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Mar: Sem 3 - Principles I (Full) > 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)

S2

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2
Q

what perecent of water is in adipose tissue?

A

low percentage in adipose tissue

S2

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3
Q

What are the two main 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

S2

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4
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, Urine, CSF, Joint fluid, aqueous humor.

S2

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5
Q

List the different ways of fluid/electrolye movement

A
  • Diffusion
  • Osmosis
  • Osmolarity
  • Osmolality
  • Oncotic pressure

S3-7

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6
Q

What is diffusion?

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

S3

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7
Q

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

A
  • Glucose
  • Protein (Albumin)
  • Electrolytes

S3

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8
Q

What is the primary extracellular cation?

A
  • Sodium (Na+)

S3

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9
Q

What is the primary intracellular cation?

A
  • Potassium (K+)

S3

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10
Q

What is osmosis?

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

S4

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11
Q

What is osmotic pressure?

A
  • Pressure that resists the movement of water through osmosis

S4

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12
Q
  • What is osmotic pressure affected by?
A
  • Temperature
  • Number of Molecules
  • Volume

S4

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13
Q

What is the equation for osmotic pressure?

A

P = nRT/V
* V=volume
* N= number
* T=temperture

S4

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14
Q

What is osmolarity?

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

S5

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15
Q

Patient A has serum glucose of 600mg/dl

Patient B has serum glucose of 250mg/dl

Who has higher osmolarity?

A
  • Patient A

Pt with glucose of 600 has more particles

S5

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16
Q

What is osmolality?

A
  • Number of osmotically active particles per Kg of solvent

S6

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17
Q

What is normal osmolality?

A
  • 280-290 mOsm

S6

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18
Q

What is oncotic pressure?

A
  • The component of total osmotic pressure due to colloids

S7

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19
Q

List examples of colloids

A
  • Albumin
  • Globulins
  • Fibrinogen

S7

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20
Q

What percentage of oncotic pressure is due to albumin?

A
  • 65-75%

S7

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21
Q

What makes up our daily fluid intake?

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

S8

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22
Q

What makes up our daily fluid output?

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

S8

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23
Q

How do we regulate intake and output of fluid?

A
  • We are responsible for:
    • intake: oral fluids & food
    • Output: urinary secretion

S9

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24
Q

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

A
  • 60%

S9

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25
Q

What hormones regulate urine output?

A
  • Antidiuretic hormone [ADH]
  • Atrial natriuretic peptide [ANP]
  • Aldosterone

S9

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26
Q

How does ADH regulate urine output?

A
  • Renal H2O excretion in response to plasma tonicity

tonicity: a measure of effective osmolarity

S9

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27
Q

How does ANP regulate urine output?

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

S9

A&P: ANP/ANF talk to the kidney to increase prostaglandins [PG] production in the kidneys.
-More PG result in increases RBF—> increases GFR —>increase UO to get rid of fluid and electrolytes to reduce strain/stretch on atria.

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28
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.

S9

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29
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

S10

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30
Q

What is the trigger for fluid balance?

A
  • Increased thirst or increase ADH

S10

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31
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

happens in minutes to hours

S11

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32
Q

For compensatory mechanisms to occurs for acute disturbances in circulating volume, what sensors must be present?

A
  • low and high pressure baroreceptors
  • RAA Axis

S11

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33
Q

Overview of RAAS

A
  • Renin relased
  • Angiotensinogen → Angiotension 1
  • Angiotensin 1 → Angiotension 2
  • Vasocontriction + aldosterone release
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34
Q
  • Where is Renin released?
  • What does Renin do to angiotensinogen?
A
  • Released from juxtaglomerular cells
  • Cleaves angiotensinogen to make angiotensin I

S12

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35
Q

When ANG I → ANG II, what will this cause?

A
  • Vasoconstriction and aldosterone release

S12

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36
Q

Where is aldosterone released from and what does it cause?

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

S12

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37
Q

In the absence of ongoing fluid loss, volume loss is restored within how many hours?

