Fluid and Blood Flashcards
Body fluid distribution
TBW 60% ICF 40% (2/3) ECF 20% (1/3) ISF 16% (3/4) Plasma 4% (1/4)
[[need about 25-35mL/kg/day to maintain this]]
Normal electrolyte composition in body
Na+ 140 (ECF)
10 (ICF)
K+ 4.5 (ECF)
150 (ICF)
Cl- 117 (ECF)
103 (ICF/ Plasma)
Bicarb 28 (ECF)
Mg++ 2 (ECF)
40 (ICF)
Ca++ 5 (ECF)
1 (ICF)
5 (plasma)
Hypokalemia
<3.5
- caused by vomit, diarrhea, NG output, diuretics, metabolic alkalosis [[intracellular shifts]]
- skeletal muscle cramps/ weakness/ paralysis
-EKG changes PR interval --> shorter QT interval--> longer T wave--> flattened U wave present
[[treat with K+]]
Hyperkalemia
> 5.5
caused by poor excretion [[renal failure, K sparing diuretics]]
ACIDOSIS [[extracellular shifts]]
succinylcholine, tumor lysis
cardiac rhythm changes
Early;
PR –> longer
T wave –> peaked
QT –> shorter
Middle;
P–> flat
QRS–> wide
Late; VF
[[GIVE CALCIUM]] ^stabilize cardiac membrane -hypervent -insulin + D50 -bicarb
Hyponatremia
<135
can exist in all hydration states (hypo, iso, hyper)
evaluate plasma osmotic and ECF to determine cause
SIAD, CHF, Cirrhosis, TURP syndrome, Cushings
S/S N/V, SKELETAL MUSCLE WEAKNESS, mental changes [[seizure --> coma]] cerebral edema (cell swells)
[[RESTORE Na+ BALANCE]]
manipulate serum osmotic and with fluid resusitation/ diuretics
*must be done slowly
Hypernatremia
> 145
can exist in all hydration states (hypo, iso, hyper)
evaluate plasma osmotic and ECF to determine cause
DI, impaired thirst,
Sodium bicarb admin
S/S thirst, mental status changes [[coma --> seizure]] cerebral dehydration (cell shrinks)
[[RESTORE Na+ BALANCE]]
manipulate serum osmotic and with fluid resusitation/ diuretics
*must be done slowly
Hypocalcemia
<8.5
hypoPTH decreased vit D renal osteodystrophy Pancreatitis Sepsis
S/S skeletal muscle cramps nerve irritability mental status changes--> seizure CHVOSTEK SIGN [[facial spasm when tapped]] TROUSSEAU SIGN [[carpal pedal spasm when BP cuff inflated]] LARYNGOSPASM [[with PTH ectomy]]
EKG change
QT interval –> long
[[GIVE CALCIUM]]
or Vit D
Hypercalemia
> 10.5
HyperPTH cancer thyrotoxicosis thiazide diuretic immobilization *massive transfusion
S/S nausea ab pain HPTN mental status change --> seizure psychosis
EKG changes
QT intervak –> short
give 0.9% NaCl or lasix
Hypomagnesium
<1.3
alcohol abuse
common with hypoK
diuretics
critical illness
S/S
skeletal muscle weakness
TORSADES DE POINTES
[[GIVE Mg SULFATE
Hypermagnesium
> 2.5
excessive administration
[[bronchodilator or uterine relaxation]]
renal failure
adrenal insuff
Lose deep tendon reflex
4-6.5 mEq/L
10-12 mg/dL
Respiratory depression
6.5-7.5 mEq/L
>18 mg/dL
CARDIAC AREST
>10 mEq/L
>25mg/dL
[[GIVE CALCIUM CHLORIDE]]
Ca++ and Mg++ inverse relationship
Net Filtration
+ net filtration favors fluid into the tissues
- net filtration favors fluid absorption into vasculature
[[The forces that favor filtration from the capillary are capillary hydrostatic pressure and interstitial oncotic pressure, and the forces that oppose filtration are capillary oncotic pressure and interstitial hydrostatic pressure. The sum of their effects is known as net filtration pressure]]
overall balance is slightly +
filtered to interstitial space and returned to intravascular space via lymphatic system
Endothelial Glycocalyx
-gel layer capillary epithelium
creates physiologically active barrier with in vascular space
[[barrier between vessel and blood]]
binds to circulating plasma albumin
[[preserves oncotic pressure and decreases capillary permeability to water]]
