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N928 - Basic Principles > Fluid & Blood important > Flashcards

Fluid & Blood important Flashcards

1
Q

How is hourly maintenance of fluid calculated?

A 
0-10kg = 4mg/kg/hr
11-20kg = 1mg/kg/hr
>20kg = 1mg/kg/hr
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2
Q

What is the equation for NPO deficit?

A

hourly maintenance requirement x # of hours NPO

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3
Q

What is the loss of fluid during a minimal surgical procedure?

A

0-2mL/kg

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4
Q

What is the loss of fluid during a moderate surgical procedure?

A

2-4mL/kg

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5
Q

What is the loss of fluid during a severe surgical procedure?

A

4-8mL/kg

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6
Q

LR
pH
osmolarity
electrolyte composition

A

pH 6.5
osmolarity 273mOsm/L

130 mM Na
109 mM Cl
28mM lactate 
4mM K
2.7mM Ca
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7
Q

Normal Saline

pH
osmolarity
electrolyte composition

A

ph 5.0

osmolarity 308mOsm/L

154mM Na & Cl

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8
Q

What are advantages of crystalloid (5)

A
  1. inexpensive
  2. promotes urinary flow
  3. restores third-space loss
  4. used for ECF replacement
  5. used for initial resuscitation
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9
Q

What are disadvantages of crystalloid? (7)

A
  1. dilutes plasma proteins
  2. reduces capillary osmotic pressure
  3. peripheral edema
  4. transient
  5. potential for pulmonary edema
  6. impaired immune response
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10
Q

What are advantages of colloid? (4)

A
  1. sustained increase in plasma volume
  2. requires smaller volume for resuscitation
  3. less peripheral edema
  4. more rapid resuscitation
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11
Q

What are the disadvantages of colloids? (4)

A
  1. can cause coagulopathy
  2. anaphylactic reaction
  3. decreases Ca
  4. can cause renal failure
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12
Q

What are 3 purposes of parenteral fluid therapy

A
  1. maintenance fluids
  2. replacement of fluids lost as a result of surgery and anesthesia
  3. correction of electrolyte disturbances
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13
Q

What are the 3 main categories of IVF

A

hypotonic
isotonic
hypertonic

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14
Q

What are the 2 main types of IV fluids

A

crystalloids

colloids

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15
Q

What are 2 examples of crystalloids?

A

Normal Saline

Lactated Ringers

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16
Q

What are 4 examples of colloids?

A
  1. albumin
  2. plasmanate
  3. Dextran
  4. hetastarch
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17
Q

What are 2 concerns about normal saline?

A

crystalloid

  1. hyperchloremic metabolic acidosis
  2. fluid overload (only 1/4 stays in the vessel)
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18
Q

What are 2 concerns about lactated ringers?

A
  1. metabolic alkalosis

2. potassium accumulation in patients with RENAL FAILURE

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19
Q

For every 1mL of blood loss, how much crystalloid should be given?

A

3mL

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20
Q

What is the replacement ratio of blood to colloid?

A

1mL blood loss = 1mL colloid administered

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21
Q

What is a colloid?

A

solution containing osmotically active substances of high molecular weight that do not easily cross the capillary membrane and will draw fluid into the vascular space & expand circulating blood volume

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22
Q

Where does albumin come from?

A

the liver…

manufactured from pooled donor plasma

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23
Q

What is the indications for albumin administration?

A
  1. treatment of shock d/t loss of plasma
  2. acute burns
  3. fluid resuscitation
  4. hypo-albuminemia
  5. following paracentesis
  6. liver transplantation

*pt started with higher Hct and you are trying to not transfuse

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24
Q

What are the adverse reactions to albumin administration?

A
  1. pruritus
  2. fever
  3. rash
  4. N/V
  5. tachycardia
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25
Q

What is the duration of effect for albumin?

A

16-24H

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26
Q

How much does 25% albumin expand the intravascular volume by?

A

x5 of the volume given

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27
Q

What is the ratio of blood loss to 5% albumin? 25% albumin?

A

1:1 5%

1/5th
5:1 25%

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28
Q

What is the BAD thing about hetastarch?