A
  • 12-72 hours

S12

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38
Q

In the absence of ongoing fluid loss, how is RBC restored? How long does this take?

A
  • through erythropoiesis in 4-8 weeks

S12

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39
Q

What are the Electrolytes and Osmolarity of Normal Saline (0.9%)?

A
  • Na+: 154 mEq/L
  • K: -
  • Chloride: 154 mEq/L
  • Osmolarity: 308 mOsm/L

S14

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40
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

S14

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41
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

S14

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42
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

S14

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43
Q

What are the Electrolytes and Osmolarity of Hetastarch 6%?

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

S14

44
Q

What are crystalloids?

A
  • Isotonic
  • Solutions of electrolytes in water
  • The are called balanced solutions (not really though, misnomer)
  • LR is probably considered the most “balanced” crystalloid

S15

45
Q

What are indications of using crystalloids?

A
  • Replacement of free water and electrolytes
  • Volume expansion

S15

46
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

S16

47
Q

What are the negative effects of crystalloids?

A
  • Tissue Edema
    • Lungs, GI Tract, Soft Tissues
  • Hypercoagulability
    • Anticoagulant factors diluted
    • micro emboli

S16

48
Q

List the different types crystalloids

A
  • Normal saline (0.9%)
  • Hypertonic saline (3%)
  • Lactated Ringers
  • Dextrose solutions

S17-20

49
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:
    • ↑ Cl- and K+ concentraions

S17

50
Q
  • How does hypertonic saline (3%) work?
  • What does it treat?
A
  • pulls water out of ICF to ECF including plasma
  • Treats:
    • hypoosmolar hyponatremia
    • increased ICP
    • TURP

S18

51
Q

In comparison to NS, what does the osmolarity, Na, and Cl look like in LR?

A
  • lower osmotarity
  • lower Na+
  • lower Cl-

S19

52
Q

What is added to LR to act as a buffer?

A
  • Lactate

S19

53
Q

how does LR excreter excess water faster than NS?

A

suppresses ADH secretion which allows for diuresis

S19

54
Q

Why would you not want to use LR on a liver pt?

A
  • LR relies on hepatic metabolism
  • This can cause an increase build of lactate in the patient.

S19

55
Q

What happens to dextrose solution when the glucose is metabolized?

A
  • Dextrose becomes a hypotonic solution/a source of free water
  • Does not say in the vascular space
  • Water moves freely between all compartments

andy?

56
Q
  • What percent dextrose is a source of free water?
  • What is this not suitable for and why?
A
  • D5
  • not suitable for volume expansion bc water moves freely between all compartments

S20

57
Q

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

A
  • Dextrose 10%
  • Better options out there

S20

58
Q

What are colloids?

A
  • Large molecules of a homogeneous, non-crystalline substance
    • dispersed in a second substance (usually a balanced crystalloid).
    • Particles cannot be separated (through filtration or centrifuge)

S21

59
Q

What are the two main types of colloids?

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

S21

60
Q

How do colloids work?

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

S22

61
Q

What are the negative effects of colloids?

A
  • Causes hemodilution
    • Decreases plasma viscosity
    • Inhibit RBC aggregation
  • Uncertain effect on immune, coag, and renal system (AKI)
    • maximum recommended dosages

S22

62
Q
  • What is hydroxyethyl starch?
  • where is is derived from?
  • what is it substituted on?
A
  • modified natural polymers of amylopectin
  • dervied from potato or maize
  • substitution onto glucose

This is a man made colloid

S23

63
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

S23

64
Q

What are the S/E of Hydroxyethyl Starch r/t molecular weight?

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

S23

65
Q

Dextrans are a type of colloid. Where are the derive from?

A
  • highly branched polysaccharide
  • produced by a bacteria called Leuconostoc Mesenteroides

S24

66
Q

Describe the plasma volume of dextrans.

A
  • Plasma volume similar to the starches
  • duration: 6-12 hours [stays in vascular space for a long time]

S24

67
Q

What is Dextran-40 used for?
Why?
How?

