EXAM 3: Fluid & Blood Product Management Flashcards by Claudia Means

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

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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

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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

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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

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The extracellular fluid compartment is made up of the _____ and the _____ volumes.

plasma volume (PV)
interstitial fluid volume

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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%

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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

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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

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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

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Review charts/diagrams on slides 7-9.

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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

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______ 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)

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_______ 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

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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

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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)

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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].

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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

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In other words, the endothelial glycocalyx binds to circulating ____ _____, repels ____ _____, and encourages ____ ____.

plasma albumin
blood components
laminar flow

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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

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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

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Tonicity compares the ______ of solutions - the effect of a solution on the ____ volume.

osmolality

cell

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______: 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 ($$)

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______: 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.

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______ solutions have a LOWER osmolality than body fluids causing absorption of water by the cells (_____)

2 examples:

hypotonic
swelling

0.45% NS
D5W

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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.

0. 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.

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

Colloids are indicated for severe hypovolemia (i.e. trending towards hypovolemia but not to the point of needing PRBCs) because they correct more _____ than crystalloids.

rapidly 5% albumin most commonly administered

Crystalloids are _____effective if given in sufficient amounts (__-__x more). Rapid administration of large volumes of crystalloids (>4-5 L) is more frequently associated with tissue _____ – impairment of _____ transport, impaired _____ healing, and impaired return of ____ function after major surgery.

equally 3-4x more edema oxygen tissue bowel

Albumin is a _____ colloid from pooled donor plasma. It is heated (pasteurized) to 60 C to _____ viral infections, hepatitis v. blood products. It is a high molecular weight _____. Albumin 25% has a _____ volume vs. albumin 5% is volume _____ w/ ____ _____ to 250-500 mL (considered potentially iso-oncotic)

natural *reduce (not eliminate) protein small expanded - NS

Dextran is _____ and composed of dextrose _____ (Macrodex, Rheomacrodex). It improves _______ by decreasing blood _____ and _____ effects. B/c of this, it can have significant effects on ______. If more than 1.5 g/kg is given, _____ should be checked. There is a potential for ______ reaction. Dextran 1 can be administered first. It acts as ____ and binds w/ antibodies to prevent reaction.

``` synthetic dextrose starches micro-circulation viscosity, platelet coagulation bleeding times ``` anaphylactic hapten **not really given as a volume expander but has the potential to pull volume in - vascular surgeons may want to use this.

The typical limit for Dextran 40 is ___mL/kg in a 24 hour period.

20 mL/kg

Hespan (____starch) is a _____ colloid (____ _____). It has a ______ effect on coagulation and inhibits platelet/clot _____ impairing _____ and ____ factors. It has ___ antigenic effect and anaphylaxis is _____. A recent study shows that ___mL/kg (some say 500-1000 mL) is the maximum to infuse to avoid coagulopathy. Hetastarch can bind w/ amylase to prevent its normal ______ causing elevated amylase levels.

HETAstarch - synthetic - plant starch (large - basically IV potato) dilutional formation von Willebrand, factor VIIIc NO - rare 20 mL/kg excretion **probably won't use - MAYBE use as volume expander if patient is actively bleeding - start albumin, etc. and maybe give Hespan

Voluven is a ______ starch or ______ - 130/0.4. This allows for ____ mL/kg per day (compared to Hespan). It is more rapidly ______, has higher _____ (20-30x) with minimal ____ storage. There is not necessarily a decrease in osmotically active particles due to a higher number at a lower molecular weight. (*she did not explain this)

hydroxyethyl startch - TETRAstarch 50 mL/kg metabolized, clearance, tissue storage (the higher the molar substitution, the slower the metabolism) Voluven: average MW 130, 0.4 molar substitution Hespan: MW 450, 0.7 molar substitution “Hydroxyethyl starch (HES) solutions are synthetic colloids. In a randomized trial of more than 800 patients undergoing major abdominal surgery, administration of HES 130/0.4 solution versus 0.9 percent saline to provide goal-directed fluid therapy did not reduce the composite outcome of death or major postoperative complications (36 versus 32 percent), and may have had harmful effects (eg, increased risk of acute kidney injury) [16]. Similar results have been reported in systematic reviews comparing HES solutions with various types of fluid therapy. We do not use HES solutions for fluid therapy in surgical patients.”

Review Chart on Slide 33.

Crystalloid Advantages: 1) ______ 2) Promotes ____ ____ 3) Restores _____ losses 4) Used for _____ fluid repletion and for initial resuscitation

inexpensive urinary flow third-space extracellular

Crystalloid Disadvantages: 1) _____ plasma proteins 2) causes ____ of capillary osmotic pressure 3) causes ____ _____ 4) has a _____ effect 5) has potential for _____ _____

