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Anesthesiology > 6. Fluid balance and nutrition > Flashcards

6. Fluid balance and nutrition Flashcards

1
Q

Crystalloids

A
  • Small enough to pass through vessel wall

- 0,9% NaCl, Ringer, hypertonic saline (3, 5, and 7.5 %)

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2
Q

Colloids

A
  • Too large (>35kDa) to penetrate vessel wall - stays in vessel
  • Albumin, starch, plasma, dextran
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3
Q

Extracellular fluid compartment components

A

1/3 intravascular, 2/3 interstitial

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4
Q

Total body water components

A

Intracellular fluid (40%) + extracellular fluid (20 %) (Blood+interst)

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5
Q

Normal osmolality

A

280 Osm

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6
Q

Fluid tonicity (isotonic, hypotonic etc)

A

Fluid osmolality compared to plasma

  • Isotonic - same as plasma
  • Hypotonic - less than plasma (fluid is absorbed faster)
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7
Q

Preload = ? (and how to increase/decrease)

A

Fluid volume

  • Increase: packed RBCs, colloids, crystalloids
  • Decrease: diuretics
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8
Q

Contractility - how to increase

A
  • Dobutamine

- Dopamine

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9
Q

Afterload = ? (How to increase/decrease)

A

SVR: Systemic vascular resistance

  • Increase/vasopress: Epinephrine, norepinephrine
  • Decrease/vasodilate: Nitroprusside, nitrates
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10
Q

Starling forces in infusional therapy

A
  • Hydrostatic and osmotic forces / semipermeable membranes
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11
Q

Osmotic vs oncotic pressure

A

Osmotic: independent of molecular size
Oncotic: osmotic pressure generated by macromolecules

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12
Q

Daily fluid loss in fever

A

1500-2000 ml

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13
Q

Daily fluid loss by tracheotomy

A

700 ml

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14
Q

Daily fluid loss in suction of bronchial secretion

A

500-1000 ml

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15
Q

Daily fluid loss in hyperventilation

A

500 - 2000 ml

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16
Q

Assessment of intravascular volume

A

Macrocirculation: preload, contractility, afterload

Monitor: Skin turgor, tongue, urine output

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17
Q

Swan-Ganz catheter

A

Pulmonary artery catheter - to detect HF or sepsis, monitor therapy and effect of drugs

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18
Q

PICCO plus

A

Arterial line with thermistor in end (detect temperature differences used to calculate CO) - used for hemodynamic monitoring (CO, pulse, preload etc)

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19
Q

Static hemodynamic parameters

A
  • Central venous pressure (CVP)
  • Pulmonary artery occlusion pressure (PAOP)
  • Right ventricular EDV (end-diastolic volume)
  • Left ventricular EDA (end-diastolic area)
  • Global end-diastolic volume (GEDV)
  • Intrathoracic blood volume (ITBV)
  • Not suitable for assessing fluid responsiveness*
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20
Q

Dynamic hemodynamic parameters

A
  • Systolic pressure variation (SPV)
  • Stroke volume variation (SVV)
  • Pulse pressure variation (PPV) - during pos. pressure ventilation (“PPV”)
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21
Q

SPV normal value

A

< 10 mmHg

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22
Q

PPV normal value

A

< 13 %

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23
Q

SVV normal value

A

< 10 %

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24
Q

Testing dynamic hemodynamic parameters

A
  • S-G, PICCO, Echocardiography
  • CO = SV * HR
  • Inferior vena cava
  • Passive leg raising test
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25
Q

György formula

A

For electrolyte disturbances

Na+ x K+ x OH-) / (Ca++ x Mg++ x H-

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26
Q

Treatment of hyperkalemia

A
  • Calcium
  • Glucose-insulin
  • Beta-mimetics
  • NaHCO3
  • Hemodialysis
  • Sodium polystyrene sulfonate resin (GI necrosis)
  • FSD
  • Treat underlying disorder
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27
Q

Treatment of hypokalemia

A
  • Decrease potassium loss, find cause (e.g vomiting, diarrhea, diuretics, polyuria, laxatives)
  • Increase K+ stores (KCl - except in DKA)
  • Look for toxicity (ECG, ileus)
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28
Q

Ionized Ca++ levels

A

> 1,29 mmol/l

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29
Q

Corrected Ca2+ levels to serum albumin

A

> 2,6 mmol/l

30
Q

MAH

A

Malignancy associated hypercalcemia - most frequent paraneoplastic SY, serious emergency

31
Q

Hypercalcemia/MAH therapy

A
  • Forced rehydration (NaCl 0,9% - 300-500 ml/hr)
  • After! FSD (furosemide?) 20-40 mg iv (not thiazide!)
  • Iv bisphosphonate (pamidronat, zoledronic acid)
  • Calcitonin
  • Hemodialysis
  • Steroid: lymphomas
  • RANKL AB (denosumab)
32
Q

Hyponatremia

A
  • E.g SIADH
  • Higher urine osmolality (> 100 mOsm/l)
  • Lower serum osmolality (< 280 mOsm/l)
  • Serum Na+ < 135 mmol/l
  • I.c edema
33
Q

Jenny-spm: cramping/tremors are usually caused by hypo- or hyper-electrolytes?

