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JT - Basics > Week 11 Handout > Flashcards

Week 11 Handout Flashcards

1
Q

What is the importance of fluid and blood management?

A

Maintenance of:
* Intravascular Volume
* Fluid Exchange
* Oxygen Delivery

These components are crucial for ensuring adequate perfusion and preventing complications during surgical procedures.

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2
Q

What are the risks associated with fluid and blood management?

A

Where we can go wrong:
* Under-resuscitation
* Over-resuscitation
* Complications
* Surgical Risks and Considerations

Both under-resuscitation and over-resuscitation can lead to serious complications.

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3
Q

What factors increase surgical risks?

A

Factors Increasing Surgical Risks:
* Emergency Surgery
* Surgeries with Expected High Blood Loss
* Long Surgeries with Large Fluid Shifts

These factors can complicate fluid management and recovery.

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4
Q

What are examples of high-risk procedures?

A

Examples of High Risk Procedures:
* Open Aortic Surgery
* Peripheral Vascular Surgery
* Neurosurgery
* Thyroid Surgery
* Prostatectomy

These procedures often involve significant blood loss and fluid shifts.

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5
Q

What are examples of moderate risk procedures?

A

Examples of Moderate Risk Procedures:
* Liver Biopsies
* Most Surgical Procedures

Moderate risk procedures typically have fewer complications related to fluid management.

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6
Q

What are examples of low-risk procedures?

A

Examples of Low Risk Procedures:
* Endoscopy
* Bronchoscopy
* Cataract Extraction

These procedures generally have minimal impact on fluid balance.

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7
Q

Define Intracellular Volume (ICV).

A

Intracellular Volume (ICV) is the volume of fluid contained within the cells of the body.

It is a key component of total body water.

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8
Q

Define Extracellular Volume (ECV).

A

Extracellular Volume (ECV) is the volume of fluid outside the cells, further broken down into:
* Intravascular (Plasma) Volume
* Interstitial (Tissue) Volume
* Transcellular Fluids (e.g., CSF, synovial, GI Secretions)

ECV plays a crucial role in maintaining overall fluid balance.

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9
Q

What factors keep fluid balance in the body?

A

Four components:
* Capillary Hydrostatic Pressure
* Interstitial Fluid Pressure
* Plasma Oncotic Pressure
* Interstitial Oncotic Pressure

These forces govern the movement of fluids between capillaries and interstitial spaces.

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10
Q

What is Capillary Hydrostatic Pressure (Pc)?

A

Capillary Hydrostatic Pressure (Pc) is the pressure within the capillaries generated by the heart pumping blood.

It influences fluid movement out of capillaries into surrounding tissues, particularly in conditions like heart failure.

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11
Q

What is Interstitial Fluid Pressure (Pif)?

A

Interstitial Fluid Pressure (Pif) is the pressure exerted by the fluid in the interstitial space, typically helping to push fluid back into capillaries.

Increased Pif can occur in conditions like compartment syndrome.

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12
Q

What is Plasma Oncotic Pressure (πp)?

A

Plasma Oncotic Pressure (πp) is the osmotic pressure exerted by proteins, primarily albumin, in the blood.

A decrease in πp can lead to fluid leakage into tissues, causing conditions such as edema.

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13
Q

What is Interstitial Oncotic Pressure (πif)?

A

Interstitial Oncotic Pressure (πif) is the osmotic pressure exerted by proteins in the interstitial fluid.

Increased πif can worsen tissue edema by drawing fluid out of capillaries.

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14
Q

What is the Starling Equation?

A

Jv = Kf × ((Pc - Pif) - σ(πp - πif))
* Jv = net fluid movement (positive means filtration, negative means absorption)
* Kf = permeability of capillaries
* σ = reflection coefficient

This equation describes the fluid movement across capillary membranes.

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15
Q

What does an upward/leftward shift of the Frank-Starling Curve indicate?

A

UPWARD/LEFTWARD SHIFT indicates:
* ↑ Contractility / ↑ Performance
* Positive inotropes (e.g., dobutamine, epinephrine)
* Sympathetic stimulation
* Decreased afterload
* Mild exercise in a healthy heart

This shift reflects improved cardiac output.

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16
Q

What does a downward/rightward shift of the Frank-Starling Curve indicate?

