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Principles of Anesthesia I > Final - Fluid Mgmt > Flashcards

Final - Fluid Mgmt Flashcards

1
Q

What percentage of total body weight is water?

A
  • 60%

Elderly and Obese patients will have lower percent of water in the body.

Pediatrics will have HIGHER percent of water in the body (Table 47.1)

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2
Q

What are the two main compartments fluid compartments?
How much does each compartment make up of TBW?

A
  • Intracellular Fluid (ICF) makes up two-thirds of total body water
  • Extracellular Fluid (ECF) makes up one-third of total body water
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3
Q

What are the 3 different compartments of the ECF?
A. intracellular
B. interstitial
C. extravascular
D. intravascular
E. transcellular
F. intrastitial

A

B. Interstitial: lymphatics and protein-poor fluid around the cell.

D. Intravascular: plasma volume

E. Transcellular: GI Tract, Urin, CSF, Joint fluid, aqueous humor.

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4
Q

Diffusion involves solute particles filling the solvent by moving from ___ to ___ concentrations.
A. low to high
B. high to low
C. different to same

A

B.. High to Low concentration
* occur across permeable membranes
* relate to electrical gradients

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5
Q

What are types of solutes found in our body? Select 2.
A. norepinephrine
B. glucose
C. proteins
D. ADH

A

B. Glucose
C. Proteins (Albumin, globulins, fibrinogen)
and Electrolytes!

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6
Q

What is the primary extracellular cation?

primary intracellular cation?

A

extra: Sodium (Na+)
intra: Potassium (K+)

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7
Q

Osmosis is the movement of water through a semipermeable membrane from ___ solute concentration.
A. low to high
B. high to low
C. similar

A

movement of WATER which diffuses from low to high solute concentration

Semipermeable membrane is what separates pure water from water with solute!

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8
Q

What is osmotic pressure?
A. pressure that has less pull on water
B. pressure that proteins place on walls of container
C. pressure that resists the movement of water thru osmosis
D. pressure that allows water to move freely thru membranes

A

C. Pressure that resists the movement of water through osmosis

more oncotic pressure = more pull

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9
Q

What is osmolarity?

A. number of osmotically active particles per L of solvent
B. number of osmotically inactive particles per L of solvent
C. number of osmotically active particles per kg of solvent
D. number of osmotically inactive particles per kg of solvent

A

A. Number of osmotically active particles per L of solvent

Higher osmolarity, higher “pulling power”

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10
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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11
Q

What is osmolality?

A. number of osmotically active particles per L of solvent
B. number of osmotically inactive particles per L of solvent
C. number of osmotically active particles per kg of solvent
D. number of osmotically inactive particles per kg of solvent

A

C. Number of osmotically active particles per Kg of solvent

unit is usually mOsm

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12
Q

What is normal osmolality?
A. 200-210 mOsm
B. 250-260 mOsm
C. 280-290 mOsm
D. 300-310 mOsm

A

C. 280-290 mOsm

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13
Q

Oncotic pressure is the component of total osmotic pressure due to ___?

A. electrolytes
B. colloids
C. crystalloids
D. glucose

A

B. component of total osmotic pressure due to colloids

aka albumin, globulins, fibrinogen

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14
Q

What percentage of oncotic pressure is due to albumin?

A

65-75%

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15
Q

What makes up our daily average intake?
Solids:
Metabolism:
Liquids:

A

Solids - 750 mL
Metabolism - 350 mL
Liquids - 1400 mL

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16
Q

What makes up our daily output?
Insensible loss:
GI loss:
UOP:

A

Insensible Loss - 1000 mL
GI loss - 100 mL
Urine output - 0.5-1 mL/kg/hr

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17
Q

Urine secretion accounts for ____-% of daily water loss.

A
  • 60%
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18
Q

What 3 hormones regulate urine output?

A
  • ADH
  • ANP
  • Aldosterone
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19
Q

How does ADH regulate urine output?

A

Renal H2O excretion/retention in response to plasma tonicity

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20
Q

How does ANP regulate urine output?

A
  • ANP is activated by ↑ fluid volume
  • ↑ Atrial Stretch = ↑ Renal Excretion
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21
Q

How does Aldosterone regulate urine output?

A
  • Regulates sodium and potassium levels
  • Aldosterone is released if sodium and fluid volume decreases, causing sodium and water conservation.
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22
Q

What are the sensors for fluid balance?

