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Principles I* > E4- Perioperative Fluid Mgmt > Flashcards

E4- Perioperative Fluid Mgmt Flashcards

1
Q

What percentage of total body weight is water?
Who has lower TBW %?

A
  • 60%
  • Elderly + Obese patients = lower percent of TBW

Elderly + Obese patients = lower percent of TBW

Pediatrics = HIGHER TBW

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2
Q

What are the two main compartments fluid compartments?

A
  • ICF = 2/3 TBW
  • ECF = 1/3 TBW
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3
Q

What are 3 different compartments of the ECF?

A
  • Interstitial = lymphatics + protein-poor fluid around the cell.
  • Intravascular = plasma volume
  • Transcellular = GI Tract, Urine, CSF, Joint fluid, aqueous humor.
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4
Q

What is diffusion?

A
  • Solute particles moving or filling solvent volume
  • High to Low concentration
  • Speed is proportional to the distance square
  • Can occur across permeable membranes
  • Can relate to electrical gradients
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5
Q

What are examples of the type of solutes that are in our body?

A
  • Glucose
  • Protein (Albumin)
  • Electrolytes
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6
Q

What is the primary extracellular cation?

A
  • Sodium (Na+)
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7
Q

What is the primary intracellular cation?

A
  • Potassium (K+)
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8
Q

What is osmosis?

A
  • Semipermeable membrane separates pure water from water with solute
  • Osmosis is just movement of WATER
  • Diffuses from low to high solute concentration
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9
Q

What is osmotic pressure?

A
  • Pressure that resists the movement of water through osmosis
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10
Q

What is osmotic pressure affected by?
Formula?

A
  • Directly related = temp + # molecules
  • Indirectly related = Volume
  • P = nRT/V

PV = nRT

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11
Q

What is osmolarity?

A
  • Number of osmotically active particles per L of solvent
  • Higher osmolarity = higher “pulling power”
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12
Q

Patient A has serum glucose of 600mg/dl

Patient B has serum glucose of 250mg/dl

Who has higher osmolarity?

A
  • Patient A
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13
Q

What is osmolality?

A
  • Number of osmotically active particles per Kg of solvent
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14
Q

What is normal osmolality?

A
  • 280-290 mOsm
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15
Q

What is oncotic pressure?

A
  • The component of total osmotic pressure due to colloids
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16
Q

List examples of colloids

A
  • Albumin
  • Globulins
  • Fibrinogen
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17
Q

What percentage of oncotic pressure is due to albumin?

A
  • 65-75%
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18
Q

What makes up our daily intake?

Normal Daily Balance

A
  • Solids = 750 mL
  • Liquids = 1400 mL
  • Metabolism = 350 mL
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19
Q

What makes up our daily output?

Normal Daily Balance

A
  • Insensible Loss = 1000 mL
  • GI loss = 100 mL
  • Urine output = 0.5-1 mL/kg/hr
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20
Q

Urine secretion accounts for ____-% of daily water loss.

A
  • 60%
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21
Q

What 3 hormones regulate urine output?

A
  • ADH
  • ANP
  • Aldosterone
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22
Q

How does ADH regulate urine output?

A
  • Renal H2O excretion in response to plasma tonicity
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23
Q

How does ANP regulate urine output?

A
  • ANP is activated by ↑ fluid volume
  • ↑ Atrial Stretch = ↑ Renal Excretion
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24
Q

How does Aldosterone regulate urine output?

A
  • Regulates Na + K levels
  • Aldosterone is released if sodium + fluid volume decreases&raquo_space; Na + H2O conservation
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25
Q

What are the 3 sensors for fluid balance?
Locations?

A
  • Hypothalamic osmoreceptors
  • Low-pressure baroreceptors = large veins and RA
  • High-pressure baroreceptors = carotid sinus and aortic arch
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26
Q

What are 2 trigger for fluid balance?

A
  • Increased thirst
  • Increase ADH
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27
Q

What are the 5 compensatory mechanisms for acute disturbances in circulating volume?
When do they occur?

A
  • Venoconstriction
  • Mobilization of venous reservoir
  • Autotransfusion from ISF to plasma
  • Reduced urine production
  • Maintenance of CO = tachycardia + inotropy

MINUTES TO HOURS

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28
Q

What are the 3 sensors to acute disturbances in circulating volume?

A

o LOW + high pressure baroreceptors

o RAA axis

primarily low

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29
Q

Where is Renin released?

What does Renin do to angiotensinogen?

A
  • Released from juxtaglomerular cells
  • Cleaves angiotensinogen to make angiotensin I
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30
Q

When ANG I → ANG II, what will this cause?