``` 1 - dilutes 2 - reduction 3 - peripheral edema 4 - transient 5 - pulmonary edema ```

Colloid Advantages: 1) causes ____ increase in plasma volume 2) requires ____ volume for resuscitation 3) causes ___ peripheral edema 4) tends to remain _____ 5) causes more ____ resuscitation 6) useful in conditions of altered vascular ______ ***replacing blood loss with a colloid is at what ratio ??

``` 1 - sustained 2 - smaller 3 - less 4 - intravascular 5 - rapid 6 - permeability ``` *** 1:1

Colloid Disadvantages: 1) _____ 2) can cause ______ (dextran > hetastarch > hextend) 3) can cause anaphylactic reactions (_____) 4) decreases ____ (albumin) 5) can cause ____ failure (dextran) 6) can cause osmotic _____ 7) can cause impaired ____ response (albumin)

``` 1 - expensive 2 - coagulopathy 3 - dextran 4 - Ca++ 5 - renal 6 - diuresis 7 - immune ```

The historical/traditional 4 requirements of fluid management include: 1) _______ fluid ______ 2) correction of pre-existing _____ ______ 3) Replacement of ongoing ____ ____ 4) Adjustment of ____ and _____ of fluids

1 - maintenance infusion 2 - volume deficit 3 - fluid losses 4 - amount/composition

The ERAS plan for elective surgery follows CHEERS DREAM:

``` C - carb loaded & not hungry (drink clear carb drink 2 hours prior to surgery) H - hydrated/not thirsty E - euvolemic E - eunatremic Ready to Start to ``` DR - drink EA - eat Mobilize ASAP, achieving this on the same day of surgery in many instances or the following day...

The goal of ERAS (enhanced recovery after surgery) is to: 1) maintain physiological function and facilitate post-op recovery after major surgery 2) attenuate ___ response during surgery and to increase patient participation during the post-op recovery 3) decrease post-op ______

2 - stress 3 - complications patient, surgeon (and his/her orders), pre-op nurse, anesthesia, and post-op nurse HAVE to be involved in care

ERAS Pre-op Fluid Management: Remain _____ & ______, avoid prolonged ______ and mechanical bowel preps, consume a clear carb drink __-__ hours pre-op. 2 Benefits: Patients are ____ ____ to be fluid responsive after induction. Reduced post-op ____ ______.

hydrated, euvolemic, fasting, 2-3 hours LESS LIKELY insulin resistance

ERAS Intraoperative Fluid Management: - Maintain central _____ - Minimize excess ___ and ____* - INDIVIDUALIZE fluid plan - For low-risk patients/low-risk surgery - use the ____ ____ approach - For most patients/major surgery use _______ approach - To determine volume therapy, use a ____ _____ to determine _____**

- euvolemia (maintenance w/ 1-3 mL/kg/hr crystalloid) - Na+ and water* - zero-balance approach - goal-directed fluid therapy (GDFT) - fluid challenge - responsiveness** (may need pressors to buy time as you administer fluids - or hypotension could just be from vasodilation and fluids would not be needed) **Excessive fluid administration – most commonly seen as edema of the gut wall and prolonged ileus “Administering more fluid (typically crystalloid) than is needed has been associated with harm. 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 endothelial glycocalyx. The glycocalyx is a layer of membrane-bound proteoglycans and glycoproteins that coats healthy vascular endothelium. It plays an important role in managing vascular permeability by acting as a second barrier to extravasation. Unfortunately, it is easily damaged; 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’’)

Goal-directed fluid therapy utilizes a ____ _____ to individualize fluid therapy. It reduces complications after major surgery by ___-___%. The goal is to _____ _____ from circulation and to optimize ____ _____. Perioperative _____ should be tolerated. Post-op oral fluid intake or enteral nutrition should be started back as early as possible to d/c IV intake.

CO monitor 25-50% replace losses stroke volume oliguria (not predictive of post-op renal insuff.) - commonly d/t ADH release

Review SVV/PPV diagrams on slides 40-41.

For the calculation of a valid SVV/PVV, a number of physiological/clinical criteria must be met or considered: 1) FULL _____ _____ (no ______ breaths) 2) No ______ 3) Tidal volume >/= __-__ mL/kg - higher tidal volumes elicit higher variation 4) Heart rate :: respiratory rate ratio >/= ___ 5) PEEP must be considered - a higher PEEP will result in _____ variations 6) An open abdomen has been shown to _____ SVV/PPV by 40-50% 7) Changes in lung or chest compliance or patient position may affect readings as may left or right ventricular dysfunction or pneumoperitoneum.

