Week 11 Handout Fluid And Blood Flashcards
(200 cards)
1
Q
Why is fluid and blood management important?
A
For maintaining intravascular volume, effective fluid exchange, and oxygen delivery.
2
Q
What are the goals of fluid and blood management?
A
Maintain perfusion, fluid balance, and tissue oxygenation.
3
Q
What errors can occur in fluid management?
A
Under-resuscitation can lead to tissue hypoperfusion, while over-resuscitation can cause edema and pulmonary congestion.
4
Q
What are the higher risk surgical procedures?
A
Emergency surgeries, surgeries with high blood loss, and long procedures with extensive fluid shifts.
5
Q
What can be a potential result of high-risk surgeries?
A
Delayed extubation and third spacing.
6
Q
What are examples of high-risk procedures?
A
Open aortic surgeries, peripheral vascular procedures, neurosurgery, thyroidectomy, and prostatectomy.
7
Q
What are examples of moderate-risk procedures?
A
Liver biopsies and most standard surgical operations.
8
Q
What are examples of low-risk procedures?
A
Endoscopy, bronchoscopy, and cataract surgery.
EGD with varices is considered high risk.
9
Q
What is the Total Body Water (TBW) in relation to lean body mass?
A
TBW is approximately 60% of lean body mass.
10
Q
What are the components of Total Body Water?
A
Intracellular Volume (ICV) is about 2/3 of TBW, and Extracellular Volume (ECV) is about 1/3 of TBW.
11
Q
What divides the Extracellular Volume?
A
Plasma (intravascular), interstitial fluid, and transcellular fluid (CSF, synovial, GI secretions).
12
Q
What regulates fluid balance?
A
Starling forces regulate movement between intravascular space and interstitial space.
13
Q
What are the four components of Starling forces?
A
Capillary Hydrostatic Pressure, Interstitial Fluid Pressure, Plasma Oncotic Pressure, and Interstitial Oncotic Pressure.
14
Q
What does Capillary Hydrostatic Pressure (Pc) do?
A
Generated by cardiac output, it pushes fluid out of vessels and is elevated in CHF, causing edema.
15
Q
What is Interstitial Fluid Pressure (Pif)?
A
Normally slightly negative, it favors reabsorption and increases in compartment syndrome, limiting movement.
16
Q
What role does Plasma Oncotic Pressure (πp) play?
A
It pulls fluid into vessels via albumin and decreases in malnutrition or liver failure, leading to ascites and edema.
17
Q
What does Interstitial Oncotic Pressure (πif) do?
A
It pulls fluid out and increases in sepsis due to protein leakage into tissues.
18
Q
What is the Starling Equation?
A
Jv=Kf×[(Pc−Pif)−σ(πp−πif)] where Jv is net fluid movement, Kf is capillary permeability, and σ is the reflection coefficient.
19
Q
What does a positive Jv indicate?
A
Positive Jv means filtration, while negative Jv means absorption.
20
Q
What are clinical examples of Starling forces?
A
Crystalloids increase Pc or πif, leading to more filtration. Colloids (albumin) increase πp or Pif, leading to reabsorption.
Low oncotic pressure can lead to pulmonary or peripheral edema, making mechanical ventilation more challenging.
21
Q
What happens in burns or sepsis regarding Starling forces?
A
Increased Kf and decreased σ lead to fluid and proteins leaking out to tissues, resulting in edema.
22
Q
What are the daily fluid requirements for adults?
A
Adults need approximately 25–35 mL/kg/day.
23
Q
What factors are evaluated in volume status?
A
History: Diuretics, GI loss, alcohol, diabetes, vomiting; Physical exam: Skin turgor, vitals, mucous membranes, edema; Urine output; Labs: BUN, Cr, H&H, specific gravity.
24
Q
What are the urine output categories?
A
Oliguria: <0.5 mL/kg/hr; Adequate: 0.5 mL/kg/hr; Overhydration: > 1.0 mL/kg/hr.
25
What does the Frank-Starling curve illustrate?
Preload increases stroke volume to a point; Left shift = improved contractility; Right shift = decreased function (CHF, ischemia).
26
What determines the Frank-Starling curve?
