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Fluid and Blood Therapy - Hooge slides Flashcards

1
Q

What is the purpose of parenteral fluid therapy

A

Maintenance fluids
Replacement of fluids lost as a result of surgery/anesthesia
Correction of electrolyte disturbances

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2
Q

What is the main concern with NS

A

Hyperchloremic metabolic acidosis

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3
Q

What are the main concerns with LR

A

Metabolic alkalosis

Potassium accumulation in patients with renal failure

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4
Q

Where does albumin come from

A

Pooled donor plasma

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5
Q

What are the indications for albumin

A

Shock d/t loss of plasma, acute burns, fluid resuscitation, hypo-albuminemia, following paracentesis, liver transplantation

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6
Q

Adverse reactions of albumin

A

Pruritis, fever, rash, N&V, tachycardia

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7
Q

DOA of albumin

A

16-24 hours

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8
Q

What is Plasmanate

A

A protein-containing colloid

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9
Q

When do you use plasmanate

A

Hypovolemic shock - especially burn shock, hypoproteinia (low protein state)

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10
Q

Adverse reactions of plasmanate

A

Chills, fever, urticaria, N&V

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11
Q

How is albumin supplied

A

5% and 25% solutions

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12
Q

How is plasmanate supplied

A

5% in 250ml or 500ml

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13
Q

DOA of plasmanate

A

24-36 hours

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14
Q

What is Dextran

A

An artificial colloid - polysaccharides molecule

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15
Q

When do you use dextran

A

Improve micro circulatory flow in micro surgeries, extracorporeal circulation during cardio pulm bypass

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16
Q

Adverse reactions of dextran

A

Anaphylaxis, coagulation abnormalities, interference with cross-match blood, precipitation of acute renal failure

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17
Q

Dextran supplied as

A

Dextran 70 - 6% solution with avg mw 70,000

Dextran 40 - 10% solution with avg mw 40,000

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18
Q

DOA of dextran

A

6-12 hours

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19
Q

What is hetastarch

A

Synthetic colloid made from plant starch

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20
Q

Indication for hetastarch

A

Hypovolemia

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21
Q

Max dose of hetastarch

A

20ml/kg

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22
Q

Hetastarch adverse reactions

A

Hypersensitivity, coagulopathy, hemodilution, circulatory overload, and metabolic acidosis

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23
Q

How is hetastarch supplied

A

Hespan 6% solution in NS

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24
Q

DOA hetastarch

A

24-36 hours

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25
Q

What is hextend

A

It is 6% hetastarch in a buffered solution including lactate buffer, balanced electrolytes, and physiologic glucose

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26
Q

What is a benefit of hextend over hetastarch

A

Studies show that you can give more than 20ml/kg without coagulopathy issues

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27
Q

What is voluven

A

It’s another plant-derived colloid with smaller molecules than other HES solutions

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28
Q

What is the benefit of voluven over other HES colloids

A

Less plasma accumulation, safer in patients with renal impairment, comparable effects on volume expansion and hemodynamics, fewer coagulation affects

**acceptable alternative to albumin

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29
Q

Why would we move from fluid therapy to blood component therapy

A

Necessary to increase oxygen carrying capacity while also increasing intravascular volume and restoring homeostasis

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30
Q

What are the transfusion triggers

A 
Perioperative blood loss
Clinical condition of patient
Patient-specific blood volume
Calculation of allowable blood loss
Access to patient blood type
Patient preferences
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31
Q

What are the benefits and risks of blood component therapy

A

Benefits = increased oxygen carrying capacity & improved coagulation

Risks = infection and incompatibility

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32
Q

How do we estimate blood loss

A

Subjective - measuring net suction volume and counting or weighting sponges (usually underestimated)

Objective - sodium fluroescein dye

POCT - hgb/hct (this does not measure blood loss)

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33
Q

What are the clinical condition triggers of patient to consider giving product

A

Tachycardia
Decreased mixed venous o2 saturation
Measurement of systemic o2 delivery (DO2)

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34
Q

What is the equation for DO2

A

CO X CaO2

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35
Q

How do you calculate CaO2?