``` 1 - mechanical ventilation - no spontaneous 2 - arrythmias 3 - >/= 7-8 mL/kg 4 - >/= 4 (heart must be 4x RR) 5 - higher 6 - reduce ```

If a patient has SVV/PVV of greater than 10-15%, they are considered ____ ______.

fluid responsive | *on mechanical ventilation, venous return decreases w/ inspiration (SVV/PVV decrease) - exaggerated w/ hypovolemia

Variations in SV and PP occur as a result of interactions between the cardiovascular and respiratory systems. An alternative to SV optimization is to minimize the variation in either SV or PP across the respiratory cycle. During inspiration (with positive pressure ventilation), the increase in intrathoracic pressure compresses the venae cavae. This subsequently reduces _____, and therefore the ___, once that blood has passed through the pulmonary circulation and is ejected from the left side of the heart. In theory, patients who exhibit a SVV or PPV greater than ~__-__% may be hypovolemic and therefore may respond ______ to a fluid challenge.”

preload SV 10-15% positively

_____ respiratory variations in the arterial pressure or the plethysmographic waveforms indicate that the patient is on the ____ portion of the Frank-Starling relationship. ____ variation indicate the patient is on the plateau. CO maximization concepts aim at increasing CO until it reaches the plateau. This goal can be achieved by ___________ respiratory variation.

large - steep portion small - plateau minimizing **to see this on a monitor, change the SPEED

High respiratory variation = ____ _____ Low respiratory variation = ____ ____ ____

volume responsive NOT volume responsive

Enhanced recovery partnership recommended cases for goal-directed fluid therapy: 1) Major surgery w/ a 30-day mortality rate >__% 2) Major surgery w/ anticipated blood loss > ____ mL 3) Major ______ surgery 4) Intermediate surgery (30-day mortality >0.5%) in high-riisk patients (age > ___, history of ___, ___. ___, or ____) 5) Patients w/ ongoing evidence of _____ and/or tissue ______ (i.e. persistent ____ _____) 6) Unexpected blood loss and/or fluid loss requiring > ___ L of fluid replacement

*Test question from this probably 1 - >1% 2 - >500 mL 3 - intra-abdominal 4 - age >80, L ventricular failure, MI, CVA, peripheral arterial disease 5 - hypovolemia, tissue hypoperfusion (lactic acidosis) 6 - >2 L

Review GDFT Outcomes on slide 43.

Hypovolemia can lead to _____ and ____ ______. Hypervolemia can lead to ____ ____ and _____ _____. Euvolemia DECREASES complications!

hypoperfusion, organ dysfunction tissue edema adverse outcomes

Traditional Method: Maintenance Fluids 1) Greater fluids are required for _______ size. 2) There is a _____ association between metabolic rate and water requirements - _____ size means greater metabolic rate. Holliday/Segar developed a formula for determining caloric requirements based on weight: __ mL water required for every kcal expended - the _____ rule developed.

1 - decreasing 2 - direct - smaller 1 mL - 4:2:1 rule (for maintenance fluids)

1) Traditional Maintenance Fluid - Estimation Method: First the first __kg - ___ mL/kg/hr Next 10 kg - ___ mL/kg/hr Each kg above ___ kg - add ___ mL/kg/hr

first 10 kg - 4 mL/kg/hr next 10 kg - add 2 mL/kg/hr every kg above 20 kg - add 1 mL/kg/hr

What are the maintenance fluid requirements for a 25 kg child?

40 + 20 + 5 65 mL/hr

Calculating maintenance fluids: for any patient above 20 kg, just add ___ to their weight to quickly calculate maintenance rate per hour. Ex: 50 kg patient requires what rate?

40 90 mL/hr

2) Replacement of Fluid Deficits: Preoperative Deficits 1) Calculate _____ ____ 2) Multiply by the number of hours _____ 3) Administer ___ over the first ____, then ___ each over the next ___ hours. Also assess for volume deficits as previously discussed (dry mucosa, poor skin turgor, etc. With ERAS, we consider them to have NO deficit. Inpatient NPO and w/ IV fluids is considered NO deficit.

maintenance rate NPO 1/2 - first hour 1/4 each over next 2 hours **if only 45 min surgery - consider heart condition, do they need it, etc.