A

WILL CAUSE BLEEDING / COAGULATION ISSUES

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29
Q

What is the maximum dose of hetastarch?

A

20mL/kg

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30
Q

What are the adverse reactions associated with hetastarch?

A
  1. hypersensitivity
  2. coagulopathy
  3. hemodilution
  4. circulatory overload
  5. metabolic acidosis
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31
Q

What is the difference between hetastarch and hextend?

A

hetastarch has higher bleeding / coagulopathy risk

hextend is in a buffered solution

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32
Q

What is the benefit of Voluven?

A

safer in patients with renal impairment

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33
Q

What are the 3 reasons for blood component therapy?

A
  1. increase O2 carrying capacity
  2. increase intravascular volume
  3. restore hemostasis
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34
Q

What are 6 transfusion “triggers”?

A
  1. perioperative blood loss
  2. clinical condition of the patient (hx ischemia?)
  3. patient-specific blood volume
  4. calculation of allowable blood loss
  5. access to pt blood type (has T&S been sent?)
  6. patient preferences
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35
Q

What are 2 benefits and 2 risks of blood component therapy?

A

benefits:

  1. increased O2 carrying
  2. improved coagulation

Risks:

  1. infection
  2. incompatibility
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36
Q

What are subjective ways of measuring EBL?

A

measuring net suction volume & counting or weighing sponges

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37
Q

Is EBL usually under- or over- estimated?

A

UNDERestimated

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38
Q

Does POC test show EBL?

A

NO, only Hct or Hgb

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39
Q

What are 3 physiological changes that can be seen if a patient is in need of blood component therapy?

A
  1. tachycardia
  2. decreased mixed venous oxygenation
  3. measurement of DO2 (systemic oxygen delivery)
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40
Q

How is DO2 measured?

A

*systemic oxygen delivery

DO2 = CO x CaO2

oxygen delivery = cardiac output x O2 carrying capacity of arterial blood

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41
Q

What is CaO2?

A

1.34 x Hgb x SpO2 + (0.003 x PaO2)

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42
Q

What is CO?

A

HR x SV

preload
afterload
inotropy

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43
Q

What O2 delivery demonstrates a higher chance of survival?

A

> 600mL / min / m^2

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44
Q

What is the estimated blood volume for a full term infant?

A

80-90mL/kg

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45
Q

What is the estimated blood volume for an infant?

A

80mL/kg

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46
Q

What is the estimated blood volume for an adult?

A

Man 75mL/kg

Woman 65mL/kg

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47
Q

What is the estimated blood volume for an adult man?

A

75mL/kg

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48
Q

What is the estimated blood volume for an adult woman?

A

65mL/kg

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49
Q

What is the estimate blood volume for an obese adult?

A

50mL/kg

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50
Q

What it the maximum allowable blood loss? MABL

A

(EBV x (starting Hct - target Hct) / starting Hct

Transfusion target is 21-30%

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51
Q

What is the difference between type & screen and type & cross?

A

cross is the ULTIMATE test of blood compability

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52
Q

Type and screen is a test of what?

A

ABO test
Rh test (AKA type D)
positive: you HAVE the Rh D antigen
negative: you LACK the Rh D antigen

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53
Q

Blood group A has what antigen

and antibodies?

A

Blood group A HAS A antigen on RBC …

Blood group A has ANTI-B antibodies in serum

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54
Q

What is the blood compatibility for group A?

A

A, O

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55
Q

Blood group B has what antigen and antibodies?

A

blood group B HAS B antigen on RBC…

blood group B has ANTI-A antibodies in serum

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56
Q

What is the blood compatibility for group B?

A

B, O

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57
Q

What is the antigen and antibodies for group AB?

A

group AB HAS both A and B antigen on RBC

blood group AB does not have any antibodies in the serum

58
Q

What is the blood compatibility for blood group AB?

A

AB, A, B, O

59
Q

Blood group O has what antigen and antibodies?

A

Blood group O does NOT have any antigen on the RBC

Blood group O has ANTI-A & ANTI-B antibodies in the serum

60
Q

What is the blood compatibility of blood group O?

