what is the purpose of IV placement?
NPO “non per os”
Fluid Loss
Blood Loss
Drug Administration
plasma volume is approx. what?
~2 L
what percentage of water is intracellular vs. extracellular?
intracellular = 65% extracellular = 35%
osmolality
the concentration of an osmotic solution per 1000 grams of solvent
osmolarity
the concentration of osmotic solution per liter of fluid
normal OSMotic pressure
Normal = 285 mOsm/L
normal ONCotic pressure
Oncotic pressure (mmHg) Normal = 28 mmHg
Frequently used in place of osmotic pressure or tension, is related to the number of non-penetrating particles found in solution
tonicity
Of equal tension. Denoting a solution having the same tonicity as another solution with which it is compared
isotonic
Having a higher concentration of solute particles per unit volume than a comparison solution, regardless of kinds of particles. A solution in which cells shrink due to efflux of water.
hypertonic
Having a lower concentration of solute particles per unit volume than a comparison solution, regardless of kinds of particles. A solution in which cells expand due to influx of water.
hypotonic
what happens to a RC in a hyper-, hypo-, and isotonic solution?
hypertonic = shrinks hypotonic = swells isotonic = nothing
what are the normal plasma values for Na+ and K+?
135-145
3.5-5.0
which commonly given fluid contains Ca2+ and why does that matter?
LR
Ca2+ can start the coagulation cascade
what dictates whether the solution should be delivered via the peripheral or central venous route?
The tonicity of an IV fluid
Extremely hypotonic and hypertonic solutions may be infused in small volumes and into large vessels, where dilution and distribution are rapid.
The generally accepted upper limit for a peripheral IV is ______ mOsm/L
900
T or F: K+ can be given peripherally
FALSE
in normal adults, what is the average daily fluid loss?
Total ~2500 ml/day
4-2-1 Rule
Example: 70kg pt 4ml/kg/hr*10kg = 40 ml/hr 2ml/kg/hr*10kg = 20 ml/hr 1ml/kg/hr*50kg = 50 ml/hr 70kg = 110 ml/hr
what is the Sensible Fluid Loss Perioperative for minor, moderate and major surgery?
2-4 ml/kg/hr minor surgery (hernia)
4-6 ml/kg/hr moderate surgery (chole)
6-10 ml/kg/hr major surgery (bowel resection)
Replace 1mL blood loss with ___mL crystalloid or ___mL colloid
3
1
Monitor vitals and maintain urine output at a MINIMUM _____ml/kg/hr
0.5
fluid calculation
Hysterectomy 70 kg Female NPO Deficit 10 hrs = 1100 ml NS Maintenance 110 ml/hr Blood loss = 300 = 900 ml NS Sensible loss 4 ml/kg/hr = 280 ml/hr Total case 3 hours = 1100+330+900+840 = 3170 ml
how much blood can a 4x4 and lap pad hold?
Surgical sponge (4x4)
10mL blood
“Lap pads”
100-150mL blood
Aqueous solution of low MW ions with or without glucose
Examples: NS, Lactated Ringers, Plasma-Lyte
crystalloid
Aqueous solution of high MW substances
Maintain plasma colloid oncotic pressure
Albumin, Hetastarch, etc.
colloid
Intravascular halflife of crystalloids is
20-30min
advantages/disadvantages of crystalloids and colloids
CHART
A potential complication of giving too much Normal saline is what?
Hypochloremic metabolic acidosis
which fluid can lower Na levels?
LR
when would you give 3% and 7.5% NaCl?
Severe hyponatremia or hypovolemic shock
how much fluid should be given in the first hour?
half of NPO deficit + maintenance
what are some potential side effects of dextran?
coagulopathy, renal dysfunction, anaphylaxis, osmotic diuresis
what is normovolemic hemodilution?
take blood out of pt before a case and give it back at the end
how do you calculate EBL?
[(Hcti-Hcta) / Hct avg] x EBV = ABL
For each unit of PRBC transfused you can expect the HCT to increase by ___% or Hgb to increase by ____ g/dl
3%
1
transfusion is rarely indicated when the hemoglobin concentration is greater than ____ g/dL and is almost always indicated when it is less than ___ g/dL, especially when anemia is acute
10
6
when and how would you administer PRBC?
Admin pt. who require RBC but no volume
Carefully checked against blood slip and patient ID
Transfusion w/170 micron filter
Blood warmed prior to infusion
when is the Rh system particularly important?
in childbearing women, can cause reactivity between mom and baby
which blood compatability test is more sensitive and which test is for antibodies?
type and cross = sensitive
type and screen = antibodies
what is the universal donor?
O-
what blood product do you not warm?
platelets
when is a platelet transfusion recommended?
Plt < 50k increase Sx blood loss
Oncology Pt >10,000/mm3
Target > 100k/mm3
Each unit increases 5-10k/mm3
which transfusion product is associated with hemophelia pts?
Cryopercipitate
what blood product are you most likely to see a reaction/complication from and why?
platelets—multidonor
what is the most common non-infectious reaction to blood products?
fever
what do AHTR and TRALI stand for?
Acute Hemolytic Transfusion Reaction
Transfusion Related Acute Lung Injury
three most common site for arterial cannulation?
radial
femoral
brachial
what does Allen’s test check for?
collateral circulation
what sites are contraindicated in patients with Raynaud’s Syndrome for art lines?
radial and ulnar
what is Raynaud’s syndrome?
constriction of vessels decreases blood supply to the fingers
which artery is prone to pseudoaneurysm and atheroma formation as documented following cardiac catheterization. It also has an increased incidence of infection.
femoral
when would you need to gain central venous access?
Monitoring central venous pressure Fluid administration Infusion of caustic Rx TPN (total parenteral nutrition) Air emboli aspiration Transcutaneous pacing leads Poor peripheral access
what are some contraindications for central venous access?
R atrial tumors
Fungating tricuspid valve vegetations
Contraindications relative to site:
Local sepsis
Previous vessel damage
Suspected injury to IVC or SVC
What are some common sites for central venous access?
Femoral vein
External jugular
Internal jugular*
Subclavian vein
what is Seldinger’s Technque?
when you thread a catheter over a wire
potential complications from central venous access
Pneumothorax/hemothorax Air embolism Arrhythmias Carotid artery puncture/cannulation Infection**
when you see a sudden dramatic increase in lactate, this would indicate what?
anaerobic metabolism