Inotropes (dobutamine), afterload, acidosis, hypoxia.
27
What happens to stroke volume with increased preload?
As preload increases, the heart muscle stretches more, leading to stronger contractions and increased stroke volume, but overstretching weakens the pump.
28
What causes an upward/leftward shift in the Frank-Starling curve?
Positive inotropes (e.g., dobutamine, epinephrine), sympathetic stimulation, decreased afterload, mild exercise (in a healthy heart).
29
What causes a downward/rightward shift in the Frank-Starling curve?
Negative inotropes (e.g., beta blockers, calcium channel blockers), myocardial ischemia or infarction, heart failure, acidosis, hypoxia, hypercapnia, increased afterload.
30
What are crystalloids used for?
First-line resuscitation fluids for shock, dehydration, burns, and perioperative fluid losses.
31
What types of crystalloids are commonly used?
Isotonic (NS, LR, Plasmalyte), hypotonic (D5W), hypertonic (3% saline).
32
What are the advantages of crystalloids?
Cheap, accessible, metabolized, no allergenic potential, renally cleared.
33
What are the disadvantages of crystalloids?
Dilutional effect, 75–80% goes to interstitial space, risk of edema if >4–5 L, large infusions can impair oxygen transport, hyperchloremic metabolic acidosis with excessive saline use.
34
What are colloids?
Colloids are large-molecule fluids that exert oncotic pressure to retain fluid in vasculature.
35
What do colloids contain?
Colloids contain high-molecular-weight substances such as albumin, starches, and gelatin.
36
What is the mechanism of colloids?
Colloids reduce transcapillary filtration and prolong intravascular volume expansion.
37
What are the types of colloids?
Colloids are classified into natural (blood-derived) and synthetic types.
38
What are examples of natural colloids?
Examples of natural colloids include albumin (5% or 25%) and plasma protein fraction (e.g., Plasmanate).
39
What are examples of synthetic colloids?
Examples of synthetic colloids include HES (hydroxyethyl starch), gelatins, and dextrans.
40
What is a risk associated with HES?
HES is associated with acute kidney injury (AKI) and coagulopathy.
41
What are the advantages of colloids?
Colloids have a longer intravascular half-life (3–6 hours) and require less volume to achieve the same effect.
42
In what situations are colloids useful?
Colloids are useful in hemorrhagic shock, severe hypoalbuminemia, and major protein losses (e.g., burns, sepsis).
43
What are the disadvantages of colloids?
Colloids are expensive and may cause pulmonary edema, acid-base disturbances, and hypervolemia.
44
What are the risks of synthetic colloids?
Synthetic colloids like HES can lead to AKI and increased mortality, while gelatins and dextrans can cause anaphylaxis and kidney damage.
45
What is the total daily fluid loss?
The total daily fluid loss is approximately 2500 mL/day.
46
What are the sources of daily fluid loss?
Sources include skin evaporation (~400 mL/day) and respiratory evaporation (~400 mL/day).
47
What is the importance of evaporative losses?
Evaporative losses are essential for thermoregulation, accounting for 25% of heat loss.
48
What is the 4-2-1 rule for maintenance fluids?
The 4-2-1 rule states: First 10 kg = 4 mL/kg/hr, Next 10 kg = 2 mL/kg/hr, Each kg >20 kg = 1 mL/kg/hr.
49
How do you calculate maintenance fluids for a 100 kg patient?
For a 100 kg patient: 10×4 + 10×2 + 80×1 = 140 mL/hr.
50
How do you calculate maintenance fluids for a 14 kg patient?
For a 14 kg patient: 10×4 + 4×2 = 48 mL/hr.
51
What is the formula for NPO deficit?
The formula for NPO deficit is NPO hours × hourly maintenance rate.
52
What is the replenishment schedule for NPO deficit?
Replenishment schedule: 1st hour = 50% of total deficit, 2nd and 3rd hour = 25% each.
53
What factors are related to evaporative fluid loss?
Open wounds, procedure duration, exposed surface area (evaporation), redistribution of body fluids.
54
What is the estimated evaporative fluid loss for superficial trauma?
1–2 mL/kg/hr (e.g., minor ortho).
55
What is the estimated evaporative fluid loss for minimal trauma?
