Week 4- Fluid and Blood Transfusion

Question 1

Importance of thorough preoperative evaluation of fluid balance status

Answer 1

Patient History
Systemic B/P
Heart Rate
Urine Output
Hematocrit
BUN
Electrolytes
CVP

Question 2

Importance of thorough preoperative evaluation of fluid balance status
Grandma?(class discussion)

Answer 2

we know grandma and grandpa area already dry. now they are super dry.

Question 3

Perioperative Assessment of Intravascular Fluid Status

causes of intravascular volume depletion

Answer 3

Causes of Intravascular Volume Depletion
Prolonged GI losses
Chronic Hypertension
Chronic Diuretic Use
Sepsis
Trauma

Question 4

chronic hypertension

Answer 4

blood pressure maintain within 20% of baseline

Question 5

Physical signs and symptoms of Hypovolemia

Answer 5

Supine Hypotension
(implies blood volume deficit greater than 30%)
Orthostasis or Positive tilt test
( increases in HR greater than 20 beats/min and decreases in systolic BP greater than 20 mmHg when the patient assumes the standing position)
Oliguria

Question 6

Is Hematocrit a useful tool in determining hypovolemia?

Answer 6

Hematocrit a useful tool ?? Yes they will be concentration to a crit of 40%

Question 7

What are some of the initial (early) signs and symptoms of hypovolemic shock

Answer 7

Hypovolemia shock- tachycardia- decreased urine out

Question 8

Hemoconcentration

Answer 8

(hct is a poor indicator of blood volume). High Hct means the patient is dry

Question 9

Azotemia

Answer 9

(nitrogenous products in blood)

Question 10

Low urine sodium concentration

Answer 10

(less than 20 meq for every 1000 ml of urine)

Question 11

Metabolic acidosis

Answer 11

(reflects hypoperfusion). Due to Na++ reabsorption

Question 12

Body Fluid Compartments

Answer 12

Total body water is divided into:
ICF
ECF (PV + ISF)

Question 13

TBW content varies with:

Answer 13

Age
Gender
Body Habitus

Question 14

Hypervolemia

Answer 14

increases the risk of pulmonary edema

Question 15

Hypovolemia

Answer 15

increases the risk of organ hypoperfusion

Question 16

Intra-Operative fluid loss

Answer 16

Most fluid looses occurring intraoperatively are replaced with isotonic type solutions:
Lactated ringers (LR)
Plasmalyte (Normosol)
Normal saline (NS)-used to dilute blood as well

Question 17

colloids

Answer 17

They are high molecular weight solutions which tend to stay intravascularly. The half – life is approximately 3 – 6 hours

Question 18

Indications for Colloid Solutions

Answer 18

Fluid resuscitation (hemorrhage) prior to transfusion Ex. Trauma
Fluid resuscitation (hypoalbuminemia or protein loss) Ex. Burns

Question 19

Blood Derived Colloids, name them

Answer 19

5 % albumin
25 % albumin
5 % plasma protein fraction
Heated to 60º C for 10 hours to decrease the risk of hepatitis or viral diseases

Question 20

Synthetic Colloids

Answer 20

Dextrose starches
Dextran 70 (macrodex) MW 70,000
Dextran 40 (rheomacrodex) MW 40,000
Dextran 40 improves microcirculation blood flow because it decreases blood viscosity. It also has anti-platelet effects. (Vascular surgery)
Referred to as LMD (Low molecular Dextran)

Question 21

More on Dextran…

Answer 21

Doses greater than 20 ml/kg/day can:
Interfere with blood typing
Prolong bleeding time
Cause renal failure
Cause anaphylactoid/anaphylactic reactions
Dextran 1 (promit) may be given prior to dextran to prevent severe anaphylaxis

Question 22

Hetastarch (hespan)

Answer 22

6 % solution MW 450,000. Plasma expander less expensive than albumin

Anaphylactoid reactions are rare

Coagulation and bleeding times are not affected when infusions are not greater than 1 literMax. dose 20 ml/kg/day

Hespan 6% in saline and Hextend 6% in balanced electrolytes (Ca)

Half-life for 90% of hydroxyethyl starch particles is 17 days.- reaction will be down the road if it happens.

Do not use hydroxyethyl starch (HES) products, including Hespan®, in critically ill adult patients, including patients with sepsis, due to increased risk of mortality and renal replacement therapy (RRT).

