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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
What are the 3 sensors for fluid balance? Locations?
* Hypothalamic osmoreceptors * Low-pressure baroreceptors = large veins and RA * High-pressure baroreceptors = carotid sinus and aortic arch
26
What are 2 trigger for fluid balance?
* Increased thirst * Increase ADH
27
What are the 5 compensatory mechanisms for acute disturbances in circulating volume? When do they occur?
* Venoconstriction * Mobilization of venous reservoir * Autotransfusion from ISF to plasma * Reduced urine production * Maintenance of CO = tachycardia + inotropy MINUTES TO HOURS
28
What are the 3 sensors to acute disturbances in circulating volume?
o LOW + high pressure baroreceptors o RAA axis | primarily low
29
Where is Renin released? What does Renin do to angiotensinogen?
* Released from juxtaglomerular cells * Cleaves angiotensinogen to make angiotensin I
30
When ANG I → ANG II, what will this cause?
* Vasoconstriction and aldosterone release
31
Where is aldosterone released from? What does it do?
* adrenal cortex * causes salt and water retention
32
In the absence of ongoing fluid loss, loss volume should be restored within ______- hours (range).
* 12-72 hours
33
In the absence of ongoing fluid loss, RBC should be restored through ______________ in ______ weeks (range).
* erythropoeisis * 4-8 weeks.
34
What are the Electrolytes and Osmolarity of Normal Saline (0.9%)?
Na = 154 mEq/L K = 0 Chlorid = 154 mEq/L Osmolarity = 308 mOsm/L
35
What are the 4 Electrolytes and Osmolarity of LR?
Na = 130 mEq/L K = 4 mEq/L Chloride = 109 mEq/L Lactate = 28 mEq/L Osmolarity = 274 mOsm/L | NOT LIVER PTS
36
What are the 4 Electrolytes and Osmolarity of Plasmalyte?
Na = 140 mEq/L K = 5 mEq/L Cl = 98 mEq/L Acetate = 27 mEq/L Osmolarity = 295 mOsm/L
37
What are the Electrolytes and Osmolarity of Albumin 5%?
Na+: 145 +/- 15 mEq/L K+: <2.5 mEq/L Cl-: 100 mEq/L Osmolarity: 330 mOsm/L
38
What are the Electrolytes and Osmolarity of Hetastarch 6%?
Na+: 154 mEq/L Cl-: 154 mEq/L Osmolarity: 310 mOsm/L
39
What are crystalloids?
* Solutions of electrolytes in water * The are called **balanced** solutions (not really though, misnomer) * LR/plasmalyte = probably considered the most "balanced" crystalloid
40
What are 2 indications of using crystalloids?
* Replacement of free water and electrolytes * Volume expansion
41
Distribution of crysatlloid through entire _______. what percentage will be in the intravascular space after 20 minutes? What about after 30 minutes?
* ECF * 70% in the intravascular space after 20 minutes * 50% in the intravascular space after 30 minutes
42
What are the negative effects of crystalloids?
* Tissue Edema (Lungs, GI Tract, Soft Tissues) * Hypercoagulability (Anticoagulant factors diluted)- micro emboli
43
NS 0.9% is the most commonly fluid, but what are 5 negative consequence of this fluid?
* 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
What fluid will pull water out of the ICF to the ECF including the plasma? What does this fluid treat?
* Hypertonic Saline 3% * hypo-osmolar hyponatremia , inc ICP , TUR syndrome
45
What is added to LR to act as a buffer?
* Lactate
46
You want to avoid using this fluid for patients with liver insufficiency.
* 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
Which fluid will **excrete excess water faster** than NS d/t the transient decrease in plasma tonicity which **suppresses ADH secretion and allow diuresis**?
* LR
48
What happens to dextrose solution when the glucose is metabolized?
* 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
What fluid could be used for caloric intake in diabetic patients?
* Dextrose 10% * Better options out there
50
What are colloids?
* 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
What are two main types of colloids?
* Semisynthetic colloids (Starches) * Human plasma derivatives (FFP, Albumin)
52
How do colloids work?
* Increasing colloid oncotic pressure (pulling force), >>> increases potential plasma volume expansion
53
What are 4 negative effects of colloids?
* Causes hemodilution * Decreases plasma viscosity * Inhibit RBC aggregation * Uncertain effect on immune, coag, + renal system - maximum recommended ddoses
54
What colloid is derived from **potatoes or maize** (polymers of **amylopectin**)?
* Hydroxyethyl Starch
55
The metabolism of hydroxyethyl starch is dependent on ______________.
* 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
What are the S/E of Hydroxyethyl Starch?
* Coagulopathy through dilution effects * leading to reduction in VWF, Factor VIII, Clot Strength. * Renal Dysfunction | DONT give to renal pt or bleeding pt
57
The dextran is a highly branched __________ produced by a bacteria called _______________.
* polysacchrides * Leuconostoc Mesenteroides
58
Dextran have a plasma volume effect similar to that of starches, with a duration of _______ hours (range).
