EXAM 3: Fluid & Blood Product Management Flashcards
Water is the major component of the body - __-__% of total body weight. The percentage is influenced by ____, ___, and _____ of the patients (fat holds ___ water than lean tissue).
50-70%
gender, age, tissues
fat holds LESS than lean
Table on Slide 4
Males have ____ total body water than females.
Thin body builds have ____ water than larger body builds.
Younger patients have ____ water than older patients.
From birth to 10 years old, there are ___ male/female differences in total body water.
Males > females
thin > obese
younger > older
NO gender difference
Intracellular fluid volume is about ___ of the total body water (28 L in a 70 kg male). This includes the fluid inside _____ and ______. It comprises the biggest amount of fluid; however, we do not have as much control over changes in this fluid.
2/3
all cells
aqueous medium
extracellular fluid volume is about ___ of our total body water (14 L in a 70 kg male). This is the fluid _____ cell in the ______ system, _____, and the ________. We have more control over changes in volume in this compartment.
1/3
outside
cardiovascular, organs, interstitial spaces
The extracellular fluid compartment is made up of the _____ and the _____ volumes.
plasma volume (PV) interstitial fluid volume
The plasma volume is __ of the ECF (3.5 L) - it includes the _____ fluid, but OUTSIDE the erythrocytes. It is ____ of total body water.
1/4
intravascular
8-9%
The interstitial fluid volume is __ of the ECF (10.5 L) and includes _______, _______, and _______. It is separated from the plasma volume by the walls of ____ _____. There is very little in the form of free fluid - an increase is known as _____.
3/4
extravascular, interstitial fluid, extracellular fluid
blood vessels
edema
Extracellular Fluid Compartments:
intravascular : ______
extravascular: _______/lymph, _____ (inaccessible), ____fluids, and _____ fluids
plasma
interstitial fluid/lymph, bone water (inaccessible), cavitary fluids, and transcellular fluids
*Review slide 7
Interstital fluid and lymph:
- rapid exchange with plasma component - slow exchange with plasma component (ex. cartilage and \_\_\_\_\_\_\_ )
Cavitary fluids: ex. _______, ______, ______
Transcellular fluids: salivary, _____, biliary, _____, dermal, mucosal {respiratory & gastrointestinal}, intraocular, _______ (gastrointestinal & intrathecal}
dense connective tissue
peritoneal, pericardial, pleural
hepatic, pancreatic, intraluminal
Review charts/diagrams on slides 7-9.
Under normal conditions, the compartments are relatively stable in relation to _____ and ______. There is ______ exchange of water between the different fluid compartments. The 2 forces influencing the movement are ______ and ______ pressures.
volume and composition
continuous
hydrostatic, osmotic
**Starling was not aware
of the reduction in fluid extravasation by the glycocalyx,
which has revised the original Starling equation*
*Starling described four forces that regulate fluid
homoeostasis. The sum of tissue oncotic and luminal
hydrostatic pressures forces fluid out of the vessel into
the tissue. The sum of tissue hydrostatic and luminal
oncotic pressures forces fluid out of the tissue into the
vessel. In the model, net force at the arteriolar end of
the capillary pushes fluid out, but pushes fluid back in
at the venous end. However, this model is inadequate,
with experiments over the past 25 years revealing
additional processes in action. Starling was not aware
of the reduction in fluid extravasation by the glycocalyx,
which has revised the original Starling equation
______ pressure - the pressure within the capillaries from the weight of the blood and the pressure from the cardiac pumping mechanics. It results in small amounts of intravascular plasma volume moving INTO the interstitial fluid compartment.
Typically, the water returns to the ____ capillaries from the interstitial fluid compartment.
hydrostatic
venous (and some lymph)
_______ pressure is the _____ pressure that must be applied to the solution of greater concentration to prevent water movement across the membrane.
osmotic - pressure pulling water INTO the intravascular space
hydrostatic
When 2 compartments are separated by a semi-permeable membrane w/ aqueous solutions of unequal concentrations, the water will move from the more _____ to the more ______ in an effort to equalize the concentrations.
dilute to concentrated
**fluid administration can affect this
The solutions that exist in the compartments contain ______ that account for the osmotic forces.
