Exam IV: Peds Intraop Fluid Mngmnt Flashcards
Children have small size, large surface area to _____ratio and immature ______ mechanisms.
volume
homeostasis
Hypo- and hyper______, hypo- and hyper_____ are common.
natremia
kalemia
Children overload _____ and dehydrate ____.
easily
easily
Large amounts of IV fluids should be _____.
warmed
____ should continue perioperatively.
TPN
Use volumetric chambers, micro-drips and/or pumps for children ____ years old
<10
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 ____ _____.
glucose
non-glucose crystalloid
transfused PRBCs
Intraop
“Old” PRBCs have higher ____. Beware of potentially lethal hyper_____ for massive transfusion (>1 blood volume).
K+
hyperkalemia
Massive transfusion leads to hypo______ (citrate binds ____)
hypocalcemia
Ca++
Use _____ for dilutional thrombocytopenia or documented decreased platelet count.
platelets
Use ____ for dilutional coagulopathy or surgical “oozing”.
FFP
_____: Albumin, hetastarch, blood products
Colloids
Consider autologous donation, directed donors, cell saver, deliberate hypotension, or normovolemic hemodilution for ____ ____ ____ procedures.
high blood loss
____ _____ a low Hct in healthy, hemodynamically stable patients, especially if blood losing is over.
“Ride out”
Hypernatremia
Acute: ____, ____, _____
Treatment: ____ or ____ ____ with slow correction of Na+
Irritability, coma, seizures
Colloid or NS bolus
Hyponatremia
Acute: Headache, nausea, weakness, confusion, irritability, seizures
Advanced: _____ arrest, _____ _____ injury
Treatment: ____ correction for asymptomatic case
Acute: _____ correction
Respiratory arrest, irreversible neurologic injury
Slow
Rapid
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:
Peaked
lengthening
widening
IV Ca++, bicarbonate for acidosis, glucose/insulin
Hypokalemia
Acute: Vomiting, diarrhea
Muscle weakness, _____ QT, _____ T waves, ___ waves
Treatment: Oral supplements if possible or ____ ____ correction
prolonged
dampened
U
slow IV
Intraoperative fluids lost by (4)
- 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
Replace blood loss __:__ with blood products or colloids OR __:___ with isotonic crystalloid*
1:1
1:1.5 – 3
*numbers vary for ratio of blood loss to crystalloid
HYPERCHLOREMIC ACIDOSIS
large amounts of NS cause excess _____ which leads to acidosis
Cl-
HYPERCHLOREMIC ACIDOSIS
acidosis does not occur with equivalent amounts of ___
LR
HYPERCHLOREMIC ACIDOSIS
LR is _____ with blood products
incompatible
(Ca++ binds to citrate which leads to emboli)
HYPERCHLOREMIC ACIDOSIS
Consider _____ to NS when transfusing (Ex: plasmalyte, normosol).
alternative
Massive Blood Transfusion (MBT) in Children
Defined: Replacement of one or more blood volumes (BV) - or >___mL/kg in <___ hours
30
4
Massive Blood Transfusion (MBT) in Children
____ until crossmatched (O+ can be used in males???)
O-
Massive Blood Transfusion (MBT) in Children
Damage control approaches ___ ____ ____ in children.
not fully studied
Massive Blood Transfusion (MBT) in Children
MBT-induced coagulopathy usually d/t _____.
Other causes: _____, ____
Fixed ratio (1:1:1) not fully researched in children.
dilution
Fibrinolysis, DIC
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.
2 – 2.5
1 – 1.5
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.
70
1
every BV
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 ___-____ _____
life-threatening bleeding.
Massive Blood Transfusion (MBT) in Children
In the lit: Early use of ____ in children supported
TXA
Massive Blood Transfusion (MBT) in Children
____: Suspect with ongoing bleeding if pre-op coags and plt ct were WNL.
Treat the ____ (shock, acidosis, sepsis)
DIC
cause
MBT in children
Hyperkalemia: Risk increases with increased PRBC ____ ____ and _____
shelf time and irradiation.
MBT - hyperkalemia
Usually ___ _____ with slow rate through peripheral IV.
not problematic
MBT - hyperkalemia
120ml/min/70 kg = ___mL/kg/min/small child
2
MBT - hyperkalemia
Hyperkalemia during MBT usually d/t:
tissue injury, rapid transfusion, acidosis (poor perfusion), hypothermia, hypocalcemia.
MBT - hyperkalemia
Hyperkalemic EKG: _____ dysrhythmia and ____ T waves (p. 213)
Ventricular
peaked
MBT - hyperkalemia
Treatment:
Ca++, hyperventilation, bicarb, albuterol, glucose/insulin (p. 214)
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: _____________________
Small bore PIV vs large bore CVL
MBT:
Hypocalcemia and/or citrate toxicity EKG: Widened QRS, prolonged QT, peaked T waves
Hypocalcemia and hyperkalemia treated with _____.
Ca++
MBT:
Treat documented ____ with bicarb.
acidosis
MBT:
Prevent/treat _____ aggressively.
hypothermia
MBT:
TEG and ROTEM (_____ therapy) growing in popularity
targeted!!!!
MBT:
lethal triad
hypothermia
coagulopathy
acidosis
Maintenance IV Fluid Requirements(_______- Rule)
4-2-1
weight: < 10 kg needs ___ ml/kg/hr
4
weight: 10-20 kg needs ___+___ mL/kg for each kg > ____
40 + 2
10
weight > 20 kg needs ___+___ mL/kg for each kg > ____
60+1
20
How many hours has the child been NPO?
What is the child’s hourly maintenance rate?
Deficit equation is ________________
Deficit = maintenance rate x hours NPO
Third Space Losses*
level mild (insensible, small incision, scopes) = __-__ mL/kg/hr
3-4
Third Space Losses*
level mod (ortho, large incision) = __-__ mL/kg/hr
5-7
Third Space Losses*
level extensive (open, abdominal, spinal) = ____ mL/kg/hr
> 10
Maximum Allowable Blood Loss
Calculate child’s ____ ____ _____ (EBV)
estimated blood volume
Maximum Allowable Blood Loss
Choose transfusion trigger (frequently Hct of ___ used)
25
Maximum Allowable Blood Loss
10-15 mL/kg PRBCs causes Hgb increase by __-___ g/dL
2-3
MABL =
(EBV x (starting Hct - trigger Hct)) / starting Hct
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.
1st
2nd
3rd
20
