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2-General Anesthesia Exam 2 > Fluid management > Flashcards

Fluid management Flashcards

1
Q

What is the importance of fluid replacement (4)?

A
  • Intravascular volume
  • Left ventricular filling pressure
  • Cardiac output
  • Systemic blood pressure
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2
Q

What is the ultimate goal?

A

Adequate oxygen delivery to tissues

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3
Q

What is needs to be considered along with fluid replacement?

A

Electrolytes, acid base balance, coagulation

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4
Q

What is the characteristic of the intracellular compartment?

A

~Two-thirds of total body weight

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5
Q

Where is the large amount of intracellular fluid?

A

Large amount in skeletal muscle

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6
Q

What is the major intracellular cation?

A

potassium

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7
Q

What is the major intracellular anion?

A

phosphate

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8
Q

What is the characteristic of the extracellular compartment?

A

~One-third of total body weight

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9
Q

What is the major extracellular cation?

A

sodium

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10
Q

What is the major extracellular anion?

A

chloride

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11
Q

What are the different types of extracellular fluids?

A

Intravascular volume (1/4); Interstitial volume (3/4); Transcellular

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12
Q

What is transcellular fluid?

A

Bodyfluidswhich are formed from the transport activities of cells

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13
Q

What is an example of transcellular fluid?

A

E.g. Pleural fluid, peritoneal fluid, sweat, urine, lymph & CSF

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14
Q

What is the total body water for males?

A

~60% of body weight

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15
Q

What is the total body water for females?

A

~50-55% of body weight

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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

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17
Q

What is the total body water for neonates and infants?

A

~70-80% of body weight

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18
Q

What needs to be adjusted in neonates and infants?

A

Water soluble drug doses are higher in this population, e.g. succinylcholine

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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

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20
Q

What is the % of water for muscle?

A

75% water

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21
Q

What is the % of water for adipose tissue?

A

~10% water

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22
Q

What is the total body water of obese pts?

A

55cc/kg

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23
Q

What is the total body water of female pts?

A

65cc/kg

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24
Q

What is the total body water of male pts?

A

70cc/kg

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25
Q

What is the total body water of child pts?

A

80cc/kg

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26
Q

What is the total body water of neonate pts?

A

90cc/kg

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27
Q

What is the total body water of premature pts?

A

100cc/kg

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28
Q

What percentage of the interstitial compartment of ECC?

A

75%

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29
Q

What percentage of the intravascular compartment of ECC?

A

25%

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30
Q

What is the total daily fluid loss?

A

About 2500mL

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31
Q

How much fluid is lost in the urine?

A

1.5 liters

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32
Q

How much fluid is lost in respiratory tract evaporation?

A

400 ml

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33
Q

How much fluid is lost in skin evaporation?

A

400 ml

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34
Q

How much fluid in perspiration

?

A

100 ml

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35
Q

How much evaporation losses from skin and respiratory account for heat loss?

A

20-25% heat loss

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36
Q

What is the old rule for fluid replacement- maintenance?

A

4/2/1 Rule (also known as the Classic Approach)

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37
Q

What does the 4/2/1 rule take into account?

A

Maintenance, Replacement (fluid deficit and insensible loss), Blood Loss

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38
Q

What are the components of the 4/2/1 Rule?

A
  • 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
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39
Q

What are the components for a 70 kg patient using the 4/2/1 Rule?

A

1st: 40cc
2nd: 20 cc
3rd: 50 cc (Remaining kg)
Total: 110cc

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40
Q

What is the calculation of fluid deficit?

A

the hourly maintenance rate multiplied by the number of hours the patient is NPO

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41
Q

What is the fluid deficit in the first hour?

A

Half of the deficit replaced in the first hour

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42
Q

What is the next two hours fluid deficit?

A

The remaining deficit administered equally over the next two hours

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43
Q

What is the management of insensible loss from Minimal tissue trauma (ex. herniorrhaphy)?

A

2-4 cc/kg/hr

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44
Q

What is the management of insensible loss from Moderate tissue trauma (ex. cholecystectomy): ?

A

4-6 cc/kg/hr

45
Q

What is the management of insensible loss from Severe tissue trauma (ex. bowel resection)

A

6-8 cc/kg/hr

46
Q

What is the crystalloid replacement for every cc of blood loss?

A

3 ml crystalloid

47
Q

What is the PRBC/whole blood replacement for every cc of blood loss?

A

1 ml PRBC/whole blood

48
Q

Why is it imperative to keep up with fluid and blood replacement?

A

normal hemodynamics and ultimately oxygen delivery to tissues

49
Q

Review estimated blood loss.

A

Slide 50

50
Q

What is the EBL for a 4x4?

A

~10 mL

51
Q

What is the EBL for a ray tec?

A

~10-20 mL

52
Q

What is the EBL for a Lap sponges?

A

~100 mL

53
Q

What is the EBL for premature infants?

A

90-105 ml/kg

54
Q

What is the EBL for full term infants?

A

80-90 ml/kg

55
Q

What is the EBL for infants (>3 months)?

A

70-75 ml/kg

56
Q

What is the EBL for adult females?

A

65 ml/kg

57
Q

What is the EBL for adult males?

A

70 ml/kg

58
Q

What is the EBL for obese?

A

Lean body weight plus 20%

59
Q

What is the EBV for a 6kg full term infant?

A

540ml (6kg x 90ml)

60
Q

What is the EBV for a 60 kg adult female?

