Exam IV: Peds Intraop Fluid Mngmnt

Question 1

Children have small size, large surface area to _____ratio and immature ______ mechanisms.

Answer 1

volume
homeostasis

Question 2

Hypo- and hyper______, hypo- and hyper_____ are common.

Answer 2

natremia
kalemia

Question 3

Children overload _____ and dehydrate ____.

Answer 3

easily
easily

Question 4

Large amounts of IV fluids should be _____.

Answer 4

warmed

Question 5

____ should continue perioperatively.

Answer 5

TPN

Question 6

Use volumetric chambers, micro-drips and/or pumps for children ____ years old

Answer 6

<10

Question 7

Intraop

Give maintenance _____ to patients on preop TPN or high glucose solutions.
Use ___-____ _____ (LR, NS, plasmalyte) for maintenance and 3rd space losses.
Use NS* or plasmalyte to mix with ____ _____.

Answer 7

glucose
non-glucose crystalloid
transfused PRBCs

Question 8

Intraop

“Old” PRBCs have higher ____. Beware of potentially lethal hyper_____ for massive transfusion (>1 blood volume).

Answer 8

K+
hyperkalemia

Question 9

Massive transfusion leads to hypo______ (citrate binds ____)

Answer 9

hypocalcemia
Ca++

Question 10

Use _____ for dilutional thrombocytopenia or documented decreased platelet count.

Answer 10

platelets

Question 11

Use ____ for dilutional coagulopathy or surgical “oozing”.

Answer 11

FFP

Question 12

_____: Albumin, hetastarch, blood products

Answer 12

Colloids

Question 13

Consider autologous donation, directed donors, cell saver, deliberate hypotension, or normovolemic hemodilution for ____ ____ ____ procedures.

Answer 13

high blood loss

Question 14

____ _____ a low Hct in healthy, hemodynamically stable patients, especially if blood losing is over.

Answer 14

“Ride out”

Question 15

Hypernatremia
Acute: ____, ____, _____
Treatment: ____ or ____ ____ with slow correction of Na+

Answer 15

Irritability, coma, seizures
Colloid or NS bolus

Question 16

Hyponatremia
Acute: Headache, nausea, weakness, confusion, irritability, seizures
Advanced: _____ arrest, _____ _____ injury
Treatment: ____ correction for asymptomatic case
Acute: _____ correction

Answer 16

Respiratory arrest, irreversible neurologic injury
Slow
Rapid

Question 17

Hyperkalemia
Acute: Renal insufficiency, massive tissue trauma, acidosis, sux with myopathies, burns, motor neuron disease, sepsis, massive transfusion, MH
_____ T waves, PR _____, QRS _____, eventual sinusoidal
Treatment:

Answer 17

Peaked
lengthening
widening
IV Ca++, bicarbonate for acidosis, glucose/insulin

Question 18

Hypokalemia
Acute: Vomiting, diarrhea
Muscle weakness, _____ QT, _____ T waves, ___ waves
Treatment: Oral supplements if possible or ____ ____ correction

Answer 18

prolonged
dampened
U
slow IV

Question 19

Intraoperative fluids lost by (4)

Answer 19

• Surgical blood loss
• Surgical trauma/capillary leaking leading to protein movement into the interstitial space (3rd space loss)
• Anesthesia causes vasodilation which causes relative hypovolemia
• Direct evaporation

Question 20

Replace blood loss __:__ with blood products or colloids OR __:___ with isotonic crystalloid*

Answer 20

1:1
1:1.5 – 3

*numbers vary for ratio of blood loss to crystalloid

Question 21

HYPERCHLOREMIC ACIDOSIS

large amounts of NS cause excess _____ which leads to acidosis

Answer 21

Cl-

Question 22

HYPERCHLOREMIC ACIDOSIS

acidosis does not occur with equivalent amounts of ___

Answer 22

LR

Question 23

HYPERCHLOREMIC ACIDOSIS

LR is _____ with blood products

Answer 23

incompatible
(Ca++ binds to citrate which leads to emboli)

Question 24

HYPERCHLOREMIC ACIDOSIS

Consider _____ to NS when transfusing (Ex: plasmalyte, normosol).

Answer 24

alternative

Question 25

Massive Blood Transfusion (MBT) in Children Defined: Replacement of one or more blood volumes (BV) - or >___mL/kg in <___ hours

Answer 25

30 4

Question 26

Massive Blood Transfusion (MBT) in Children ____ until crossmatched (O+ can be used in males???)

Answer 26

O-

Question 27

Massive Blood Transfusion (MBT) in Children Damage control approaches ___ ____ ____ in children.

Answer 27

not fully studied

Question 28

Massive Blood Transfusion (MBT) in Children MBT-induced coagulopathy usually d/t _____. Other causes: _____, ____ Fixed ratio (1:1:1) not fully researched in children.

