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Principles I > Fluid and Blood Therapy > Flashcards

Fluid and Blood Therapy Flashcards

1
Q

Why is hypovolemia common in patients scheduled for surgery?

A

NPO status
surgical trauma
evaporation
dry anesthetic gases

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2
Q

Why complications can result from hypovolemia that cause a significant increase in postoperative morbidity and mortality?

A

Ranges from PONV to serious complications such as organ dysfunction and prolongation of hospital stay

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3
Q

What are the goals of fluid therapy?

A

Avoid or correct a hypovolemic state
Restore intravascular volume
Maintain oxygen-carrying capacity of the intravascular volume
**Maintain adequate tissue perfusion

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4
Q

How is total body water (TBW) determined?

A

Percentage of body weight, varies with age, gender, and body habitus

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5
Q

What is the TBW of the average 70 kg adult male?

A

60%

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6
Q

What is the TBW of the average 70 kg adult female?

A

55%

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7
Q

What is the TBW of premature infants?

A

80-90%

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8
Q

What is the TBW of term infants?

A

75%

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9
Q

What is the TBW of the elderly?

A

50-55%

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10
Q

What are the different body fluid compartments and their volume?

A

TBW = 42 L (60%)
ECF = 15 L (20%) ICF = 27 L (40%)
- Plasma = 3 L (4%)
- Interstitial fluid = 12 L (16%)

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11
Q

How does water move between the ICF and ECF?

A

Osmotically active particles attract water across semipermeable membranes until equilibrium is attained

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12
Q

What is the ratio of plasma to interstitial fluid across the capillary membrane?

A

1:4

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13
Q

What is osmosis?

A

water moving across a membrane from solution of low concentration to a solution of high concentration

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14
Q

Will a higher concentration solution have a lower or higher osmotic pressure than a lower concentration solution?

A

higher - more osmotically active particles

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15
Q

What is osmolality?

A

Number of osmotically active particles per kilogram of water

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16
Q

What is osmolarity?

A

Number of osmotically active particles per liter of solution

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17
Q

How is osmolality calculated?

A

Osmolality = (serum Na+ x 2) + blood glucose + blood urea (mmol/kg)

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18
Q

What is tonicity?

A

measure of particles which are capable of exerting an osmotic force, used to describe osmolality of a solution relative to plasma

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19
Q

What does isotonic mean?

A

2 solutions with the same osmolarity (no osmotic pressure generated across cell membranes)

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20
Q

What is a hypotonic solution?

A

solution with a lower osmolarity than plasma

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21
Q

What is a hypertonic solution?

A

solution with a higher osmolarity than plasma

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22
Q

How does water move between the plasma and ISF?

A

Colloid oncotic pressure

Starling forces

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23
Q

What are the different Starling forces?

A

Capillary hydrostatic pressure
ISF hydrostatic pressure
ISF colloid osmotic pressure
Plasma colloid osmotic pressure

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24
Q

What is the colloid osmotic pressure?

A

Osmotic pressure exerted by the macromolecules (colloid molecules), prevents fluid from leaving the plasma and exerts a “pull” from the interstitial space

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25
Q

How does plasma colloid oncotic pressure maintain plasma volume?

A

Proteins
Albumin
Gamma globulins

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26
Q

How much crystalloid is required to expand the IV compartment 1 L?

A

3-4 L of crystalloid

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27
Q

What are dextrose solutions used for?

A

to replace daily water requirement or replace water deficits

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28
Q

What are dextrose solutions not suitable for?

A

resuscitation or rapid volume replacement

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29
Q

Are dextrose solutions hypo or hypertonic?

A

Hypo, glucose initially osmotically active but then is rapidly metabolized leaving free water with/without electrolytes

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30
Q

How much D5W would be required to replace 500 mL plasma volume?

A

7L D5W

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31
Q

What is the most commonly used crystalloid fluid?

A

LR

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32
Q

What is the tonicity of LR?

A

Slightly hypotonic with osmolarity of 273, 100 mL free water/L

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33
Q

What electrolyte abnormality does LR cause?

A

Hyponatremia, tends to lower serum Na to 130 mEq/L

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34
Q

In LR, lactate is converted by ____ into _______.

A

Liver, bicarbonate

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35
Q

Which fluid is the most physiologic?

A

LR, has least effect on ECF

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36
Q

What patient population would you want to avoid giving LR?

A

renal patients due to potassium content in LR

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37
Q

What is the only fluid acceptable to use with blood transfusions?

A

NS

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38
Q

What is the osmolality of NS?

A

308

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39
Q

What can large volumes of NS cause?

A

Dilutional hyperchloremic metabolic acidosis due to chloride content in NS
(bicarb concentration decreases as chloride concentration increases)

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40
Q

What electrolyte abnormality would indicate the administration of hypertonic crystalloids?

