Fluid Management Flashcards
anion gap
difference between cations and anions
Na+-(Cl-+HCO3-)
Normal = <12
>12 indicates pt has metabolic acidosis
Respiratory acidosis results in…
- reduced myocardial contractility
- increased PVR
- decreased SVR
Respiratory alkalosis results in…
- hypokalemia
- hypocalcemia
- dysrhythmias
- bronchoconstriction
- cerebrovasoconstricion
- hypotension
Metabolic acisosis results in…
- reduced myocardial contractility
- increased PVR
- decreased SVR
Metabolic alkalosis results in…
- hypokalemia
- hypocalcemia
- arrhythmias
- compensatory hypoventilation/hypercarbia
- reduced tissue oxygenation
treatment of metabolic alkalosis
- expansion of intravascular volume
- administer K
- administer carbonic anhydrase inhibitor
Base excess or deficit
- Used to measure deviation from normal bicarbonate level to help determine adequacy of intravascular volume
- 0 = normal bicarbonate level
- -2 to <0 = metabolic acidosis (base deficit)
- >0 to +2 = metabolic alkalosis (base excess)
Plasma solute concentrations
- Na: 140
- K: 4.3
- Mg: 2
- Cl: 105
- HCO3-: 24
- phosphate: 2
- Protein: 1
- Total Osm: 291
- pH: 7.4
ECF solute concentrations
- Na: 140
- K: 4.3
- Mg: 2
- Cl: 105
- HCO3-: 24
- phosphate: 2
- protein: 0
- Total Osm: 290
- pH: 7.4
ICF solute concentrations
- Na: 12
- K: 120
- Mg: 40
- Cl: 5
- HCO3-: 12
- Phosphate: 100
- protein: high
- Total osm: 290
- pH: 7.2
sources of intra-op fluid requirements
- maintenance
- healthy adults require 2.5L/day over 24 hours
- fluid deficit
- Blood loss
- evaporative loss
- 3rd space loss
calculating maintenance fluids
- 4-2-1 rule
- 4 ml/kg/hr for first 10 kg
- 2 ml/kg/hr for second 10 kg
- 1 ml/kg/hr for each additional kg
Fluid deficit
- the maintenace requirement multiplied by the number of hours pt was NPO
- if receiving maintenace IVF, no NPO deficit
- if baseline hypovolemia exists, consider the overall deficit greater than just NPO deficit
- replace fluid to restore MAP, HR and filling pressures BEFORE induction
Fluid deficit replacement strategy
- 1/2 of deficit replaced during first hour of surgery
- 1/4 of deficit replaced during second hour of surgery
- 1/4 of deficit replaced during third hour of surgery
Blood loss estimations
- soaked gauze 4x4 = 10 ml
- soaked laparotomy pads = 100-150 ml
- suction containers
- floor and drapes
- consider if gauze and pads are being used wet or dry by surgeon
floor spill approximations
- 1 inch diameter = 5ml
- 2 inch diameter = 20 ml
- 3 inch diameter = 45 ml
- 4 inch diameter = 80 ml
Estimated blood volume
- neonates
- premie = 95 ml/kg
- term = 85 ml/kg
- infant = 80ml/kg
- child = 70 ml/kg
- adult
- men = 75 ml/kg
- women = 65 ml/kg
allowable blood loss
ABL = (EBV x (starting HCT - allowable HCT))/ starting HCT
*helps anesthetist plan when to transfuse patient
Evaporative loss
- evaporative loss is directly related to amount of surface area of surgical wound and duration of exposure
3rd space loss
due to fluid shifts and intravascular volume deficit caused by redistribution of fluids
Ex. trauma, infection, burns, ascites
Replacing evaporative and 3rd space losses
- short, superficial procedure = 0-2ml/kg/hr
- moderate, uncomp untra-abd, orthopedic = 3-5 ml/kg/hr
- Severe, long, invasive = 6-9 ml/kg/hr
- Emergency, mult injuries = 10-15 ml/kg/hr
Blood loss replacement
- 3:1 crystalloid for blood
- 1:1 blood/colloid for blood
ERAS
- enhanced Recovery after surgery
- fluid philosophy of avoidance of sodium and water overload
- carboloading pre-op
- maintain normothermia
- avoid opioids
- **questioning science behind replacement of 3rd space losses
Goal directed fluid therapy
- using advanced monitoring to make estimations of functional circulating volume
- is the patient going to respond to fluid?
- stroke volume variation
- pulse pressure variation
- systolic pressure variation
Frank Starling curve

hypotonic solutions
- Osm 253
- replaces water loss
- called “maintenance fluids”
- not used in OR
- Example: D5W
- water moves into ISF and cells
isotonic solutions
- osm 300
- replaces water and electrolyte loss
- called replacement fluids
- used in OR
- ex: LR, NS
hypertonic solutions
- D5 1/2 NS osm (432), 3% NS osm (1026)
- for hyponatremia or shock
- draws fluid into intravascular space
LR facts
- NS with electrolytes (K+, Ca++) and buffer (lactate)
- isotonic (275)
- provides 100 ml free water per liter of solution
- tends to lower Na+
- lactate gets converted to bicarb
- solution most similar to ECF
- avoid in ESRD b/c it contains K+
- do not mis with PRBC as the Ca++ binds to citrate in blood
LR electrolytes
- Na+ 130 mEq/L
- K+ 4 mEq/L
- Ca++ 3 mEq/L
- Cl- 110 mEq/L
- lactate 28 mEq/L
- glucose 0g/L
- pH 6.5

