11. Advanced Fluid Management - Editing Flashcards
1
Q
hydrostatic pressure
A
pressure exerted against the capillary walls
2
Q
intravascular hydrostatic pressure drives blood what way
A
out of blood vessel
3
Q
interstitial hydrostatic pressure drives blood what way
A
into blood vessels
4
Q
oncotic pressure
A
form of osmotic pressure exerted by proteins
pulls fluid towards itself
5
Q
intravascular oncotic pressure drives fluid what way
A
into blood vessels
6
Q
interstitial oncotic pressure drives fluid what way
A
out of blood vessels
7
Q
oncotic pressure opposes?
A
oncotic pressure opposes hydrostatic pressyre
8
Q
decreased intravascular oncotic pressure can lead to what
A
edema
9
Q
why is there edema in pregnancy
A
incr plasma volume
decr plasma [albumin]
decr cap oncotic pressure
incr interstitial fluid (edema)
10
Q
why is there edema in liver failure
A
decr plasma [albumin]
decr cap oncotic pressure
incr edema
11
Q
capillary arterial end net filt pressure and direction
A
net filtration pressure of 13
OUT of blood vessels
12
Q
venous end net filt pressure and direction
A
net filtration pressure 7
INTO blood vessels
INTO blood vessels
13
Q
What happens to the 6 left in the interstitial fluid?
A
taken by lymphatic system back to lymph nodes
drains into subclavian vein
drain into subclavian vein
14
Q
lymphatic system function
A
maintain fluid balance
protects body from infection
protect body from infection
15
Q
moles
A
refer to compounds
NaCl
16
Q
osmoles
A
refer to ions
Na+ Cl-
17
Q
osmolality
A
number osmoles/kg solvent
18
Q
osmolarity
A
number osmoles/L
19
Q
plasma osmolarity
A
280-290 mOsm/L
20
Q
what 3 things regulate osmolarity
A
hypothalamus
carotid baroreceptors
kidneys
21
Q
what does the hypothalamus do to regulate osmolarity
A
osmolarity high=
tells posterior pituitary to:
secrete ADH
sense of thirst
22
Q
what do the carotid and baroreceptor and kidneys do to regulate osmolarity
A
sense a decrease in blood volume
send message to brain to secrete ADH
23
Q
molarity
A
how concentrated one solution is compared to another
24
Q
hyperosmolar
A
higher conc of total solutes than other side of membrane
25
hypoosmolar
lower concentration of total solutes thatn other side of membrane
26
tonicity
which direction water moves
27
hypertonic
water moves toward the solution
28
hypotonic
water moves away from the solution
29
hypertonic IV solution definition
osmolarity of >375 mOsm/L
30
effects of hypertonic IV solution on the body
cells of the body shrink
blood volume incr/expands
| blood volume increases
31
3 hypertonic IV solutions
mannitol
hypertonic 3% N/S
D5 Solution (except D5W)
32
mEq/L of 3% N/S
513 mEq/L
33
D5 solution
5% dextrose in bag or vial
34
D50 solution
50% dextrose in bag or vial
35
5% dextrose is what mg/mL?
50mg/mL
36
50% dextrose is what mg/mL
500mg/mL
37
pediatric dose of dextrose
0.25-0.5g/kg
38
adult dose of dextrose
0.5-1g/kg
39
3 indications for hypertonic fluids
3% N/S to correct plasma sodium conc.
glucose solution for maintenance for NPO or normalize sugar
mannitol for increase renal perfusion and neurosurgery to shrink brain cells
40
complications of hypertonic IV fluids
- if 3% N/S given too rapidly then the brain can have central pontine myelinolysis and death
- osmotic diuresis
- loss of electrolytes
- intracellular dehydration
- coma
41
hypotonic IV solution definition
osmolarity of <250mOsm/L
42
effects of hypotonic IV fluids on the body
cells of the body will expand
blood volume decr
| blood volume decreases
43
3 hypotonic solutions
0.45% N/S
2.5% Dextrose in Water
D5W
44
is D5W really hypotonic?
