in the donor RBCs RBC antigens are not removed Prevents anaphylaxis in IgA deficient patients
105
Irradiation
Exposes blood to gamma radiation Disrupts WBC DNA in the donor cells & destroys donor leukocytes Prevents graft-vs-host disease in immunocompromised patients GVHD → donor leukocytes attach recipient bone marrow → pancytopenia, fever, hepatitis, & diarrhea
106
When to administer irradiated blood?
1st/2nd degree relative blood donors Leukemia Lymphoma Hematopoietic stem cell transplants DiGeorge syndrome
107
Blood Transfusion Infectious Complications
CMV Hepatitis B Hepatitis C HIV
108
Acute Hemolytic Reaction S/S
Occurs when patient receives incompatible blood product Hemoglobinuria, HoTN, & bleeding - Fever/chills - Chest pain - Dyspnea - Nausea - Flushing
109
Acute Hemolytic Reaction Treatment
1. Stop the transfusion 2. Maintain UOP > 75-100 mL/hr (IVF, Mannitol 12.5-25 g, Furosemide 20-40 mg) 3. Alkalinize the urine HCO3¯ 4. Send urine & plasma Hgb samples to blood bank 5. Check platelets, PT, & fibrinogen 6. Send unused blood to the blood bank to double-check cross-match 7. Support hemodynamics
110
Non-Hemolytic Transfusion Reaction
Fever most common Presentation includes fever, chills, HE, nausea, & malaise
111
Non-Hemolytic Transfusion Reaction Treatment
Supportive Acetaminophen
112
Allergic Transfusion Reaction
Rarely severe Present w/ urticaria & facial swelling
113
Allergic Transfusion Reaction Treatment
Antihistamines
114
TRALI
Transfusion-related ALI non-cardiogenic pulmonary edema Most common cause transfusion related mortality Cause: HLA human leukocyte antigens & neutrophil antibodies present in the donor plasma Donor antibodies cause neutrophil activation → endothelial injury → capillary leak → pulmonary edema → impaired gas exchange → hypoxemia → acidosis & death
115
Donor populations /w high antibodies concentration
Multiparous women Blood transfusion history Organ transplant
116
Blood products w/ highest TRALI incidence
Blood products containing plasma Platelets or FFP HLA & neutrophil antibodies present in donor plasma
117
Recipients at increased risk to develop TRALI
Critical illness Sepsis Burns Post- CPB
118
TRALI S/S
Onset < 6 hours after transfusion Bilateral infiltrates on CXR PaO2/FiO2 < 300 mmHg SpO2 < 90% on RA Normal PAOP
119
TRALI Management
1° supportive Maximize PEEP LPV low VT Avoid overhydration
120
TACO
Transfusion-associated circulatory overload Volume overload cause by expanding the patient plasma volume beyond compensatory ability
121
TACO S/S
Pulmonary edema Hypervolemia LV dysfunction Mitral regurgitation ↑PAOP ↑BNP
122
TACO Management
Supportive
123
Massive Transfusion
Alkalosis - citrate metabolizes HCO3¯ Hypocalcemia Hypothermia Hyperglycemia (dextrose) Hyperkalemia - stored RBCs the cell membrane become dysfunctional & allows K+ to leak; reduce risk by admin washed or fresh cells < 7 days old
124
Trauma Lethal Triad
Acidosis (hypoperfusion) Hypothermia Coagulopathy - Acidosis impairs hemostasis - PT & PTT prolonged < 34°C - Massive volume resuscitation causes dilutional coagulopathy
125
Intraop Blood Salvage Indications
EBL expected > 1L or 20% EBV Pre-existing anemia Patient refuses allogenic blood products
126
How much volume required to admin 250 mL (1 unit) saline diluted RBCs?
500-750 mL 2-3x Hct 50-60%
127
What blood products are not returned to the patient w/ intraop blood salvage?
Platelets & coagulation factors Dilutional coagulopathy
128
How does salvaged blood compared to blood bank?
↑O2 carrying capacity Better maintain concave shape
129
Intraop Blood Salvage CONTRAINDICATIONS
Sickle cell anemia Thalassemia Oncologic procedures Topical drugs (antibiotics) in the sterile field Infected surgical site C-section controversial d/t theoretical amniotic fluid embolism risk

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