A
  • Hypothalamic osmoreceptors
  • Low-pressure baroreceptors (large veins and RA)
  • High-pressure baroreceptors (carotid sinus and aortic arch)
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23
Q

What is the trigger for fluid balance?

A
  • Increased thirst or increase ADH
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24
Q

What are the compensatory mechanisms for acute disturbances in circulating volume?

A
  • Venoconstriction
  • Mobilization of venous reservoir
  • Autotransfusion from ISF to plasma
  • Reduced urine production
  • Maintenance of CO…tachycardia, increased inotropy
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25
Q

Where is Renin released?

What does Renin do to angiotensinogen?

A
  • Released from juxtaglomerular cells
  • Cleaves angiotensinogen to make angiotensin I
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26
Q

When ANG I → ANG II, what will this cause?
A. vasodilation and aldosterone release
B. vasodilation and ADH release
C. vasoconstriction and ADH release
D. vasoconstriction and aldosterone release

A

D. Vasoconstriction and aldosterone release

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27
Q

Where is aldosterone released from?

A
  • Aldosterone is released from the adrenal cortex and causes salt and water retention
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28
Q

In the absence of ongoing fluid loss, loss volume should be restored within ______- hours (range).

A
  • 12-72 hours
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29
Q

In the absence of ongoing fluid loss, RBC should be restored through erythropoiesis in ______ weeks (range).

A
  • 4-8 weeks.
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30
Q

What are the Electrolytes (Na+ and Cl-) and Osmolarity of Normal Saline (0.9%)?

A

Na+: 154 mEq/L
Chloride: 154 mEq/L
Osmolarity: 308 mOsm/L

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31
Q

What are the Electrolytes and Osmolarity of LR?

A

Na+: 130 mEq/L
K+: 4 mEq/L
Chloride: 109 mEq/L
Lactate: 28 mEq/L
Osmolarity: 274 mOsm/L

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32
Q

What are the Electrolytes and Osmolarity of Plasmalyte?

A

Na+: 140 mEq/L
K+: 5 mEq/L
Cl-: 98 mEq/L
Acetate: 27 mEq/L
Osmolarity: 295 mOsm/L

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33
Q

What are the Electrolytes and Osmolarity of Albumin 5%?

A

Na+: 145 +/- 15 mEq/L
K+: <2.5 mEq/L
Cl-: 100 mEq/L
Osmolarity: 330 mOsm/L

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34
Q

What are the Electrolytes and Osmolarity of Hetastarch 6%?

A

Na+: 154 mEq/L
Cl-: 154 mEq/L
Osmolarity: 310 mOsm/L

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35
Q

What are crystalloids?
A. Balanced solution of sodium and chloride in saline
B. Solutions of electrolytes in water
C. Balanced solution of sodium and chloride in water
D. Solutions of electrolytes in saline

A

B. Solutions of electrolytes in water
they are called balanced solutions (but not really balanced; misnomer)

LR is probably considered the most “balanced” crystalloid

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36
Q

What are indications of using crystalloids?

A
  • Replacement of free water and electrolytes
  • Volume expansion
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37
Q

With crystalloid administration and distribution throughout the EFC, what percentage will be in the intravascular space after 20 minutes?

What about after 30 minutes?

A
  • 70% in the intravascular space after 20 minutes
  • 50% in the intravascular space after 30 minutes
38
Q

What are the negative effects of crystalloids?

A
  • Tissue Edema (Lungs, GI Tract, Soft Tissues)
  • Hypercoagulability (Anticoagulant factors diluted)- micro emboli
39
Q

NS 0.9% is the most commonly fluid, but what are the negative consequence of this fluid?

A
  • Dilutes Hct and Albumin
  • Late onset of diuresis
  • Increase AKI and dialysis in ICU patients
  • Causes hyperchloremic metabolic acidosis if too much is given resulting in increase in chloride and potassium concentrations.
40
Q

What fluid will pull water out of the ICF to the ECF including the plasma? Furthermore, this fluid is used to treat HYPO-osmolar hyponatremia and treat increase ICP.

A
  • Hypertonic Saline 3%
  • Can be used to treat SEVERE TUR syndrome
41
Q

What is added to LR to act as a buffer?

42
Q

You want to avoid using this fluid for patients with liver insufficiency.