Question 23

Advantages of crystalloids

Answer 23

Inexpensive
Greater urine output
Replaces interstitial fluid

Question 24

Disadvantages of crystalloids:

Answer 24

Short lived hemodynamic improvement
Peripheral edema
Pulmonary edema

Question 25

Advantages of colloids:

Answer 25

Smaller infused volume Prolonged increase in plasma volume (half life is 3 – 6 hours) Minimal peripheral edema Lower ICP (controversial)

Question 26

Disadvantages of colloids:

Answer 26

Expensive Coagulopathy (dextran more than hetastarch) Pulmonary edema (capillary leaky states)

Question 27

Colloids and Crystalloids

Answer 27

There is no evidence to support the superiority of either colloids or crystalloid containing solutions

Question 28

Urine Output/Goal During Surgery

Answer 28

Adequate is 0.5 - 1 ml/kg/hour

Question 29

Intraoperative Fluid Replacement

Answer 29

``` In healthy adults undergoing elective surgery, the following must be taken into consideration: NPO loss Insensible loss (third space) EBL Replacement Maintenance ```

Question 30

Intraoperative Fluid Replacement

Answer 30

``` The predicted daily maintenance fluid requirements for healthy adults may exceed 2500ml/day. Insensible loss (diaphoresis, respiration, etc.) may exceed 1000ml/day Urinary losses to maintain renal function average 1000ml/day, GI losses 200ml/day ```

Question 31

Intraoperative Fluid Replacement

Answer 31

Surgical Patients require additional fluids and electrolytes to replace losses from the ECF to nonfunctional “third space” We base our fluid replacement on the anticipated need categorized by the amount and duration of tissue trauma caused

Question 32

Insensible losses

Answer 32

500-1000mL/day (respiratory/cutaneous)

Question 33

Evaporation

Answer 33

(most common from larger wounds)

Question 34

Fluid shifts/internal redistribution (third spacing)

Answer 34

Ex. Burns, trauma, extensive injuries

Question 35

The following is an accepted example of “third space” replacement

Answer 35

Minor trauma 2 ml/kg/hr *Values vary Moderate trauma 4 ml/kg/hr between sources Extensive trauma 8 ml/kg/hr Keep in mind that colloids may be required if EBL is extensive

Question 36

Calculation of Third Space Losses | Mild

Answer 36

(lower abdominal) 0 – 2 ml/kg/hr (hysterectomy, herniorrhaphy)

Question 37

Calculation of Third Space Losses | Moderate

Answer 37

(upper abdominal) 2 – 4ml/kg/hr (colectomy, gastrectomy)

Question 38

Calculation of Third Space Losses | Extreme

Answer 38

(combined upper/lower) 4 – 8 ml/kg/hr (thoracotomy, AAA repair)

Question 39

Mobilization of third space fluids occurs in about 72 hours post-op

Answer 39

Mobilization of third space fluids occurs in about 72 hours post-op

Question 40

Maintenance fluid | calculation

Answer 40

Maintained with isotonic solution 4cc/kg for the 1st 10kg of body weight (Up to 10 kg) 2cc/kg for the next 10kg of body weight (11- 20 kg) 1cc/kg for the rest of the body weight (21 kg and above)

Question 41

hourly maintenance

Answer 41

Another option for hourly maintenance (approximation) in the adult patient is to use 1.5 cc/Kg/hr Mostly done in emergency cases when calculations are not feasible

Question 42

NPO Deficit

Answer 42

Deficit is described as the maintenance rate x the hours of NPO

Question 43

Fluid maintenance administration per hour

Answer 43

Give ½ in the first hour, ¼ in the second hour, and ¼ in the third hour.

Question 44

Formula to Calculate Adjusted Body Weight

Answer 44

actual patient weight + ideal patient weight /2

Question 45

Ideal Body Weight

Answer 45

First 5 feet = 100 pounds then For females add 5 pounds for every inch above 5 feet For males add 7 pounds for every inch above 5 feet

Question 46

Ideal Body Weight Obesity

Answer 46

Obesity is 20 % above the ideal body weight | Morbid obesity is twice the IDEAL BODY WEIGHT

Question 47

Ideal Body Weight | morbid obesity

Answer 47

Morbid obesity is twice the IDEAL BODY WEIGHT

Question 48

obese patient calculate fluid and drugs

Answer 48

For obese patients calculate fluid and drugs required according to the adjusted body weight