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ANE 8509 Principles of Anesthesia I > Final- Perioperative Fluid Therapy (7/25/23) > Flashcards

Final- Perioperative Fluid Therapy (7/25/23) 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?

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 different compartments of the ECF?

A
  • Interstitial: lymphatics and protein-poor fluid around the cell.
  • Intravascular: plasma volume
  • Transcellular: GI Tract, Urin, CSF, Joint fluid, aqueous humor.
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4
Q

What is diffusion?

A
  • Solute particles moving or filling solvent volume
  • High to Low concentration
  • Speed is proportional to the distance square
  • Can occur across permeable membranes
  • Can relate to electrical gradients
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5
Q

What are examples of the type of solutes that are in our body?

A
  • Glucose
  • Protein (Albumin)
  • Electrolytes
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6
Q

What is the primary extracellular cation?

A
  • Sodium (Na+)
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7
Q

What is the primary intracellular cation?

A
  • Potassium (K+)
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8
Q

What is osmosis?

A
  • Semipermeable membrane that separates pure water from water with solute.
  • Osmosis is just the movement of WATER
  • Diffuses from low to high solute concentration
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9
Q

What is osmotic pressure?

A
  • Pressure that resists the movement of water through osmosis
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10
Q

What is osmotic pressure affected by?

A
  • Temperature
  • Number of Molecules
  • Volume

PV = nRT

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11
Q

What is osmolarity?

A
  • Number of osmotically active particles per L of solvent
  • Higher osmolarity, higher “pulling power”
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12
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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13
Q

What is osmolality?

A
  • Number of osmotically active particles per Kg of solvent
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14
Q

What is normal osmolality?

A
  • 280-290 mOsm
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15
Q

What is oncotic pressure?

A
  • The component of total osmotic pressure due to colloids
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16
Q

List examples of colloids

A
  • Albumin
  • Globulins
  • Fibrinogen
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17
Q

What percentage of oncotic pressure is due to albumin?

A
  • 65-75%
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18
Q

What makes up our daily intake?

A
  • Solids (750 mL)
  • Liquids (1400 mL)
  • Metabolism (350 mL)
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19
Q

What makes up our daily output?

A
  • Insensible Loss (1000 mL)
  • GI loss (100 mL)
  • Urine output (0.5-1 mL/kg/hr)
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20
Q

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

A
  • 60%
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21
Q

What hormones regulate urine output?

A
  • ADH
  • ANP
  • Aldosterone
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22
Q

How does ADH regulate urine output?

A
  • Renal H2O excretion in response to plasma tonicity
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23
Q

How does ANP regulate urine output?