2–4 mL/kg/hr (lap appendectomy).
56
What is the estimated evaporative fluid loss for moderate trauma?
4–6 mL/kg/hr (lap chole, ortho).
57
What is the estimated evaporative fluid loss for severe trauma?
6–10 mL/kg/hr (Whipple, open belly).
58
What complications arise from under-resuscitation?
Hypovolemia → ↓ perfusion → end-organ injury/complications, ↓ DO2, ↑ blood viscosity → thrombotic events, PONV, myocardial ischemia, renal dysfunction.
59
What complications arise from over-resuscitation?
Volume overload → pulmonary edema, CHF, capillary disruption, dilutional anemia, impaired coagulation, abdominal distention, ↑ bowel motility.
60
What is the definition of Goal-Directed Fluid Therapy (GDFT)?
Individualized fluid therapy using real-time hemodynamic data (SV, CO, CI, MAP) to optimize tissue perfusion and balance oxygen delivery vs demand.
61
What are the benefits of GDFT?
↓ perioperative complications (esp. AKI), shorten hospital stay, improve GI recovery, possibly improve survival.
62
What dynamic variables are used in GDFT?
PVI (Plethysmography variability index), SVV (stroke volume variation), PPV (pulse pressure variation).
## Footnote
PPV >13% → fluid responsive.
63
What monitoring techniques are used in GDFT?
Pulse contour (FloTrac, LiDCO), esophageal Doppler, TEE/TTE, thermodilution (PAC), noninvasive (ClearSight, CNAP).
64
What are the targets of GDFT protocols?
Achieve adequate preload, stop fluids when volume optimization is reached to avoid overload.
65
What is the role of GDFT in Enhanced Recovery (ERAS)?
Integrates GDFT to improve perioperative outcomes and fluid balance, especially in high-risk surgeries.
66
What are traditional methods for estimating blood loss (EBL)?
Suction: subtract irrigation from canister; visual estimation: soaked 4x4 gauze ~10–15 mL, soaked lap pads ~100–150 mL.
67
What are the limitations of estimating blood loss (EBL)?
Highly subjective, underestimates actual loss, poor for detecting occult bleeding.
68
What is the method for Quantitative Blood Loss (QBL)?
Sponge weighing: pre- and post-use weighing; 1 gram difference ≈ 1 mL blood loss.
69
What are the limitations of lab measurements for blood loss?
H/H lags behind real-time loss, affected by fluid shifts/dilutional effect post-resuscitation.
70
What are the fluid replacement ratios for blood loss?
Crystalloids: 3:1; colloids or blood: 1:1.
71
What are the ASA Transfusion Guidelines?
Rarely needed if Hgb >10 g/dL; almost always indicated if Hgb <6 g/dL (especially in acute anemia).
## Footnote
Don't rely on a single Hgb number—consider full clinical picture.
72
What is the Estimated Blood Volume (EBV) for premature infants?
90–105 mL/kg
73
What is the Estimated Blood Volume (EBV) for newborns?
80–90 mL/kg
74
What is the Estimated Blood Volume (EBV) for infants and children?
70–75 mL/kg
75
What is the Estimated Blood Volume (EBV) for adult males?
70 mL/kg
76
What is the Estimated Blood Volume (EBV) for adult females?
65 mL/kg
77
How do you calculate EBV for obese patients?
Use (lean body weight + 20%), then: Males: 70 mL/kg, Females: 65 mL/kg
78
What is the acceptable hematocrit (HCT) for healthy individuals?
HCT ≥18–21%
79
What is the acceptable hematocrit (HCT) for individuals with systemic disease or chronic illness?
HCT ≥24%
80
What is the acceptable hematocrit (HCT) for individuals with symptomatic cardiac disease?
HCT ≥30%
81
What factors should be considered when individualizing transfusion decisions?
Risk factors, Clinical status, Hemodynamics
82
What is the Allowable Blood Loss (ABL) formula?
ABL=(HCTinitial−HCTallowable) × EBV/HCTinitial
83
What does the ABL formula help determine?
How much blood loss can be tolerated before transfusion is required
84
Provide an example of ABL calculation.