A

Severe hyponatremia

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41
Q

With what clinical conditions would hypertonic crystalloids be useful?

A

resuscitation of severe hypovolemic shock or burn patients

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42
Q

What are some undesired effects of hypertonic crystalloids?

A

Hyperchloremia
Hypernatremia
Cellular dehydration
Limited intravascular duration

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43
Q

Should you administer hypertonic crystalloids fast or slow?

A

SLOW

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44
Q

What are colloids?

A

Solutions that contain large molecules that are retained in the intravascular space (“plasma expanders”)

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45
Q

What does colloid duration in the vasculature depend on?

A

Size of the molecules, their overall oncotic effect, and plasma 1/2 lives

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46
Q

What are some adverse effects of colloids?

A

Effects on platelets and coagulation
Anaphylaxis
Action in reticulo-endothelial system

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47
Q

What is the molecular weight of endogenous albumin?

A

69,000

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48
Q

What is the degradation 1/2 life of endogenous albumin?

A

18 days

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49
Q

How much albumin is synthesized a day by hepatocytes to maintain normal plasma concentration of 40 g/L?

A

9-12 g/day

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50
Q

How much of the plasma colloidal oncotic pressure is attributed to endogenous albumin?

A

60-80%

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51
Q

What determines the concentration of endogenous albumin in the ISF?

A

capillary permeability

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52
Q

How is albumin in the ISF return to circulation?

A

lymphatic system

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53
Q

How are blood-derived colloids prepared to minimize hepatitis/viral disease transmission?

A

heated to 60 degrees Celsius for 10 hours

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54
Q

What is the molecular weight of 5% and 25% albumin solutions?

A

66,000-69,000

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55
Q

What are clinical benefits of giving albumin 5% and 25%?

A

Provides high colloid osmotic pressure

Expands IV volume up to 5 x’s volume given by drawing fluid in from ISF

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56
Q

How much of the albumin 5% or 25% infused escaped from the IV space/hour?

A

4-5%

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57
Q

What is the plasma half-life of albumin 5% and 25%?

A

16 hours

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58
Q

What is plasma protein fraction 5%?

A

5% solution of selected proteins prepared from human blood, serum, or plasma

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59
Q

What is plasma protein fraction 5% composed of?

A

Mixture of proteins, but mostly albumin in a concentration of >/= 83% of total protein composition

60
Q

What is an adverse effect of plasma protein fraction 5%?

A

allergic reaction resulting in hypotension

61
Q

What are the synthetic colloids?

A

Dextran and Hydroxyethyl starch

62
Q

What is the molecular weight of Hydroxyethyl starch 6%?

A

450,000

63
Q

What is Dextran composed of?

A

Highly branched polysaccharide molecules

64
Q

What is a benefit to administering Dextran 70?

A

Better volume expander

65
Q

What is a benefit to administering Dextran 40?

A

Improves blood flow through microcirculation; reduced red cell and platelet sludging
Volume expansion
Hemodilution-induced reduction in blood viscosity

66
Q

With what type of surgery will you most likely use Dextran 40?

A

Vascular surgeries

67
Q

What is an adverse effect of Dextrans?

A

Can be antigenic; anaphylactoid/anaphylactic

68
Q

What are benefits to giving HES?

A

Less expensive than albumin and non-antigenic

Highly effective plasma expander

69
Q

What is the duration of HES?

A

approximately 24-36 hours

70
Q

What other colloid is HES comparable to?

A

5% albumin

71
Q

How is HES metabolized and excreted?

A

Large molecules broken down by amylase; small molecules eliminated by kidneys; primarily excreted by the kidneys

72
Q

What is a common adverse effect after HES administration?

A

Pruritis

73
Q

What are crystalloids generally used for?

A

maintenance fluid for insensible losses and as replacement for body fluid deficits

74
Q

What are colloids generally used for?

A

Fluid replacement and shock resuscitation

75
Q

Which type of fluid is ideal for initial management of ECF losses?

A

Crystalloids

76
Q

What can large volumes of crystalloids cause?

A

Hemodilution and decreased plasma colloidal oncotic pressure –> edema and transudates

77
Q

How much does an infusion of 500 mL albumin or HES 6% expand plasma volume?

A

500 mL

78
Q

How much do colloids expand plasma volume per gram of colloid?

A

Expands plasma volume 20 mL

79
Q

What are perioperative goals for fluid management?

A 
**Enhance microvascular blood flow so that oxygen is delivered to tissues
Meet basal fluid requirements
Replace losses
Restore/maintain hemodynamic stability
Maintain aerobic cellular metabolism
80
Q

What is the formula to determine oxygen delivery to the tissues?

A

DO2 (oxygen delivery) = CI (cardiac index) x CaO2 (arterial oxygen content)

81
Q

What things must you consider when calculating oxygen delivery to the tissues?