A
  • Vasoconstriction and aldosterone release
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31
Q

Where is aldosterone released from?
What does it do?

A
  • adrenal cortex
  • causes salt and water retention
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32
Q

In the absence of ongoing fluid loss, loss volume should be restored within ______- hours (range).

A
  • 12-72 hours
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33
Q

In the absence of ongoing fluid loss, RBC should be restored through ______________ in ______ weeks (range).

A
  • erythropoeisis
  • 4-8 weeks.
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34
Q

What are the Electrolytes and Osmolarity of Normal Saline (0.9%)?

A

Na = 154 mEq/L
K = 0
Chlorid = 154 mEq/L
Osmolarity = 308 mOsm/L

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35
Q

What are the 4 Electrolytes and Osmolarity of LR?

A

Na = 130 mEq/L
K = 4 mEq/L
Chloride = 109 mEq/L
Lactate = 28 mEq/L
Osmolarity = 274 mOsm/L

NOT LIVER PTS

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36
Q

What are the 4 Electrolytes and Osmolarity of Plasmalyte?

A

Na = 140 mEq/L
K = 5 mEq/L
Cl = 98 mEq/L
Acetate = 27 mEq/L
Osmolarity = 295 mOsm/L

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37
Q

What are the Electrolytes and Osmolarity of Albumin 5%?

A

Na+: 145 +/- 15 mEq/L
K+: <2.5 mEq/L
Cl-: 100 mEq/L
Osmolarity: 330 mOsm/L

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38
Q

What are the Electrolytes and Osmolarity of Hetastarch 6%?

A

Na+: 154 mEq/L
Cl-: 154 mEq/L
Osmolarity: 310 mOsm/L

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39
Q

What are crystalloids?

A
  • Solutions of electrolytes in water
  • The are called balanced solutions (not really though, misnomer)
  • LR/plasmalyte = probably considered the most “balanced” crystalloid
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40
Q

What are 2 indications of using crystalloids?

A
  • Replacement of free water and electrolytes
  • Volume expansion
41
Q

Distribution of crysatlloid through entire _______.

what percentage will be in the intravascular space after 20 minutes?

What about after 30 minutes?

A
  • ECF
  • 70% in the intravascular space after 20 minutes
  • 50% in the intravascular space after 30 minutes
42
Q

What are the negative effects of crystalloids?

A
  • Tissue Edema (Lungs, GI Tract, Soft Tissues)
  • Hypercoagulability (Anticoagulant factors diluted)- micro emboli
43
Q

NS 0.9% is the most commonly fluid, but what are 5 negative consequence of this fluid?

A
  • Dilutes Hct and Albumin
  • Late onset of diuresis
  • Increase AKI and dialysis in ICU patients
  • Causes hyperchloremic metabolic acidosis if too much is given
  • increase in Cl and K concentrations.
44
Q

What fluid will pull water out of the ICF to the ECF including the plasma?
What does this fluid treat?

A
  • Hypertonic Saline 3%
  • hypo-osmolar hyponatremia , inc ICP , TUR syndrome
45
Q

What is added to LR to act as a buffer?

A
  • Lactate
46
Q

You want to avoid using this fluid for patients with liver insufficiency.

A
  • LR
  • Impair hepatic metabolism will have a hard time metabolism the lactate that is in LR.
  • This can cause an increase build of lactate in the patient.
47
Q

Which fluid will excrete excess water faster than NS d/t the transient decrease in plasma tonicity which suppresses ADH secretion and allow diuresis?

A
  • LR
48
Q

What happens to dextrose solution when the glucose is metabolized?

A
  • Dextrose becomes a hypotonic solution
    * A source of free water
  • Does not say in the vascular space
  • **NOT suitable for volume expansion
  • Water moves freely between all compartments**
49
Q

What fluid could be used for caloric intake in diabetic patients?

A
  • Dextrose 10%
  • Better options out there
50
Q

What are colloids?

A
  • Large molecules of a homogeneous, non-crystalline substance that is dispersed in a second substance (usually a balanced crystalloid).
  • Particles cannot be separated (through filtration or centrifuge)
51
Q

What are two main types of colloids?

A
  • Semisynthetic colloids (Starches)
  • Human plasma derivatives (FFP, Albumin)
52
Q

How do colloids work?

A
  • Increasing colloid oncotic pressure (pulling force),&raquo_space;> increases potential plasma volume expansion
53
Q

What are 4 negative effects of colloids?

