Parenteral Fluids

Question 1

Crystalloid IVF

Answer 1

Solutions that contain sodium as main osmotically active particle (most common)

Question 2

Colloid IVF

Answer 2

Solutions that contain high-molecular weight substances that do not migrate easily across cap walls (more likely to stay in vascular compartment)

Question 3

Blood/blood product IVF

Answer 3

RBCs similar to colloids because they stay in vascular space

Question 4

Isotonic crystalloids

Answer 4

Solutions with same salt concentration as normal cells of body
*most commonly used crystalloid cause similar to body
Ex: normal saline (.9% NaCl/NS), lactated ringer’s solutions, plasma-lyte

Question 5

Hypertonic crystalloid

Answer 5

A solution with higher salt concentration than normal cells of body
Ex: 3% normal saline

Question 6

Hypotonic crystalloid

Answer 6

Solutions with lower salt conc than normal cells of body

Ex: .5 or .25 NS (more in kids)

Question 7

Other types of crystalloids

Answer 7

D5W (5% dextrose in water)

Question 8

What does lactated ringer’s solution contain?

Answer 8

Lactate, K+ and Ca2+ in addition to NaCl

Question 9

What does plasma-lyte contain?

Answer 9

Contains less chloride then the other isotonic crystalloids

Thought to be most physiologic solution

Question 10

What do isotonic crystalloids do?

Answer 10

Distribute uniformly throughout ECF space

Interns prefer NS but surgeons like LR

Question 11

When are isotonic crystalloids used?

Answer 11

For tx of dehydration or hypovolemia (when severe should be corrected ASAP to correct intravascular vol depletion)
*crystalloids are preferred choice

Question 12

What are used for IV-boluses?

Answer 12

NS, LR and plasma-lyte (or PRBCs)

Question 13

When is a hypertonic crystalloid used mostly?

Answer 13

Mostly used in situations where there is life-threatening hyponatremia with significant water excess
*must calculate replacement rate

Question 14

What could overly rapid correction with a hypertonic crystalloid lead to?

Answer 14

Osmotic demyelination or central pontine myelinolysis

Question 15

How do hypotonic crystalloids work?

Answer 15

Distribute throughout total body water

Used for maintenance fluids

Question 16

When are hypotonic crystalloids inadequate?

Answer 16

For replacing intravascular vol deficits (not used for tx of dehydration/hypovolemia)

Question 17

How does D5W work?

Answer 17

Similar total body water distribution to hypotonic crystalloids
Used to treat hypoglycemia (caution in DM)

Question 18

When are colloids used?

Answer 18

When crystalloids fail to sustain plasma vol due to low osmotic pressure (b/c more likely to expand vascular compartment)

ex: pt with burns or peritonitis when there is considerable protein loss from vascular space
* more expensive

Question 19

Colloid preparations

Answer 19

5 or 25% albumin
Dextran 40 or 70 (dif molecular weight)
Hydroxyethyl starch (hetastarch)

Question 20

When are albumin preparations used?

Answer 20

Edematous pts to mobilize interstitial fluid into vascular space (not when pts albumin >2.5)

Question 21

What pts are albumin preps most helpful for?

Answer 21

With liver disease, peritonitis or burns, surgical pts or experiencing third-spacing

Question 22

What is third spacing?

Answer 22

Concept that body fluids collect in a third body compartment that isn’t normally perfused with fluids

Question 23

What is Dextran?

Answer 23

Synthetic glucose polymer which expands intravascular vol equal to amount infused
Less frequent than albumin

Question 24

What is hydroxyethyl starch?

Answer 24

Glycogen-like synthetic molecule that increases vascular vol to an amount > vol infused
Less expensive than albumin (so alternative)

Question 25

Types of blood products?

Answer 25

Packed RBCs Platelets Fresh frozen plasma

Question 26

When are packed RBCs used?

Answer 26

With crystalloids to expand intravascular vol (remain entirely within vascular space) For blood transfusions

Question 27

When are platelets used?