____ in plasma, interstitial (extracellular)
____ intracellular
Usually, ALL compartments are _______.
electrolytes
Na+
K+
isoosmolar (Na/K ATPase Pump)
Factors affecting fluid distribution & regulation:
1) _____ ______: (protein mesh that encourages laminar flow - CAN be damaged)
2) ______ system: response to hypotension (____ is released)
3) ______ ______: response to increased osmolality (___ is released)
4) ____ ____ ____: released w/ increased stretch of receptors in atrial walls
1) endothelial glycocalyx (protein mesh that encourages laminar flow - CAN be damaged)
2) renin-angiotensin-aldosterone system - renin
3) antidiuretic hormone - ADH
4) atrial natriuretic peptide
**vascular space > EG > the vascular wall: Structure of the endothelial glycocalyx: The glycocalyx is a complex gel between flowing blood and the endothelial cell wall. It interacts with plasma proteins and lipids [9]. The composition and dimensions of the glycocalyx fluctuate as it continuously replaces material sheared by flowing plasma [10], while throughout the vasculature, the thickness varies 10-fold, between 0.1 and 1 lm [11].
The glycocalyx forms a luminal mesh that provides
endothelial cells with a framework to bind
plasma proteins and soluble GAGs [5, 9]. The glycocalyx
itself is inactive, but once plasma constituents are
bound, it forms the physiologically active endothelial
surface layer [12].
The endothelial glycocalyx:
1) plays a protective role in ______ fluid exchange
2) _______ flow
3) Blood component rheology (plasma:cellular components, _____)
4) Plasma ____ pressure
5) Signal _____
6) Immune, modulation, and ____ _____
It is composed of glyco_____, poly_____, and _____ acids and provides a ____ ____ effect.
1 - transcapillary 2 - microcirculatory flow 3 - viscosity 4 - oncotic 5 - transduction 6 - vascular tone
glycoproteins, polysaccharides, and hyaluronic acid - double barrier
In other words, the endothelial glycocalyx binds to circulating ____ _____, repels ____ _____, and encourages ____ ____.
plasma albumin
blood components
laminar flow
Administration of excessive fluid will result in hypervolemia and a subsequent increase in intravascular hydrostatic pressure with release of atrial natriuretic peptides that can damage the ____ ______. The glycocalyx is a layer of membrane-bound proteoglycans and glycoproteins that coats healthy vascular endothelium. It plays an important role in managing vascular _______ by acting as a second barrier to extravasation. Unfortunately, it is easily ______; sepsis or hypervolemia can cause damage to the glycocalyx and, thus, leakage. Therefore, intravenous fluid that is given without evidence of hypovolemia can damage the glycocalyx and shift out of the circulation into the interstitial space (commonly referred to as ‘‘third spacing’’).
endothelial glycocalyx
permeability
damaged
The endothelial surface layer is surprisingly fragile. Destruction of the glycocalyx can lead to _____ leak, _____, accelerated ______, ____ aggregation, _______ and loss of ______ responsiveness
capillary edema inflammation platelet hypercoagulability vascular
Tonicity compares the ______ of solutions - the effect of a solution on the ____ volume.
osmolality
cell
______: osmolality of solution is the SAME as that of body fluids
3 examples:
isotonic (isoosmotic)
0.9% NS (some say this is hypotonic)
LR - most commonly used
Plasmalyte - most similar to plasma ($$)
______: osmolality of solution is HIGHER than body fluids causing water to move out of cells (shrinks cells)
2 examples:
hypertonic
5% NS
10% mannitol
Ex: 5% NS if patient is severely hyponatremic
Ex: 10% mannitol for neuro cases - shrink brain tissue by pulling fluid intravascularly and then give Lasix to get rid of the extra fluid.