A
  • Causes hemodilution
  • Decreases plasma viscosity
  • Inhibit RBC aggregation
  • Uncertain effect on immune, coag, + renal system - maximum recommended ddoses
54
Q

What colloid is derived from potatoes or maize (polymers of amylopectin)?

A
  • Hydroxyethyl Starch
55
Q

The metabolism of hydroxyethyl starch is dependent on ______________.

A
  • Molecular weight of molecules (small, medium, large)
  • 70 to 80% of larger molecules are still in the intravascular space at 90 minutes.
  • Plasma volume effect last longer
56
Q

What are the S/E of Hydroxyethyl Starch?

A
  • Coagulopathy through dilution effects
  • leading to reduction in VWF, Factor VIII, Clot Strength.
  • Renal Dysfunction

DONT give to renal pt or bleeding pt

57
Q

The dextran is a highly branched __________ produced by a bacteria called _______________.

A
  • polysacchrides
  • Leuconostoc Mesenteroides
58
Q

Dextran have a plasma volume effect similar to that of starches, with a duration of _______ hours (range).

A
  • 6-12 hours
59
Q

According to lecture, what is Dextran-40 used for?
Why?

A
  • Microvascular Surgery
  • Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation
  • coat the RBC and may interfere with cross-matching
60
Q

What are 3 examples of human plasma derivative colloids?

A
  • Albumin 5%
  • FFP
  • Immunoglobulin Solution
61
Q

Indications for human plasma derivatives

A
  • volume replacement
  • trauma
  • sepsis
  • paracentesis
62
Q

Fluid alterations in the preoperative settings (9).

A
  • Na+ distribution disorder
  • Dialysis requirement
  • Chronic use of diuretics
  • Dx of HTN
  • Fasting
  • Bowel Prep
  • Acute Hemorrhage
  • NVD, Suction
  • 3rd spacing
63
Q

Fluid alterations in the intraoperative settings (6).

A
  • Vasodilation from anesthetics
  • Sympathetic blockade (narcotics)
  • Autoregulatory response
  • Acute Hemorrhage
  • Insensible Loss
  • Inflammation related redistribution
64
Q

Assessment of Low Intravascular Volume

A
  • Hypovolemia - ↑HR, ↓Pulse Pressure, ↓BP, ↓Cap Refill
  • 25% of volume must be lost
  • Decreased Urine Output d/t RAA axis
  • CVP
  • Tissue Perfusion = Lactate, Mixed venous O2
65
Q

Assessment of High Intravascular Volume (6)

A
  • Increase capillary hydrostatic pressure
  • Excess fluids in lungs, bowels, muscle
  • Edema
  • Reduced tissue oxygenation
  • Poor wound healing
  • Hypo/Hyper Coagulation
66
Q

What factors do you need to consider as a CRNA when assessing urine output for intravascular volume?

A
  • Low UO can be d/t stress hormone (cortisol) release from anesthetic
  • Low UO can be d/t low intravascular volume and** inadequate perfusion** to the kidney
  • Low UO can be d/t the patient’s position, Steep Trendelenburg
67
Q

When would you use the “classic” fluid therapy?
What’s another name?

A
  • NPO Deficit
  • Ongoing maintenance
  • Anticipated surgical loss

4-2-1 Rule

68
Q

NPO Status for Clear Liquids

A
  • 2 hours
69
Q

NPO Status for Breast Milk

A
  • 4 hours
70
Q

NPO Status for Infant Formula

A
  • 6 hours
71
Q

NPO Status for a Light Meal (scramble egg w/toast, coffee w/milk)

A
  • 6 hours
72
Q

NPO Status for Meat/Fatty, Fried Food, Full Meal

A
  • 8 hours
73
Q

Formula for Classic Fluid Therapy.

A
  • 1st 10 kg = 4 mL/kg/hr
  • 2nd 10kg = 2 mL/kg/hr
  • Each kg over 20 kg = 1 mL/kg/hr

4-2-1 RULE

74
Q

Mr. Cartman’s Weight is 80 kg. Calculate Total NPO deficit using the classic fluid therapy.

A

Cartman is 80kg, using the 4-2-1 Rule.
4 mL/kg for 1st 10 kg = 40 mL
2 mL/kg for 2nd 10 kg= 20 mL
1 mL/kg for last 60 kg = 60 mL

120 mL/ hr x 8 hours = 960 mL deficit

75
Q

If Cartman’s fluid deficit is 960 mL and fluid maintenance is 120 mL/hour, what is the fluid plan for this patient?

A
76
Q

How much blood would the following hold when estimating blood loss in surgery:

Lap Sponge:
Raytech:
4x4 Gauze:

What to remmeber with suction?