3) Replacement of Ongoing Fluid Losses: Intraoperative blood loss: - With acute blood loss, ISF and extravascular fluid are transferred to the _____ space which _____ plasma volume. - So, if replacing blood loss w/ crystalloid, they must be given in amounts ___ blood loss* (replenishes intravascular AND interstitial fluid loss). - If colloids are used to replace blood loss, they are usually given __ to ___ as they remain intravascular. - When risk of anemia is greater then the risk of transfusion, give _____ to __ ratio.

intravascular space, maintains equal to 3x amount of blood loss (3:1)(Nagelhout says more like 2:1 or less) colloids: 1:1 PRBCs 1:1 (when to give PRBCs? when the patient needs oxygen-carrying capacity)

If a patient's blood loss is 100 mL, how much crystalloid would you add to the patient's total fluid intake?

300 mL in addition to maintenance rate and any deficit administration

4) Replacement of Ongoing Fluid Losses (Traditional) 1 "Third Spacing" - the distributional change of isotonic solution from a functional fluid compartment to a nonfunctional space. This can be caused by _____ trauma, _____ injuries, _____, _____, or _____. 2) This can also include ______ losses from air turnover in operative suites or respiratory evaporation.

``` surgical muscle burns peritonitis ascites ``` evaporative losses

It is difficult to calculate intraoperative losses from 3rd spacing b/c it is difficult to assess the degree of surgical trauma. It is based on ____ and degree of ______. Minimal trauma (herniorrhaphy, laparoscopic surgery): replace __-__ mL/kg Moderate (cholecystectomy): __-__ mL/kg Severe (bowel resection): __-__ mL/kg

weight & degree of trauma min: 0-2 mL/kg mod: 2-4 mL/kg sev: 4-8 mL/kg

CONTROVERSY: “In addition, until recently, liberal administration of fluid was commonplace to replace third-space losses. The third space was originally described as an all-consuming nonfunctional compartment where fluid can get sequestered during major surgery. It has never been localized, and tracer studies do not support its existence. Therefore, empiric filling of this ‘‘space’’ is not needed, and the term should be abandoned – fluid is either ______ or shifted into the ______.” Recently published studies have found that “replacement of ___ ____ losses… unnecessary” The suggestion is that _____ crystalloid administration improves outcomes after major elective GI surgery, but further investigation is required.

intravascular - interstitium (shifts DO occur, but no "third space" that needs to be replaced) third space restrictive *some studies suggest using more colloid instead of crystalloid in greater amounts

When to transfuse? - Increased risk historically - Allow hematocrit of ___ - Older or CAD, transfuse at ____

25 | 29

Decision Criteria for Transfusion: Class I: <15% volume decrease, <750 mL blood loss, Hgb > 10 - NOT necessary if no preexisting _____- Class II: 15-30% reduction, 750-1500 mL blood loss, Hgb 8-10 - NOT necessary, unless preexisting ____ and/or ____ ______ Class III: 30-40% reduction, 1500-2000 mL blood loss, Hgb 6-8 - _____ necessary Class IV: >40% reduction, > 2000 mL blood loss, Hgb

*in adult person weighing 70 kg with 5000 mL blood volume I - anemia II - anemia, cardiopulmonary disease III - probably necessary IV - necessary **Note: less conservative w/ children b/c blood volumes are smaller

Indications for Transfusing: 1) The risks of bleeding in surgical patients are determined by the extent/type of surgery, the capacity to control bleeding, the expected rate of bleeding, and the outcomes of uncontrolled bleeding. 2) RBC transfusions should not be dictated by a single _____ "trigger" but instead should be based on each individual patient's risks of developing complications of inadequate oxygenation. RBC transfusions are rarely indicated when the ____ concentration is > __ and are nearly always indicated when it is <___. The indications for autologous transfusion may be more liberal than for allogeneic transfusion. 3) Prophylactic platelet transfusion is _____ when thrombocytopenia is due to increased platelet destruction. Surgical patients w/ microvascular bleeding usually need platelet transfusion if the platelet count is < _____ and rarely platelet transfusion if the platelet count is > ____. 4) FFP is indicated for urgent ____ of _____ therapy, correction of known coagulation factor deficiencies for which specific concentrates are unavailable, and correction of microvascular bleeding when prothrombin and partial thromboplastic times are > 1.5 times normal. FFP is NOT indicated for increasing ____ _____ or _____ concentration. 5) _______ should be considered for patients w/ von Willebrand's disease unresponsive to desmopressin, bleeding patients w/ von Willebrand's disease, and bleeding patients w/ fibrinogen levels <80-100.

2 - hemoglobin - hemoglobin - >10, <6 3 - ineffective - <50,000, >100,000 4 - reversal of warfarin - plasma volume or albumin concentration 5 - cryoprecipitate

Estimated Blood Volume: ``` Preterm: ____ mL/kg Full-term: ___ mL/kg Infant: ___ mL/kg School Age: ___ mL/kg Adult: Males - ____, Females ____ ```

``` preterm - 100 / 95 full-term - 90 / 85 infant - 80 school - 75 adult male - 75 adult female - 65 ```

What is the formula for estimating blood volume?