Normal saline facts
- 0.9% NaCl in water
- isotonic: osm 308
- in large volume produces high Cl- content which leads to dilutional hyperchloremic acidosis
- preferred solution for diluting PRBCs
0.9% NS electrolytes
- Na+ 154 mEq/L
- K+ 0 mEq/L
- Ca++ 0 mEq/L
- Cl- 154 mEq/L
- lactate 0 mEq/L
- glucose 0 g/L
- pH 6.0

Normosol-R electrolytes
- Na+ 140 mEq/L
- K+ 5 mEq/L
- Ca++ 0 mEq/L
- Cl- 98 mEq/L
- glucose 0 g/L
- Mg++ 3 mEq/L
- Acetate 27 mEq/L (buffer)
- gluconate 23 mEq/L
- pH 7.4
D5W
- hypotonic solution: osm 260
- rarely used perioperatively
- causes free water intoxication and hyponatremia
- provides 170-200 calories/1000 ml for energy
- can cause hyperglycemia
- except in DM pt receiving insulin or neonate

3% NaCL
- Na/Cl 513 mEq
- used rarely for low volume resuscitation
- mostly used to treat hyponatremia
- risk of hyperchloremia, hypernatremia, and cellular dehydration

Colloid solutions
- onsmotically active
- stay intravascular 3-16 hours while crystalloid stays about 15 minutes
- high molecular weight
- volume administered is equivalent to fluid/blood lost from intravascular volume
albumin
- obtained from fractionated human plasma
- possible to have reaction
- does not contain coagulation factors or blood group antibodies
- available as 5% or 25%
- size of molecule, which determines different oncotic pressures
- 5% solution common in OR
- 5% solutions causes oncotic pressure of 20

Dextran
- Synthetic colloid
- water soluble glucose polymers that get enzymatically degraded to glucose
- might have to give extra insulin
- Dextran 70- used for volume expansion
- draws fluid in from ISF
- Dextran 40- used for prevention of thrombosis
- decreases viscoscity of blood

Dextran side effects
- anaphylactoid reaction
- platelet inhibition
- noncardiac pulmonary edema
- inerference with crossmatching
Hetastarch
(Hespan 6%)
- synthetic colloid
- as effective as albumin for volume expansion
- nonantigenic- does not create immune response
- cheaper than albumin
- stored in reticuloendothelial system for several hours and renally excreted
- max dose: <20 ml/kg/day because it pulls SO much fluid from cells
- oncotic pressure 30
indications for blood transfusions
- expand intravascular volume
- *increase oxygen carrying capacity
- hemoglobin and hematocrit
- rarely if HGB > 10
- definitely if HGB <6
- if between, depends on pts risk for complications and inadequate oxygenation
- use of “trigger” not recommended
risks of blood product administration
- Hepatitis B or C
- HIV
- Bacterial sepsis
- allergic reactions/febrile reactions
- lung injury
- hemolytic reactions
- noncardiogenic pulmonary edema
- acute hypotensive transfusion reaction
PRBCs facts
- Type and Rh factor is sufficient for most people to be compatible
- 1 unit PRBC increases HGB 1 gm/dl
- HCT of one unit is 70%
- decreases as the PRBCs age
PRBCs reconstituted with:
- 0.9% NS
- 5% dextrose in 0.4% NS
- 5% dextrose in 0.9% NS
- Normosol-R
PRBC citrate toxicity
- citrate binds to Ca++, causes hypocalcemia
- monitor ionized calcium
complications of autologous blood
- anemia
- pre-op myocardial ischemia from the anemia
- administration of the wrong unit
- need for more frequent blood transfusion
- febrile and allergic reaction
Platelet facts
- one unit comes from centrifuging single unit of whole blood
- volume 200-400 ml
- one unit increases platelet count 7,000-10,000 one hour after transfusion
- incidense of platelet related sepsis is 1 in 12,000
- bacterial contamination risk 1:2,000
Platelet uses
- thrombocytopenia
- dysfunctional platelets
- active bleeding
- platelet count <50,000
FFP facts
- contains clotting factors and plasma proteins
- volume 200-250 ml
- must be ABO compatible
- each unit increases each clotting factor level by 2-3%
FFP uses
- urgent reversal of warfarin
- know coagulation factor deficiencies
- correction of microvascular bleeding when PT or PTT is increased
- correction of microvascular bleeding in a pt transfused with more than one blood unit when PT and PTT cannot be obtained in timely fashion
cryoprecipitate facts
- the last thing to consider transfusing
- derived from precipitate remaining after FFP is thawed
- ABO compatible
- administer rapidly through filter 200 ml/hr, complete within 6 hours
cryoprecipitate contents
- factor VII
- fibrinogen
- vWF
- XIII
Cryoprecipitate uses
- von Willebrand’s disease
- fibrinogen deficiencies