A

1.34 X hgb X spo2

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36
Q

What is the estimated blood vol of a full term infant?

A

80-90 ml/kg

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37
Q

What is the equation for maximum allowable blood loss?

A

MABL = /starting hematocrit

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38
Q

Normal hgb range for men

A

13.2-16.6 g/dL

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39
Q

Normal hgb range for women

A

11.6-15 g/dL

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40
Q

Normal hct range for men

A

42-52%

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41
Q

Normal hct range for women

A

37-47%

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42
Q

Hgb and hct level considerations for transfusion

A

Hgb: 7-10 g/dL
Hct: 21-30%

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43
Q

Estimated blood volume of infants

A

80 ml/kg

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44
Q

Estimated blood volume of adults

A

65-75 ml/kg

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45
Q

Estimated blood volume of obese adults

A

50 ml/kg

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46
Q

Blood group A can receive which blood groups

A

A, O

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47
Q

Blood group B can receive which blood groups

A

B, O

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48
Q

Blood group AB can receive which blood groups?

A

A, B, AB, O

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49
Q

Blood group O can receive which blood groups?

A

O only

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50
Q

Rh + can receive which blood groups

A

Rh +/-

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51
Q

Rh - can receive which blood groups?

A

Rh -

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52
Q

Which blood group is the universal recipient?

A

AB +

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53
Q

Which blood type is the universal donor

A

O -

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54
Q

Why give RBCs?

A

Hemorrhage and improve o2 delivery to tissues

  • symptomatic anemia
  • Acute blood loss > 30% blood volume
  • hemodynamically unstable
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55
Q

Why give FFP?

A

Reversal of anticoagulant effects

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56
Q

Why give platelets?

A

Prevent hemorrhage in patients with thrombocytopenia or platelet function deficits

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57
Q

Why give cryo?

A

Hypofibrinogenemia (setting of massive hemorrhage or consumptive coagulopathy)

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58
Q

What are the changes in banked blood?

A 
Less DPG
Less ATP
Oxidative damage
Increased adhesion to endothelium
Acidosis
Change in shape/decreased flexibility of RBC
Microaggregates
Hyperkalemia
Absence of viable platelets once refrigerated for 2 days
Absence of factor V and VIII
Hemolysis
Accumulation of pro inflammatory metabolic and breakdown products
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59
Q

What level of hgb indicates significant mortality

A

Hgb < 5 g/dl

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60
Q

What is the record survival of hgb of jehovah witness

A

1.8 g/dl

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61
Q

Most common surgical procedures requiring transfusion

A 
Ortho
Colorectal
Cardiac
Major vascular
Liver transplant
Trauma
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62
Q

What are the thre components of the strategy to reduce unnecessary transfusions and maximize patient outcomes

A
  1. Optimize patients own RBC mass
  2. Minimized blood loss
  3. Optimize patients physiologic tolerance of anemia
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63
Q

Preop strategies for blood therapy

A

Screen and treat for anemia, iron deciency and administer erythropoiesis stimulating agents as indicated

ID and manage any bleeding risks (i.e. meds)

Assess pt reserve and optimized patient specific tolerable blood loss

Have an evidence based plan

Preop autologous blood donation in select situations
- may need to come 30 days preop to accommodate

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64
Q

Intraop strategies for blood therapy

A

Perform surgery when optimized
Use blood-sparing techniques
Continually measure and assess hgb/hct
Plan/optimize fluid management of nonblood products
Optimize CO, oxygen delivery, and ventilation
Use blood salvage and autologous transfusion when possible

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65
Q

Post op strategies for blood therapy

A

Treat anemia/iron deficiency with erythropoiesis stimulating agents

Vigilant monitoring/mgmt of post op bleeding

Normothermia to minimize o2 consumption

Avoid/treat infections promptly

Manage anticoags

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66
Q

Class 1 hemorrhage characteristics and Tx indication

A

Reduction of volume < 15%
Blood loss <750 ml
Hgb >10
RBC tx not necessary if no preexisting anemia