A

DOWNWARD/RIGHTWARD SHIFT indicates:
* ↓ Contractility / ↓ Performance
* Negative inotropes (e.g., beta blockers)
* Myocardial ischemia or infarction
* Heart failure
* Acidosis
* Hypoxia
* Increased afterload

This shift reflects reduced cardiac output and efficiency.

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17
Q

What are the types of intravenous fluids?

A

Types of Intravenous Fluids:
* Crystalloids
* Colloids

Each type has distinct properties and uses in fluid resuscitation and management.

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18
Q

What are crystalloids?

A

Crystalloids are isotonic solutions commonly used for:
* Resuscitation
* Perioperative fluid replacement

Examples include Normal Saline and Lactated Ringer’s.

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19
Q

What are the advantages of crystalloids?

A

Advantages of Crystalloids:
* Readily available
* No allergenic potential
* Easily metabolized and renally cleared
* Restore both intravascular volume and hydration

They are often the first-line treatment for fluid resuscitation.

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20
Q

What are the disadvantages of crystalloids?

A

Disadvantages of Crystalloids:
* Dilution effect requiring large volumes
* Transient plasma expansion
* Risk of hyperchloremic metabolic acidosis

Overuse can lead to complications, especially in critical patients.

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21
Q

What are colloids?

A

Colloids contain high-molecular-weight substances that exert oncotic pressure, reducing transcapillary filtration.

They help retain fluid intravascularly, making them effective for plasma volume expansion.

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22
Q

What are the advantages of colloids?

A

Advantages of Colloids:
* Longer intravascular half-life than crystalloids
* More efficient for restoring intravascular volume
* Useful in severe intravascular deficits

Colloids can be critical in situations like hemorrhagic shock.

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23
Q

What are the disadvantages of colloids?

A

Disadvantages of Colloids:
* Higher cost than crystalloids
* Potential for complications like pulmonary edema
* Safety concerns with synthetic colloids

Risks include renal injury and coagulopathy, particularly with certain types.

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24
Q

What is the normal daily water loss?

A

Normal Daily Water Loss averages: 2500 mL per day

This includes losses from urine, sweat, and respiration.