A

O ONLY

61
Q

What are the antigen and antibodies for blood type Rh+?

A

Rh+ blood group has antigen D on the RBC

blood group Rh+ does not have any antibodies in the serum

62
Q

What is the blood compatibility of group Rh+?

A

Rh +
AND
Rh -

63
Q

What are the antigen and antibodies for blood type Rh-?

A

blood group Rh- does NOT have antigen on the RBC

blood group Rh- has Anti-D antibodies IF SENSITIZED

64
Q

What kind of blood compatibility does Rh- blood have?

A

Rh - ONLY

65
Q

What blood group is the universal donor?

A

O-

66
Q

What blood group is the universal recipient?

A

AB+

67
Q

Who can receive O+ blood?

A

Anyone EXCEPT women of childbearing age, or those who have received a blood transfusion in the past

68
Q

Why give RBC and what are 3 indications?

A

hemorrhage & improve O2 delivery to tissues

  1. symptomatic anemia in high risk patients
  2. acute blood loss >30% of blood volume
  3. hemodynamically unstable patients
69
Q

Why is FFP given?

A

reversal of anticoagulant effects

70
Q

Why are platelets given?

A

prevent hemorrhage in patients with thrombocytopenia or platelet function deficits

71
Q

Why is cryoprecipitate given?

A

hypofibrinogenemia (in the setting of massive hemorrhage or consumptive coagulopathy)

72
Q

What changes happen to banked blood?

A 
depletion of:
     - 2, 3-diphosphoglyverate (DPG)
     - ATP
oxidative damage
increased adhesion to endothelial cells
acidosis
change in RBC morphology
accumulation of microaggregates
hyperkalemia (up to 17.2 mEq/L)
loss of viable platelets (after 2 days in fridge)
loss of Factors V & VIII
hemolysis
accumulation of pro-inflammatory, metabolic, & breakdown products
73
Q

What Hgb is associated with significant mortality?

A

< 5g/dL

74
Q

What is the recorded Hgb that was survived?

A

1.8 g/dL

75
Q

At what Hgb should transfusion be considered?

A

7-10 g/dL

76
Q

At what Hct should transfusion be considered?

A

21-30%

77
Q

What is the ASA taskforce recommendation regarding transfusion with Hgb >= 10 g/dL

A

“usually unnecessary’

78
Q

What is the ASA taskforce recommendation regarding transfusion with Hgb 6 - 10 g/dL

A

based on clinical factors

79
Q

What is the ASA taskforce recommendation regarding transfusion with Hgb =< 6 g/dL

A

“usually necessary”

80
Q

What is the ASA taskforce recommendation regarding transfusion with Hgb =< 6 g/dL

A

“usually necessary”

81
Q

What are 6 surgical procedures that commonly require a blood transfusion?

A
  1. orthopedic (esp hip & knee replacement) → esp acetabular fx
  2. colorectal
  3. cardiac
  4. major vascular
  5. liver transplant
  6. trauma
82
Q

What is patient blood management?

A

strategy used to reduce unnecessary transfusions and maximize patient outcomes

83
Q

What are 3 techniques of patient blood management?

A
  1. optimize pts own red blood cell mass
  2. minimize blood loss
  3. optimize pts physiological tolerance of anemia (crystalloid or colloid)
84
Q

What are 6 preoperative strategies of patient blood management?

A
  1. screen & treat anemia or iron deficiency (erythropoiesis stimulating agents
  2. identify & manage bleeding risks of meds or chronic dz
  3. assess pt reserve & optimize pt specific tolerable blood loss
  4. formulate plan with evidence-based transfusion strategy
  5. PREOPERATIVE AUTOLOGOUS blood donation (select situations)
  6. may require up to 30d pre-op to accommodate therapy
85
Q

What are 6 intraoperative strategies of patient blood management?

A
  1. hematologicaly optimize before elective surgery
  2. blood sparing techniques
  3. continually measure & assess Hct and Hgb
  4. plan & optimize fluid management of nonblood products
  5. optimize CO, ventilation, DO2
  6. use blood salvage & autologous transfusion if possible
86
Q

What are 5 postoperative strategies of patient blood management?