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67
Q

Class 2 hemorrhage characteristics and blood tx indication

A

Reduction of volume 15-30%
Blood loss 750-1500ml
Hgb 8-10
RBC tx not necessary unless preexisting anemia or cardiopulmonary disease

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68
Q

Class 3 hemorrhage characteristics and indicator for blood tx

A

Reduction of volume 30-40%
Blood loss 1500-2000ml
Hemoglobin 6-8
RBC tx probably necessary

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69
Q

Class 4 hemorrhage characteristics and indications for RBC

A

Reduction of volume > 40%
Blood loss > 2000ml
Hgb < 6
Necessary RBC tx

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70
Q

Definition of RBC transfusion

A
  1. Replacement of estimated blood volume within 24 hours
  2. > 10 units of RBCs over 25 hours
  3. 50% of blood volume within 3 hours or less
71
Q

What are the major concerns for massive transfusion

A

Dilutional coagulopathy or dilution all thrombocytopenia
Banked blood anticoagulated with sodium citrate, which binds calcium and inhibits coagulation
Rapid infusion can decrease ionized calcium (aka citrate intoxication)

72
Q

What is the blood component of choice for improving oxygen carrying capacity

73
Q

What is the administration ratio of PRBCs?

A

1:2 because RBCs have a higher HCT

74
Q

How much dose one unit of PRBCs increase Hgb and HCt

A

Hgb: 1g/do
Hct: 2-3%

75
Q

Which blood component contains all of the coagulation factors?

76
Q

What are the indications for giving FFP

A

Deficiency of coagulation factors with abnormal coag tests in the presence of active bleeding
Planned surgery in the presence of abnormal coag tests
Reversal of warfarin
Warfarin-related intracranial hemorrhage
Planned procedure when vit K is inadequate to reverse the warfarin effect, thrombocytopenia thrombocytopenia purpura, and congenital or acquired factor deficiency with no alternative therapy
Trauma patients requiring massive transfusion

77
Q

Platelets indication

A

Prevent bleeding or stop ongoing bleeding in patients with low platelet count or functional platelet disorders

78
Q

What is a normal platelet count

A

150,000-450,000 cells /mcL

79
Q

When to transfuse platelets in bleeding patients

A

<50,000 cells in severe bleeding including DIC
<30,000 cells when bleeding, not life-threatening or considered not severe
<100,000 cells for bleeding in multiple trauma patients or patients with intracranial bleed

80
Q

When to prophylactically transfusion threshold

A

Before neuro or ocular surgery = <100,000
Before epidural = < 80,000
Before major surgery or in DIC = < 50,000
Vaginal delivery = < 30,000 and when traumatic delivery < 50,000
Before central line < 20,000

81
Q

What is cryoprecipitate

A

Contains factor VIII (von Wille brands) and fibrinogen

82
Q

When do you administer cryo?

A

Patients with von willebrands or patients with probable or documented deficits in fibrinogen (<80-100 mg/dL)

83
Q

How should you administer cryo?

A

As rapidly as possible - at least 200ml/hr

84
Q

What is the most common and serious blood transfusion complication

A

Incompatibility

85
Q

What happens in incompatibility

A

An immune reaction with risk of an acute hemolytic reaction

86
Q

What causes half of all deaths of blood transfusions

A

Incompatibility r/t procedural or administrative error

87
Q

How does GA complicate blood transfusion incompatibility

A

GA can obscure the symptoms associated with a hemolytic reaction

88
Q

Transfusion associated graft vs host disease

A

Results when donor lymphocytes incorporate themselves into the tissues of the recipient, leading the recipients immune system to attack the embedded recipient tissues