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25
What is the 4-2-1 Rule for calculating fluid requirements?
The 4-2-1 Rule: * First 10 kg: 4 ml/kg/hr * Next 10 kg: 2 ml/kg/hr * Remaining weight: 1 ml/kg/hr ## Footnote This rule helps estimate fluid needs based on weight.
26
What accounts for about 25% of heat loss?
Fluid loss ## Footnote Fluid loss is significant in maintaining body temperature.
27
What is the 4-2-1 Rule for calculating fluid requirements?
First 10 kg: 4 ml/kg/hr, Next 10 kg: 2 ml/kg/hr, Remaining weight: 1 ml/kg/hr ## Footnote This rule helps in estimating fluid needs based on body weight.
28
Calculate the fluid requirement for a 100 kg patient using the 4-2-1 Rule.
Total: 140 ml/hr ## Footnote Calculation: First 10 kg = 40 ml, Next 10 kg = 20 ml, Remaining 80 kg = 80 ml.
29
Calculate the fluid requirement for a 14 kg patient using the 4-2-1 Rule.
Total: 48 ml/hr ## Footnote Calculation: First 10 kg = 40 ml, Remaining 4 kg = 8 ml.
30
What is the formula for calculating NPO fluid deficit?
NPO fluid deficit = Hours NPO x Hour fluid requirement ## Footnote This formula is crucial for determining fluid needs during fasting.
31
What percentage of NPO deficit should be replenished in the first hour?
50% ## Footnote This is part of a strategy to gradually restore fluid balance.
32
What is the percentage of NPO deficit to be replenished in the 2nd and 3rd hours?
25% each ## Footnote This ensures a steady approach to fluid replacement.
33
What are evaporative losses primarily due to?
Evaporation and internal redistribution of body fluids ## Footnote These losses are significant in surgical settings.
34
What factors influence evaporative losses?
* Surface area exposed * Duration of surgical procedure ## Footnote Larger wounds and longer surgeries increase fluid loss.
35
What is the evaporative loss range for superficial trauma?
1 to 2 mL/kg/hr ## Footnote This is a common measurement in fluid management.
36
What is the evaporative loss range for severe trauma?
4 to 6 mL/kg/hr ## Footnote Severe cases require higher fluid management.
37
What are the consequences of under-resuscitation?
* Hypovolemia * Decreased microvascular perfusion * Reduced tissue perfusion * End-organ complications * PONV * Renal dysfunction * Myocardial ischemia * Hemoconcentration ## Footnote These issues highlight the importance of adequate fluid management.
38
What are the consequences of over-resuscitation?
* Vascular overload * Microvascular congestion * Decreased DO2 * Endothelial glycocalyx disruption * Decreased tissue oxygenation * Altered coagulation * Hemodilution ## Footnote Over-resuscitation can lead to serious complications.
39
What is the goal of fluid and blood management?
Euvolemia ## Footnote Achieving euvolemia is critical for patient stability.
40
41
What does GDFT stand for?
Goal Directed Fluid Therapy
42
What was the origin of GDFT?
Studies showing improved survival in critically ill patients when tissue oxygen delivery was optimized
43
What do traditional fixed-volume formulas, like the 4-2-1 rule, fail to account for?
Individual variability, increasing the risk of fluid imbalance
44
What are some benefits of GDFT according to meta-analyses?
* Reduces perioperative complications (e.g., acute kidney injury) * Shortens hospital stays in major surgeries * May improve bowel recovery after abdominal procedures
45
What are the monitoring techniques used in GDFT?
* Pulse contour analysis (e.g., FloTrac, LiDCO) * Esophageal Doppler for real-time LV function * TEE/TTE for global hemodynamic assessment * Dilution techniques (e.g., thermodilution via PACs or PiCCO) * Noninvasive monitors (e.g., ClearSight, CNAP)
46
What is the role of the Plethysmography Variability Index (PVI) in GDFT?
To assess fluid responsiveness
47
Fill in the blank: GDFT protocols guide ______ based on real-time data.
fluid administration
48
What does GDFT aim to avoid?
Excessive fluid administration seen in liberal fluid strategies
49
What is the relationship between GDFT and Enhanced Recovery After Surgery (ERAS) protocols?
ERAS protocols integrate GDFT to optimize perioperative outcomes
50
What are the challenges in GDFT research?
Results vary based on surgical type and GDFT implementation
51
What is the importance of accurate estimation of blood loss?
Guides fluid resuscitation and transfusion decisions
52
What are common techniques used for estimating blood loss?
* Suction canisters * Visual estimation (e.g., soaked sponges, laparotomy pads)
53
What is a limitation of visual estimation for blood loss?
Highly subjective and varies between providers
54
What does sponge weighing indicate in blood loss estimation?
1 gram difference = 1 mL blood loss
55
What are hematocrit and hemoglobin considered in blood loss estimation?
