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Methods I > Advanced Fluid Management > Flashcards

Advanced Fluid Management Flashcards

1
Q

______ is the pressure exerted against the capillary walls

A

hydrostatic pressure

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2
Q

The intravascular hydrostatic pressure is pressure (inside/outside) the capillary walls and drives fluid (inside/outside) the blood vessels

A

inside

outside

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3
Q

interstitial hydrostatic pressure is pressure (inside/outside) the capillary walls and drives fluid (inside/outside) the blood vessels

A

outside

inside

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4
Q

_______ is a form of osmotic pressure exerted by proteins (i.e., albumin) that tends to pull fluid towards itself

A

Oncotic pressure

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5
Q

Intravascular oncotic pressure pulls fluid (into/out of) the blood vessels

A

into

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6
Q

interstitial oncotic pressure pulls fluid (into/ out of) the blood vessels

A

out of

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7
Q

Oncotic pressure opposes the forces of hydrostatic pressure, and decreased intravascular oncotic pressure can lead to _____

A

edema

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8
Q

In pregnancy:

plasma volume (increases/ decreases)

plasma albumin concentration (increases/ decreases)

capillary oncotic pressure (increases/ decreases)

fluid in the interstitial space (increases/decreases)

A

increases
decreases
decreases
increases

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9
Q

in liver failure:

plasma albumin concentration (increases/decreases)

capillary oncotic pressure is (increased/decreased)

A

decreases (hypoalbuminemia) due to a decrease in albumin synthesis

decreased = edema

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10
Q

on the capillary arterial end, there is a net filtration pressure of ____ being forced (into/out of) the blood vessels

A

13

out of

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11
Q

on the venous end, there is a net filtration pressure of ____, being drawn (into/ out of) the blood vessels

A

7

into

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12
Q

What is the net filtration pressure in the interstitial space?

A

6

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13
Q

The interstitial fluid is taken by the lymphatic system back to the lymph nodes, which drain into the _____

A

subclavian vein

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14
Q

What are the 2 roles of the lymphatic system?

A
  1. helps maintain fluid balance (returns interstitial fluid to the blood)
  2. protects the body from infection (produces white blood cells from lymphocytes)
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15
Q

___ refer to compounds

Such as NaCl

A

moles

ex. NaCl

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16
Q

_____ refer to ions, such as Na+ and Cl-

A

osmoles

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17
Q

For example, 1 mole of NaCl is equivalent to ___osmole of Na+ and ____ osmole of Cl- (for a total of ___osmoles)

A

1
1
2

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18
Q

This is defined as the number of osmoles per kg of solvent

A

osmolality

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19
Q

This is defined as the number of osmoles per liter

A

osmolarity

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20
Q

plasma osmolarity = ______ mOsm/L

A

280-290

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21
Q

What are the 3 structures that regulate osmolarity

A
  1. Hypothalamus
  2. carotid baroreceptors
  3. kidneys
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22
Q

Whenever osmolarity is high, the hypothalamus tells the posterior pituitary to do what 2 things?

A
  1. secrete ADH

2. give us a sense of thirst

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23
Q

When the carotid baroreceptors sense a decrease in blood volume, they send a message to the brain to secrete ____

A

ADH

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24
Q

______ describes how concentrated one solution is compared to another

A

Molarity

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25
Q

A _______ solution has a higher concentration of total solutes than other side of the membrane

A

Hyperosmolar

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26
Q

A ______ solution has a lower concentration of total solutes than other side of the membrane

A

hypoosmolar

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27
Q

_____ describes which direction water moves

A

tonicity

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28
Q

A ____ solution means that water moves toward the solution

A

hypertonic

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29
Q

A _____ solution means that water moves away from the solution

A

hypotonic

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30
Q

A hypertonic IV solution is defined as having an osmolarity of ______

A

> 375mOsm/L

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31
Q

When a patient receives a hypertonic IV fluid:

  1. . The cells of the body (like RBC’s, brain cells, etc) will (shrink/expand)
  2. Blood volume (decreases/ increases)
A
  1. shrink

2. increases/expands

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32
Q

name 3 hypertonic solutions:

A
  1. Mannitol
  2. Hypertonic (3%) N/S
    (513 mEq/L)
3. D5 solutions
(except D5W)
-D5 0.9% N/S
-D5 0.45% N/S
-D5 LR
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33
Q

D5 solutions mean that there is ____% dextrose in a bag or vial

A

5%

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34
Q

D50 means that there is ____% dextrose in the bag or vial

A

50%

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35
Q

5% dextrose in solution = ____mg/mL

A

50

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36
Q

50% dextrose in solution = ___mg/mL

A

500

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37
Q

What is the pediatric dose of dextrose for hypoglycemia?