A
  • ANP is activated by ↑ fluid volume
  • ↑ Atrial Stretch = ↑ Renal Excretion
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24
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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25
What are the sensors for fluid balance?
* Hypothalamic osmoreceptors * Low-pressure baroreceptors (large veins and RA) * High-pressure baroreceptors (carotid sinus and aortic arch)
26
What is the trigger for fluid balance?
* Increased thirst or increase ADH
27
What are the compensatory mechanisms for acute disturbances in circulating volume?
* Venoconstriction * Mobilization of venous reservoir * Autotransfusion from ISF to plasma * Reduced urine production * Maintenance of CO…tachycardia, increased inotropy
28
Where is Renin released? What does Renin do to angiotensinogen?
* Released from juxtaglomerular cells * Cleaves angiotensinogen to make angiotensin I
29
When ANG I → ANG II, what will this cause?
* Vasoconstriction and aldosterone release
30
Where is aldosterone released from?
* Aldosterone is released from the adrenal cortex and causes salt and water retention
31
In the absence of ongoing fluid loss, loss volume should be restored within ______- hours (range).
* 12-72 hours
32
In the absence of ongoing fluid loss, RBC should be restored through erythropoiesis in ______ weeks (range).
* 4-8 weeks.
33
What are the Electrolytes and Osmolarity of Normal Saline (0.9%)?
Na+: 154 mEq/L Chloride: 154 mEq/L Osmolarity: 308 mOsm/L
34
What are the Electrolytes and Osmolarity of LR?
Na+: 130 mEq/L K+: 4 mEq/L Chloride: 109 mEq/L Lactate: 28 mEq/L Osmolarity: 274 mOsm/L
35
What are the Electrolytes and Osmolarity of Plasmalyte?
Na+: 140 mEq/L K+: 5 mEq/L Cl-: 98 mEq/L Acetate: 27 mEq/L Osmolarity: 295 mOsm/L
36
What are the Electrolytes and Osmolarity of Albumin 5%?
Na+: 145 +/- 15 mEq/L K+: <2.5 mEq/L Cl-: 100 mEq/L Osmolarity: 330 mOsm/L
37
What are the Electrolytes and Osmolarity of Hetastarch 6%?
Na+: 154 mEq/L Cl-: 154 mEq/L Osmolarity: 310 mOsm/L
38
What are crystalloids?
* Solutions of electrolytes in water * The are called balanced solutions (not really though, misnomer) * LR is probably considered the most "balanced" crystalloid
39
What are indications of using crystalloids?
* Replacement of free water and electrolytes * Volume expansion
40
With crystalloid administration and distribution throughout the EFC, what percentage will be in the intravascular space after 20 minutes? What about after 30 minutes?
* 70% in the intravascular space after 20 minutes * 50% in the intravascular space after 30 minutes
41
What are the negative effects of crystalloids?
* Tissue Edema (Lungs, GI Tract, Soft Tissues) * Hypercoagulability (Anticoagulant factors diluted)- micro emboli
42
NS 0.9% is the most commonly fluid, but what are the negative consequence of this fluid?
* 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.
43
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.
* Hypertonic Saline 3% * Can be used to treat SEVERE TUR syndrome
44
What is added to LR to act as a buffer?
* Lactate
45
You want to avoid using this fluid for patients with liver insufficiency.
* 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.
46
Which fluid will excrete excess water faster than NS d/t the transient decrease in plasma tonicity which suppresses ADH secretion and allow diuresis?
* LR
47
What happens to dextrose solution when the glucose is metabolized?
* Dextrose becomes a hypotonic solution * Does not say in the vascular space * Water moves freely between all compartments
48
What fluid could be used for caloric intake in diabetic patients?
* Dextrose 10% * Better options out there
49
What are colloids?
* Large molecules of a homogeneous, non-crystalline substance that is dispersed in a second substance (usually a balanced crystalloid). * Particles cannot be separated
50
What are the two main types of colloids?
* Semisynthetic colloids (Starches) * Human plasma derivatives (FFP, Albumin)
51
How do colloids work?
* Colloids work by increasing colloid oncotic pressure (pulling force), which increases potential plasma volume expansion
52
What are the negative effects of colloids?
* Causes hemodilution * Decreases plasma viscosity * Inhibit RBC aggregation * Uncertain effect on immune and renal system (AKI)
53
What colloid is derived from potatoes or corn (polymers of amylopectin)?
* Hydroxyethyl Starch
54
The metabolism of hydroxyethyl starch is dependent on ______________.
* 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
55
What are the S/E of Hydroxyethyl Starch?
* Coagulopathy through dilution effects, leading to reduction in VWF, Factor VIII, Clot Strength. * Renal Dysfunction
56
The dextran is a highly branched polysaccharide produced by a bacteria called _______________.
* Leuconostoc Mesenteroides * She probably won't ask this question....
57
Dextran have a plasma volume effect similar to that of starches, with a duration of _______ hours (range).
* 6-12 hours
58
According to lecture, what is Dextran-40 used for? Why?