starts isotonic but glucose is rapidly metabolized in the body and becomes hypotonic
45
indications for hypotonic IV fluids
hypernatremia (water deficit)
| water deficit
46
2 complications of hypotonic fluids
```
cause phlebitis (go through central line)
cerebral edema (contraindicated in pts with increased ICP)
```
47
isotonic solution definition
osmolarity of 250-375 mOsm/L
48
4 types of isotonic solution
LR
N/S 0.9%
normosol (plasmalyte)
5% albumin
49
osmolarity of LR
273 mOsm/L
| slightly hypotonic
50
contents of LR
Na
K
Ca
Cl
lactate
51
what is lactate converted to by the liver?
bicarb and glucose
52
4 contraindications to LR
```
liver disease/liver failure
neurosurgery
incr ICP
ceftriaxone (Rocephin)
```
53
questionable CI to LR
pts w/metabolic acidosis/pyloric stenosis
blood
diabetes
renal failure
54
why not hang LR with blood
Ca is clotting factor IV
calcium could chelate the citrate anticoagulant preservative and form clots
55
why not hang LR in liver failure
lactate builds up and cant be converted thus causing lactic acidosis (elevated anion gap metabolic acidosis)
56
why avoid LR in diabetes?
lactate is converted to glucose and exacerbates hyperglycemia
57
why avoid LR in renal failure?
LR contains potassium and renal failure pts are at risk for hyperkalemia
58
why avoid LR in neurosurgery?
slightly hypotonic fluid could incr ICP
59
why is ceftriaxone (rocephin) CI with LR for neonates?
risk of fatal ceftriaxone-calcium salt precipitation in the bloodstream
60
why is ceftriaxone (Rocephin) CI in pts > 28 days with LR?
cannot be given simultaneously because it may precipitate in IV line
61
why is LR CI in pts with pyloric stenosis?
pts with pyloric stenosis have met alkalosis
Lactate converts to bicarb = worsens alkalosis
62
osmolarity of 0.9% N/S
308 mOsm/L
slightly hypertonic to plasma/LR
| slightly hypertonic
63
each L of 0.9% N/S contains how much mEq of sodium?
154mEq
64
what can large volumes of N/S 0.9% administration lead to?
non anion gap metabolic acidosis
65
osmolarity of normosol
294 mOsm/L
66
contents of normosol
Na, K, Mg, Cl
* doesnt have lactate or calcium
67
potassium conc in normosol
5mEq/L
68
potassium conc in LR
4mEq/L
69
indications for plasmalyte
blood transfusions
liver failure
| liver failure
70
why is plasmalyte better for liver failure than LR
does not contain lactate
71
why is plasmalyte better for pts in metabolic acidosis?
plasmalyte is more alkalinizing than LR
72
conc bicarb normosol
50mEq/L
73
conc bicarb LR
28mEq/L
74
contraindications for normosol
none
75
most common colloid used in hypovolemic pts
5% albumin
76
5% albumin will expand the intravascular volume how much?
mL for mL
77
20-25% mannitol indication
large blood volume deficit
oncotic deficit
hypoproteinemia
78
Hespan
colloid used as alternative to albumin
6% hetastarch
79
what is the risk with hespan
black box warning increased mortality
80
when would you use hespan?
allergy to albumin
| jehovah witness
81
Blood volume preterm infant
90-100mL/kg
82
blood volume pregnant pt at term
90-100 mL/kg
83
blood volume full term neonate
90mL/kg
84
blood volume infant
80mL/kg
85
blood volume male
70-75mL/kg
86
blood volume female
60-65mL/kg
87
blood volume elderly & obese
~15% less than adults
88
TBW males: healthy, obese, geriatric
healthy- 60%
obese- 50%
geriatric- 50%
89
TBW females: healthy, obese, geriatric
healthy- 50%
obese- 40-45%
geriatric- 40-45%
90
TBW neonate
80%
91
TBW infant
70%
92
intracellular fluid % of TBW
65%
93
extracellular fluid % of TBW
35%
94
extracellular: interstitial fluid
70-75%
| TBW 25%
95
extracellular fluid: intravascular fluid
25-30%
96
TBW overall breakdown
intracellular: 65%
interstitial: 25%
intravascular: 10%
97
interstitial + intravascular =
extracellular = 35% of TBW
98
what % of total fluid in the human body is blood?