A

0.25-0.5g/kg

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38
Q

What is the adult dose of dextrose for hypoglycemia?

A

0.5g-1g/kg

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39
Q

1 amp (50ml) D50 = How many grams of glucose?

A

25 g

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40
Q

1000mL D5W = How many grams of glucose?

A

50g (50mg/mL)

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41
Q

Vancomycin can come in 500mL D5W. How many grams of glucose is this?

A

25 g

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42
Q

What are 3 indications for hypertonic IV fluids?

A
  1. 3% normal saline can be indicated to correct the plasma sodium concentration of a hyponatremic patient
    - -However, sodium of this concentration must be infused very slowly or else it can cause the brain cells to shrink too rapidly, which can lead to neurologic problems and/or death
  2. Glucose solutions can be indicated for maintenance fluids for NPO patients or to correct normalize blood sugar in hypoglycemic patients
  3. Mannitol can be indicated to increase renal perfusion and diuresis or for neurosurgery in instances where the surgeon wants to “shrink” the brain cells in an effort to decrease intracranial pressure
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43
Q

What are 2 potential complications of hypertonic IV fluids?

A
  1. If plasma sodium levels are increased too rapidly with hypertonic (3%) normal saline (i.e., if 3% N/S is given too rapidly), the brain cells can shrink so fast that it can cause “central pontine myelinolysis” and even death
  2. a rapid increase in plasma osmolarity can lead to osmotic diuresis, loss of electrolytes (via the diuresis), intracellular dehydration, and coma
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44
Q

A hypotonic IV solution is defined as having an osmolarity of ____

A

<250mOsm/L

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45
Q

When a patient receives a hypotonic IV solution:

  1. The cells of the body (shrink/expand)
  2. blood volume (decreases/increases)
A
  1. expand

2. decreases

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46
Q

Name 3 hypotonic IV fluids

A
  1. 0.45% N/S
    (77mEq/L)
  2. 2.5% Dextrose in Water
  3. D5W
    - Although D5W starts out isotonic, it is considered hypotonic because it quickly becomes hypotonic when the glucose is rapidly metabolized in the body
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47
Q

Therefore, hypotonic fluids are administered to patients who have ______

A

concentrated electrolytes (mainly hypernatremia)

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48
Q

What are 2 complications with hypotonic fluids?

A
  1. possibly cause phlebitis

2. can cause cerebral edema if large volumes are administered

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49
Q

How should hypotonic fluids be administered?

A

through a central line if possible

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50
Q

When are hypotonic fluids contraindicated?

A

patients who are at risk of increased ICP

should be avoided in neurosurgery

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51
Q

An isotonic IV solution is defined as having an osmolarity of _______

A

250-375mOsm/L

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52
Q

What are 4 examples of isotonic solutions

A
  1. Lactated Ringers (LR)
  2. 0.9% normal saline
  3. Normosol (Plasmalyte) (no lactate or calcium/ substitute magnesium)
  4. 5% albumin

Isotonic solutions can be given without necessarily worrying about water moving into or out of the cells and plasma

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53
Q

The osmolarity of LR is ____

A

273mOsm/L

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54
Q

LR is slightly ______ compared to the plasma

A

hypotonic

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55
Q

What are the 5 contents that make up LR?

A
  1. Na+
  2. K+
  3. Ca+2
  4. Cl-
  5. lactate
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56
Q

The lactate in LR is converted to ___ and ____ by the liver

A

bicarb and glucose

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57
Q

What are the 7 contraindications to using Lactated Ringers?