A

Hypo (Ca, Na, Mg, K)

34
Q

SIADH therapy

A

SeNa < 125 mmol/l

  • Restriction of free water intake (500-100 ml/d)
  • Demeclocyclin

SeNa < 115 mmol/l

  • 3 % NaCl, then 0,9 % NaCl
  • Furosemide

Vaptans: V2 antagonists

35
Q

Limitations of increasing SeNa

A

Increase in SeNa must not exceed 0,5 mmol/l/h

If too fast correction - central pontine myelinolysis

36
Q

Phases after operation

A

I. Catabolic phase (5-10 days)
II. Early anabolic phase (2-6 weeks)
III. Late anabolic phase (2-6 months)

37
Q

OFNoSH

A

Organisation of Food and Nutritional Support in Hospitals

38
Q

Mild malnutrition weight loss

A

< 10 % weight loss in last 6 months (important!)

39
Q

Moderate malnutrition weight loss

A

10 - 19 % weight loss in last 6 months (important!)

40
Q

Severe malnutrition weight loss

A

> 20 % weight loss in last 6 months (important!)

41
Q

Lab parameters to look at in malnutrition

A
  • Serum albumin
  • Serum transferrin
  • Serum prealbumin
42
Q

REE: Resting energy expenditure

A

REE = BEE x stress factor

43
Q

TEE: Total energy expenditure (kcal/day)

A

TEE = REE x activity factor

44
Q

Stress factors influencing REE

A
  • Major surgery
  • Polytrauma
  • Burns (Highest influence - 2,20!!)
  • Sepsis
  • COPD
45
Q

Activity factors influencing TEE

A
  • Sedated-ventilated patient (lower activity - 1-1,2)
  • Ventilated (lower activity - 1,2)
  • Ward patient (1,3-1,7)
46
Q

Risk of overfeeding

A
  • Fatty liver
  • Hyperglycemia
  • Leukocyte dysfunction
  • Hyperosmolarity
  • CO2 production increase
  • Respiratory insufficiency
47
Q

Carbohydrates

A

60-80 % of nutrition

48
Q

Rate-limiting point in nutrition in sepsis

A

Pyruvate dehydrogenase - has decreased activity in sepsis, and extra pyruvate is the substrate of lactic acid production in hypoxia

49
Q

Max glucose intake dose in ICU pts

A

5 g/kg/d

50
Q

Daily minimum of carbohydrates

A

150 g

51
Q

Lipids

A

20-40 % of nutrition

52
Q

Max dose of lipid intake per day

A

1 - 1,5 g/kg/d

53
Q

Overdose of lipids

A
  • Hypertriglyceridemia
  • Fatty liver
  • Leukocyte R sensitivity lowered
  • AA (prostaglandin, TXA, leukotriene precursor)
54
Q

For which pts are lipids not recommended

A
  • Hypertriglyceridemia
  • Severe metabolic acidosis, hypoxia
  • DKA
  • Acute necrotizing pancreatitis
  • Serious lung disease
  • Trauma (infection rate, resp. insuff)
55
Q

Protein daily intake

A

1 - 1,4 g/kg/d (50% should be branched chain)

56
Q

Contraindication of protein intake

A

Congenital metabolic disorder

57
Q

General nutrition guide

A
  • Prefer enteral nutrition
  • Enteral nutrition (NG tube) should be started within 24 hrs
  • If EN is impossible: prokinetics, small bowel nutrition or parenteral nutrition
58
Q

Problems with enteral nutrition

A
  • Gastric residual volume
  • Gastric bacterial colonization
  • Aspiration pneumonia
  • Enteral ischemia
59
Q

Problems with parenteral nutrition

A
  • Bowel mucosal atrophy
  • Overfeeding
  • Hyperglycemia
  • Infection risk
  • Permanent line needed
  • More expensive (?)
60
Q

General enteral nutrition guide

A
  • Polymer formula
  • Upper body elevated 45°
  • Start within 24-48 hrs if no contraind
  • Begin with 25 ml/h and increase by 25 ml/h every 4 hrs
61
Q

Enteral nutrition consideerations

A
  • Lack of bowel sounds: does not (!) mean you have to reduce EN
  • GRV: gastric residual volume must be considered - try metoclopramide if too high (> 250 ml)
  • Single vomiting and diarrhea - not (!) contraindications
62
Q

Indications for parenteral nutrition

A
  • EN impossible for > 3 days
  • Malnutrition: early initialization required
  • EN is not possible/recommended: perioperative, pancreatitis, GI obstruction, malabsorption, short bowel syndrome
  • Patient doesn´t want to have EN (vomiting , lack of appatite)
  • If no justified indications - PN should not be used!!
63
Q

Pharmanutrition

A

Some nutrient that also has biological effects (antioxidants, PG, NO, vitamins)

64
Q

When is micronutrient substitution required?

A
  • When patient have less than 1000 ml enteral nutrient intake
  • When using parenteral nutrition as it only contains macronutrients (sånn som jeg forsto sliden)
65
Q

Malabsorption - vitamins affected

A

A, D, E, K

66
Q

Which vitamin often lacks from vitamin products and why?

A

Vitamin K - anticoagulation potential

67
Q

Most important trace elements

A

Zinc and Selenium

- Most products do not contain iron due to risk of anaphylaxis

68
Q

Zinc deficiency

A
  • Dermatitis
  • Alopecia
  • Decreased healing
  • Gonadal atrophy
  • Immune system decrease
69
Q

Selenium

A
  • Cardiomyopathy
  • Myositis
  • Arthritis
  • Hair and nail disorders
70
Q

ATP and nutrition

A

Tissue oxygenation will not give ATP on its own unless supported by adequate nutrition

71
Q

Clinical nutrition consists of

A
  • Screening
  • Assessment
  • Plan
  • Documentation
  • Reassessment

Anesthesiology (13 decks)

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