Fluid management Flashcards
(109 cards)
1
Q
What is the importance of fluid replacement (4)?
A
- Intravascular volume
- Left ventricular filling pressure
- Cardiac output
- Systemic blood pressure
2
Q
What is the ultimate goal?
A
Adequate oxygen delivery to tissues
3
Q
What is needs to be considered along with fluid replacement?
A
Electrolytes, acid base balance, coagulation
4
Q
What is the characteristic of the intracellular compartment?
A
~Two-thirds of total body weight
5
Q
Where is the large amount of intracellular fluid?
A
Large amount in skeletal muscle
6
Q
What is the major intracellular cation?
A
potassium
7
Q
What is the major intracellular anion?
A
phosphate
8
Q
What is the characteristic of the extracellular compartment?
A
~One-third of total body weight
9
Q
What is the major extracellular cation?
A
sodium
10
Q
What is the major extracellular anion?
A
chloride
11
Q
What are the different types of extracellular fluids?
A
Intravascular volume (1/4); Interstitial volume (3/4); Transcellular
12
Q
What is transcellular fluid?
A
Bodyfluidswhich are formed from the transport activities of cells
13
Q
What is an example of transcellular fluid?
A
E.g. Pleural fluid, peritoneal fluid, sweat, urine, lymph & CSF
14
Q
What is the total body water for males?
A
~60% of body weight
15
Q
What is the total body water for females?
A
~50-55% of body weight
16
Q
What is true about the total body water of neonates and infants?
A
have a higher water content per kg of body weight due to a larger volume of distribution
17
Q
What is the total body water for neonates and infants?
A
~70-80% of body weight
18
Q
What needs to be adjusted in neonates and infants?
A
Water soluble drug doses are higher in this population, e.g. succinylcholine
19
Q
What is the cause of decreased TBW for women, elderly and obesed patients?
A
Women, elderly and obese patients have decreased TBW due to decreased water content of adipose tissue
20
Q
What is the % of water for muscle?
A
75% water
21
Q
What is the % of water for adipose tissue?
A
~10% water
22
Q
What is the total body water of obese pts?
A
55cc/kg
23
Q
What is the total body water of female pts?
A
65cc/kg
24
Q
What is the total body water of male pts?
A
70cc/kg
25
What is the total body water of child pts?
80cc/kg
26
What is the total body water of neonate pts?
90cc/kg
27
What is the total body water of premature pts?
100cc/kg
28
What percentage of the interstitial compartment of ECC?
75%
29
What percentage of the intravascular compartment of ECC?
25%
30
What is the total daily fluid loss?
About 2500mL
31
How much fluid is lost in the urine?
1.5 liters
32
How much fluid is lost in respiratory tract evaporation?
400 ml
33
How much fluid is lost in skin evaporation?
400 ml
34
How much fluid in perspiration
| ?
100 ml
35
How much evaporation losses from skin and respiratory account for heat loss?
20-25% heat loss
36
What is the old rule for fluid replacement- maintenance?
4/2/1 Rule (also known as the Classic Approach)
37
What does the 4/2/1 rule take into account?
Maintenance, Replacement (fluid deficit and insensible loss), Blood Loss
38
What are the components of the 4/2/1 Rule?
- 1st 10kg 4cc/kg/hr
- 2nd 10kg 2cc/kg/hr
- Remaining kg 1cc/kg/hr
- Hourly maintenance fluid rate is the sum of these three values
39
What are the components for a 70 kg patient using the 4/2/1 Rule?
1st: 40cc
2nd: 20 cc
3rd: 50 cc (Remaining kg)
Total: 110cc
40
What is the calculation of fluid deficit?
the hourly maintenance rate multiplied by the number of hours the patient is NPO
41
What is the fluid deficit in the first hour?
Half of the deficit replaced in the first hour
42
What is the next two hours fluid deficit?
The remaining deficit administered equally over the next two hours
43
What is the management of insensible loss from Minimal tissue trauma (ex. herniorrhaphy)?