A
  1. Liver disease/ Liver failure
    The lactate from LR builds up in liver failure patients (because the lactate can’t be converted to bicarb by the failing liver), and this buildup of lactate can lead to lactic acidosis (elevated anion gap metabolic acidosis, to be exact)
  2. Neurosurgery or patients with increased ICP
    - Giving even a slightly hypotonic fluid could theoretically increase the volume of water in brain cells and further increase intracranial pressure
  3. Concomitant administration of ceftriaxone (Rocephin) and Lactated Ringer’s is contraindicated in newborns (≤ 28 days of age)
  4. Patients with metabolic alkalosis/pyloric stenosis
    - Patients with pyloric stenosis often have metabolic alkalosis, and the lactate from LR converts to bicarb and can worsen the metabolic alkalosis

THESE are THEORETICAL

  1. Hanging with blood?
    -blood should not be diluted or flushed with calcium-containing fluids because calcium could chelate the citrate anticoagulant preservative in stored blood products and result in blood clots prior to infusion
    (studies have negated this since)
  2. Diabetes?
    - patients with diabetes may be dehydrated preoperatively. An intravenous line of normal saline is initiated while waiting for surgery. Lactated Ringer’s solution is avoided as the lactate is converted to glucose and exacerbates the hyperglycemia
  3. Renal failure?
    - LR has potassium in it, it has traditionally been avoided in renal failure patients because renal patients who haven’t been dialyzed are at a greater risk for hyperkalemia.
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58
Q

Concommitant administration of LR and ______ is contraindicated in newborns <28 days of age

A

ceftriaxone (rocephin)

-risk of fatal ceftriaxone-calcium salt precipitation in the neonate’s bloodstream

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59
Q

Rocephin mixed with LR forms a precipitate; it can form in the _____ in neonates, but apparently only in the ____in older kids/adults

A

bloodstream

IV line

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60
Q

LR has a potassium concentration of ____ mEq/L

A

4

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61
Q

For a hyperkalemic patient in renal failure, ___ should be preferred over NS

A

LR

62
Q

The osmolarity of 0.9% N/S is _____mOsm/L

A

308

63
Q

although 0.9% N/S is considered “isotonic”, it is slightly ____ when compared to the plasma

A

hypertonic

64
Q

Each liter of 0.9% N/S contains ____mEq of sodium

A

154

65
Q

Administration of large volumes of normal saline leads to _____

A

non-anion gap metabolic acidosis

66
Q

What are the 4 contents of plasmalyte?

A
  1. Na+
  2. K+
  3. Mg+2
  4. Cl-

So plasmalyte differs from LR in the sense that it doesn’t contain lactate or calcium, but it contains magnesium instead

67
Q

It should also be noted that the potassium concentration in plasmalyte is slightly (higher/lower) than it is in LR

A

higher

5mEq/L to 4 mEq/L

68
Q

The osmolarity of plasmalyte is ____ mOsmol/L

A

294

69
Q

Plasmalyte be used as an alternative to LR in what 2 situations?

A
  1. blood transfusions ( does not contain calcium)

2. Liver failure (does not contain lactate)

70
Q

Plasmalyte is also more “alkalinizing” than LR (because it has 50mEq bicarb per liter as opposed to 28mEq/L in LR), and is thus preferable to LR in patients with _____

A

metabolic acidosis

71
Q

what are the contraindications to plasmalyte?

A

none

72
Q

_____ is the most common colloid used in the operating room for treating hypovolemic patients

A

5% albumin

73
Q

When are 20% and 25% albumin considered?

A

considered in a large blood volume deficit or an oncotic deficit resulting from hypoproteinemia

74
Q

What tonicity is 5% albumin considered?

A

isotonic

75
Q

What tonicity is 20% and 25% albumin considered?

A

hypertonic

76
Q

_____is a colloid that can be used as an alternative to Albumin

A

Hespan (6% Hetastarch)

77
Q

What is the black box warning of Hespan?