* Microvascular Surgery * Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation ## Footnote Dextran-40 will coat the RBC and may interfere with cross-matching
59
What are examples of human plasma derivative colloids?
* Albumin 5% * FFP * Immunoglobulin Solution
60
Fluid alterations in the preoperative settings (long list, common sense).
* Na+ distribution disorder * Dialysis requirement * Chronic use of diuretics * Dx of HTN * Fasting * Bowel Prep * Acute Hemorrhage * NVD, Suction * 3rd spacing
61
Fluid alterations in the intraoperative settings (alterations caused by CRNA).
* Vasodilation from anesthetics * Sympathetic blockade (narcotics) * Autoregulatory response * Acute Hemorrhage * Insensible Loss * Inflammation related redistribution
62
Assessment of Low Intravascular Volume
* Hypovolemia - ↑HR, ↓Pulse Pressure, ↓BP, ↓Cap Refill, 25% of volume must be lost * Decreased Urine Output * CVP * Tissue Perfusion: Lactate, Mixed venous O2
63
Assessment of High Intravascular Volume
* Increase capillary hydrostatic pressure * Excess fluids in lungs, bowels, muscle * Edema * Reduced tissue oxygenation * Poor wound healing * Hypo/Hyper Coagulation
64
What factors do you need to consider as a CRNA when assessing urine output for intravascular volume?
* 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
65
When would you use the "classic" fluid therapy?
* NPO Deficit * Ongoing maintenance * Anticipated surgical loss
66
NPO Status for Clear Liquids
* 2 hours
67
NPO Status for Breast Milk
* 4 hours
68
NPO Status for Infant Formula
* 6 hours
69
NPO Status for a Light Meal (scramble egg w/toast, coffee w/milk)
* 6 hours
70
NPO Status for Meat/Fatty, Fried Food, Full Meal
* 8 hours
71
Formula for Classic Fluid Therapy.
* 1st 10 kg = 4 mL/kg/hr * 2nd 10kg = 2 mL/kg/hr * Each kg over 20 kg = 1 mL/kg/hr
72
Mr. Cartman's Weight is 80 kg. Calculate Total NPO deficit using the classic fluid therapy.
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
73
If Cartman's fluid deficit is 960 mL and fluid maintenance is 120 mL/hour, what is the fluid plan for this patient?
74
How much blood would the following hold when estimating blood loss in surgery: Lap Sponge: Raytech: 4x4 Gauze:
Lap Sponge (packs of 5): 100 mL Raytech (pack of 10): 20 mL 4x4 Gauze: 10 mL
75
What is the traditional crystalloid replacement ratio for a unit of blood loss preoperatively?
* 3L to 1 unit of blood loss
76
How much fluid can be loss with a bowel prep?
* 2000 mL
77
What is the fluid deficit for a fever?
* 10% fluid deficit for every 1 degree Celsius above 38C
78
What are the different categories of evaporative/ redistribution losses?
* Minimal: 0-2 mL/kg/hr (robotics case) * Moderate: 2-4 mL/kg/hr * Severe: 4-8 mL/kg/hr (open belly)
79
What is the Parkland Burn Formula?
* 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.*
80
What is the percent body surface area of the entire head and neck?
* 9%
81
What is the percent body surface area of the entire right arm? Entire Left arm?
* 9% * 9%
82
What is the percent body surface area of the anterior trunk? Posterior trunk?
* 18% * 18%
83
What is the percent body surface area of the entire right leg? Entire left leg?
* 18% * 18%
84
What is the percent body surface area of the groin?
* 1%
85
What fluid is used to replace burn patients?
* Lactated Ringers
86
When is the Parkland Burn formula used?
* 20% of TBSA is burned * 2nd and 3rd degree burns only
87
If an 80kg patient has 20% of their TBSA burned, what would be the total fluid needed to be replaced in this patient?
* 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
88
For goal directed therapy, fluid administration is based on:
* CVP * CO * SV * SVV *Patient will either be fluid responsive or unresponsive. If fluid responsive, a bolus will be administered. Fluid replacement is individualized.*
89
What have studies shown about the results of goal directed therapy?
* Less AKI * Less Respiratory Failure * Decrease Wound Infection * Decrease Mortality
90
What is the maintenance dose for goal directed therapy?
* 1-3 mL/kg/hr of crystalloid
91
For goal directed therapy, a fluid challenge of ___________ mL will be used to increase SV.
* 250 mL
92
What is used in goal directed therapy with blood loss or blood products?
* More likely to replace with colloid or blood products 1:1, rather crystalloids (3:1)
93
What are the LIMITS to arterial waveform pressure monitoring (SVV Monitoring)?
* 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.*
94
What three factors does the arterial waveform pressure monitor take into account to calculate the Stroke Volume Variance?
* Systolic Pressure Variation: The difference between lowest systolic peak and highest systolic peak. * Pulse Pressure Variation: The difference between the lowest diastolic pressure and the highest systolic pressure * Stroke Volume Variation: The area under the "curve"
95
What is normal Stroke Volume Variance (SVV)?
* 10-15% * If above 15%, patient will be responsive to fluid (give fluid bolus)

ANE 8509 Principles of Anesthesia I (27 decks)

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