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N928 Basic Principles of Anesthesia > Fluid Management & Blood Therapy > Flashcards

Fluid Management & Blood Therapy Flashcards

1
Q

Hypovolemia is

A

Common in patients scheduled for surgery due to NPO status, bowel preps, surgical trauma, evaporative losses and dry anesthetic gases

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2
Q

Hypovolemia is associated with significant increase in

A

Postoperative morbidity and mortality

PONV, organ dysfunction, prolonged hospital stays, and delirium

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3
Q

Goals of fluid therapy include

A

Avoid or correct a hypovolemia state
Restore intravascular volume
Maintain oxygen carrying capacity intravascularly
Maintain adequate tissue perfusion

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4
Q

Inadequate tissue perfusion leads to

A

Poor surgical outcomes

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5
Q

Total body water is

A

60% of lean body weight

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6
Q

Intercellular water is

A

40% of body weight (2/3rds of TBW)

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7
Q

Extracellular water is

A

20% of body weight (1/3rd TBW)
Plasma volume 4%
Interstitial volume 16%

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8
Q

Total body water varies with

A

Age, gender, and body habitus

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9
Q

The total body water in an average 70 kg adult male is

A

60% TBW

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10
Q

The total body water of an average 70 kg adult female is

A

55% TBW

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11
Q

The total body water of term infants is

A

75% TBW

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12
Q

The total body water for premature infants is

A

80-90% TBW

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13
Q

The total body water for elderly patients is

A

50-55% TBW

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14
Q

Osmosis is

A

the movement of water across a membrane from low solute to high solute

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15
Q

The solution with the higher concentration always has

A

a higher osmotic pressure than solution of lower concentration

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16
Q

Osmolality is

A

the number of osmotically active particles per kilogram of water

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17
Q

Osmolarity is

A

the number of osmotically active particles per liter of solution

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18
Q

Osmolality can be calculated by

A

(serum Na+ x 2) + blood glucose + blood urea (mmol/kg)

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19
Q

Tonicity is

A

the measure of particles which are capable of exerting an osmotic force

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20
Q

Isotonic means

A

two solutions with the same osmolarity

no osmotic pressure is generated across cell membranes

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21
Q

Hypotonic is a

A

solution with a lower osmolarity than plasma

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22
Q

Hypertonic is a

A

solution with a higher osmolarity than plasma

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23
Q

Plasma communicates continually with interstitial fluid via

A

capillary pores

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24
Q

What dictates fluid movement?

A

osmotic forces and hydrostatic pressures

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25
Q

Plasma colloid oncotic pressure maintains plasma volume using

A

proteins, albumin, and gamma globulins

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26
Q

Osmotic pressure is exerted by

A

macromolecules (colloid molecules)

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27
Q

Colloid molecules are responsible for

A

preventing fluid from leaving the plasma and exerting a “pull” from the interstitial space

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28
Q

Endothelial glycocalyx is a

A

gel layer in capillary epithelium that creates a physiologically active barrier within vascular space

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29
Q

_____ creates a barrier between vessel and blood

A

endothelial glycocalyx

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30
Q

Endothelial glycocalyx binds to

A

circulating plasma albumin, preserving oncotic pressure and decreasing capillary permeability to water
also contains inflammatory mediators, free radical scavenging, and activation of anticoagulation factors

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31
Q

Neurohormonal factors that influence fluid dynamics include

A

RAAS- reabsorption of sodium (and water)
antidiuretic hormone- reabsorption of water
Atrial natriuretic peptide- stimulates kidneys to release sodium and water, thereby reducing intravascular volume

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32
Q

Fluid volume status is assessed

A

during preop evaluation

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33
Q

Assessing for fluid volume status includes

A

skin turgor, mucous membrane, edema, lungs sounds, vital signs, urine output, HCT, urine specific gravity, BUN/creatinine

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34
Q

Crystalloid solutions are rapidly distributed

A

throughout ECF, hence the large volumes required to expand IVF

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35
Q

How much crystalloid is required to expand the IV compartment of 1L?

A

3-4L of crystalloid

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36
Q

When using crystalloid solutions, we ideally want to use

A

isotonic fluids with electrolyte composition similar to ECF

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37
Q

The electrolytes of lactated ringer include (Na, K, Ca, Cl, Lactate, glucose, and pH)

A 
Na: 130 mEq/L
K: 4 mEq/L
Ca: 3 mEq/L
Cl: 110 mEq/L
Lactate: 28 mEq/L
Glucose: 0 g/L
pH: 6.5
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38
Q

Lactated ringer solution is

A

saline with electrolytes (K+, Ca++) and buffer (lactate)
slightly hypotonic (275), provides 100 cc free water per L of solution & tends to lower Na+
Lactate is converted to bicarb
- more physiologic than 0.9% NS

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39
Q

Lactated ringers should be avoided in

A

ESRD as it contains K+ & not mixed with PRBC because calcium binds to citrate

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40
Q

Normal saline is

A

0.9% NaCl in water
isotonic solution- osmolality 308
in large volumes produces high Cl- content, which leads to dilutional hyperchloremic metabolic acidosis

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41
Q

Normal saline is the preferred solution for

A

diluting PRBCs

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42
Q

Normal saline is composed of (Na, K, Ca, Cl, Lactate, glucose, and pH)

A 
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
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43
Q

Normosol-R is composed of (Na, K, Ca, Cl, glucose, Mg, acetate, gluconate, pH)

A 
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
Gluconate: 23 mEq/L
pH: 7.4
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44
Q

D5W is considered a

A

hypotonic solution

has little place perioperatively

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45
Q

Concerns with D5W administration is

A

free water intoxication and hyponatremia

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46
Q

D5W provides

A

170-200 calories/1000 cc for energy and can cause hyperglycemia except in patients with DM receiving insulin or neonates