A

increased mortality in critically ill patients, or in patients with renal disease, bleeding, or undergoing cardiopulmonary bypass

78
Q

circulating blood volume of a pre-term infant

A

90-100 mL/kg

79
Q

circulating blood volume of a pregnant patient at term

A

90-100 mL/kg

80
Q

circulating blood volume of a full term neonate

A

90 mL/kg

81
Q

circulating blood volume of infants

A

80 mL/kg

82
Q

circulating blood volume of an adult male

A

70-75 mL/kg

83
Q

circulating blood volume of an adult female

A

60-65 mL/kg

84
Q

circulating blood volume of elderly/obese

A

~15% less than adults

85
Q

healthy males percent total body water

A

60%

86
Q

obese/geriatric males percent total body water

A

50%

87
Q

healthy females percent total body water

A

50%

88
Q

obese/geriatric females percent total body water

A

40-45%

89
Q

neonates percent total body water

A

80%

90
Q

infants percent total body water

A

70%

91
Q

___% of total body water (total body weight) is intracellular fluid (ICF)

A

65%

92
Q

___% of total body water (total water weight) is extracellular fluid (ECF)

A

35%

93
Q

The extracellular fluid is broken up into _____ and _____compartments

A

intravascular and interstitial

94
Q

Interstitial = _____% of ECF, which equates to ____% of total body water

A

70-75%

25%

95
Q

Intravascular = ____% of ECF, which equates to ____% of total body water

A

25-30%

10%

96
Q

Here is how the final breakdown of total body water is divided:
___% is intracellular, ____% is interstitial, and ___% is intravascular (the interstitial and intravascular make up the ___% extracellular fluid)

A

65%
25%
10%
35%

97
Q

What percent of total fluid volume of the human body is blood?

A

10%

98
Q

What kind of diuretic is lasix?

and what does it inhibit?

A

loop diuretic

sodium and water reabsorption in the loop of Henle

99
Q

What is lasix used to treat perioperatively?

A

fluid overload

edema, pulmonary edema, nephrotic syndrome, CHF

100
Q

besides fluid overload, what 2 uses does lasix help?

A
  1. chronic hypertension

2. Offsetting the increased production of ADH during surgery

101
Q

What type of diuretic is mannitol and why?

A

osmotic diuretic

it increases the osmolarity of the blood and is hypertonic

102
Q

mannitol causes diuresis through increased blood flow to what organ?

A

kidneys

103
Q

What are 2 preoperative indications for mannitol?

A
  1. renal protection and perfusion

2. brain surgery (decreases ICP)

104
Q

Spironolactone is more of a home medication; what is the IV form of this that can be administered in the OR?

A

Aldactone

105
Q

Spironolactone is _____ sparing

A

potassium

-doesn’t lower serum potassium concentration after diuresis

106
Q

Acetazolamide (Diamox) is both a ______ and a _____

A

carbonic anhydrase inhibitor

diuretic

107
Q

Acetazolamide (Diamox) will increase ___ in the body and decrease _____

A

PaCO2

HCO3-

108
Q

Acetazolamide (Diamox) cause patients to pee bicarbonate which can cause _____

A

metabolic acidosis

109
Q

What are 3 uses of Acetazolamide (Diamox)?

A
  1. As a diuretic to treat heart failure related edema
  2. To treat glaucoma and lower intraocular pressure (by decreasing aqueous humor formation)
  3. To treat altitude sickness (which is caused by hyperventilation and subsequent hypocarbia) by raising PaCO2
110
Q

What is the side effect associated with the use of Acetazolamide (Diamox)?

A

hypokalemia

Although Acetazolamide can cause metabolic acidosis (which would raise potassium), it’s use is associated with hypokalemia (probably due to the fact that the patient pees out the potassium)

111
Q

a kidney disorder that causes the body to excrete too much protein in the urine, and is usually caused by damage to the clusters of small blood vessels in the nephrons

A

Nephrotic syndrome

112
Q

What are the 3 main symptoms of nephrotic syndrome?

A
  1. Proteinuria
  2. Hypoalbuminemia
  3. Fluid overload (edema)
    - This is caused by the hypoalbuminemia (caused by the protein excretion), which decreases plasma oncotic pressure and causes fluid to enter the interstitial space
113
Q

What is the treatment for nephrotic syndrome?