Answer 27

Pts with thrombocytopenia or impaired platelet function to prevent or treat bleeding

Question 28

When is fresh frozen plasma used?

Answer 28

To correct major bleeding complications in pts on warfarin and/or with vitamin k deficiency

Question 29

Different amounts of IVF given at a time

Answer 29

Bolus (large amt at once) Maintenance Replacement

Question 30

When do you use a bolus IVF?

Answer 30

Hypovolemia (dehydration or acute blood loss) Can give 250 ml-1 L bolus Caution with HF

Question 31

What does maintenance IVF account for?

Answer 31

Ongoing losses of water and electrolytes under normal physiologic conditions via urine, sweat, respirations and stool

Question 32

When is maintenance IVF used?

Answer 32

When pts not eating or drinking normally (provide water and electrolyte balance)

Question 33

Normal maintenance IVF used

Answer 33

D5/.5 NS with 20 meq KCl (always dependent on clinical scenario)

Question 34

kg method for determining maintenance IVF in normal adult pts

Answer 34

For 1st 10kg of body wt--100 ml/kg/day For 2nd 10kg of body wt--50 ml/kg/day For weight >20 kg--20 ml/kg/day Divide total of above by 24 hrs to determine hourly rate of infusion

Question 35

When would potassium be added to maintenance IVF?

Answer 35

Treat hypokalemia or for maintenance if pt is NPO *never use bolus potassium-containing IVF Caution when replacing K in pt with kidney disease

Question 36

What does replacement IVF do?

Answer 36

Correct any existing water and electrolyte deficits caused by GI, urinary, skin or blood losses or third spacing *type used depends on electrolyte disturbances and type of fluid lost

Question 37

What to remember when pt is hypo or hypernatremic with replacement IVG

Answer 37

Caution exercised to avoid overly rapid correction (lead to demyelination or CPM)

Question 38

Replacement with a surgery pt

Answer 38

Need maintenance fluids and replacement of fluids lost (urine output, blood loss, third spacing due to intervention at operating site-abdomen) Monitor urine output and vital signs

Question 39

Parkland formula for burn pts

Answer 39

Total fluid required during first 24 hrs= (% of 2nd and 3rd degree burns) x (body weight in kg) x 4 ml Replace with LR: 1/2 total amount infused during 1st 8 hrs 1/4 total during 2nd 8 hrs 1/4 total during 3rd 8 hrs

Question 40

Rule of nines for burn pts

Answer 40

``` Each arm is 9% Head is 9% Anterior and posterior trunk 18% each Each leg is 18% Perineum is 1% ```

Question 41

How does body compensate for inadequate nutrient intake?

Answer 41

Breakdown glycogen stores, gluconeogenesis, lipolysis and amino acid oxidation from muscle

Question 42

Types of parenteral nutrition

Answer 42

Total parenteral nutrition (TPN) | Peripheral parenteral nutrition (PPN)

Question 43

Indications for total parenteral nutrition

Answer 43

Small bowel resection Complete bowel resection IBD Bowel rest may induce remission Pre-existing nutritional deprivation (not tolerate nutrition) Anticipates or actual inadequace energy intake by mouth Significant multisystem disease

Question 44

Route of entry for TPN

Answer 44

Central venous access via SVC (most common type of access) | Support here expected to be longer term (>7 days)

Question 45

Route of entry for PPN

Answer 45

``` Peripheral venous access Infrequently used (support expected to be short tern <7 days) ```

Question 46

Why is central vein administration preferred for TPN?

Answer 46

Avoid intimal damage and thrombophlebitis due to osmolality of solution

Question 47

What to monitor while on TPN

Answer 47

Ins and outs Daily weights Labs (lytes, BUN, creatinine, BMP, LFTs-daily to weekly while inpatient)

Question 48

Complications associated

Answer 48

``` Metabolic/lyte abnormalities Cath related: Air embolism Pneumothorax cath-associated DVT Catheter infection Thrombophlebitis ```