Indirect, lagging indicators affected by fluid shifts and IV replacement
56
What is the difference between Estimated Blood Loss (EBL) and Quantitative Blood Loss (QBL)?
EBL is quicker but less accurate than QBL
57
What is a critical component of hemodynamic monitoring?
Watch for changes in HR, BP, SpO₂, Pulse Pressure Variation
58
What is the recommended fluid replacement ratio for crystalloids?
Replace at a 1:1 ratio
59
According to the ASA Taskforce on Blood Transfusion, when is transfusion almost always indicated?
When hemoglobin concentration is less than 6 g/dL, especially in acute anemia
60
What is the blood volume for a premature infant at birth?
90–105 mL/kg
61
What is the Allowable Blood Loss (ABL) equation?
ABL = (HCTinitial – HCTallowable) x EBV/HCTinitial
62
What does blood transfusion enable?
Targeted replacement of deficient components: RBCs, platelets, coagulation factors, or plasma volume
63
What is the volume of whole blood?
~500–515 mL
64
What are the risks associated with whole blood?
* Hyperkalemia * Infectious disease transmission * Transfusion reactions
65
What does one unit of PRBCs raise Hgb and Hct by?
* Hgb by ~1 g/dL * Hct by 2–3%
66
What are leukocyte-reduced PRBCs indicated for?
To reduce the risk of febrile reactions, alloimmunization, CMV transmission
67
What is the shelf life of frozen RBCs?
Stored in glycerol for 10 years
68
What are the indications for platelet transfusion?
* plt <50,000/μL * For high-risk procedures, keep plt >75,000–100,000/μL * Prophylactic: plt <10–20,000/μL in at-risk patients
69
What does Fresh Frozen Plasma (FFP) contain?
All clotting factors, albumin, globulins, complement
70
What is the volume of FFP?
~200–600 mL
71
What is the goal when administering FFP?
Achieve 30% normal factor activity
72
What is the goal of factor replacement therapy?
Achieve 30% normal factor activity
73
What are the indications for using factor replacement therapy?
* Multiple factor deficiencies * Warfarin reversal (if PCC unavailable) * Liver disease coagulopathy * TTP (with plasmapheresis) * Massive transfusion protocols
74
What is the typical dose for factor replacement therapy?
10–15 mL/kg
75
What does cryoprecipitate contain?
* Fibrinogen * Factor VIII * Factor XIII * vWF * Fibronectin
76
What is the volume and dose for cryoprecipitate?
* Volume: 10–20 mL/unit * Dose: 1 unit/10 kg → ↑ fibrinogen by ~50 mg/dL
77
What are the indications for using cryoprecipitate?
* Hypofibrinogenemia (<80–100 mg/dL) * Massive transfusion * Congenital fibrinogen disorders * Von Willebrand disease (unresponsive to DDAVP) * Factor XIII deficiency
78
What is Prothrombin Complex Concentrate (PCC) used for?
Vitamin K-dependent factor replacement for urgent warfarin reversal
79
What is the last-resort option for life-threatening bleeding?
Recombinant Factor VIIa
80
What is the dose for recombinant Factor VIIa?
15–20 µg/kg
81
What is the purpose of TEG/ROTEM in transfusions?
To guide transfusions where available
82
What are the key components of blood donor screening?
* Medical history review * Antibody screening * Infectious disease screening * ABO and Rh typing * Bacterial contamination monitoring * Leukocyte reduction * CMV screening
83
What does an indirect Coombs test detect?
Non-ABO antibodies associated with hemolytic transfusion reactions
84
What are the infectious diseases screened in blood donation?
* Hepatitis B * Hepatitis C * Syphilis * HIV (anti-HIV-1 and anti-HIV-2 antibodies)
85
What is the purpose of leukocyte reduction in blood transfusions?
To reduce febrile reactions, immunosuppression, and CMV transmission
86
What is the function of a Cell Saver Machine?
Collects, filters, and washes shed surgical blood for reinfusion
87
What is the role of a blood warmer during transfusions?
Warms blood to 37°C to prevent hypothermia and associated complications
88
What is Acute Normovolemic Hemodilution (ANH)?
Blood removed and replaced with crystalloids/colloids preoperatively, then reinfused
89
What are the pharmacologic interventions for blood conservation?
* Antifibrinolytics (e.g., tranexamic acid) * Desmopressin (DDAVP) * Factor concentrates
90
What is the purpose of monitoring hemoglobin and hematocrit?
Standard monitoring of coagulopathy
91
What does hyponatremia indicate?
Na⁺ < 135 mEq/L
92
What are the classifications of hyponatremia?
* Hypovolemic (e.g., diuretics, GI losses) * Euvolemic (e.g., SIADH, hypothyroidism) * Hypervolemic (e.g., CHF, cirrhosis)
93
What is a key clinical manifestation of hyponatremia?
Neurological symptoms due to cerebral edema
94
What is the treatment for hypovolemic hyponatremia?
Isotonic saline
95
What defines hypernatremia?
Na⁺ > 145 mEq/L
96
What are the classifications of hypernatremia?
* Hypovolemic (e.g., GI or renal losses) * Euvolemic (e.g., diabetes insipidus) * Hypervolemic (e.g., hypertonic saline administration)