A

3900ml (60kg x 65ml)

61
Q

What is the EBV for a 80 kg male?

A

5600ml (80kg x 70ml)

62
Q

What is the EBV calculation?

A

body wt (kg) x average blood volume (ml/kg)

63
Q

What is an allowable blood loss (ABL) formula?

A

ABL= [EBV x (Hi-Hf)]/Hi

Hi – Initial hemoglobin
Hf – Final hemoglobin

64
Q

What is the foundation of goal directed fluid therapy?

A

Interventions specifically performed to affect a meaningful clinical variable

65
Q

What is the goal of goal directed fluid therapy?

A

Management of fluids such that stroke volume is optimized is well-validated and shown to reduce morbidity

66
Q

What is the goal standard for perioperative fluid therapy?

A

Goal Directed Fluid Therapy

67
Q

Begin the case with reasonable maintenance fluids with ___________

A

no deficit replacement

68
Q

What is the characteristics of goal directed fluid therapy?

A

Fluids given as targeted boluses when they are expected to lead to a hemodynamic improvement

69
Q

How much of a bolus is given at a time?

A

250mL

70
Q

What is true about vasopressor use and Goal Directed Fluid Therapy?

A

Use of vasopressors a sign of strength

71
Q

What is the relationship between mechanical ventilation and stroke volume variation?

A

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
Q

Which stroke volume increases during inspiration?

A

The left ventricular stroke volume increases during inspiration because left ventricular preload increases while left ventricular afterload decreases

73
Q

Which stroke volume decreases during inspiration?

A

the right ventricular stroke volume decreases during inspiration because right ventricular preload decreases while right ventricular afterload increases.

74
Q

What is the Stroke volume variation?

A

SVV is the degree of variability in stroke volume during inspiration and expiration

75
Q

What is the SVV in a fully ventilated patient, with normal a SVV of lung compliance, with a regular heart rate indicate?

A

> 10% suggests the patient might be dry

76
Q

More than ______ variance in the stroke volume between inspiration and expiration

A

10%

77
Q

If SVV is ______, you can try giving fluid.

A

10%

78
Q

What occurs if the patient is volume responsive?

A

the Stroke Volume Index should increase

79
Q

What are stroke volume variation inhibitors?

A
  • 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
Q

What is true about severe arrhythmias?

A

IVC and SVC variability remain accurate

81
Q

What does literature support say about the use of SVV for mechanical ventilation?

A

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
Q

What does literature support say about the use of SVV for spontaneous ventilation?

A
  • 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
Q

_________- can dramatically affect SVV

A

Arrhythmias

84
Q

What needs to be considered before additional volume?

A

SVR: Effects of vasodilatation therapy on SVV should be considered before treatment with additional volume

85
Q

According to WHO Stratification on Implementation, what are some surgical risk factors?

A
  • Major surgery with a mortality rate >1%
  • Major surgery with an anticipated blood loss of >500mL
  • Major intra-abdominal or orthopedic surgery
86
Q

According to WHO Stratification on Implementation, what are patient risk factors?

A
  • 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
Q

Review graph of WHO Stratification on Implementation.

A

Slide 59

88
Q

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)

A

GDFT recommended

Low patient risk, high surgical risk

89
Q

According to WHO Stratification on Implementation, what is the recommendation for this patient:

Laparoscopic cholecystectomy, 34 year old, ASA 1 patient, healthy

A

Zero balance fluid management, GFDT not indicated

Low patient and surgical risk

90
Q

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)

A

GDFT recommended, consider postop intensive care

High patient risk, high surgical risk

91
Q

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)

A

GDFT recommended

High patient risk, low surgical risk

92
Q

Review fluid response algorithm and ca se studies.

A

Slide 61-62

93
Q

What is Large-volume administration of 0.9% saline associated with?

A

development of hyperchloremic metabolic acidosis due to high chloride load

94
Q

What is the chloride content of NS?

A

154mEq

95
Q

Plasma bicarb concentration decreases as chloride __________

A

concentration increases

96
Q

What fluids are not associated with acid/base disturbances?

A

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
Q

What is the recommended solution of GDFT?

A

1-3ml/kg/hr balanced salt solution ideal

98
Q

What is the electrolyte concentration of plasma?

A 
Na-142
Potassium-4
Chloride-103
Phosphate- 1.4 
Magnesium-2
Calcium-5
99
Q

What is the pH of plasma?

A

7.4

100
Q

what is the osmolarity of plasma?

A

291

101
Q

What is the electrolyte concentration of plasmalyte-A/Normosol-R/Isolyte-S?

A 
Na-140-141
Potassium-5
Chloride-98
Phosphate- 1 (only isolyte-s)
Magnesium-3
Acetate-27
Gluconate-23
102
Q

What is the pH of plasma plasmalyte-A/Normosol-R/Isolyte-S?

A

7.4

103
Q

what is the osmolarity of plasmalyte-A/Normosol-R/Isolyte-S?

A

294-295

104
Q

What is the electrolyte concentration of Lactated ringer?

A 
Na-130
Potassium-4
Chloride-110
Calcium-3
Lactate-28
105
Q

What is the pH of Lactated ringer?

A

6.2

106
Q

what is the osmolarity of Lactated ringer?

A

275

107
Q

What is the electrolyte concentration of NS?

A

Sodium-154

Chloride-154

108
Q

What is the pH of NS?

A

5.6

109
Q

what is the osmolarity of NS?

A

310

2-General Anesthesia Exam 2 (11 decks)

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