2-4 cc/kg/hr
44
What is the management of insensible loss from Moderate tissue trauma (ex. cholecystectomy): ?
4-6 cc/kg/hr
45
What is the management of insensible loss from Severe tissue trauma (ex. bowel resection)
6-8 cc/kg/hr
46
What is the crystalloid replacement for every cc of blood loss?
3 ml crystalloid
47
What is the PRBC/whole blood replacement for every cc of blood loss?
1 ml PRBC/whole blood
48
Why is it imperative to keep up with fluid and blood replacement?
normal hemodynamics and ultimately oxygen delivery to tissues
49
Review estimated blood loss.
Slide 50
50
What is the EBL for a 4x4?
~10 mL
51
What is the EBL for a ray tec?
~10-20 mL
52
What is the EBL for a Lap sponges?
~100 mL
53
What is the EBL for premature infants?
90-105 ml/kg
54
What is the EBL for full term infants?
80-90 ml/kg
55
What is the EBL for infants (>3 months)?
70-75 ml/kg
56
What is the EBL for adult females?
65 ml/kg
57
What is the EBL for adult males?
70 ml/kg
58
What is the EBL for obese?
Lean body weight plus 20%
59
What is the EBV for a 6kg full term infant?
540ml (6kg x 90ml)
60
What is the EBV for a 60 kg adult female?
3900ml (60kg x 65ml)
61
What is the EBV for a 80 kg male?
5600ml (80kg x 70ml)
62
What is the EBV calculation?
body wt (kg) x average blood volume (ml/kg)
63
What is an allowable blood loss (ABL) formula?
ABL= [EBV x (Hi-Hf)]/Hi
Hi – Initial hemoglobin
Hf – Final hemoglobin
64
What is the foundation of goal directed fluid therapy?
Interventions specifically performed to affect a meaningful clinical variable
65
What is the goal of goal directed fluid therapy?
Management of fluids such that stroke volume is optimized is well-validated and shown to reduce morbidity
66
What is the goal standard for perioperative fluid therapy?
Goal Directed Fluid Therapy
67
Begin the case with reasonable maintenance fluids with ___________
no deficit replacement
68
What is the characteristics of goal directed fluid therapy?
Fluids given as targeted boluses when they are expected to lead to a hemodynamic improvement
69
How much of a bolus is given at a time?
250mL
70
What is true about vasopressor use and Goal Directed Fluid Therapy?
Use of vasopressors a sign of strength
71
What is the relationship between mechanical ventilation and stroke volume variation?
induces cyclic changes in vena cava blood flow, pulmonary artery blood flow, and aortic blood flow. At the bedside, respiratory changes in aortic blood flow are reflected by “swings” in blood pressure whose magnitude is highly dependent on volume status
72
Which stroke volume increases during inspiration?
The left ventricular stroke volume increases during inspiration because left ventricular preload increases while left ventricular afterload decreases
73
Which stroke volume decreases during inspiration?
the right ventricular stroke volume decreases during inspiration because right ventricular preload decreases while right ventricular afterload increases.
74
What is the Stroke volume variation?
SVV is the degree of variability in stroke volume during inspiration and expiration
75
What is the SVV in a fully ventilated patient, with normal a SVV of lung compliance, with a regular heart rate indicate?
>10% suggests the patient might be dry
76
More than ______ variance in the stroke volume between inspiration and expiration
10%
77
If SVV is ______, you can try giving fluid.
10%
78
What occurs if the patient is volume responsive?
the Stroke Volume Index should increase
79
What are stroke volume variation inhibitors?
- Open chest procedures
- Small tidal volumes
- Spontaneous ventilation
- High PEEP
- Decreased chest compliance
- Pulmonary HTN
- Pneumoperitoneum
- Severe arrhythmias
- Non-supine position
- Severe atherosclerosis
- Right heart dysfunction
80
What is true about severe arrhythmias?