Answer 28

dilution Fibrinolysis, DIC

Question 29

Massive Blood Transfusion (MBT) in Children ___-____ BVs lost causes significant thrombocytopenia which leads to bleeding Consider platelet (plt) transfusion after ___-___ BVs. Plt needs dependent on starting plt count & function.

Answer 29

2 – 2.5 1 – 1.5

Question 30

Massive Blood Transfusion (MBT) in Children Replacement of 1 – 1.5 BVs with PRBCs and fluids leads to ___% loss of clotting factors Consider FFP after __ BV Author recommendation: Give FFP after 1 BV loss then 1 FFP : 2 PRBCs Check coags after ____ ____ loss.

Answer 30

70 1 every BV

Question 31

Massive Blood Transfusion (MBT) in Children FDA approved factor VII (Novo 7): Hemophilia, congenital factor VII deficiency Caution in children when using off-label (surgery or trauma induced bleeding) and ONLY for ___-____ _____

Answer 31

life-threatening bleeding.

Question 32

Massive Blood Transfusion (MBT) in Children In the lit: Early use of ____ in children supported

Answer 32

TXA

Question 33

Massive Blood Transfusion (MBT) in Children ____: Suspect with ongoing bleeding if pre-op coags and plt ct were WNL. Treat the ____ (shock, acidosis, sepsis)

Answer 33

DIC cause

Question 34

MBT in children Hyperkalemia: Risk increases with increased PRBC ____ ____ and _____

Answer 34

shelf time and irradiation.

Question 35

MBT - hyperkalemia Usually ___ _____ with slow rate through peripheral IV.

Answer 35

not problematic

Question 36

MBT - hyperkalemia 120ml/min/70 kg = ___mL/kg/min/small child

Answer 36

2

Question 37

MBT - hyperkalemia Hyperkalemia during MBT usually d/t:

Answer 37

tissue injury, rapid transfusion, acidosis (poor perfusion), hypothermia, hypocalcemia.

Question 38

MBT - hyperkalemia Hyperkalemic EKG: _____ dysrhythmia and ____ T waves (p. 213)

Answer 38

Ventricular peaked

Question 39

MBT - hyperkalemia Treatment:

Answer 39

Ca++, hyperventilation, bicarb, albuterol, glucose/insulin (p. 214)

Question 40

MBT - hyperkalemia Author recommendation: Anticipate blood loss, transfuse early, PIV if possible, use warming devices and minimize use of “old” blood, especially if irradiated. Dilemma: _____________________

Answer 40

Small bore PIV vs large bore CVL

Question 41

MBT: Hypocalcemia and/or citrate toxicity EKG: Widened QRS, prolonged QT, peaked T waves Hypocalcemia and hyperkalemia treated with _____.

Answer 41

Ca++

Question 42

MBT: Treat documented ____ with bicarb.

Answer 42

acidosis

Question 43

MBT: Prevent/treat _____ aggressively.

Answer 43

hypothermia

Question 44

MBT: TEG and ROTEM (_____ therapy) growing in popularity

Answer 44

targeted!!!!

Question 45

MBT: lethal triad

Answer 45

hypothermia coagulopathy acidosis

Question 46

Maintenance IV Fluid Requirements(_______- Rule)

Answer 46

4-2-1

Question 47

weight: < 10 kg needs ___ ml/kg/hr

Answer 47

4

Question 48

weight: 10-20 kg needs ___+___ mL/kg for each kg > ____

Answer 48

40 + 2 10

Question 49

weight > 20 kg needs ___+___ mL/kg for each kg > ____

Answer 49

60+1 20

Question 50

How many hours has the child been NPO? What is the child’s hourly maintenance rate? Deficit equation is ________________

Answer 50

Deficit = maintenance rate x hours NPO

Question 51

Third Space Losses* level mild (insensible, small incision, scopes) = __-__ mL/kg/hr

Answer 51

3-4

Question 52

Third Space Losses* level mod (ortho, large incision) = __-__ mL/kg/hr

Answer 52

5-7

Question 53

Third Space Losses* level extensive (open, abdominal, spinal) = ____ mL/kg/hr

Answer 53

>10

Question 54

Maximum Allowable Blood Loss Calculate child’s ____ ____ _____ (EBV)

Answer 54

estimated blood volume

Question 55

Maximum Allowable Blood Loss Choose transfusion trigger (frequently Hct of ___ used)

Answer 55

25

Question 56

Maximum Allowable Blood Loss 10-15 mL/kg PRBCs causes Hgb increase by __-___ g/dL

Answer 56

2-3

Question 57

MABL =

Answer 57

(EBV x (starting Hct - trigger Hct)) / starting Hct

Question 58

Replace ½ of fluid deficit during ____ hour ¼ during ____ hour ¼ during ____ hour Maintenance + 3rd space + deficit = mL/Hour Do not exceed ___ mL/kg/hour (unless replacing blood loss). EBL must be replaced in addition to above. Roll “left-over” to next hour.

Answer 58

1st 2nd 3rd 20