A
  1. treat anemia
  2. monitor & manage post-op bleeding
  3. maintain normothermia to minimize O2 consumption
  4. avoid and/or treat infections
  5. manage anticoagulant medications
87
Q

How many classes of hemorrhage are there?

A

4

88
Q

What is Class 1 hemorrhage?

reduction in volume
mLs lost
Hgb
indication for transfusion

A

<15 % reduction in blood volume
<750mL
>=10 g/dL

transfusion not necessary if no preexisting anemia

89
Q

What is Class 2 hemorrhage?

reduction in volume
mLs lost
Hgb
indication for transfusion

A

15-30% reduction in blood volume
-750 - 1500 mL
8-10 g/dL

transfusion not necessary unless preexisting anemia or cardiopulmonary disease

90
Q

What is Class 3 hemorrhage?

reduction in volume
mLs lost
Hgb
indication for transfusion

A

30-40% reduction in blood volume
1500-2000mL
6-8 g/dL

transfusion probably necessary

91
Q

What is Class 4 hemorrhage?

reduction in volume
mLs lost
Hgb
indication for transfusion

A

> 40% reduction in blood volume
2000mL
=< 6g/dL

transfusion IS necessary

92
Q

3 indications for massive transfusion

A
  1. replacement of estimated blood volume within 24 hours
  2. > = 10 units of RBC over 24 hours
  3. 50% of blood volume within 3 hours or less
93
Q

What are concerns of massive transfusion?

A
  1. dilutional coagulopathy
  2. dilutional thrombocytopenia
  3. banked blood has citrate; binds to calcium and inhibits coagulation
  4. rapid infusion can ↓ ionized calcium [aka. citrate intoxication; give CaCl]
94
Q

How much will one unit of PRBC raise the Hct by?

A

2-3%

95
Q

What is the replacement of blood with PRBC?

A

1mL PRBC to 2mL blood loss

96
Q

What is contained in FFP?

A

all coagulation factors

97
Q

What are 6 indications of FFP administration?

A
  1. deficiency of coagulation factors with abnormal coagulation tests & active bleeding
  2. planned surgery in the presence of abnormal coagulation tests
  3. reversal of WARFARIN in the presence of active bleeding
  4. WARFARIN related intracranial hemorrhage
  5. planned procedure when Vit K is inadequate to reverse Warfarin
    - - thrombotic thrombocytopenic purpura
    - – congenital or acquired factor deficiency with no alternative therapy
  6. trauma patients requiring massive transfusion
98
Q

What is the broad indication for platelet administration?

A

prevention of bleeding or to stop bleeding in patients with low platelet count or functional platelet disorders

99
Q

What is a normal platelet count?

A

150,000 - 450,000 cells / microL

100
Q

What are lab parameters to transfuse platelets?

A

<50,000 - 100,000 cells / microL

50000 - 100000 if microbleeding is present or pt is at risk of continued bleeding

101
Q

What must platelets be before neurosurgery or ocular surgery?

A

100.000 cells / microL

102
Q

What must platelets be before major surgery?

A

50,000cells / microL

103
Q

What must platelets be in DIC?

A

50,000 cells / microL

104
Q

What must platelets be before CVC placement?

A

20,000 cells / microL

105
Q

What must platelets be before epidural/spinal anesthesia?

A

100,000 cells / microL

106
Q

What must platelets be before vaginal delivery?

A

30,000 cells / microL

traumatic surgery is 50,000 cells / microL

107
Q

What does cryoprecipitate contain?

A

Factor VIII (vW factor) & fibrinogen

108
Q

What are indications for cryoprecipitate administration?

A
  1. pt with vW dz

2. pt with probable or documented deficits in fibrinogen ( <80-100 mg/dL)

109
Q

What is important to remember about cryoprecipitate administration?

A

administration must be as rapid as possible; at least 200mL/hr

and the infusion must be completed within 6 hours

110
Q

What is the most common and most serious complication of blood transfusions?

A

incompatibility

111
Q

What occurs during a blood transfusion reaction?