A
  • Microvascular Surgery (limb reattchement, breast flap)
  • Inhibits factor VIII, VWF, Platelet Aggregation prevent coagulation
  • Coats the RBC…may interfere with cross-matching

S24-lecture

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

68
Q

What are examples of human plasma derivative colloids?

A
  • Albumin 5%
  • FFP
  • Immunoglobulin Solution

S25

69
Q

Human plasma derivates: physiologic colloid oncotic pressure [COP]

A
  • Volume replacement
  • trauma
  • sepsis
  • replacement following paracentesis

S25

70
Q

Fluid alterations in the preoperative settings (long list, common sense).

A
  • Na+ distribution disorder
  • Dialysis requirement
  • Chronic use of diuretics
  • Dx of HTN
  • Preop Fasting
  • Bowel Prep
  • Acute Hemorrhage
  • NVD, Suction
  • 3rd space redistribution

S26

71
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

S26

72
Q

Assessment of Low Intravascular Volume

A
  • Signs of Hypovolemia - ↑HR, ↓Pulse Pressure, ↓BP, ↓Cap Refill (25% of volume must be lost)
  • Decreased Urine Output
    • inadequate as end-organ d/t RAA
  • CVP
    • measures central venous volume but venous system distensible
  • Tissue Perfusion: Lactate, Mixed venous O2

S27

73
Q

What are the signs of hypovolemia for low intravascular volume? how much volume must be lost for these s/sx to occur

A
  • ↑HR
  • ↓Pulse Pressure
  • ↓BP
  • ↓Cap Refill
  • 25% of volume must be lost
74
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

S27 lecture

75
Q

Assessment of High Intravascular Volume

A
  • Increase capillary hydrostatic pressure
  • Excess fluids in lungs (Crackles/edema), bowels, muscle
  • Decreased gut motility
  • Reduced tissue oxygenation
  • Poor wound healing
  • Hypo/Hyper Coagulation

If he is fluid overloaded, HE DRIP

S28

76
Q

A study of 13 patients (11 adults and 2 peds) all died from what? Why?

A

post-op pulmonary edema
-we give way too much volume in surgery historically speaking

S28

77
Q

what is the 4-2-1 plan?
What does it take into account?

A
  • it is the “classic” fluid therapy

Takes into account:
* NPO deficit
* ongoing maintenance (hourly)
* anticipated surgical loss (blood & insensible)

S29

78
Q

NPO Status:
* Clear Liquids
* Breast Milk
* Infant Formula
* Light Meal
* Meal/Fatty, Fried

A
  • Clear Liquids: 2 hours
  • Breast Milk: 4 hours
  • Infant Formula: 6 hours
  • Light Meal: 6 hours
  • Meal/Fatty, Fried: 8 hours

S30

79
Q

How is ERAS protocol changing NPO status?

A
  • Maintain homeostasis by allowing NPO status to be delayed
  • Can have carbohydrated 2 hours before surgery.

S30-lecture

80
Q

Classic approach for NPO/MAINTENANCE

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

S31

81
Q

Mr. Cartman’s Weight is 80 kg. Calculate Total NPO deficit for 8 hours 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

S32

82
Q

How do we replace the deficit in the OR?

Mr. Cartman’s has a 960 ml deficit. How would you replace this?

A
  • ½ in the 1st hour of surgery
    • 480 ml
  • ¼ in the 2nd hour.
    • 240 ml
  • ¼ in the 3rd hour.
    • 240 ml

S33

83
Q

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

S33/34

A

Add blood loss…could easily exceed 1L in the 1st hour

S34-36

84
Q

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

Suction:
Lap Sponge:
Raytech:
4x4 Gauze:

A
  • Suction: be sure to subtract the irrigation fluids
  • Lap Sponge (packs of 5): 100 mL
  • Raytech (pack of 10): 20 mL
  • 4x4 Gauze: 10 mL

S37

dont argue with what the surgeon says the blood loss is…just chart what you know!

85
Q

How much fluid can be loss with a bowel prep?

A
  • 2000 mL

Andy?

86
Q

What is the fluid deficit for a fever?

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

andy?