S&S = rash, leukopenia, thrombocytopenia
Sepsis and death usually occur

89
Q

TRALI

A

Transfusion related acute lung injury

ALI occurring within 6 hours of transfusion in patients previously free of ALI

Occurs as frequently as 1:432 units of platelets or as infrequently as 1:7900 units of FFP

Likely underreported

90
Q

TRIM

A

Transfusion related immunomodulation

Presence of leukocytes in allogenic blood

Homologous transfusions, which invariably contain some leukocytes, have been implicated in immunosuppresion of recipients, leading to unexpectedly early recurrences of cancer and higher than expected rates of post op infection

91
Q

Nonhemolytic transfusion reactions

A

Occur in 1-5% of all transfusions

S&S = fever, chills, urticaria

92
Q

Leukoreduction

A

Use of filters to reduce the level of WBCs - proven to be effective in reducing the incidence of non hemolytic transfusion reactions and is likely to be effective in the reduction of TRIM

93
Q

What do leukocytes do to the blood product recipient?

A

Leukocytes exert a variety of immunomodulatory effects on the recipient in a magnitude that is proportional to the length of time the donor unit is stored

94
Q

Donor directed blood transfusion

A

Homologous blood transfusion from a donor selected by the recipient and believed by some to decrease the risk of transmission of disease

95
Q

What are the types of autologous blood transfusion

A

Intraoperative and postoperative blood salvage
Preop blood donation
Acute normovolemic hemodilution

96
Q

Cell salvage

A

Aspiration of blood shed into the surgical field which is washed to remove debris and then reinfused

97
Q

What are contraindications of cell salvage

A

Surgery involving wounds contaminated by bacteria, sepsis, bowel contents, amniotic fluid, or malignant cells

98
Q

What cases are most likely to use cell salvage

A

Cardiac, orthopedic, radial prostatectomy, nephrectomy, AAA, aneurysm

99
Q

How does preop blood donation work

A

Collection and storage of a recipients own blood for reinfusion at a later date

100
Q

What are the risk of preop blood donation

A

Preop anemia and resultant MI
Bacterial contamination
Clerical error - administration of wrong blood

101
Q

How much preop blood donation is wasted

102
Q

What is acute normovolemic hemodilution

A

Transfusion alternative involving the removal of whole blood from a patient immediately before or after the initiation of anesthesia and surgery and replacing volume with crystalloid or colloid

Blood lost during surgery will have a low hct

Reinfusion of the whole blood with normal hct and clotting factors is initiated when Intraoperative loss of blood has stopped or earlier if the patients condition warrants it

103
Q

What is the role of fluids in a human body

A

Transport - oxygen and nutrients to cells and remove waste
Temp regulation - blood circulation to sling and sweating increase heat dissipation helping to keep body at constant temp
Maintain internal environment - maintain metabolism

104
Q

What is the percentage of total body fluid for a newborn, toddler, child, man, woman, senior

A 
Newborn - 80%
Toddler - 70%
Child - 65%
Man - 60%
Woman - 55%
Senior 50-55%
105
Q

What proportion of TBW is intracellular fluid

106
Q

What proportion of TBW is extracellular fluid?

107
Q

What percentage of extracellular fluid is plasma and what percentage is interstitial fluid?

A

75% ISF

25% plasma

108
Q

Which electrolytes predominate intracellularly

A

Potassium
Mag
Phosphate
Proteins

109
Q

Which electrolytes predominate extracellularly

A 
Sodium
Chloride
Calcium
Glucose
Bicarbonate
110
Q

Osmolality definition

A

Number of osmoles of solute in a kg of solvent

111
Q

Osmolarity definition

A

Number of osmoles of solute in liter of solution

112
Q

What is normal plasma osmolality

A

290 mOsm/L

113
Q

Hypertonic definition

A

Increases plasma osmolality above 295mOsm/L

114
Q

Isotonic

A

Normal plasma osmolality = 290 mOsm/L

115
Q

Hypotonic

A

Decreased plasma osmolality below the normal level <275mosm/L

116
Q

Isotonic loss of fluid

A

Example: hemorrhage
Clinically: ECF volume depletion
Serum sodium and osmolality = normal
ICF = normal