HCT + 50 x weight (kg)

Allowable blood loss (ABL) can be determined by: 1) Calculation: ABL = 2) Preoperative estimation: loss of __-__% estimated blood volume (EBV) 3) Hgb of __ g/dL or __ g/dL in elderly or w/ cardiac/pulmonary disease

1) ABL = EBV x (Hct start - Hct allowed) / Hct start * Not an absolute trigger but consider transfusion at this point * use EBV 75 mL/kg in males, 65 mL/kg in females 2) 10-20% loss of EBV 3) 8 g/dL if healthy, 10 g/dL if not You also have to consider how much volume you have administered - are they diluted out? Are they still losing blood? If healthy, hold off on transfusing until they have stopping bleeding.

Blood Typing: The ANTIGENS __, __, and ___ are on the erythrocytes' ______. ANTIBODIES anti __ & __, form in the ____ naturally to which ever antigens that are NOT present. Ex: Type A has __ antigens and antibodies against ___ antigens. Type O has __ antigens and almost always has antibodies against both __ and ___ antigens. Type AB has both __ and __ antigens, but makes no antibodies against A or B antigens.

Antigens: A, B, Rh (D) - membranes Antibodies - Anti-A, B - plasma Type A: A antigens, anti-B antibodies Type O: NO antigens, antibodies against A/B antigens Type AB: A, B antigens - NO antibodies

Type A blood: __ antigens, ___ antibodies, compatible w/ ___ and ___

A Anit-B A or O

Type B blood: ___ antigens, ___ antibodies, compatible with ___, ___

B anti-A B, O

Type AB blood: ___ antigens, ___ antibodies, compatible w/ ___, ___, ___, ___ blood

A/B antigens NO antibodies AB, A, B, O

Type O blood: ___ antigens, ___ antibodies, compatible with ___

NO antigens anti-A AND anti-B O

Type Rh-positive: ___ antigens, ___ antibodies, compatible w/ ___ and ____

D antigens NO antibodies Rh + and -

Type Rh-negative: ___ antigens, ____ antibodies, compatible with ____

NO antigen Anti-D *IF* sensitized Rh negative only

During the _____ procedure, the donor blood is exposed to serum of KNOWN _____ and observed for antigen antibody reaction. Confirmation of the result is by mixing the donor serum w/ erythrocytes of a KNOWN _____ type.

typing serum w/ known antibodies erythrocytes w/ known antigen type

ABO incompatibility causes _____ of ____. __ antigens are the most common, occurring on 85% of patient's RBCs. However, people who don't have these antigens, do not automatically develop antibodies to ___. They will make the antibody if they are _____ to the antigen 70% of the time (pregnancy).

hemolysis of RBCs D - Rh Positive D - exposed *The fetus’ Rh positive blood enters the Rh negative maternal circulation and could stimulate the production of plasma anti-D antibodies. RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. RhoGAM is administered by intramuscular (IM) injection. RhoGAM is purified from human plasma containing anti-Rh (anti-D).

There are other antigens found in blood, however, they are less common and don't result in _____ production w/ exposure as readily (1%). Therefore, ____ takes longer. If found in a patient's blood, the _____ takes longer.

antibody hemolysis crossmatch

_____ is an in vitro check of what is to occur in vivo. It takes ___-___ minutes and is ____ specific. It double checks ____ and ___ type (5 minutes) and then has 3 phases/tests: 1) Major: donor's ___ w/ the recipient's _____ 2) Minor: recipient's ____ with the donor's _____ 3) Check for ___ ______(Kell, Kidd)

crossmatch 45-60 min unit specfic ABO, Rh type 1 - RBCs, plasma 2 - RBCs, plasma - not as much plasma in donor PRBCs 3 - IgE antibodies

_____ or ______ checks ABO & Rh type of recipient - this takes ___ minutes. It is NOT unit specific - it just screens for _____ in general. It is indicated if ____ ____ is a possibility, but not likely. The stored blood is available to more than one patient.

Type & screen - indirect Coombs test 30 min antibodies blood loss *** not crossmatched

Chances of Reactions: - Crossmatch 1: 100,000 - Type & screen: 1: 10,000 - Type-specific: 1: 1,000 (going by what patient has on card) - O-negative: 1: 500 Type-specific blood can be available in __ minutes and O-negative blood can be available ______.