87
Q

What are the different categories of evaporative/ redistribution losses?

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

S38, lecture

controversial

88
Q

The parkland formula is based on what?
what is it adusted due o?

A
  • Rule of 9’s
    • 20% TBSA of 2nd/3rd degree burns
  • Adjusted due to:
    • obesity
    • kids

S39

89
Q

What is the Parkland Burn Formula?

A
  • 4 mL x kg x % BSA burn (whole number) = Fluids to replaced
    • 1/2 over the first 8 hours
    • 1/2 over the next 16 hours

Formula adjusted for obese patients and children

S39

90
Q

What is the percent body surface area of the following: (front and back of body)
* front/back of head:
* Each arm
* Each leg
* Chest:
* Abdomen:
* Groin:

A
  • Front/back of head: 9%
  • Chest: 18%
  • Each arm: 9 %
  • Each leg: 18%
  • Abdomen: 18%
  • Groin: 1%

S39

91
Q

What is the percent body surface area of the anterior trunk? (includes upper and lower)

Posterior trunk?

A
  • 18%
  • 18%

S39

92
Q

What fluid is used to replace burn patients?

A
  • Lactated Ringers

S39

93
Q

When is the Parkland Burn formula used?

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

S39

94
Q

If an 80kg patient has 40% 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 80kg x 40 =12800 mL total
  • 6400 mL replaced in the first 8 hours
  • 6400 mL replaced in the next 16 hours

S39 lecture

95
Q

4-2-1 is an old estimation for fluid replacement. What is goal directed theraphy and fluid administration is based on?

A
  • Goal: keep CO at a level that delivers appropriate amounts of oxygen to the tissues

Fluid administration based on:
* CVP- not specific
* CO
* SV -determines if they are fluid responsive
* SVV -determines if they are fluid responsive
* SWAN- use declining
* SVO2- measures O2 extraction
* TEE- quantify LV cavity size/EF (not a standard of care)
* lactate levels: decreasing level signals successful resuscitation

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

S40

96
Q

What are the reasons for using GDT (goal directed therapy)?

A

Allows decisions to use:
* more fluid
* vasopressors
* inotropes
* blood products

S41

97
Q

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

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

S41

98
Q

What is the maintenance dose for goal directed therapy?

A
  • 1-3 mL/kg/hr of crystalloid

S42

99
Q

For goal directed therapy, a fluid challenge of ___________ mL will be used to increase SV.

A
  • 250 mL

S42

100
Q

What is used in goal directed therapy with blood loss or blood products?

A
  • Colloids 1:1 (1 colloid for every blood product)
  • Did 3:1 in the past

S42

101
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. Need normal on all of these factors to have SVV

S43

its ironic that patients we would need to measure this on are the patients that this information will not be accurate with, haha

102
Q

What are the 3 different types of monitoring using an aterial line for fluid responsiveness?

A
  • Systolic Pressure Variation
  • Pulse Pressure Variation:
  • Stroke Volume Variation

S44 and lecture

103
Q

How do you utilize Systolic Pressure Variation

A
  • Max systolic pressure -min systolic pressure
  • during one cycle of mechanical breath

Normal: 7-10 mmhg

Increase: volume responsive or have residual prelaod reserve

S44

104
Q

How do you utilize pulse pressure variation?

A
  • The difference between the lowest systolic pressure and the highest diastolic pressure
  • Over entire RR cycle
  • Normal <13-17%
  • >13-17% = positive respone to volume expanson
105
Q

How do you utilize stroke Volume Variation?

A
  • variation of SV in 30 seconds
  • The area under the “curve” (still highest and lowest values)
106
Q

What is normal Stroke Volume Variance (SVV)?

A
  • 10-15%

(erikson: 10-13%)

S44

107
Q
  • For SVV, what do you do if its >15%?
  • What do you do if pt is hypotensive but SVV is normal or low?
A
  • If >15%, patient will be responsive to fluid (give fluid bolus)
  • Pt will not be fluid responsive. Give ionotrpes

S44 lecture

Mar: Sem 3 - Principles I (Full) (29 decks)

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