A

fixing the underlying condition that’s causing it

114
Q

Adults are said to have a major burn injury if ___% of their total body surface area (TBSA) is burned

A

> 20

115
Q

Kids & elderly patients are said to have a major burn injury if ___% their total body surface area (TBSA) is burned

A

> 10

116
Q

Anyone is said to have a major burn if any one of what 3 areas are burned?

A

face, airway, genitalia

117
Q 
Rule Of 9s For Total Body Surface Area (TBSA):
When compared to an adult, a child has:
\_\_% more in the head
\_\_% less in the legs
\_\_% less in the genitalia
A

9%
8%
1%

118
Q

What are 10 physiological differences of patients after thermal injury

A
  1. Hypovolemia and decreased cardiac output
    - –1. Drainage & evaporation from burn wounds
    - –2. An intense inflammatory response, leading to vasodilation and increased capillary permeability
  2. massive leak of fluid and electrolytes from the intravascular space into the interstitial space (increased capillary permeability)
    - –1. Relative hypovolemia, hypotension, and possibly burn shock
    - –2. Massive edema (in both injured & non-injured tissues) (from increased capillary permeability)
  3. Hypothermia (loss of skin barriers)
  4. anemia and thrombocytopenia
    - –Bleeding from burn wounds
    - –Heat induced damage to RBCs
    - –Fluid resuscitation
  5. hypercoaguable state
    - –increased risk for venous thrombosis, PE, DIC
  6. Proliferation of nicotinic Ach receptors (after 24 hours)
    - –1. Resistance to nondepolarizers
    - –2. Sensitivity to Sux
  7. possible acute renal failure
    - –related to hypovolemia and decreased CO
  8. Altered pulmonary physiology
  9. hyper metabolic phase
119
Q

Patients after thermal injury:

What 2 things cause the hypovolemia and the decreased CO?

A
  1. Drainage & evaporation from burn wounds

2. An intense inflammatory response, leading to vasodilation and increased capillary permeability

120
Q

Patients after thermal injury:

massive leak of fluid and electrolytes from the intravascular space into the interstitial space, which can lead to what 2 things?

A
  1. relative hypovolemia, hypotension, and burn shock

2. massive edema from increased capillary permeability

121
Q

Patients after thermal injury:

The anemia and thrombocytopenia is caused by what 3 things?

A
  1. bleeding from burn wounds
  2. heat induced damage to RBC
  3. fluid resuscitation
122
Q

how do thermal injury patients interact with muscle relaxants?

A

resistant to non-depolarizers

sensitivity to sux

123
Q

Patients after thermal injury:

what are 3 possible pulmonary complications

A
  1. decreased pulmonary compliance
  2. Increased lung vascular & permeability and PVR
    - Characteristic of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)
  3. possible carbon monoxide poisoning
124
Q

patients after thermal injury:

the hyper metabolic phase is due to a massive surge in catecholamines and corticosteroids, which can lead to what 4 things?

A
  1. Increased myocardial oxygen consumption & work (from tachycardia and hypertension)
    Vitals may remain elevated for up to 2 years post burn
  2. Insulin resistance
  3. Fever
  4. Liver dysfunction

This can take several weeks to develop, but if left untreated, hypermetabolism can lead to physiologic exhaustion and death

125
Q

What is the first priority in patients with burn injury?

A

Immediate airway assessment

-The potential exists for massive, life threatening airway edema

126
Q

What is the proper airway management for patients with with face, neck, upper chest, or inhalational burns?

A

prompt awake fiberoptic intubation with maintenance of spontaneous ventilation may be the safest option

Many burned patients will remain intubated after surgery because of the need for continued airway patency and pulmonary rehabilitation

127
Q

Drug dosing for burn patient in the initial burn shock phase (48 hours) is (increased/ decreased)?

A

decreased

Vasodilation and increased vascular permeability lead to large fluid shift to the interstitial space, leading to low blood volume, increased hematocrit, and low cardiac output
Because renal & hepatic flow is decreased, lower drug doses are required

128
Q

Drug dosing for burn patients in the hyper metabolic phase (48-72 hours, lasting weeks or months) is (increased/ decreased)?