A
  • 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.
43
Q

Which fluid will excrete excess water faster than NS d/t the transient decrease in plasma tonicity which suppresses ADH secretion and allow diuresis?

44
Q

What happens to dextrose solution when the glucose is metabolized?

A
  • Dextrose becomes a hypotonic solution
  • Does not say in the vascular space
  • Water moves freely between all compartments
45
Q

What fluid could be used for caloric intake in diabetic patients?

A
  • Dextrose 10%
  • Better options out there
46
Q

What are colloids?

A
  • Large molecules of a homogeneous, non-crystalline substance that is dispersed in a second substance (usually a balanced crystalloid).
  • Particles cannot be separated
47
Q

What are the two main types of colloids?

A
  • Semisynthetic colloids (Starches)
  • Human plasma derivatives (FFP, Albumin)
48
Q

How do colloids work?

A
  • Colloids work by increasing colloid oncotic pressure (pulling force), which increases potential plasma volume expansion
49
Q

What are the negative effects of colloids?

A
  • Causes hemodilution
  • Decreases plasma viscosity
  • Inhibit RBC aggregation
  • Uncertain effect on immune and renal system (AKI)
50
Q

What colloid is derived from potatoes or corn (polymers of amylopectin)?

A
  • Hydroxyethyl Starch
51
Q

The metabolism of hydroxyethyl starch is dependent on ______________.

A
  • 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
52
Q

What are the S/E of Hydroxyethyl Starch?

A
  • Coagulopathy through dilution effects, leading to reduction in VWF, Factor VIII, Clot Strength.
  • Renal Dysfunction
53
Q

The dextran is a highly branched polysaccharide produced by a bacteria called _______________.

A
  • Leuconostoc Mesenteroides
  • She probably won’t ask this question….
54
Q

Dextran have a plasma volume effect similar to that of starches, with a duration of _______ hours (range).

A
  • 6-12 hours
55
Q

According to lecture, what is Dextran-40 used for?
Why?

A
  • Microvascular Surgery
  • Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation

Dextran-40 will coat the RBC and may interfere with cross-matching

56
Q

What are examples of human plasma derivative colloids? Select 3
A. dextrose 5%
B. immunoglobulin solution
C. RBCs
D. albumin 25%
E. FFP
F. hydroxyethyl starch

A

D. Albumin 5%
E. FFP
B. Immunoglobulin Solution

57
Q

Fluid alterations in the preoperative setting include:
A. autoregulatory responses
B. bowel prep
C. sympathetic blockade
D. preop fasting
E. insensible losses
F. 3rd space redistribution

A

B.D.F.
list:
* Na+ distribution disorder
* Dialysis requirement
* Chronic use of diuretics
* Dx of HTN
* Fasting
* Bowel Prep
* Acute Hemorrhage
* NVD, Suction
* 3rd spacing

58
Q

Fluid alterations in the intraoperative settings (alterations caused by CRNA).

A
  • Vasodilation from anesthetics
  • Sympathetic blockade (narcotics)
  • Autoregulatory response
  • Acute Hemorrhage
  • Insensible Loss
  • Inflammation related redistribution
59
Q

What would your assessment of Low Intravascular Volume look like when 25% of volume is lost? Select 3.
A. increased capillary hydrostatic pressure
B. tachycardia
C. decreased UOP
D. poor wound healing
E. elevated lactate
F. increased pulse pressure

A

BCE
* Hypovolemia - ↑HR, ↓Pulse Pressure, ↓BP, ↓Cap Refill, 25% of volume must be lost
* Decreased Urine Output
* CVP
* Tissue Perfusion: Lactate, Mixed venous O2

60
Q

Assessment of High Intravascular Volume

A
  • Increase capillary hydrostatic pressure
  • Excess fluids in lungs, bowels, muscle
  • Edema
  • Reduced tissue oxygenation
  • Poor wound healing
  • Hypo/Hyper Coagulation
61
Q

What factors do you need to consider as a CRNA when assessing urine output for intravascular volume?