A
  • cardiac status; ability to increase cardiac output to meet DO2 demands
  • Pulmonary status; ability to maintain SaO2
  • Ability of O2 delivery to meet O2 demands
82
Q

What is the average normal water metabolic rate for a normothermic 70 kg patient? (how much water is gained and lost in a day)

A

2500 mL water/day (gain 400 mL from metabolic water; net hypothetical loss of 2000 mL/day)

83
Q

How can you calculate maintenance fluid requirements?

A

4-2-1 rule

weight in kg + 40

84
Q

How can you calculate NPO deficits?

A

hours fasted x maintenance requirements

85
Q

What are some examples of obligatory losses?

A
  • evaporation (most apparent with large wounds and directly proportionate to surface area exposed and duration of exposure)
  • internal redistribution of body fluids (Third spacing; can be massive resulting in severe intravascular depletion)
86
Q

What is third space sequestration?

A

Traumatized, inflamed, or infected tissue (burns, surgery, peritonitis) can sequester large amounts of fluid in interstitial space, translocate fluid across serosal surfaces (ascites), translocate fluid into bowel lumen

87
Q

What do you need to know to calculate the third space loss?

A

Type of procedure
Degree of exposure
Amount of surgical manipulation

88
Q

What is the additional fluid requirement for minimal trauma?

A

1-2 mL/kg/hr

89
Q

What is the additional fluid requirement for moderate trauma?

A

4-7 mL/kg/hr

90
Q

What is the additional fluid requirement for severe trauma?

A

8-10 mL/kg/hr

91
Q

What is the primary reason to administer blood?

A

maintain O2 carrying capacity

92
Q

How much blood loss can most adults tolerate?

A

10% of EBV

93
Q

When would you want to check a Hgb?

A

After 15-20% loss of EBV ( in healthy patients, earlier if comorbidities present)

94
Q

What Hgb and Hct do healthy patients tolerate?

A

Hgb of 6-7 g/dL and Hct 18-21%

95
Q

You would maintain normovolemia with crystalloid or colloid until what point?

A

Danger of anemia outweighs risk of transfusion

96
Q

How much crystalloid do you infuse for every mL of blood loss?

A

3 mL crystalloid: 1 mL blood lost hourly

97
Q

How much colloid do you infuse for every mL of blood loss?

A

1 mL colloid: 1 mL blood lost hourly

98
Q

What is the systematic approach to a fluid plan?

A

maintenance needs + deficit + 3rd space + blood loss = systematic approach

99
Q

What is the total blood volume (TBV) composed of?

A 
RBC volume (2L)
Plasma volume (3L)
100
Q

What tends to increase blood volume?

A

Muscularity and physical activity

101
Q

What tends to decrease blood volume?

A

Obesity, inactivity, and chronic disease

102
Q

As you get older, your estimated blood volume increases or decreases?

A

decreases

103
Q

What is the EBV for an adult male?

A

75 mL/kg

104
Q

What is the EBV for an adult female?

A

65 mL/kg

105
Q

What is the EBV for a geriatric male?

A

65 mL/kg

106
Q

What is the EBV for a geriatric female?

A

60 mL/kg

107
Q

What is the EBV for children?

A

75 mL/kg

108
Q

What is the EBV for infants?

A

80 mL/kg

109
Q

What is the EBV for neonates?

A

premature - 95 mL/kg

full term - 85 mL/kg

110
Q

What formula can you use to calculate allowable blood loss?

A

ABL = 3[(EBV x Hct preop) - (EBV x Hct allowable)]

111
Q

How much will 1 unit PRBC increase Hgb and Hct?

A

Increases Hgb by 1 g/dL and Hct 2-3% in adults

112
Q

How much of a RBC transfusion will increase Hgb by 3 g/dL and Hct by 10%?

A

10 mL/kg transfusion

113
Q

How can you estimate how much blood is lost?

A

Suction canisters
Sponges
Watch the surgical field
Scale weight

114
Q

How much blood does a 4x4 sponge hold?

A

10 cc

115
Q

How much blood does a Ray-tech sponge hold?

A

10-20 cc

116
Q

How much blood do lap pads hold?

A

100 cc

117
Q

How much blood do wet sponges hold?

A

20-30% of dry value

118
Q

How do you split up the NPO deficit if the surgery is to last 3 hrs?

A

1/2 NPO deficit the 1st hour, then 1/4 the 2nd hour, and the last 1/4 the 3rd hour

119
Q

What is type specific compatibility testing?

A

ABO-Rh typing only; 99.8% compatible

120
Q

What is a type and screen?

A

ABO-Rh type and screen for specific antibodies commonly associated with non-ABO hemolytic reactions; 99.94% compatible

121
Q

What is a type and crossmatch?