* 6-12 hours
59
According to lecture, what is Dextran-40 used for? Why?
* Microvascular Surgery * Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation * coat the RBC and may interfere with cross-matching
60
What are 3 examples of human plasma derivative colloids?
* Albumin 5% * FFP * Immunoglobulin Solution
61
Indications for human plasma derivatives
* volume replacement * trauma * sepsis * paracentesis
62
Fluid alterations in the preoperative settings (9).
* Na+ distribution disorder * Dialysis requirement * Chronic use of diuretics * Dx of HTN * Fasting * Bowel Prep * Acute Hemorrhage * NVD, Suction * 3rd spacing
63
Fluid alterations in the intraoperative settings (6).
* Vasodilation from anesthetics * Sympathetic blockade (narcotics) * Autoregulatory response * Acute Hemorrhage * Insensible Loss * Inflammation related redistribution
64
Assessment of Low Intravascular Volume
* 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
Assessment of High Intravascular Volume (6)
* Increase capillary hydrostatic pressure * Excess fluids in lungs, bowels, muscle * Edema * Reduced tissue oxygenation * Poor wound healing * Hypo/Hyper Coagulation
66
What factors do you need to consider as a CRNA when assessing urine output for intravascular volume?
* 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
When would you use the "classic" fluid therapy? What's another name?
* NPO Deficit * Ongoing maintenance * Anticipated surgical loss 4-2-1 Rule
68
NPO Status for Clear Liquids
* 2 hours
69
NPO Status for Breast Milk
* 4 hours
70
NPO Status for Infant Formula
* 6 hours
71
NPO Status for a Light Meal (scramble egg w/toast, coffee w/milk)
* 6 hours
72
NPO Status for Meat/Fatty, Fried Food, Full Meal
* 8 hours
73
Formula for Classic Fluid Therapy.
* 1st 10 kg = 4 mL/kg/hr * 2nd 10kg = 2 mL/kg/hr * Each kg over 20 kg = 1 mL/kg/hr ## Footnote 4-2-1 RULE
74
Mr. Cartman's Weight is 80 kg. Calculate Total NPO deficit using the classic fluid therapy.
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
If Cartman's fluid deficit is 960 mL and fluid maintenance is 120 mL/hour, what is the fluid plan for this patient?
76
How much blood would the following hold when estimating blood loss in surgery: Lap Sponge: Raytech: 4x4 Gauze: What to remmeber with suction?
Lap Sponge (packs of 5): 100 mL Raytech (pack of 10): 20 mL 4x4 Gauze: 10 mL adding irrigant
77
# %%% What is the traditional crystalloid replacement ratio for a unit of blood loss preoperatively?
* 3L to 1 unit of blood loss
78
# %%% How much fluid can be loss with a bowel prep?
* 2000 mL
79
# %%% What is the fluid deficit for a fever?
* 10% fluid deficit for every 1 degree Celsius above 38C
80
What are the different categories of evaporative/ redistribution losses?
* 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
What is the Parkland Burn Formula? Adjusted for?
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
What is the percent body surface area of the entire head and neck?
* 9% ## Footnote 4.5% ea anterior + posterior
83
What is the percent body surface area of the entire right arm? Entire Left arm?
* 9% * 9% | 4.5% anterior + posterior !
84
What is the percent body surface area of the anterior trunk? Posterior trunk?
* 18% * 18% | 9% ea for upper + lower
85
What is the percent body surface area of the entire right leg? Entire left leg?
* 18% * 18% ## Footnote 9% ea anterior + posterior
86
What is the percent body surface area of the groin?
* 1%
87
What fluid is used to replace burn patients?
* Lactated Ringers
88
When is the Parkland Burn formula used?
* 20% of TBSA is burned * 2nd and 3rd degree burns only
89
If an 80kg patient has 20% of their TBSA burned, what would be the total fluid needed to be replaced in this patient?
* 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
For goal directed therapy, fluid administration is based on:
* 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
Goal directed therapy fluid admin is based on?
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
What have studies shown about the results of goal directed therapy?
* Less AKI * Less Respiratory Failure * Decrease Wound Infection * Decrease Mortality
93
Goal directed therapy allows decisions to use?
* more fluids * vasopressors * inotropes * blood products
94
What is the maintenance dose for goal directed therapy?
* 1-3 mL/kg/hr of crystalloid
95
For goal directed therapy, a fluid challenge of ___________ mL will be used to increase SV.
* 250 mL
96
What is used in goal directed therapy with blood loss or blood products?
* More likely to replace with colloid or blood products 1:1, rather crystalloids (3:1)
97
What are the LIMITS to arterial waveform pressure monitoring (SVV Monitoring)?
* 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
What three factors does the arterial waveform pressure monitor take into account to calculate the Stroke Volume Variance?
* 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
What is SVV? What is normal Stroke Volume Variance (SVV)?
* 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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