______ solutions have a LOWER osmolality than body fluids causing absorption of water by the cells (_____)
2 examples:
hypotonic
swelling
0.45% NS
D5W
Evaluation of Fluid & Electrolyte Status:
______ _____ d/t prolonged NPO time, bowel prep, blood loss, and/or excessive blood draws is the most common fluid disturbance in surgical patients.
volume deficit
To assess for volume-deficit, assess the patient’s:
1) blood pressure: ____ _____ - >20 mmHg indicates a deficit of __-__% of body weight; you may also see a decreased BP w/ ______ ___ flow
2) Heart rate: _____ w/ hypotension (or can be medication related)
3) Mucous membrane ____
4) Skin ____
5) Urine output: decrease in UOP intra-op is NOT a predictor of ____ ____ (d/t release of ADH in response to stress of surgery).
1 - orthostatic hypotension - 6-8% - inspiratory gas flow (PPV - have decreased venous return exaggerated w/ hypovolemia)
2 - increases
3 - moisture
4 - turgor
5 - renal damage
We evaluate changes in the _____. However, there is an ongoing movement of water and solute between the ICF and ECF compartments - what effects one effects the other.
Patients with a suspected deficit should receive a ____ _____.
Remember, anesthesia can lead to ______ ______ which will be exaggerated in patients w/ fluid deficits.
ECF - goal is to keep patients normovolemic
urinary catheter
circulatory depression
**if patients have a volume deficit and are constricted, any vasodilation from anesthesia can cause significant hypotension
Consequences of UNDER-resuscitation:
1) Hypovolemia & reduced circulating volume can lead to reduced ______ ______ and decreased _____ delivery, reduced ____ _____, and ultimately ____ _____ complications.
2) Post-op ___/____
3) ____ dysfunction
4) ______ ischemia
5) Hemo______: increased blood _____, ______ events
1 - microvascular perfusion, O2, tissue perfusion, end-organ
2 - N/V
3 - renal
4 - myocardial
5 - concentration - viscosity, thrombotic
Consequences of OVER-resuscitation (more common):
1) Vascular overload can lead to ____, microvascular _____ and decreased ____ delivery, _____ _____ disruption, and decreased tissue _______.
2) Altered ______
3) Hemo_____: anemia, thrombocytopenia, altered viscosity, and coagulopathy
4) ______ GI motility
5) ______ infection rates & poor wound healing
6) Decreased organ perfusion
7) Prolonged post-op ____ _____
8) Increased pneumonia
9) Hepatic _____/______
1 - CHF, congestion, O2, endothelial glycocalyx, O2
2 - coagulation
3 - dilution
4 - decreased (d/t edema in GI mucosa - ileus post-op)
5 - increased
7 - mechanical ventilation
9 - congestion/dysfunction
Increased concentration occurs when _____ ____ water is LOST, the serum Na+ and serum osmolality ______. This can be d/t inadequate water intake, fever, or loss of fluid from burns.
electrolyte-free water
increase
Decreased concentration can occur when water is present in body fluids in _____ - the serum Na+ and serum osmolality ______.
excess
decrease
____natremic/____volemic concentration: electrolyte rich fluids are (vomit, diarrhea, fistula drainage) are lost and replaced w/ water only. To treat, replace w/ _____.
Hyponatremic/hypovolemic
fluids WITH electrolytes - LR
*losing a LOT of fluids - dropping Na+ and NOT replacing it
____natremic/_____volemic concentration: failure of the kidneys to conserve Na+
hyponatremic/normovolemic
____natremic/_____volemic concentration: absorption of fluids from TURP or if D5W was used to replace volume deficit (important to know what pre-op Na+ levels are.