117
Q

Signs and symptoms of isotonic loss of fluid

A

Increased HR
decreased BP, cap refill, and UO
Vasoconstriction
Inadequate tissue/organ perfusion

118
Q

How to treat isotonic loss of fluid

A

Administer isotonic fluid

119
Q

Isotonic gain of fluid

A

Example: excessive LR administration
Clinically ECF volume overload
Serum Na and osmolality = normal
ICF volume = normal

120
Q

Signs and symptoms of isotonic gain of fluid

A

Increased HR, BP, body weight
Dependent pitting edema
Inadequate tissue/organ perfusion

121
Q

Treatment of isotonic gain of fluids

A

Restrict fluids

Diuretics

122
Q

Definition of hypotonic fluid disorders

A

Plasma osmolality is low caused by a low serum sodium = osmotic gradient = water shifts from ECF to ICF = ICF volume expansion

123
Q

Hypertonic loss of Na

A

Example: diuretics, decreased aldosterone (addisons, 21 hydroxylase definicency)

ECF volume depletion
Serum sodium and osmolality decreased
Increased ICF volume d/t gradient

124
Q

Signs and symptoms of hypertonic loss of Na

A

Increased HR
Decreased BP, cap refill, UOP
Confusion, mental status change

125
Q

Treatment of hypertonic loss of sodium

A

Administer isotonic fluid

126
Q

gain of pure water

A

Increased ECF,
Decreased serum sodium and osmolality
Increased ICF volume

127
Q

Signs and symptoms of gain of pure water

A

Confusion, drowsiness, mental status change

128
Q

Treatment of gain of pure water

A

Restrict water, treat underlying problem

129
Q

Gain of hypotonic solution

A

“Hypervolemic hypernatremia”
Ex: absorption of electrolyte free irrigation solution - as in TURP

Increased ECF
Decreased serum sodium and osmolality
Increased ICF d/t gradient

130
Q

Clincical signs of gain of hypotonic solution

A

Seizure, pulmonary edema, difficulty ventilating, cerebral edema

131
Q

Treatment of gain of hypotonic solution

A

Diuresis

3% NS

132
Q

Hypotonic gain of sodium

A

Example overload states - cirrhosis, nephrotic, CHF

“Hypervolemic hyponatremia”

Increased ECF
Decreased serum sodium and osmolality
Increased ICF d/t gradient

133
Q

Clinical S&S of hypotonic gain of sodium

A

Dependent edema, cavity effusions, SOB, increased body weight, mental status change

134
Q

Treatment of hypotonic gain of sodium

A

Restrict salt and water

Diuretics

135
Q

Hypertonic fluid disorders

A

Plasma osmolality is high caused by a high serum sodium or glucose = osmotic gradient = water shifts from ICF to ECF = ICF contracts (cell shrinks)

136
Q

Hypotonic loss of sodium

A

“Hypovolemic hypernatremia”
Example: sweating (marathon), osmotic diarrhea/diuresis, vomiting

Decreased ECF, increased serum sodium and osmolality, decreased ICF

137
Q

S&S hypotonic loss of sodium

A

Dry skin and mucous membranes, dizzy, confusion, mental status change, increased HR

138
Q

Treatment of hypotonic loss of sodium

A

Administer isotonic fluid then switch to hypotonic fluid

139
Q

Loss of pure water

A

“Euvolemic hypernatremia”
Example: DI, excessive water evaporation off the skin surface (fever, burn, insensible loss)

Decreased ECF, increased serum sodium and osmolality, decreased ICF

140
Q

Signs and symptoms loss of pure water

A

Confusion, drowsiness, mental status change

141
Q

Treatment of loss of pure water

A

Administer D5W, treat underlying problem

Give arginine vasopressin to replace missing ADH if pt has DI

142
Q

Hypertonic gain of sodium

A

Hypervolemic hypernatremia

Example: NaHCO3 infusion, hypertonic saline, antibiotics that contain Na, sodium modeling in hemodialysis