A
  • Low UO can be d/t stress hormone 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
62
Q

When would you use the “classic” fluid therapy?
A. NPO deficit
B. > 500 mL blood loss
C. anticipated surgical loss
D. decreased SV
E. irregular heart rate/rhythms

A

A. NPO Deficit
C. Anticipated surgical loss
and ongoing maintanence

63
Q

NPO Status for Clear Liquids

64
Q

NPO Status for Breast Milk

65
Q

NPO Status for Infant Formula

66
Q

NPO Status for a Light Meal (scrambled eggs w/toast, coffee w/milk)

67
Q

NPO Status for Meat/Fatty, Fried Food, Full Meal

68
Q

Formula for Classic Fluid Therapy.

A
  • 1st 10 kg = 4 mL/kg/hr
  • 2nd 10kg = 2 mL/kg/hr
  • Each kg over 20 kg = 1 mL/kg/hr
69
Q

Mr. Cartman’s Weight is 80 kg. Calculate Total NPO deficit using the classic fluid therapy.

A

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

70
Q

If Cartman’s fluid deficit is 960 mL and fluid maintenance is 120 mL/hour, what is the fluid plan for this patient?

71
Q

How much blood would the following hold when estimating blood loss in surgery:

Lap Sponge:
Raytech:
4x4 Gauze:

A

Lap Sponge (packs of 5): 100 mL
Raytech (pack of 10): 20 mL
4x4’s: 10 mL

72
Q

What is the traditional crystalloid replacement ratio for a unit of blood loss preoperatively?

left from last yrs class

A
  • 3L to 1 unit of blood loss
73
Q

How much fluid can be loss with a bowel prep?

A
  • 2000 mL

left from last years class

74
Q

What is the fluid deficit for a fever?

left from last years class

A
  • 10% fluid deficit for every 1 degree Celsius above 38C
75
Q

What are the different categories of evaporative/ redistribution losses?

A
  • Minimal: 0-2 mL/kg/hr (robotics case)
  • Moderate: 2-4 mL/kg/hr
  • Severe: 4-8 mL/kg/hr (open belly)
76
Q

What is the Parkland Burn Formula?

A
  • 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 patients.

77
Q

What is the percent body surface area of the entire head and neck?

78
Q

What is the percent body surface area of the entire right arm?

Entire Left arm?

79
Q

What is the percent body surface area of the anterior trunk?

Posterior trunk?

80
Q

What is the percent body surface area of the entire right leg?

Entire left leg?

81
Q

What is the percent body surface area of the groin?

82
Q

What fluid is used to replace burn patients?

A
  • Lactated Ringers
83
Q

When is the Parkland Burn formula used?

A
  • 20% of TBSA is burned
  • 2nd and 3rd degree burns only
84
Q

If an 80kg patient has 20% of their TBSA burned, what would be the total fluid needed to be replaced in this patient?

A
  • 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
85
Q

For goal directed therapy, fluid administration is based on:

A
  • CVP
  • CO
  • SV
  • SVV

Patient will either be fluid responsive or unresponsive. If fluid responsive, a bolus will be administered. Fluid replacement is individualized.

86
Q

What have studies shown about the results of goal directed therapy?

A
  • Less AKI
  • Less Respiratory Failure
  • Decrease Wound Infection
  • Decrease Mortality
87
Q

What is the maintenance dose for goal directed therapy?

A
  • 1-3 mL/kg/hr of crystalloid
88
Q

For goal directed therapy, a fluid challenge of ____ mL will be used to increase SV.
A. 200
B. 250
C. 300
D. 500

89
Q

What is used in goal directed therapy with blood loss or blood products?
A. replace with colloids 1:1
B. give a fluid challenge
C. replace with crystalloid 3:1
D. replace with LR 1-3 mL/kg/hr

A

A. replace with colloid or blood products 1:1, rather crystalloids (3:1)

90
Q

What are the LIMITS to arterial waveform pressure monitoring (SVV Monitoring)?

A
  • 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.

91
Q

What three factors does the arterial waveform pressure monitor take into account to calculate the Stroke Volume Variance?
A. CVP
B. CO/CI
C. SVV
D. PP
E. SPV

A

C. Stroke Volume Variation: The area under the “curve”

D. Pulse Pressure Variation: The difference between the lowest diastolic pressure and the highest systolic pressure

E. Systolic Pressure Variation: The difference between lowest systolic peak and highest systolic peak.

92
Q

What is normal Stroke Volume Variance (SVV)?

A
  • 10-15%
  • If above 15%, patient will be responsive to fluid (give fluid bolus)

Principles of Anesthesia I (27 decks)

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