hyponatremic/hypervolemic d/t irrigation
sodium function: fluid _______, _____/______ of nerve impulses, ____/____ regulation, intracellular __ replacement, _____ activity, maintenance of cellular _____/______
retention generation/transmission acid/base K+ enzyme osmolarity/electroneutrality
potassium function: maintenance of _____ ______, deposition of _____ in liver cells, contribution to _____ _____ production, transmission/conduction of _____ _____, maintenance of cellular _____/_____
cardiac rhythm glycogen cellular energy nerve impulses osmolarity/electroneutrality
*3.5-5.0
calcium function: formation of _____, teeth, transmission of ___ _____, _____ of muscles, coagulation, maintenance of cellular ______, cardiac ____ _____ and pacemaker activity
4.5-5.5meq/l
9-11mg/dl
bones nerve impulses contraction permeability action potential
chloride function: transport of ____, ___-____ regulation, ______ acid formation in stomach, _____ retention, maintenance of cellular _____
*97-104 meq/l
CO2 acid-base hydrochloric potassium osmolarity
*97-104 meq/l
magnesium function: _____ activity, essential for_____ synthesis, ______ transmission, muscular ______
*1.5-2.5meq/L
enzyme
protein
neurochemical
excitability
phosphate function: major constituent of ____ mineral, essential component of _____ ____ and _____, contribution to energy-requiring _____ processes
*1.0-2.0 meq/L
bone
nucleic acids
proteins
metabolic
Review IV Fluid Charts on Slides 25-26.
more closely related to plasma
plasmalyte > LR > NS
.
______ contains Na+, K+, Cl-, phosphate, and Mg in similar concentrations to plasma in addition to acetate and gluconate. It has a pH of 7.4.
Plasmalyte-A, Normosol-R, Isolyte-S
BEST but $$$
If you know you’re going to have to give lots of fluids, start w/ this - also compatible w/ blood admin.
______ contains Na+, K+, and Cl- in similar concentrations to plasma in addition to calcium and lactate. Its pH is 6.2.
lactated ringers - 2nd best (less expensive)
**cannot use w/ blood administration d/t calcium/citrate binding
______: contains equal parts Na+ and Cl-. Its pH is 5.6.
- 9% NaCl
* pH can be problematic in large doses - can cause metabolic acidosis
D5W and 1/2 NS are ______ cystalloids.
hypotonic
NS, D5 1/4 NS, LR, and plasmalyte are considered ______ crystalloids.
isotonic
D5 1/2 NS, D5 NS, D5 LR, 3% S, 5% S, and 7.5% NaHCO3 are _______ crystalloids.
hypertonic
_____ are the initial choice for fluid replacement. They have an intravascular half-life of __-__ minutes. The choice is based on the fluids being replaced.
If theyre losing a ton of intravascular volume, replacing it with crytalloids should be at a : ratio because the ½ life is short
_____ is more physiologic than ____ in large volumes.
NS can produce ____ _____ _____ in large volumes (bicarb ______ as chloride concentration increases). It is preferred for transfusing ____ and is used to dilute/flush and is less expensive.
crystalloids
20-30 min (not great if losing large volumes)
3:1
LR > NS
dilutional hyperchloremic metabolic acidosis - decreases
PRBCs
LR contains ______ which binds w/ citrate in PRBCs. It also contains ____ and is therefore not an appropriate choice for patients w/ ______.
calcium
K+
ESRD
_____ is the fluid of choice for renal patients and for blood product administration.
*** 500ml bag and on microdrip
normal saline
____ should be avoided w/ neurosurgical patients. It is implicated in increasing ischemic brain injury. The patient can become hyperglycemic w/ corticosteroids.
D5
To replace blood loss w/ crystalloids, replace blood in a __:__ ratio w/ crystalloids.
3:1
Colloids are higher ____ ____ than crystalloids and have an intravascular half-life of ___-___ hours.
molecular weight
3-6 hours
Colloids are osmotically active substances. Order the colloids by osmotic activity: (6)
10% Dextran 40 > 25% albumin > 6% dextran 70 > 6% hetastarch = FFP or 5% albumin