100 kg male, HCT 40%, allowable 30% → ABL = 2800 mL
85
What are blood products used to replace?
RBCs → oxygen carrying capacity, Platelets → primary hemostasis, Plasma → clotting factors, Volume → intravascular support
86
What are the two types of blood products?
Fractionated (PRBCs, FFP, platelets) and Purified (PCC, fibrinogen concentrate, rFVIIa)
87
Which blood products contain plasma?
FFP, PCC, Fibrinogen concentrate
88
Which blood product contains platelets?
Platelets
89
Which blood products contain neither plasma nor platelets?
PRBCs, rFVIIa
90
What is the mnemonic for perfect clotting focus?
1, 2, 7, 9, 10
91
What does FFP stand for?
Full Factor Package
92
What factors does PCC contain?
Vitamin K–dependent factors: II, VII, IX, X
## Footnote
Think: '2, 7, 9, 10 – PCC’s Top Ten'
93
What is included in Cryoprecipitate?
I (fibrinogen), VIII, XIII, vWF, fibronectin
94
What does Fibrinogen Concentrate contain?
Just Factor I (Fibrinogen) – 'F is for Fibrinogen'
95
What does rFVIIa contain?
Only Factor VIIa – 'R is for Really just VIIa'
96
What is the importance of ABO compatibility?
Match ABO and Rh types to reduce hemolysis risk
97
Which blood type is the universal donor for RBCs?
Type O
98
Which blood type is the universal donor for plasma?
Type AB
99
What does whole blood contain?
RBCs, plasma, platelets, WBCs (stored to 35 days)
100
What is the volume of whole blood?
~500 mL
101
What is the hematocrit (Hct) range for whole blood?
40–45%
102
What are the risks associated with whole blood?
Hyperkalemia, infectious disease transmission, transfusion reactions
103
What is Acute Normovolemic Hemodilution (ANH)?
WB withdrawn pre-op and reinfused later.
104
What is the volume of Packed RBCs (PRBCs)?
250–350 mL
105
What is the hematocrit (Hct) of Packed RBCs (PRBCs)?
~70%
106
What is the storage temperature and shelf life of PRBCs?
1–6°C; shelf life: 21–42 days
107
What are the indications for PRBCs?
Improve O2 capacity, Anemia, acute hemorrhage
108
What is the pediatric dose of PRBCs?
10–15 mL/kg
109
What is the effect of 1 unit of PRBCs on Hgb?
↑ Hgb ~1 g/dL
110
What is the effect of 1 unit of PRBCs on Hct?
↑ Hct ~2–3%
111
What should be done when administering more than 2–3 units of PRBCs?
Warm blood to prevent hypothermia
112
What type of filter should be used for PRBC administration?
170-micron filter
113
What are the special types of PRBCs?
Leukocyte-reduced, Washed RBCs, Frozen RBCs
114
What is the benefit of leukocyte-reduced PRBCs?
Decreased febrile reactions, CMV
115
What is the purpose of washed RBCs?
Plasma proteins removed -> For IgA deficiency or allergic reactions
116
How long can frozen RBCs be stored?
Up to 10 years
117
What is the key role of platelets?
Key for primary hemostasis
118
What are the sources of platelets?
Random donor (from WB) ~ 50-70 mL/unit; Apheresis (single donor, preferred) = 6-8 WB units
119
What is the storage temperature for platelets?
20–24°C with agitation
120
What is the shelf life of platelets in a closed system?
5 days
121
What is the shelf life of opened platelets?
24 hours
122
What are the indications for platelet transfusion?
Active bleeding if PLT <50K; High-risk surgery: Keep PLT >75–100K; Prophylaxis: PLT <10–20K in at risk patients
123
How much does 1 unit of platelets increase PLT?
↑ PLT by 5–10K
124
How much does an apheresis unit increase PLT?
↑ PLT by 30–60K
125
What is the dosing guideline for platelet transfusion?
1 unit per 10 kg body weight
126
Is ABO compatibility essential for platelet transfusion?
ABO compatibility ideal but not essential
127
What should be considered for Rh− patients receiving Rh+ platelets?
Consider RhIG
128
What are some transfusion complications associated with platelets?
