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Pharmacology > Fluid and Blood > Flashcards

Fluid and Blood Flashcards

1
Q

Body fluid distribution

A 
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]]

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2
Q

Normal electrolyte composition in body

A

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)

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3
Q

Hypokalemia

A

<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+]]

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4
Q

Hyperkalemia

A

> 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
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5
Q

Hyponatremia

A

<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

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6
Q

Hypernatremia

A

> 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

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7
Q

Hypocalcemia

A

<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

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8
Q

Hypercalemia

A

> 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

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9
Q

Hypomagnesium

A

<1.3

alcohol abuse
common with hypoK
diuretics
critical illness

S/S
skeletal muscle weakness
TORSADES DE POINTES

[[GIVE Mg SULFATE

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10
Q

Hypermagnesium

A

> 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

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11
Q

Net Filtration

A

+ 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

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12
Q

Endothelial Glycocalyx

A

-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

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13
Q

Preop fluid assessment status

A
  • 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]]

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14
Q

Acidosis

A 
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]]

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15
Q

Alkalosis

A

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

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16
Q

Hypotonic solution

A

replaces water loss

D5W [[253]]

0.45% NaCl [[154]]

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17
Q

Isotonic solution

A

aka replacement fluids

replaces water and electrolyte loss

normal osmotic
[[275-295]]

LR [[273]]
NS [[308]]
plasmalyte [[294]]

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18
Q

Hypertonic Solution

A

hyponatremia or shock

D5 1/2 NS [[405mOsm/L]]

3% NS
[[1026 mOsm/L]]

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19
Q

Colloids

A

Albumin 5% [[300mOsm/L]]
^isotonic

Dextran 10% [[350]]
^hypertonic

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20
Q

Hypertonic vs Hypotonic

A

Hyper > 300
[[cell shrinks]]

Hypo < 300
[[cell swells]]

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21
Q

LR

A

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

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22
Q

0.9% NS

A 
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++

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23
Q

D5W

A

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]]

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24
Q

3% or 5% NaCl

A

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]]

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25
Q

Osmotically active substances

A

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

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26
Q

Dextran

A

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]]

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27
Q

Hetastarch

A

colloid derived from starchy plants

taken off US market for nephrotoxicity

Max dose; limited to <20mL/ kg/day
[[BOARD PREP]]

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28
Q

Albumin

A

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]]

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29
Q

Crystalloid VS Colloid

A

crystalloid;
-cheaper

-less likely to cause pulmonary edema

-wont cause the coagulation/antigenic problems
[[albumin won’t]]

-equally effective if given in sufficient amounts

colloid;
-prolonged increase in plasma volume by maintaining plasma oncotic pressure

  • 1/2 life is 3-g hrs compared to 20-30 MIN in crystalloids
  • fluid of choice in HYPOPROTEINEMIA
  • less tissue edema
  • less volume used
30
Q

Components of traditional fluid replacement

A
  1. Baseline maintenance fluid requirement
    [[use LR in most cases]]
  2. Fasting NPO deficit
    [[MIVF x hours NPO]]
  3. Replacement of blood losses
    [[1:1 for colloids vs 3:1 for crystalloids]]
  4. Evaporation losses
    [[based on invasiveness of surgery]]
31
Q

4-2-1 rule

A

determine maintenance IVF

1st 10kg 4mL/kg [[40mL]]
^if under 10kg do 4mL x weight in Kg

2nd 10kg 2mL/kg
[[20mL]

additional Kg x 1mL

add together = MIVF rate

32
Q

Fasting NPO deficit

A

MIVF x hours of NPO

[[if pt on MIVF there is no NPO def]]

if pt has baseline hypovolemia;
overall bigger deficit then just NPO
[[restore MAP, HR, filling pressure before induction]]

33
Q

How to replace NPO deficit

A

1/2 replaced in 1st hour

1/4 replaced in 2nd hour

remains 1/4 replaced in 3rd hour

[[Fluid deficit 75kg male]]

115ml/hr MIVF
8 hours NPO
115 x 8 = 920cc

Replacement
460cc in 1st hour
230cc in 2nd hour
230cc in 3rd hour

34
Q

Visual Estimation of Blood loss

A

floor and drapes

suction canister
[[talk to tech about amount of irritant]]

soaked gauze 4x4
[[10 cc of blood]]

soaked lap pad
[[100-150 cc of blood]]

35
Q

Estimated Blood Volume

A

[[EBV]]

adult 65- 75 mL/kg

36
Q

Allowable Blood Loss

A

[[ABL]]
estimates transfusion threshold

you will be given a starting Hct or Hgb
[[Hct = Hgb x 3]]

ABL= EBV x starting Hct - Tagret Hct / starting Hct

[[you set your target]]

*can also be done with Hgb

37
Q

Evaporative loss

A

directly r/t surface area of surgical wound and duration of exposure

38
Q

3rd space loss

A

r/t fluid shifts and intravascular volume def from redistribution of fluid
[[trauma, infection, SIRS, sepsis, burns, ascites]]

39
Q

Guidelines for Evaporative loss

A

superficial trauma
[[1-2mL/kg/hr]]

minimal trauma
[[2-4mL/kg/ hr]]

moderate trauma
[[4-6mL/kg/hr]]

severe trauma
[[6-8mL/kg/hr]]

40
Q

orofacial

A

Evaporation loss
[[1-2mL/kg/hr]]
^superficial trauma

41
Q

herniorrhaphy

A

Evaporation loss
[[2-4mL/kg/hr]]
^minimal trauma

42
Q

Major nonabdominal

or Lap abdominal surgery

A

Evaporation loss
[[4-6mL/kg/hr]]
^moderate trauma

43
Q

Major OPEN abdominal surgery

A

Evaporation loss
[[6-8mL/kg/hr]]
^severe trauma

44
Q

Enhanced Recovery After Surgery (ERAS)