Increased ECF, increased serum sodium and osmolality, decreased ICF

143
Q

S&S hypertonic gain of Na

A

Mental status change

144
Q

Treatment of hypertonic caring of Na

A

Stop the infusion

145
Q

Hyperglycemia

A

Hypovolemic hyponatremia
Ex: DKA, hyperosmolar non-ketotic coma

Decreased ECF
Decreased serum sodium
Increased serum osmolality
Decreased ICF

146
Q

Clinical sings and symptoms of hyperglycemia fluid shifting

A

Mental status change, diabetic coma

BG is like 600

147
Q

What are the anesthesia factors that alter fluid balance

A

Vasodilation
Releases of ADH
Increase evaporative loss from ventilation
Mobilization of third space fluids on POD 3

148
Q

Anti-diuretic hormone

A

Aka ADH, vasopressin, arginine vasopressin

Nonapeptide synthesized in the hypothalamus and release in response to stress

Causes reabsorption on the collecting duct in kidneys = water retention

149
Q

What is a positive of ADH?

A

Can potentially offset the hypovolemic effect of fasting

150
Q

Is uop a valid indicator of volume status

A

No - it’s effected by too many things

Isolated low UOP should not trigger fluid therapy and extensive diagnostic efforts

151
Q

Goal directed fluid therapy goal

A

To maximize cardiac flow parameters as a Surrogate for oxygen delivery

To improve outcomes

Part of ERAS

152
Q

What is a fluid challenge

A

Give 250-500 cc fluid - if CO increases, they are fluid responsive

153
Q

Bioimpedance sensing

A

A non-invasive and powerful technique used to assess human physiological signals due to its deep penetration into the tissues, leveraging its electrical nature

154
Q

4:2:1 method

A

Method for calculating hourly fluid maintenance requirements

4 mg/kg/hr - 0-10 kg
2 mg/kg/hr - 11-20 kg
1 mg/kg/hr - 21+ kg

155
Q

NPO deficit calculation

A

Hourly maintenance requirement x # of hours NPO

Replaced over 3 hours
Hour 1 - half the volume
Hour 2 - quarter the volume
Hour 3 - quarter the volume

156
Q

How much surgical loss is expected with a minimal invasive surgery

157
Q

How much surgical loss is expected moderate invasive

158
Q

How much surgical loss is expected severe invasive

159
Q

Fluid replacement consists of

A

NPO deficit, maintenance, and surgical loss

160
Q

Ph of LR

161
Q

Osmolarity of LR

162
Q

Composition of LR

A 
Sodium (130)
Chloride (109)
Lactate (28)
Potassium (4)
Calcium (2.7)
163
Q

Ph NS

164
Q

Osmolarity NS

165
Q

Composition NS

A

154 mM Na + Cl

166
Q

Adavantages of crystalloid over colloid

A

Inexpensive, promotes urinary flow, restores third space loss, used for ECF replacement, used for initial resuscitation

167
Q

Disadvantages of crystalloid vs colloid

A

Dilutes plasma proteins, reduces cap osmotic pressure, peripheral edema, transient, potential for pulm edema, osmotic diuresis, impaired immune response

168
Q

Advantages of colloid over crystalloid

A

Sustained increase in intravascular volume
Requires smaller volume for resuscitation
Less peripheral edema
More rapid resuscitation

169
Q

Disadvantages of colloid vs crystalloid

A

Can cause coagulopathy
Anaphylactic reaction
Decreases calcium
Can cause renal failure

170
Q

Which colloid causes the most coagulopathy

A

Dextran>hetastarch>hextend

171
Q

Which colloid is most risk for anaphylaxis

172
Q

Which colloid decreases calcium

173
Q

Which colloid is most risk to cause renal failure

Principles (11 decks)

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