IVC and SVC variability remain accurate
81
What does literature support say about the use of SVV for mechanical ventilation?
Current literature supports the use of SVV on patients who are 100% mechanically ventilated with tidal volumes of more than 8cc/kg and fixed respiratory rates
82
What does literature support say about the use of SVV for spontaneous ventilation?
- Current literature does not support the use of SVV with patients who are spontaneously breathing.
- Spontaneous breaths use negative pressure ventilation with small, varying tidal volumes
83
_________- can dramatically affect SVV
Arrhythmias
84
What needs to be considered before additional volume?
SVR: Effects of vasodilatation therapy on SVV should be considered before treatment with additional volume
85
According to WHO Stratification on Implementation, what are some surgical risk factors?
- Major surgery with a mortality rate >1%
- Major surgery with an anticipated blood loss of >500mL
- Major intra-abdominal or orthopedic surgery
86
According to WHO Stratification on Implementation, what are patient risk factors?
- Age > 80 years
- History of heart failure, MI, stroke, or peripheral arterial disease
- Evidence of hypovolemia and/or tissue hypoperfusion
- Unexpected blood loss and/or fluid loss requiring >2 liters of fluid replacement
87
Review graph of WHO Stratification on Implementation.
Slide 59
88
According to WHO Stratification on Implementation, what is the recommendation for this patient:
Open colectomy for Grade IV cancer on 51yo ASA 3 (HTN, obesity, controlled DM)
GDFT recommended
| Low patient risk, high surgical risk
89
According to WHO Stratification on Implementation, what is the recommendation for this patient:
Laparoscopic cholecystectomy, 34 year old, ASA 1 patient, healthy
Zero balance fluid management, GFDT not indicated
| Low patient and surgical risk
90
According to WHO Stratification on Implementation, what is the recommendation for this patient:
THA on a 78yo ASA 4 (CAD, COPD on home oxygen, chronic renal insufficiency)
GDFT recommended, consider postop intensive care
| High patient risk, high surgical risk
91
According to WHO Stratification on Implementation, what is the recommendation for this patient:
Transmetatarsal amputation on 60yo ASA 4 (PAD, CHF, EF 35%, CAD, HTN)
GDFT recommended
| High patient risk, low surgical risk
92
Review fluid response algorithm and ca se studies.
Slide 61-62
93
What is Large-volume administration of 0.9% saline associated with?
development of hyperchloremic metabolic acidosis due to high chloride load
94
What is the chloride content of NS?
154mEq
95
Plasma bicarb concentration decreases as chloride __________
concentration increases
96
What fluids are not associated with acid/base disturbances?
Balanced or physiological fluids that contain calcium, potassium, or magnesium, and molecular glucose or buffer components such as bicarbonate or lactate are not associated
97
What is the recommended solution of GDFT?
1-3ml/kg/hr balanced salt solution ideal
98
What is the electrolyte concentration of plasma?
```
Na-142
Potassium-4
Chloride-103
Phosphate- 1.4
Magnesium-2
Calcium-5
```
99
What is the pH of plasma?
7.4
100
what is the osmolarity of plasma?
291
101
What is the electrolyte concentration of plasmalyte-A/Normosol-R/Isolyte-S?
```
Na-140-141
Potassium-5
Chloride-98
Phosphate- 1 (only isolyte-s)
Magnesium-3
Acetate-27
Gluconate-23
```
102
What is the pH of plasma plasmalyte-A/Normosol-R/Isolyte-S?
7.4
103
what is the osmolarity of plasmalyte-A/Normosol-R/Isolyte-S?
294-295
104
What is the electrolyte concentration of Lactated ringer?
```
Na-130
Potassium-4
Chloride-110
Calcium-3
Lactate-28
```
105
What is the pH of Lactated ringer?
6.2
106
what is the osmolarity of Lactated ringer?
275
107
What is the electrolyte concentration of NS?
Sodium-154
| Chloride-154
108
What is the pH of NS?
5.6
109
what is the osmolarity of NS?
310