Febrile reactions, TRALI, sepsis (platelets stored at room temp), post transfusion purpura, bacteria contamination, alloimmunization -> platelet refractoriness
129
What are the contents of Fresh Frozen Plasma (FFP)?
All clotting factors, albumin, globulins, complement
130
What is the processing time for FFP?
Frozen within 6–8 hrs of collection
131
What is the volume of FFP per unit?
~200–600 mL/unit
132
What is the storage temperature for FFP?
−18°C for up to 1 year
133
How much do FFP units increase factor levels?
Increases factor levels by 2-3% per unit
134
What are the indications for FFP transfusion?
Multiple factor deficiencies; Warfarin reversal (if PCC unavailable); Liver disease-associated coagulopathy; TTP (with plasmapheresis); Part of massive transfusion protocols
135
What is the dosing guideline for FFP?
10–15 mL/kg
136
What is the goal for FFP transfusion in terms of factor activity?
30% normal factor activity to ensure adequate coagulation
137
What is the composition of Cryoprecipitate?
Derived from thawed FFP at 1–6°C; Contains: Fibrinogen, Factor VIII, Factor XIII, von Willebrand Factor (vWF), Fibronectin
138
What is the volume of Cryoprecipitate per unit?
10–20 mL/unit
139
What are the indications for Cryoprecipitate transfusion?
Fibrinogen <80–100 mg/dL; Massive transfusion; Congenital fibrinogen deficiency; von Willebrand disease (unresponsive to DDAVP); Factor XIII deficiency
140
What is the dosing guideline for Cryoprecipitate?
1 unit/10 kg body weight raises fibrinogen ~50 mg/dL
141
What does Prothrombin Complex Concentrate (PCC) contain?
Vitamin K-dependent factors (II, VII, IX, X)
## Footnote
Used for rapid warfarin reversal.
142
What is Recombinant Factor VIIa used for?
Last-resort for life-threatening bleeding.
## Footnote
Dose: 15–20 mcg/kg.
143
What is Fibrinogen Concentrate used for?
To correct hypofibrinogenemia quickly.
144
What guidance should be used to determine the need for factor concentrates?
Use TEG/ROTEM.
145
What is involved in donor screening?
Medical history and Indirect Coombs test.
146
What does the Indirect Coombs test detect?
Non-ABO antibodies associated with hemolytic transfusion reactions.
147
What infectious diseases are tested in blood safety?
HIV 1/2, Hepatitis B & C, and Syphilis.
148
What is the purpose of ABO/Rh typing?
Ensures compatibility with the recipient.
149
Why is bacterial contamination monitoring essential?
Essential for platelets, which are stored at room temperature and carry higher risk.
150
What are CMV-negative units used for?
For immunocompromised patients.
151
What is the purpose of leukocyte reduction?
Filtered to remove WBCs, reducing febrile reactions, CMV, and alloimmunization.
152
What does a Cell Saver Machine do?
Filters and washes autologous surgical blood for reinfusion.
153
What is the function of a Platelet Agitator?
Maintains motion to keep platelets viable.
154
What is the role of Blood Bank Refrigerators/Freezers?
Store blood components at appropriate temperatures.
155
What type of filter is used in blood tubing?
170-micron filter to remove debris/clots.
156
What is the purpose of a Blood Warmer?
Prevents hypothermia (target 37°C).
157
What is a Rapid Infuser used for?
Delivers large volumes quickly with a warming system.
## Footnote
Used in massive transfusion.
158
What should be assessed preoperatively for blood conservation?
Bleeding risk, coagulopathies, and anticoagulant history.
159
What should be optimized preoperatively?
Anemia (iron, erythropoiesis agents) and hold anticoagulants & non-aspirin antiplatelets if appropriate.
160
What special considerations are there for Sickle Cell patients?
Hydration, oxygenation, infection control, and consider exchange transfusion.
161
What techniques are used for intraoperative conservation?
Meticulous surgical technique and autologous strategies.
162
What is ANH in intraoperative conservation?
Blood removed preop and replaced with crystalloids/colloids, then reinfused.
163
What is the purpose of maintaining normothermia during surgery?
To prevent hypothermia.
164
What are topical hemostats?
Thrombin glue and fibrin sealants.