A

Lap Sponge (packs of 5): 100 mL
Raytech (pack of 10): 20 mL
4x4 Gauze: 10 mL

adding irrigant

77
Q

%%%

What is the traditional crystalloid replacement ratio for a unit of blood loss preoperatively?

A
  • 3L to 1 unit of blood loss
78
Q

%%%

How much fluid can be loss with a bowel prep?

A
  • 2000 mL
79
Q

%%%

What is the fluid deficit for a fever?

A
  • 10% fluid deficit for every 1 degree Celsius above 38C
80
Q

What are the different categories of evaporative/ redistribution losses?

A
  • Minimal: 0-2 mL/kg/hr (robotics case)
  • Moderate: 2-4 mL/kg/hr
  • Severe: 4-8 mL/kg/hr (open belly)

evaporative = gut outside body

81
Q

What is the Parkland Burn Formula?
Adjusted for?

A

RULE OF 9s
* * 4 mL x kg x TBSA% (whole number) = Fluids to replaced
* 1/2 over the first 8 hours
* 1/2 over the next 16 hours

Formula adjusted for obese + pediatrics patients.

82
Q

What is the percent body surface area of the entire head and neck?

A
  • 9%

4.5% ea anterior + posterior

83
Q

What is the percent body surface area of the entire right arm?

Entire Left arm?

A
  • 9%
  • 9%

4.5% anterior + posterior !

84
Q

What is the percent body surface area of the anterior trunk?

Posterior trunk?

A
  • 18%
  • 18%

9% ea for upper + lower

85
Q

What is the percent body surface area of the entire right leg?

Entire left leg?

A
  • 18%
  • 18%

9% ea anterior + posterior

86
Q

What is the percent body surface area of the groin?

A
  • 1%
87
Q

What fluid is used to replace burn patients?

A
  • Lactated Ringers
88
Q

When is the Parkland Burn formula used?

A
  • 20% of TBSA is burned
  • 2nd and 3rd degree burns only
89
Q

If an 80kg patient has 20% of their TBSA burned, what would be the total fluid needed to be replaced in this patient?

A
  • 4mL x kg x TBSA (%)
  • 4 x 80 x 20 =6400 mL total
  • 3200 mL replaced in the first 8 hours
  • 3200 mL replaced in the next 16 hours
90
Q

For goal directed therapy, fluid administration is based on:

A
  • CVP
  • CO
  • SV
  • SVV

Patient will either be fluid responsive or unresponsive. If fluid responsive, a bolus will be administered. Fluid replacement is individualized.

91
Q

Goal directed therapy fluid admin is based on?

A

o CVP – not super specific bc distensible
o Swan – use declining - indirect measurement

o Svo2 – measures o2 extraction
o TEE – quantify LV cavity size/EF

o CO
o Lactate levels – decreasing level signals successful resuscitation
o SV machines
o SVV machines – pulse ox/art line use

92
Q

What have studies shown about the results of goal directed therapy?

A
  • Less AKI
  • Less Respiratory Failure
  • Decrease Wound Infection
  • Decrease Mortality
93
Q

Goal directed therapy allows decisions to use?

A
  • more fluids
  • vasopressors
  • inotropes
  • blood products
94
Q

What is the maintenance dose for goal directed therapy?

A
  • 1-3 mL/kg/hr of crystalloid
95
Q

For goal directed therapy, a fluid challenge of ___________ mL will be used to increase SV.

A
  • 250 mL
96
Q

What is used in goal directed therapy with blood loss or blood products?

A
  • More likely to replace with colloid or blood products 1:1, rather crystalloids (3:1)
97
Q

What are the LIMITS to arterial waveform pressure monitoring (SVV Monitoring)?

A
  • Low HR/RR
  • Irregular rhythms
  • Mechanical Ventilation w/ Low Vt
  • Increased Abdominal Pressure
  • Thorax Open
  • Spontaneous Breathing

Any of these factors will result in an inaccurate reading on the monitor.

98
Q

What three factors does the arterial waveform pressure monitor take into account to calculate the Stroke Volume Variance?

A
  • Systolic Pressure Variation: difference between lowest systolic peak and highest systolic peak.
  • during one cycle of mechanical breath
  • Pulse Pressure Variation: difference bw systolic + diastolic bps
  • Stroke Volume Variation: The area under the “curve”
99
Q

What is SVV?
What is normal Stroke Volume Variance (SVV)?

A
  • The variation of SV in 30 seconds
  • 10-15%
  • If above 15% = fluid (give fluid bolus)
  • below 15% = pressors

Principles I* (20 decks)

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