97
What are the clinical manifestations of hypernatremia?
Neurologic symptoms due to cellular dehydration
98
What is the treatment for hypernatremia?
Gradual correction over 48 hours to prevent cerebral edema
99
What defines hypokalemia?
K⁺ < 3.5 mEq/L
100
What are the clinical manifestations of hypokalemia?
* Muscle weakness * Hyporeflexia * Ileus * ECG changes (flattened T waves, U waves, arrhythmias)
101
What is the treatment for symptomatic or severe hypokalemia?
IV K⁺ with central line use and ECG monitoring if >10 mEq/h
102
What defines hyperkalemia?
K⁺ > 5.5 mEq/L
103
What are the causes of hyperkalemia?
* Intercompartmental shifts (e.g., acidosis) * Decreased renal excretion (e.g., renal failure)
104
What is the definition of hyperkalemia?
K⁺ > 5.5 mEq/L ## Footnote Hyperkalemia can lead to serious cardiac complications.
105
What are the causes of hyperkalemia?
* Intercompartmental shifts (e.g., acidosis, trauma, succinylcholine) * Decreased renal excretion (e.g., renal failure, hypoaldosteronism, RAAS inhibitors) * Rarely, excessive intake ## Footnote Consider ruling out pseudohyperkalemia.
106
What are the hallmark signs of hyperkalemia?
* Neuromuscular weakness * Life-threatening cardiac arrhythmias ## Footnote ECG changes can progress significantly in hyperkalemia.
107
What ECG changes are associated with hyperkalemia?
* Peaked T waves * Widened QRS * Sine wave pattern ## Footnote These changes may lead to ventricular fibrillation or asystole.
108
What should be evaluated in the diagnosis of hyperkalemia?
* Renal insufficiency * Medications * Acidosis * Sources of cell lysis ## Footnote Confirm true hyperkalemia by rechecking plasma levels.
109
What is the initial treatment for hyperkalemia?
Stabilize myocardium with IV calcium ## Footnote Additional treatments involve shifting K⁺ into cells and removing K⁺.
110
What should be avoided in anesthetic considerations for hyperkalemia?
Avoid succinylcholine and potassium-containing fluids ## Footnote Monitor ECG closely during anesthesia.
111
What is the definition of hypocalcemia?
Ionized Ca²⁺ < 4.0 mg/dL or Total Ca²⁺ < 8.5 mg/dL ## Footnote Hypocalcemia can lead to severe clinical manifestations.
112
What are the causes of hypocalcemia?
* Hypoparathyroidism * Vitamin D deficiency * Hyperphosphatemia (CKD) * Calcium chelation (e.g., citrate, pancreatitis, rhabdomyolysis) * Alkalosis * Sepsis * Certain medications ## Footnote Ionized calcium is the physiologically relevant form for diagnosis.
113
What are the clinical manifestations of hypocalcemia?
* Paresthesia * Tetany (Chvostek and Trousseau signs) * Seizures * Laryngospasm * Bronchospasm * Prolonged QT interval * Decreased contractility * Hypotension * Bradycardia ## Footnote Symptoms can vary significantly.
114
What should be assessed in the diagnosis of hypocalcemia?
* Ionized calcium * Total calcium corrected for albumin * Associated hypomagnesemia * Hyperphosphatemia * Renal dysfunction * Recent transfusion or albumin administration ## Footnote Accurate diagnosis is critical for appropriate treatment.
115
What is the treatment for acute/symptomatic hypocalcemia?
IV calcium (chloride or gluconate), ideally via central line ## Footnote Avoid co-administration with bicarbonate/phosphate solutions.
116
What is the definition of hypercalcemia?
Ionized Ca²⁺ > 5.3 mg/dL or Total Ca²⁺ > 10.5 mg/dL ## Footnote Hypercalcemia can have serious cardiac and renal implications.
117
What are common causes of hypercalcemia?
* Hyperparathyroidism * Malignancy (PTHrP, bone metastases) * Granulomatous disease (vitamin D sensitivity) * Immobilization * Milk-alkali syndrome * Certain drugs (thiazides, lithium) ## Footnote Ionized calcium reflects true severity and should be corrected for albumin.
118
What are the clinical manifestations of hypercalcemia?
* Nausea * Vomiting * Weakness * Polyuria * Confusion * Coma * Shortened QT interval * Sinus bradycardia * AV block * Ventricular dysrhythmias ## Footnote Severe cases can lead to renal failure and pancreatitis.
119
What is the initial treatment for hypercalcemia?
IV saline hydration followed by loop diuretics ## Footnote Bisphosphonates or calcitonin may be used for moderate to severe cases.
120
What is Goal Directed Fluid Therapy (GDFT)?
A fluid management approach that tailors fluid administration based on real-time hemodynamic variables ## Footnote Aims to optimize oxygen delivery and prevent both over- and under-resuscitation.
121
What hemodynamic variables are considered in GDFT?
* Stroke volume (SV) * Cardiac output (CO) * Cardiac index (CI) * Mean arterial pressure (MAP) ## Footnote GDFT is particularly important in perioperative and critically ill patients.

JT - Basics (36 decks)

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