A

Confirms ABO-Rh typing
Detects antibodies to other blood groups
Detects antibodies in low titers

122
Q

How long does it take to do a type and crossmatch?

A

Can take up to 45 mins, not ideal for someone who is actively hemorrhaging

123
Q

What is the universal donor for someone with an unknown blood type?

A

O negative

124
Q

How long does it take to get ABO specific units?

A

5 minutes

125
Q

What is the probability that someone will have an unexpected antibody to ABO specific units?

A

1:1000

126
Q

If you are infusing O negative blood to someone with an unknown blood type, how long should you continue to give O negative blood?

A

If 4 units or less used of O negative, switch to cross matched blood when available; if greater than 4 units of O negative blood used, stick with O negative

127
Q

How much volume is in whole blood, how is it stored, and when is it used?

A

450 mL
Fresh storage for 24 hours
Rarely used unless there is mass casualty or other military situations; also used for >25% EBV loss with ongoing active bleeding

128
Q

How much volume is in PRBC, what is the Hct, and when are PRBC used?

A

250-350 mL volume
Hct 70%
Used to replace RBC, but not volume

129
Q

How much does one unit of platelets increase the platelet count?

A

5000-10000

130
Q

How much volume is in a single donor bag and a multiple donor bag of platelets?

A

single - 10-25 mL/bag

multiple - 50-70 mL/bag

131
Q

When are platelets given?

A

To treat thrombocytopenia or dysfunctional platelets

- <10,000-20,000 = increased risk of spontaneous hemorrhage

132
Q

How are platelets stored and how long do they last?

A

Stored at room temperature and survive 7 days post transfusion

133
Q

How much volume is in FFP and what does it contain?

A

250 mL/bag

Contains all clotting factors except for platelets

134
Q

What are some indications for FFP?

A
  • Isolated factor deficiency
  • Reversal for warfarin therapy (5-8 mL/kg)
  • Correct of coagulopathy or microvascular bleeding
  • Massive transfusion (large volumes of crystalloid/colloid depletes clotting factors)
135
Q

What is the initial dose of FFP?

A

10-15 mL/kg

136
Q

What is cryo used for?

A

Correct specific coagulopathies (used for factor VIII deficiency and hemophilia A)

137
Q

What is one major risk factor of giving cryo?

A

Carries greatest infectious risk from hepatitis since it is pooled from more than one donor

138
Q

What are some complications of transfusions?

A
  • immune hemolytic reactions
  • immune non-hemolytic reactions
  • infections (hepatitis, HIV)
  • metabolic complications (decreased pH and lactate production or increased potassium with cell lysis, increased with storage)
139
Q

What are some clotting complications of transfusions?

A
  • coagulopathy (usually occurs after massive transfusion >10 units)
  • dilutional thrombocytopenia (responds well to platelet transfusion)
  • low factors V and VIII (stored blood factors may be 15-20% of normal)
  • DIC (activation of clotting system –> microvascular fibrin deposition –> activation of fibrinolysis)
140
Q

What is TRALI?

A

Transfusion Related Acute Lung Injury

  • leading cause of transfusion related death in US
  • Noncardiogenic pulmonary edema
  • Thought to be secondary to donor leukocyte antibodies and recipient leukocytes
141
Q

What are some s/s of TRALI?

A 
Hypoxia
Cyanosis
Fever
Dyspnea
Fluid in ETT
Hypotension
142
Q

What is the treatment for TRALI?

A

Supportive treatment such as PEEP, increased FiO2, and vasopressors

143
Q

What is a massive transfusion?

A

Replacement of pt’s total blood volume in 1/2 the patient’s estimated blood volume in 3 hours or less
Transfusion of more than 10 units of whole blood

144
Q

What is citrate toxicity?

A
  • CItrate preservative (used as anticoagulant in stored blood) may bind to and chelate calcium
  • Empiric administration of calcium is not warranted unless ionized calcium levels are low
  • Clinically significant hypocalcemia resulting in cardiac depression does not occur in most normal patients unless the transfusion rate exceeds 1 unit every 5 minutes
145
Q

What are some transfusion alternatives?

A
  • Autologous donation and transfusion (pt donates blood before procedure)
  • Donor-directed transfusion
  • Autotransfusion
  • Perioperative blood salvage (cell saver)
  • Intraoperative isovolemic hemodilution
  • Substitute products for replacement of plasma and blood volume
146
Q

What are proper transfusion practices?

A

Warm the blood
Use a filter (170 micrometer filter)
Reconstitute with NS (Calcium in LR may cause blood to clot by reversing anticoagulant effect of citrate)

147
Q

What clinical signs can show you adequate perfusion?

A 
Urine output
Capillary refill
Skin color
Temperature
Pulse rate
Acid-base status
Oxygen consumption
Mixed venous O2 saturation
BP

Principles I (5 decks)

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