A

[[new way we account for fluid loss]]

  • General fluid therapy philosophy of avoidance of sodium and water overload
  • Mostly questioning science behind replacement of 3rd space losses
  • Conventional monitoring of HR, BP, peripheral perfusion, temperature, urine output, CVP, and biomarkers (lactate)
45
Q

Goal directed fluid therapy

A

Uses advanced monitoring to make estimations of functional circulating volume and responsiveness to fluid

46
Q

Pulse Contour Analysis

A

[[minimally/ non-invasive]]

Preload responsiveness by quantifying the degree of change of arterial, capnography, or pulse oximetry waveforms associated with cyclic respiratory variations

[[Stroke volume variation: >13% predicts volume responsiveness]]

47
Q

Frank- Starling Mechanism

A

[[graph]]

  • On plateau of curve, further fluid challenges will not improve hemodynamics or 02 delivery [[might actually cause more harm]]
  • Overshooting curve impairs myocardial performance [[pt at risk for pulmonary edema and CHF]]
  • Under the curve additional fluid increases sarcomere stretch [[more cross bridge formations]] greater CO [[preload dependence or VOLUME RESPONSIVE]]
48
Q

Blood Therapy and indications for transfusion

A
  • expand intravascular volume
  • increase 02 carrying capacity
-Hbg and Hct
^clinical judgement 
[[assess other factors]]
-CV status
-CO
-blood volume
-anticipated blood loss
-arterial oxygenation
-age
49
Q

PRBC

A

[[1 unit = 200mL]]

  • increases hgb 1gm/dL
  • increases hct 2-3%

Hct of 1 unit = 65-70%

[[CITRATE TOXICITY]]
^with multiple units

preserved with;
citrate
phosphate
dextrose
adenine
[[CPDA]]
50
Q

Type and Screen

A

blood test for blood type [[ABO]] and Rh factor [[positive or negative]] and antibodies

*99.94% rate of compatibility

51
Q

Crossmatch

A

further testing with the actual unit to be administered

[[mixes pt blood with unit to test for agglutination]]

52
Q

Who can get Uncrossmatched blood

A

men

women of non childbearing years who have never received a transfusion

53
Q

Irradiated- Leukocyte reduced

A

irradiation
[[prevents GVHD]]

leukocyte redu ced
[[decreases rate of complication]]
^HLA alloimmunization

54
Q

How long is a unit of PRBC good for

A

35- 42 days

55
Q

Most common blood transfusion related mortality in the US

A

[[TRALI]]
transfusion related ACUTE LUNG INJURY
[[1:8000]]

*highest risk with FFP and platelet

56
Q

Most common infectious complication of blood transfusion

A

Cytomegalovirus

[[1-3% of transfusion]]

57
Q

Some blood storage complications

A

after > 14 days begin to shoe changes

  • depletion. of DGP
  • depletion of ATP

-HYPERKALEMIA
[[as high as 17.2]]

  • altered morphology of cells
  • absence of viable platelets
  • hemolysis
58
Q

Autologus blood

A

unit of PRBC

recipients own blood for possible reinfusion at a later date

can give up to 2-3 units
[[each unit needs to be donated a week apart]]

59
Q

Complications with Autologus blood

A
  • anemia
  • preop MI from anemia
  • administration of wrong unit
  • need for more frequent blood transfusion
  • febrile/ allergic reaction
60
Q

Cell Saver

A

salvaging blood from surgical site

blood process washed and separated
[[RBC given back]]

continues circuit; but still disrupts continuity
[[jehovah witness may accept since it never leaves pt bedside]]

61
Q

Contraindications of Cell Saver

A
  • surgery with wounds contaminated with bacteria, amniotic fluid, malignant cells
  • septic patients
  • chemical contaiminants
62
Q

Risk of Large Volume of cell saver transfusion

A

dilution of clotting factors and thrombocytopenia

63
Q

Acute Normovolemic Hemodilution

A
  • removes blood from patient
  • replace blood volume lost with crystalloid or colloid
  • after surgical blood loss has slowed or stopped patient blood transfused back to them
64
Q

Platelets

A

multi donor unit [[6-10]]
or
single donor aphaeresis unit

5 days shelf life; stored at room temp

1 unit increases platelet count 7,000-10,000 1 hr after transfusion

65
Q

Uses for Platelets

A
  • thrombocytopenia
  • dysfunctional platelets
  • active bleeding

-platelet count <50,000
[[low moderate risk surgery]]

-platelet count <100,000
[[high risk surgery]]

66
Q

Risk with Platelet administration

A

HIGH bacterial contamination

[[1:12,000]]

67
Q

Fresh Frozen Plasma

A

contains clotting factors and plasma proteins
[[NO PLATELETS]]

stored frozen for up to 1 year

Volume 200-250cc

must be ABO compatible

68
Q

Uses for FFP

A

urgent reversal of warfarin

known coagulation factor deficiencies

correcting microvascular bleeding in presence of increased PT and PTT

OR
correction of microvascular bleeding
in a pt transfused with more than one blood volume when PT and pTT cannot be obtained in a timely fashion

69
Q

FFP is NOT for..

A

augmentation of plasma volume or albumin concentration

70
Q

Cryoprecipitate

A

derived from precipitate remaining after FFP thawed

contains;

  • Factor VIII
  • XIII
  • fibrinogen
  • von Willebrand factor
  • plasma
  • fibronecnin

ABO compatible

given through a filter rapidly [[200mL/hr]] and completed within. 6 hours

71
Q

Whats is cryo used for

A

to treat;
-von Willebrand’s disease

-fibrinogen deficiencies

Pharmacology (7 decks)

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