10%
99
as children grow into adults, TBW _______
decreases
100
as children grow into adults, % of intracelluar fluid ________
% of extracellular fluid ____________
% of intracellular incr
% of extracellular decr
101
lasix
loop diuretic
| inhibits water and sodium reabsorption in LOH
102
indications for lasix 3
fluid overload
- edema
- pulm edema
- nephrotic syndrome
- CHF
chronic HTN
offsetting increased ADH in surgery
103
is lasix renal protective or increase renal blood flow?
no
104
mannitol
osmotic diuretic
| increases osmolarity of blood, expands plasma volume
105
mannitol causes
incr blood osmolarity
incr plasma volume
cells shrink
106
mannitol indications
renal protection and perfusion
brain surgery (causes decr ICP)
| brain surgery
107
does mannitol increase renal perfusion?
yes
108
spirolactone
usually at home mediations
| potassium sparing
109
spironolacton is a _______ diuretic
potassium sparing diuretic
110
spironolactone SE
hyperkalemia
111
acetazolamide
carbonic anhydrase inhibitor
| decrease bicarb and increase PaCO2
112
complication of acetazolamide
metabolic acidosis
hypokalemia
113
indications for acetazolamide
diuretic to treat heart failure edema
treat glaucoma and lower intraocular pressure
epilepsy
treat altitude sickness
114
nephrotic syndrome
kidney disorder that causes the body to excrete too much protein in urine, damage to nephrons
115
3 symptoms of nephrotic syndrome
proteinuria
hypoalbuminemia
fluid overload (edema)
116
treatment for nephrotic syndrome
finding and fixing underlying cause
117
adult major burn definition
>20% of TBSA
118
kids and elderly major burn definition
>10% TBSA
119
automatic major burn
face
airway
genitalia
120
what things make it a major burn regardless of TBSA?
burn to face
airway
genitalia
121
describe rule 9
```
head 9
front 18
back 18
arm 9 each
leg 18 each
genitalia 1
```
122
rule of 9 for peds
head 18
front 18
back 18
arm 9 each
leg 14 each
genitalia 1
123
patients with major thermal injury are expected to experience:
inflammatory response
massive vasodilation
fluid shift from IV INTO interstitial
injury to muscles
loss of skin protective barriers
124
physiology after thermal injury
1. hypovolemia
2. decr CO
3. hTN
4. massive edema
5. hypothermia
6. anemia/thrombocytopenia
7. hypercoagulability
8. altered pulm phys
7. incr nicotinic Ach R
8. hypermetabolic
125
why is there hypovolemia and decreased CO in burn pts
drainage and evaporation from wounds
relative hypovolemia from vasodilation
| intense infammatory response leads to vasodilation
126
how is anemia and throbocytopenia caused in burn pts
bleeding from wounds
heat damage to RBC
fluid resuscitation
127
proliferation of nicotinic ach receptors causes what?
resistance to NDMB
sensitivity to Sux
| sensitivity to succ
128
how long dose it take for proliferation of nicotinic Ach to occur?
24 hrs post burn
129
possible complications of altered pulm physiology include
decr pulm compliance
incr lung vascular and permeability incr PVR
possible carbon monoxide poisoning
130
what is the hypermetabolic phase caused by
massive surge of catecholamines and corticosteriods
131
what does the hypermetabolic phase lead to?
tachycardia
hypertension
incr myocardial o2 consumption
multisystem organ failure
132
when does the hypermetabolic phase develop?
can take several weeks
133
what is the first priority for anesthesia management in thermal injury?
secure the airway
134
safest option to intiubate burn pts?
awake fiberoptic intubation
135
when should you promptly intubate a burn pt
burns to face
neck
upper chest
inhalational burns
136
drug dosing initial burn shock phase (48hr)
vasodilation and low cardiac output = lower drug doses
137
hypermetabolic phase (48-72hr, lasting weeks or months) drug dosing
fluid overload can occur after capillary membrane integrity returns and fluid shifts
higher drug dose
MAC increased
138
succ in burn pts
safe in first 24 hr
avoided in 24-48 hr
consider using again after 1-2 yrs
139
does the magnitude of hyperkalemic response correlate to the magnitude of burn?
no
140
3 intraoperative goals burn pt
rapid and effective intravascular volume replacement (parkland formula)
low tidal volume (6mL/kg and PIP <30
minimize heat loss
141
parkland formula
(4mL)(%BSA)(kg)= volume of LR
half given first 8 hr
half given next 16 hr
142
colloids and burn pts
conflicting ideas
| could leak from intravascular space and worsen edema