5 min immediately Type and screen predicts compatible transfusions 99.94% of the time. Type and crossmatch increases the possibility of a compatible transfusion by only one-hundredth of one percent (99.95%) - so basically not that big of a deal

Transfusion of O-neg blood: O type has NO _____ on RBCs; Rh negative has NO ____ ______. O-neg is considered the universal _____. However, the small amount of plasma in PRBCs of O-neg (2 units) can contain sufficient amounts of ____ and ____ ______ to result in hemolysis. **Once O-neg is given, you need to stick with O-neg! Group & Type-specific blood is preferred.

O: no antigens Rh neg: no D antigens donor anti-A, anti-B antibodies

Blood Storage: 1) CPD (citrate-phosphate-dextrose) or CPD-A (adenine) _____ is added 2) It is stored at __-__ degree C 3) W/ CPD, lasts ___ days 4) W/ CPD-A, lasts ___ days 5) Over time, the blood changes. K is 3.9 at day 1 and ___ at day 21! ``` increase or decrease with older blood ... Ph Pco2 viable platelets factors 5 and 8 ``` **Can be problematic w/ massive transfusions

``` 1 - preservative 2 - 1-6 degree 3 - 21 days 4 - 35 days 5 - 21 ``` ph decreases pco2 increases viable platelets decrease factors 5 & 8 decreases *pH day 1 is 7.1 to day 21 6.9 pCO2 day 1 is 48 to day 7 is 140 Viable platelets day 1 10% to day 7 0% Factors V and VIII day 1 70 to day 7 20%

PRBCs typically contain ___-___ mL with a hematocrit of __-__%. Indication: _____ associated w/ acute blood loss to increase _____ _____ capacity of blood. Reconsitute w/ ______ such as ___ or _____ 50-100 mL (D5W causes _____ and LR contains _____) *PRBCs contain less ____ than whole blood. Since this is what contains antibodies, it reduces the likelihood of _____ but also reduces the concentrations of factors __ and ___. It also contains less _____. Whole blood is indicated if blood loss is greater than ____ mL.

250-300 mL - 70-80% anemia - oxygen-carrying crystalloid - NS, Plasmalyte hemolysis, calcium plasma - reactions - V, VIII - citrate >1500 mL

For every __mL of PRBCs transfused per kg of body weight, the hematocrit should rise about __%. Based on an average blood volume of 5,000 mL, each PRBC unit should raise the hematocrit by __-__%. Pediatrics: ___mL/kg will increase the Hct by ___% or Hgb by __ g/dL

1 mL/kg - rise 1% 3-4% (if blood volume is 75 mL for male, blood volume would be for a 67 kg male, or if female (65 mL) for a 77 kg female) 10 mL/kg - 10%, 3

Platelets are indicated for the treatment of ______ without giving unnecessary blood. Platelet counts of <50,000 is associated w/ increased bleeding. One unit of platelets will increase the platelet count ____ to _____ mm3 ___ hour after. The half-life of platelets is ~__ hours. RISKS: 1) sensitization to human _____ _____ on cell membranes, 2) transmission of ___ ____ (d/t multiple donors), 3) platelets are stored at 22 C (instead of 4 C) which increases the potential for ____ _____ Possible to transfuse for one donor or leukoreduction.

thrombocytopenia (may also need w/ massive transfusions d/t dilutional thrombocytopenia) - commonly seen w/ splenectomy but wait to administer until after they have cross-clamped 10,000-20,000 24 hours 1 - leukocyte antigens (promotes formation of HLA antibodies) 2 - viral diseases 3 - bacterial growht

Fresh frozen plasma is the plasma portion from a unit of whole blood that is frozen within __ hours of collection. It contains ____ _____ except _____. Indication: treatment of _____ ______ A single unit (250 mL) should raise ____ _____ levels by __-__% RISKS: transmission of ____ disease and _____ _____ d/t preservatives

6 hours coagulation factors - no platelets coagulation factors (oozing but no true source of bleeding - may give FFP and Plts) coagulation factor - 7-8% viral - allergic reactions

Cryoprecipitate is the primary source of ___ ______ factor and also contains factor ____, _____, and _____. Indications: treating _____; treating _____ w/ ______ RISKS: transmission of ____ _____ and ____ _____

von Willebrand's, VIII, fibrinogen, fibronectin hemophilia, DIC - disseminated intravascular coagulopathy w/ fibrinolysis viral diseases, allergic reaction **when FFP is thawed, the fraction of plasma that precipitates

More than 50% of transfusions are given during the perioperative period. The overall incidence of adverse reaction to PRBCs is reported to be 0.73%. Complications Include: 1) Transfusion Reactions: _____ and _____ 2) _____ Reactions 3) _____ 4) _____ 5) Transmission of ____, ____ 6) _____ in specimen 7) W/ large volumes: ____, _____, _____ changes, _____/______ 8) ______ disorders