A

an immune reaction with risk of an acute hemolytic reaction

112
Q

What are 1/2 of deaths related to transfusion reactions caused by?

A

procedural or administration error

113
Q

What is different about blood product administration in the OR?

A

clinical picture of reaction is complicated by GA; can obscure the symptoms associated with a hemolytic reaction

114
Q

What is transfusion associated graft vs host dz?

A

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

115
Q

What are 3 s/s of transfusion graft vs host dz?

A
  1. rash
  2. leukopenia
  3. thrombocytopenia
116
Q

What is the second most common transfusion related complication?

A

transfusion related acute lung injury (TRALI)

117
Q

What is TRALI

A

transfusion related acute lung injury;

acute lung injury that occurs within 6 hours of transfusion in pts previously without ALI

118
Q

How often does TRALI occur in platelet vs FFP administration

A

plts 1:432

FFP 1:79000

119
Q

What is transfusion related immunomodulation? (TRIM)

A

presence of leukocytes in allogenic blood

120
Q

What kind of transfusions are implicated in immunosuppression of receipients?

A

homologous transfusions

121
Q

What are 3 s/s of nonhemolytic transfusion reactions?

A
  1. fever
  2. chills
  3. uticaria
122
Q

What are the types of transfusion related reactions?

A
  1. incompatibility
  2. GVHD
  3. TRALI
  4. TRIM
  5. nonhemolytic reactions
123
Q

What is leukoreduction?

A

filter out of WBCs from blood products

  • proven to be effective in reducing the incidence of nonhemolytic transfusion reactions and is liekely to be effecive in the reduction of TRIM
124
Q

What changes the effects & magnitude of leukocytes in transfused blood?

A

immunomodulatory effects on recipient in a magnitude proportional to the length of time unit is stored

125
Q

How does leukoreduction occur in the OR?

A

filters

126
Q

What are the alternatives to blood transfusion?

A
  1. donor directed blood transfusion
  2. autologous blood transfusion
  3. cell salvage
  4. preoperative blood donation
  5. acute normovolemic hemodilution
127
Q

What is donor directed blood transfusion?

A

homologous blood transfusion from a donor selected by the recipient

some believe this can decrease the transmission of infx

128
Q

What is autologous blood transfusion?

A
  1. intraoperative blood salvage
  2. postoperative blood salvage
  3. preoperative blood donation
  4. acute normovolemic hemodilution
129
Q

What is cell salvage?

A

blood in surgical field is collected, washed, and returned to patient.

130
Q

What 6 types of cases utilize cell salvage?

A
  1. cardiac
  2. orthopedic
  3. radical prostatectomy
  4. nephrectomy
  5. AAA
  6. Aneurysm
131
Q

What are contraindications to cell salvage?

A
  1. surgery involving contaminated wounds; bowel, bacteria, sepsis, amniotic fluid, malignant cells
132
Q

What is preoperative blood donation?

A

collection & storage of recipients own blood for later use

133
Q

What are the risks of preop blood donation?

A
  1. preoperative anemia (can result in myocardial ischemia)
  2. bacterial contamination
  3. clerical error - administration of the wrong blood
134
Q

How much autologously donated blood is wasted?

A

half

135
Q

What is acute normovolemic hemodilution?

A

removal of whole blood immediately before or after initiation of anesthesia & surgery.

volume is replaced by crystalloid or colloid

  • blood lost during surgery is diluted (low Hct)
  • reinfusion of blood to patient when intraoperative loss of blood has stopped.

THIS BLOOD HAS NORMAL HCT & CLOTTING FACTORS

136
Q

What value is considered hypotonic?

A

<275 mOsm / L

137
Q

What value is considered hypertonic?

A

> 295 mOsm / L

138
Q

How is oxygen demand increased in the OR?

A
  • shivering

- MH

139
Q

Normal male Hgb

A

13.2 - 16.6 g/dL

140
Q

Normal woman Hgb

A

11.6 - 15 g/dL

141
Q

Normal male Hct

A

42% - 52%

142
Q

Normal woman Hct

A

37% - 47%

N928 - Basic Principles (22 decks)

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