A

increased

Capillary membrane integrity returns, leading to edema fluid shifting back into the blood vessels (which means that blood volume, cardiac output, renal & hepatic flow will all increase, and hematocrit will decrease)
Fluid overload can occur, which can lead to higher drug dosing requirements
MAC requirements are higher in this phase

129
Q

Succinylcholine can be safely administered to burn patients within _____

A

the first 24 hours

130
Q

Succinylcholine should be avoided in burn patients ______

A

after 24-48 hours

131
Q

how long after a burn injury can an anesthetist consider giving succinylcholine again?

A

1-2 years after

132
Q

What are the 3 intraoperative goals to patients with burn injury?

A
  1. rapid and effective intravascular volume replacement
  2. low tidal volumes with mechanical ventilation
    - This has been shown to improve patient survival in patients with ALI/ARDS and currently represents the standard of care
  3. effort to minimize heat loss
133
Q

Which formula is the most widely used for resuscitation in burn patients?

A

the Parkland Formula

4 mL/kg Lactated Ringer’s solution X % of TBSA (do not convert percentage) X weight (kg)

1/2 of this is administered in the first 8 hours

the other 1/2 is administered in the next 16 hours

This fluid should be given IN ADDITION to the fluids that should be given for maintenance, insensible losses, third spacing losses, blood loss, etc

134
Q

What should the tidal volumes be for mechanically ventilated burn patients?

A

Vt= 6 mL/kg

PIP <30cm/ H2O

135
Q

Suppose a 100kg patient gets major burns over the entirety of their thorax (18% of their body surface area). According to the Parkland formula, how much fluid should they receive over 24 hours?

A

4mL x % Body Surface Area x Weight (kg) = Volume That Should Be Given

4mL x 18% x 100kg = 7,200mL

3,600mL should be given over the first 8 hours, and the other 3,600mL should be given over the subsequent 16 hours

136
Q

What are the 4 criteria for Sepsis in burn patients?

A
  1. Temperature > 38.5⁰C or below 36⁰C
  2. Unexplained tachycardia in adults or bradycardia in children < 1 year old
  3. Respiratory rate > 20 unrelated to pain or other factors
  4. WBC count > 12,000

At least 2 of the 4 criteria must be met for a patient to have Systemic Inflammatory Response Syndrome (SIRS) (and one of them must either be the temperature criteria or the abnormal white count)

137
Q

A patient is considered to have “sepsis” if they have ____ in combination with an____

A

SIRS

infection

138
Q

What are 6 possible infectious causes of sepsis

A
  1. CNS infections
    Meningitis or encephalitis
  2. Cardiovascular infections
    Infective endocarditis
  3. Respiratory infections (pneumonia)
  4. Gastrointestinal infections (peritonitis)
  5. Urinary tract infections (pyelonephritis)
  6. Generalized abscesses
139
Q

What are 2 non-infectious causes of sepsis?

A
  1. Severe trauma or hemorrhage
  2. Acute systemic disease
    - –MI
    - –PE
    - –Pancreatitis
140
Q

Pathophysiology of Sepsis:

  1. An infection activates the immune system, which releases _____
  2. . The cytokines promote ______ and increase ______, which can lead to massive hypotension/shock
  3. Patients may suffer from _____ which impairs oxygen uptake. This can cause subsequent hypoxia, even if oxygen delivery is normal
  4. patients may develop _____ insufficiency
  5. Patients may develop ____ from stress OR _____ from increased glucose utilization in the liver and subsequent decreased hepatic glucose production
  6. _____ from parathyroid gland insufficiency
  7. (increased/ decreased) CO early on AND (increased/ decreased) CO in later stages
  8. The pathway starts with SIRS, then sepsis= (____ + ____),
    then severe sepsis (____ + _______),
    then septic shock (severe _____ + ______)
A
  1. inflammatory mediators (cytokines)
    - –this reaction can be potentially fatal
  2. vasodilation; capillary permeability
    - The massive vasodilation causes relative hypovolemia, decreased tissue perfusion, metabolic acidosis, and potential eventual organ failure
  3. mitochondrial dysfunction
  4. adrenal
    - Mechanisms of adrenal suppression are related to dysfunction of the hypothalamic pituitary adrenal (HPA) axis that can result from critical illness, infections, malignancy, etc
  5. hyperglycemia or hypoglycemia
  6. hypocalcemia
  7. increased (due to the vasodilation/low afterload)
    decreased (due to acidosis and decreased organ perfusion/function)
  8. SIRS + infection
    sepsis + organ dysfunction/damage
    severe sepsis + hypotension
141
Q

Cardiac output in septic shock:

The combination of a decreased preload and myocardial depression means that in the early phase of sepsis resuscitation, patients may initially be _______ (i.e. low cardiac output) prior to receiving adequate volume resuscitation.”