1 febrile, allergic 2 hemolytic 3 TRALI (transfusion related acute lung injury) 4 TACO (transfusion assoc. circulatory overload) 5 HIV, hepatitis 6 microaggregates 7 - hypothermia, hyperkalemia, acid/base changes, hypocalcemia, hypomagnesia 8 coagulation disorders

Transfusion Reactions: 1) _____: Most common (1-5%) - temperature rarely increases above ___ C. Treat by _____ transfusion and giving ______ 2) _____: fever, pruritis, urticaria - Treat by administering ______ and in severe cases by _____ blood. Look for _____ in urine to r/o hemolytic reaction. This is usually related to ____ ____ d/t preservatives.

febrile - 38 C - SLOWING - antipyretics allergic - antihistamine - DISCONTINUING - Hemoglobin - plasma products

The greatest risk of transfusions is ____ ____ - up to 60% of all fatalities due to blood administration are due to ____ erros.

human error | clerical

______ reactions are due to ABO incompatibility. It primarily occurs when a ____ ____ leads to administration of ABO-incompatible blood.

hemolytic human error

In the OR, hemolytic reaction is manifested by intractable ______ in the operating field, _____ and ____, _____, and ________. The FIRST sign of hemolytic reaction under GA is usually ______. Free _____ in the urine is also a sign. Acute renal failure is causes by precipitation of contents of hemolyzed RBCs in the distal renal tubules. _____ is initiated by material released from the hemolyzed RBCs.

bleeding (and oozing), hypotension, shock, fever, hemoglobinuria hypotension hemoglobin - if no foley and you are suspicious of reaction, put in foley ASAP DIC

The ______ of RBCs transfused determines the SEVERITY of the hemolytic reaction. Treatment: 1) ______ ______ 2) Infuse ______ 3) Administer ____, _____, or ______ (diurese) 4) Administer _____ _____ to alkalinize the urine and increase the solubility of products in the renal tubules. 5) Confirm _____ 6) ___ ______ 7) Return unused portion of donor unit to ___ ____ 8) Treat ______ w/ platelet and coagulation factors

volume - volumes as small as 10 mL may lead to hemolytic reactions in 20-60% of recipients ``` 1 - discontinue infusion 2 - crystalloid - dilute cell lysis 3 - mannitol, lasix, dopamine 4 - sodium bicarb 5 - hemolysis 6 - re-crossmatch 7 - blood bank 8 - coagulopathy ```

Treatment of Hemolytic Reactions (ASA Guidelines): 1) _____ ______ 2) Supportive measures to maintain ____ _____ 3) Aggressive transfusion of _____, ____, and ______ to counteract consumptive coagulopathy 4) maintaining ____ _____ capacity through transfusion of ___ ____ RBCs

1- stop blood transfusion 2 - blood pressure 3 - FFP, platelets, cryo 4 - O2-carrying - type O

______ is now the leading cause of transfusion-associated fatalities. It is caused by donor _____ in plasma-containing blood components (usually FFP/platelets, occasionally RBCs) interacting w/ ______ on the patient's granulocytes (HLA or granulocyte specific) resulting in granulocytes aggregation and complement activation in the ____ ______. Symptoms occur within ___ hours of transfusion and include fever, ______, ______, and increased ______. Treatment: 1) _____ 2) start critical care supportive measures

TRALI - transfusion-related acute lung injury antibodies - antigens on granulocytes - lung capillaries 6 hours hypoxemia, acute respiratory distress (non-cardiogenic pulmonary edema), increased PIP 1 - STOP transfusion * clinically looks like ARDS * HLA and HNA antibodies are more common in FEMALES - use MALE plasma products

Review charts comparing TRALI to TACO on slide 79. TACO is simply volume _____ where rate of volume infusion of blood products is in excess of what the patient's CV status can handle - causes acute onset ____, _____, ______, ______, and heart failure. Basically pulmonary edema.

overload | dyspnea (pulmonary edema), hypertension, tachypnea, tachycardia

Review complications/risks chart on slide 80: Note that EVERYONE we transfuse will acquire _____ ______.

immunosuppression - can affect healing after surgery

Chance of transmission of _____: 1:1,500,000 to 1:2,000,000 chance that a unit of blood carriers the ___ antigen However, _____ is less feared, but has greater morbidity and mortality to blood recipients. Chance are 1:1-2 million that a unit has potential to transmit ____ ___, 1:200,000-360,000 to transmit ___ ___. 1:10,000 transfused patients will develop chronic _____ leading to liver failure or hepatocellular cancer.