contain inflammatory mediators, free radical scavenging, activation of anticoagulant factors
HYPERGLYCEMIA (hyperosmolar) major risk for damage or destruction of endothelial glycocalyx
[[alot of crystalloid can also wash it away]]
stress can damage endothelial glycocalyx
loss of endothelial glycocalyx integrity can lead to changes in transcapillary fluid dynamics in critically ill
Preop fluid assessment status
- skin turgur
- mucous membrane
- peripheral edema
- lung sounds
- VS
- HCT
- urine output
- urine spec
- BUN/Creatinine
- ABG
[[remember UO will drop in OR due to release of ADH from stress response]]
Acidosis
Cardiac; decreases contractility increases Sympathetic NS tone increased risk of arrhythmia R shift on oxyhgb curve CNS; increased cerebral blood flow and ICP
Pulm;
increased PVR
[[HYPERKALEMIA]]
Alkalosis
Cardiac;
decreased coronary blood flow
increased risk of dysthymia
Left shift on oxyhgb curve
CNS;
decreased cerebral blood flow and ICP
Pulm;
decreased PVR
[[HYPOKALEMIA]]
decreased ica
Hypotonic solution
replaces water loss
D5W [[253]]
0.45% NaCl [[154]]
Isotonic solution
aka replacement fluids
replaces water and electrolyte loss
normal osmotic
[[275-295]]
LR [[273]]
NS [[308]]
plasmalyte [[294]]
Hypertonic Solution
hyponatremia or shock
D5 1/2 NS [[405mOsm/L]]
3% NS
[[1026 mOsm/L]]
Colloids
Albumin 5% [[300mOsm/L]]
^isotonic
Dextran 10% [[350]]
^hypertonic
Hypertonic vs Hypotonic
Hyper > 300
[[cell shrinks]]
Hypo < 300
[[cell swells]]
LR
isotonic solution
^NS with K+, Ca++ and Lactate
[[273]] slightly hypotonic
^100cc free water/ L
pH 6.2 Na 130 K 4 Cl 110 Ca 3 LACTATE 28 ^mild metabolic alkalosis from lactate metabolism
K+, Ca++ and Lactate present
[[ don’t give large volume to DM pt]]
^by product of lactate is gluconeogenic
[[avoid in renal failure pt K+]]
[[don’t mix with blood Ca++]]
[[don’t give to TBI pt]]
^slightly HYPO-OSMOLAR in blood r/t LACATE
0.9% NS
isotonic [[310]] pH 5.6 Na 154 Cl 154 ^least physiologic
[[large volumes produces high Cl content –> dilution hyperchloremic acidosis–> significant impact on renal function]]
typically used two dilute PRBC –> no Ca++
D5W
hypotonic
[[260]]
not used often in period
[[neonates and DM on insulin but usually use D5 1/1 NS]]
causes FREE WATER INTOXICATION and HYPOnatremia
provides 170-200 calories/ L
[[HYPERglycemia]]
3% or 5% NaCl
hypertonic
[[1026]]
3%
[[Cl- 513 mEq/L]]
5%
[[Cl- 856 mEq/L]]
treatment for HYPOnatremia
*risk of hyperchloremia, hypernatremia, and cellular dehydration [[shrinks cell]]
[[used for renal neuro patients with SIAD]]
Osmotically active substances
high molecular weight
administered in 1:1 ratio
[[equivalent to volume of fluid/blood lost from intravascular volume]]
half -life is 16 hours
[[can also be 2-3 hrs]]
*albumin is the only natural occurring
Dextran
artificial COLLOID
[[high molecular weight]]
hyperosmolar
1/2 life 6-12 hours
side effects;
ACUTE RENAL FAILURE [[black b ox warning
anaphylaxis
[[no longer available in many countries r/t to this ]]
interference with cross matching
[[adheres to surface of platelets and RBC]]
platelet inhibition; antithrombotic effects
[[briefly used in microvascular surgery settings for this effect]]
Hetastarch
colloid derived from starchy plants
taken off US market for nephrotoxicity
Max dose; limited to <20mL/ kg/day
[[BOARD PREP]]
Albumin
colloid derived from pooled human plasma
[[heat and treated to eliminate risk of disease transmission]]
NO clotting factors or blood group antibodies
[[filtered out when heated]]
available in 5% or 25%
[[5% most used in OR]]
[[ONCOTIC PRESSUE = 20]]