165
What should be avoided in Sickle Cell considerations?
Hypoxia, low-flow states, and prolonged tourniquet use.
166
What are antifibrinolytics used for?
TXA, aminocaproic acid: ↓ bleeding in trauma/ortho/cardiac cases.
167
What does DDAVP enhance?
vWF & platelet function.
## Footnote
Useful in uremia or platelet dysfunction.
168
What standard labs are monitored for coagulopathy?
Hgb, Hct, INR, aPTT, fibrinogen, platelet count.
169
What advanced monitoring techniques guide targeted transfusions?
TEG/ROTEM.
170
What is the purpose of perfusion checks?
Monitor organ perfusion & hemodynamics as guides.
171
What is involved in postoperative blood strategies?
Bleeding surveillance, anticoagulation, and anemia management.
172
What is included in anemia management postoperatively?
Iron therapy and erythropoietin (to reduce transfusions).
173
What are algorithm-based transfusion strategies used for?
They are used for FFP, platelets, and cryoprecipitate to prevent unnecessary transfusions and complications.
174
What is the Massive Transfusion Protocol (MTP) ratio?
The MTP ratio is 1:1:1 for PRBCs, FFP, and platelets.
175
What does the MTP prevent?
It prevents dilutional coagulopathy and is essential in trauma and massive hemorrhage.
176
What is hyponatremia?
Hyponatremia is defined as Na+ < 135 mEq/L.
177
What causes hyponatremia?
Causes include excess water relative to sodium, with types being hypovolemic, euvolemic, and hypervolemic.
178
What are the clinical manifestations of hyponatremia?
Neurological symptoms predominate due to cerebral edema, ranging from mild nausea to seizures, coma, or death.
179
How should hypovolemic hyponatremia be treated?
Treat with isotonic saline.
180
What should be avoided in the treatment of hyponatremia?
Avoid rapid correction to prevent osmotic demyelination.
181
What is hypernatremia?
Hypernatremia is defined as Na+ > 145 mEq/L.
182
What causes hypernatremia?
Causes include water loss or sodium gain, classified by volume status.
183
What are the symptoms of hypernatremia?
Symptoms include cellular dehydration, restlessness, lethargy, seizures, and coma.
184
How should hypernatremia be treated?
Treat with gradual correction over 48 hours and restore intravascular volume first if hypovolemic.
185
What is hypokalemia?
Hypokalemia is defined as K+ < 3.5 mEq/L.
186
What causes hypokalemia?
Causes include diuretics, alkalosis, vomiting, diarrhea, NG suction, insulin, and B2 agonists.
187
What are the symptoms of hypokalemia?
Symptoms include muscle weakness, hyporeflexia, ileus, and ECG changes.
188
How should hypokalemia be treated?
Treat with oral or IV potassium, avoiding dextrose-containing fluids.
189
What is hyperkalemia?
Hyperkalemia is defined as K+ > 5.5 mEq/L.
190
What causes hyperkalemia?
Causes include intercompartmental shifts, decreased renal excretion, or excessive intake.
191
What are the symptoms of hyperkalemia?
Symptoms include neuromuscular weakness and life-threatening cardiac arrhythmias.
192
How should hyperkalemia be treated?
Treat by stabilizing the myocardium with IV calcium and shifting K+ into cells.
193
What is hypocalcemia?
Hypocalcemia is defined as Ca²+ < 8.5 or ionized < 4.0 mg/dL.
194
What causes hypocalcemia?
Causes include hypoparathyroid, vitamin D deficiency, and certain medications.
195
What are the symptoms of hypocalcemia?
Symptoms include paresthesia, tetany, seizures, and cardiovascular effects.
196
How should hypocalcemia be treated?
Treat with IV calcium gluconate or chloride.
197
What is hypercalcemia?
Hypercalcemia is defined as Ca²+ > 10.5 or ionized > 5.3 mg/dL.
198
What causes hypercalcemia?
Causes include hyperparathyroidism, malignancy, and certain drugs.
199
What are the symptoms of hypercalcemia?
Symptoms include nausea, vomiting, weakness, and cardiac signs.
200
How should hypercalcemia be treated?
Treat with IV saline and loops to promote calciuresis.