HIV - HIV antigen hepatitis Hep C Hep B (greater risk) hepatitis

_______ can form in storage by platelets and leukocytes and INCREASES w/ time in storage. It is associated w/ pulmonary dysfunction (TRALI). There are fewer in _____ than in ____ _____. *Administer through 40 micron filter - standard blood filter is ___ micron filter (no study shows improved results though).

microaggregates PRBCs, whole blood 170

Large volume transfusions can result in: 1) ______ (blood stored at <6 C) - may cause cardiac irritability, shivering, increased O2 consumption - WARM 2) ______: K+ content increases w/ time of storage - transfusion of 1 unit every __ minutes can cause increased K+ - if you see ____ ___ waves on EKG, consider ____ 3) ____ changes: pH of stored blood becomes more ____ the longer it is stored (preservative has a pH of 5-5.6) However, citrate metabolism to bicarbonate may contribute to metabolic _____. 4) Citrate binds _____ and _____ resulting in _____ and _____ (rarely). Consider supplemental calcium if: - transfusion exceeds __mL/min (1 unit per 5 min) - ______ or _____ disease interferes w/ metabolism of citrate - The patient is a _______

1 - hypothermia (A decrease of patient’s temp of as little as 0.5 degrees C will induce shivering and increase oxygen consumption by 400%. Arrhythmias at 32 degrees C) 2 - hyperkalemia - 5 minutes - peaked T waves - CaCl 3 - acid/base - acidic - alkalosis 4 - calcium and magnesium - hypocalcemia, hypomagnesium - >50 mL/min - hypothermia or liver disease - neonate **When large numbers of blood components are transfused over a short period of time, the metabolism of citrate is overwhelmed and the patient develops citrate toxicity. Citrate toxicity may result in adverse cardiac manifestations. Citrate is present in significant amounts in all blood components.

Transfusions can cause coagulation disorders: 1) Dilutional _______: _____ are absent from stored blood after just 24 hours. Levels below <100,000 associated w/ increased bleeding. 2) Dilution of factors ___ and ___: only 5-20% of normal level are necessary for normal clotting. It is RARE that this is the problem. If needed, give ____. 3) ____: the activation of the coagulation system w/ consumption of platelets and coagulants. To treat, ____ __ ____, administer ____ and ____.

1 - thrombocytopenia - platelets 2 - V and VIII - FFP 3 - DIC - REMOVE THE CAUSE, FFP, platelets (could be caused by hemolytic transfusion reaction, low CO, tissue hypoxia, acidosis, hypovolemia)

What are the 4 alternatives to blood transfusions?

1 - autologous transfusions 2 - cell-saver 3 - normovolemic hemodilution 4 - donor-directed transfusions

______ transfusion: patient donates their own blood Collection is started __-__ weeks prior to surgery and is only allowed if Hct is ___% (iron supplements, erythropoietin therapy*). A minimum of ___ hours between donations is required to allow plasma volume to normalize. This is NOT complication free - ____ errors, allergic reactions to ethylene oxide (used to sterilize donation bags) can occur.

Autologous 4-5 weeks prior Hct 34% (erythropoietin has black box issues) 72 hours between donations clerical errosrs

____ _____ is blood salvage and reinfusion. It is used during cardiac, vascular, and orthopedic cases. _____ w/ _____ solution is used to collect. When a sufficient amount is collected, the RBCs are concentrated and washed to remove debris and anticoagulant and is then reinfused. The Hct is usually __-__%. It is best if blood loss exceeds ___-___ mL. Contraindications include ____ ____ and _____ _____.

cell saver suction w/ heparin 50-60% 1000-1500 mL septic wound, malignant tumor

______ _______: blood is removed from the patient just prior to surgery and replaced w/ crystalloid or colloid to achieve a Hct of ___-___%. It is stored in a CPD bag until the end of surgery (6 hours) or end of blood loss, if possible. Then, it is reinfused. The principle is that the number of RBCs lost in a ____ blood loss is reduced. Yet, ____ is maintained by the normovolemic state.

normovolemic hemodilution 21-25% dilute CO

_____ _____ _______: blood donated from ABO compatible friends and family members. This requires __-__ days to process. Studies have shown that bank blood is ____ or there is no difference.

donor-directed transfusions 3-7 days safer

Review practice problems/calculations and podcasts.