A

hypodynamic

142
Q

Sepsis is considered “severe” if it is accompanied by any one of (not all three of) what 3 things?

A
  1. Cardiovascular dysfunction
  2. Acute respiratory distress syndrome (ARDS)
  3. Failure/dysfunction of at least two other organs
    - Kidneys may fail due to hypotension, and patients can develop respiratory distress (hypercarbia, low SpO2, etc) from increased alveolar capillary membrane permeability
143
Q

A patient is considered to be in septic shock if they still display _____ dysfunction after fluid resuscitation

A

cardiovascular

144
Q

What are 3 signs of cardiovascular dysfunction?

A
  1. hypotension
  2. poor signs of perfusion
  3. necessity of vasopressors to maintain normal blood pressure
145
Q

Septic shock has characteristics of both _____hypoxia (due to decreased perfusion) and _____ hypoxia (due to mitochondrial dysfunction). Septic shock is common in children because underdeveloped immune systems have difficulty fighting infections

A

Ischemic

Histotoxic

146
Q

What are the 4 criteria for diagnosis of septic shock?

A
  1. Signs of infection (fever, elevated white count, etc)
  2. Metabolic acidosis, elevated lactate, and respiratory acidosis
  3. Potential hypotension, hypoglycemia or hyperglycemia, hypocalcemia, and adrenal insufficiency
  4. The patient may develop petechiae, which can be the result of:
    - –Microbleeding associated with disseminated intravascular coagulation (DIC)
    - –Inflammatory reaction and increased vascular permeability, leading to widespread microvascular thrombosis, hemorrhagic infarction of the skin, and necrotizing vasculitis
147
Q

What are the 9 treatments of sepsis?

A
  1. . Treat the source of infection with Abx or with surgical intervention
    - –(drainage of abscess, debridement of necrotic tissue, etc)
  2. Fluid resuscitate (with some caution)
    - –Although fluids are needed to restore perfusion, we should be cautious with AGGRESSIVE fluid therapy because of the increased capillary permeability
    - –If fluids are given too quickly, they have the potential to leak into the interstitial space and cause pulmonary edema
  3. vasopressor therapy if needed
    - –start with phenylephrine, then move to norepinephrine, and then vasopressin (if hypotensive despite norepinephrine administration)
  4. fix metabolic acidosis from lack of perfusion
    - –We can look at the lactate as an indication of adequate organ perfusion (i.e., normal lactate is an indication that perfusion has been restored
  5. consider inotropes
    - if patient shows signs of myocardial dysfunction
  6. steroid therapy (hydrocortisone)
    - –if the patient is hypotensive despite fluid, vasopressor, and inotrope administration
  7. . Correct any potential hypoglycemia with dextrose
  8. correct any potential hypocalcemia with calcium chloride
148
Q

Do we treat hyperglycemia in sepsis?

A

We typically wouldn’t treat HYPERglycemia with insulin because “hyperglycemia should be considered to be adaptive and beneficial in critically ill septic patients…we do not recommend tight glucose control and limit insulin therapy.” In other words, treating hyperglycemia may actually do more harm than good in septic patients, so we should typically only treat HYPOglycemia

149
Q

What is the goal ventilation in sepsis?

A

high FiO2 and low tidal volumes

—using low tidal volumes to prevent lung injury and improve return/cardiac output

150
Q

What are the 5 main labs we look at for hemodynamic goals?

A
  1. MAP
  2. CVP
  3. pH
  4. lactate
  5. urine output
151
Q

The MAC values in sepsis are (increased/decreased)

A

decreased

152
Q

Can you use regional anesthesia in sepsis?

A

Regional anesthesia is relatively contraindicated

Methods I (4 decks)

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