Fluid and Electrolyte Management Flashcards
acute tx in patients with very high levels of Potassium?
insuling and glucose, or calcium gluconate- MOA- raises the threshold of nerves and muscles. Kayexalate can also be given if you have time- binds to Potassium, excrete out in feces
Good dietary sources of potassium (recommend to patients on Lasix)
banana, watermelon, OJ, broccoli, uncooked potatoes
calculated osmolarity
2(Na + K) + (BUN/2.8) + glucose/16
insensible fluid loss in adults per hour (for maintenance fluid)
1.5 ml/kg/hr or 135 ml/hour
Maintenance requirements for fluid replacement
4-2-1 rule (per hour) or 100-50-20 rule (for 24 hours)
daily electrolyte requirements for sodium and potassium
Sodium is 2-3 mmol/kg/day or 1-2 mmol/kg/day. potassium is 0.5-1 mmol/kg/day
how much sodium and potassium in 1 L 0.45% NaCl?
77 mmol Na, and 20 mmol K
how much sodium in 1 L 0.9% NaCl?
154 mmol sodium
resuscitation replacement
NPO deficit, bowel prep, and measurable fluid losses like NG suctioning, vomitting, ostomy output
how much fluid loss in bowel prep?
1 L
Replacement during surgery includes…
3rd space losses and blood losses
fluid loss in superficial surgical trauma
1-2 ml/kg/hr
fluid loss in moderate surgical trauma (hysterectomy, chest surgery, hemicolectomy)
5-6 ml/kg/hr
fluid loss in AAA repair, nephrectomy (severe surgical trauma)
8-10 ml/kg/hr
minimal surgical trauma (head and neck sx, hernia, knee surgery- not arthroscopic)
2-3 ml/kg/hr
replacement for blood loss in surgery
replace 3 ml of crystalloid solution for every ml of blood loss
what kind of fluid for maintenance, resuscitatin, replacement?
for maintenance- hypotonic 0.45% NaCl used. For replacement- isotonic 0.9% NaCl used. resuscitation- not sure which is better, LR or NS
types of crystalloid fluid given
LR, plasmylate, normosol, hypotonic soln, hypertonic soln
LR components
Na, Cl, K, calcium, lactate (monitor potassium and calcium)
plasmylate and normosol components
NS, K, and Mg (good for preventing arrhythmias in some heart patients)
types of colloid IV fluid given
hetastarch, albumin, dextran
when do you want to avoid hetastarch IV fluid replacement?
in patients with renal disease- is nephrotoxic. and can cause anaphylaxis
when is dextran (colloid) given IV?
used for thromboembolic prophylaxis (to prevent clots) by diluting out coag factors and platelets
if deficits in plasma volume-
reduced tissue perfusion, so capillary refill abnormal and coloring of skin pale
if deficits in interstitial fluid-
decrease turgor, dry skin, fissuring tongue, and sunken eyes
What to look at when determining if fluid replacement is working?
Physical assessment does not show turgor, dry skin, sunken eyes. HR is going down, BP is going up. Urine output greater than 1.0 ml/kg/hr
Invasive monitoring in patients with fluid replacement
CVP, PAP, PWP
Lab tests in patient that is getting replaced with fluids
Hgb, Hct
Rule of thumb for hct rise in patient that has lost fluid
If Hct rises 1%, that indicates that patient has lost 500 ml ECF if RBC loss is NIL
daily weigh gains or losses greater than ___ represent changes in body fluid content
0.5 pounds
Surgical patient that has gained 15 pounds during surgical course. Wants to know when he will go back to his normal weight.
Diuresis and associated weight loss is expected 3 or more days postup. This is when 3rd space fluid accummulations in interstitial space move into the intravascular or the intracellular space, from there pee it out. lose weight. takes time!
what are signs that you see clinically that indicate patient is losing fluid/blood?
patient tachycardic, narrow pulse pressure, reduced BP. Urine output less than 0.5 ml/kg/hr. PE- dry skin, decrease turgor, fissuring tongue, sunken eyes. abnormal cap refill and coloring. Labs: BUN:Cr ratio> 20:1, Increased hct, and Urine Na is less than 20 mEg/L
indications for replacement of blood components
If Hb less than 7 gm/dL.
If compromised patient, what level do you want to see their Hb?
may require levels above 10 gm/dL
1 unit of packed RBC contains how many ml?
250 ml
Packed RBC’s Hct
70-80%
1 unit packed RBC’s effect on Hgb
raises Hgb by 1 gm/dL
how many units of packed RBC’s would you give female patient with Hgb of 7?
Want to see patients with Hgb level at 12-14. So 5 units (1 unit inc Hgb by 1 gm/dL)
indications to give platelet concentrate?
thrombocytopenia and intraoperative platelet count less than 50,000
Platelets get consumed in surgery. For this reason, what do you want plt count to be pre-operatively?
greater than 90,000
FFP composition
coag factors, no platelets
method of increasing platelet count
1 unit RDP inc platelet count by 5-10,000/ul. 1 unit RDP for every 10 kg increases platelet count by 50,000.
1 unit SDP
=6-7 RDP
indication for how much FFP to give?
15 ml/kg (about 1 L)
in which situations would you choose to give patient FFP?
factor deficiencies, reversal of coumadin effect (coumadin patient hits head- FFP helps to get clotting factors up), TTP, and intraoperatively when PT and PTT are greater than 1.5x normal value
cryoprecipitate components
FIBRINOGEN, vWF, Factor VIII, and Factor XIII
how much fibrinogen/bag in cryoprecipitate?
200 mg/bag
Benefits to cryoprecipitate
stores longer than FFP, and less fluid required to give a high concentration of factors (nice option in CHF patients who can’t take on too much more fluid)
most common transfusion reaction
Febrile non-hemolytic transfusion reaction (FNHTR)
FNHTR d/t
cytokines IL-2, IL-6, IL-8, and TNF
why is temp taken every 10-15 minutes after blood is given?
to check for reaction (fever)- febrile non hemolytic transfusion reaction
name complications of transfusion reactions
Febrile non-hemolytic transfusion reaction, allergy, hemolytic anemia, viral transmission, hypothermia, coag disorders, citrate
classic signs of hemolytic anemia
fever, flank pain, red or brown urine
tx in hemolytic anemia
stop transfusion, and give fluids to perfuse kidneys (NS)
why do you get flank pain and red or brown urine in hemolytic anemia?
flank pain d/t intravascular hemolysis. Hb released into the bloodstream, gets trapped in kidney and can cause kidney damage- flank pain. Red/brown urine results d/t oxidation of hemoglobin as it goes through the kidneys
viral complications from transfusion reactions
Hep C (1:30,000), Hep B (1:200,000), HIV (1:500,000), CMV
to prevent hypothermia in transfusion complications,
use warmers
why would coag disorders result as transfusion complication?
massive transfusion more than 10 units may dilute platelets and factor V and VIII