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47
Q

3% NaCl has

A

513 mEq

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48
Q

5% NaCl has

A

856 mEq

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49
Q

Hypertonic solution is used for

A

low volume resuscitation, burns, or closed head trauma

principle role is treatment of hyponatremia

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50
Q

Risks with hypertonic solutions include

A

hyperchloremia, hypernatremia, and cellular dehydration

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51
Q

Colloid solutions are

A

osmotically active substances

high molecular weight

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52
Q

Colloid solutions are administered in a volume equivalent

A

to volume of fluid/blood lost from intravascular volume

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53
Q

Albumin is a

A

blood derived colloid solution
obtained from fractionated human plasma
dose not contain coagulation factors or blood group antibodies
available as 5% or 25%

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54
Q

Albumin expands IV volume up to

A

5xs volume given by

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55
Q

Albumin (exchange of fluid)

A

draws fluid in from ISF

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56
Q

dextran is a

A

synthetic colloid solution that is a water soluble glucose polymer

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57
Q

Dextran 70 is used

A

for volume expansion

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58
Q

Dextran 40 is used for

A

improved blood flow in microcirculation and prevention of thrombosis

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59
Q

Side effects of dextran include

A

highly antigenic–> anaphylactic reaction
platelet inhibition
noncardiac pulmonary edema
interference with cross matching

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60
Q

The max dose of hydroxyethyl starch is

A

limited to <20 mL/kg/day

61
Q

Hydroxyethyl starch (6%) is

A

hespan (0.95% sodium chloride in solution) or

Hextend (in a balanced electrolyte solution similar to Lactated Ringers)

62
Q

Hydroxyethyl starch is as

A

effective as albumin for volume expansion but less expensive than albumin

63
Q

Hydroxyethyl starch can cause

A

coagulopathy due to dilutional thrombocytopenia

64
Q

When comparing crystalloids to colloids, crystalloids

A

are equally effective as colloid in restoring intravascular volume if given in sufficient amounts, support urine output better, less likely to cause pulmonary edema and inexpensive

65
Q

When comparing crystalloids to colloids, colloids

A

have prolonged increase in plasma volume by maintaining plasma oncotic pressure, fluid of choice with hypoproteinemia, less tissue edema, less volume infused, intravascular half life is 3-6 hours for colloid vs. 20-30 minutes for crystalloid

66
Q

Perioperative goals include

A

meet basal fluid requirements, replace losses, restore/maintain hemodynamic stability, enhance microvascular blood flow so that oxygen is delivered to tissues, maintain aerobic cellular metabolism

67
Q

Crystalloids are effective for

A

initial management of ECF losses
hemorrhagic shock, major surgery, or trauma
large volumes lead to hemodilution & decreased plasma colloidal oncotic pressure–> edema and transudates
Continued fluid resuscitation should include colloids attempting to minimize interstitial edema of vital organs: heart, lung & brain

68
Q

Colloids are effective plasma for

A

plasma expansion

69
Q

Sources of intraoperative fluid requirements include

A

maintenance, fluid deficit, blood loss, and evaporative loss (3rd space loss)

70
Q

Water and electrolytes are lost through

A

urine, feces and insensible loss from the respiratory tract and perspirations

71
Q

The average normothermic 70 kg patient with a normal metabolic rate may lose

A

2500 ml water/day

72
Q

The maintenance fluid requirement is calculated by the

A

4-2-1 rule
4cc/kg/hr for 1st 10 kg
2cc/kg/hr for 2nd 10 kg
1 cc/kg/hr for each additional kg

73
Q

The fluid calculation for a 75 kg male is

A

40 cc +20cc + 55cc

115 cc/hour total

74
Q

Calculating the fluid deficit is done by

A

taking the maintenance requirement and multiplying it by the number of hours patient is NPO

75
Q

If a patient is receiving maintenance IV fluids, there is no NPO deficit but consider other losses:

A

preoperative bleeding, vomiting, diuresis, diarrhea, bowel prep, occult losses, fluid sequestration (edema), ascites, increased insensible losses, hyperventilation, fever and sweating

76
Q

Fluid replacement strategy is

A

1/2 deficit replaced in 1st hour of surgery + MIVF
1/4 deficit replaced in 2nd hour + MIVF
Remaining 1/4th deficit replaced in 3rd hour of surgery + MIVF

77
Q

If a patient is a 75 kg male and has been NPO for 8 hours, describe the fluid replacement strategy for this patient

A

115 cc/hr maintenance, 115 x 8= 920 cc
460 cc in 1st hour
230 cc in 2nd hour
230 cc in 3rd hour

78
Q

Evaporative loss is

A

directly related to surface area of the surgical wound and duration of exposure

79
Q

3rd space loss is due to

A

fluid shifts and intravascular volume deficit caused by redistribution of fluids
can be due to trauma, infection (sepsis), burns, and ascites

80
Q

To calculate 3rd space loss, we need to know

A

type of procedure, degree of exposure, amount of surgical manipulation

81
Q

3rd space loss replacement is based on

A

whether tissue trauma is minimal, moderate or severe

82
Q

3rd space loss for minimal surgeries

A

(eye cases, lap chole, hernia, knee scope) 0-2 ml/kg/hour

83
Q

3rd space loss for moderate surgeries

A

(open cholecystectomy, appendectomy) 3-5 ml/kg/hr

84
Q

3rd space loss for severe surgeries

A

(bowel surgery, THR) 6-9 ml/kg/hr

85
Q

3rd space loss for emergency surgeries

A

(Gun shot, MVA) 10-15 ml/kg/hr

86
Q

1 gm of blood is approximately

A

1 cc of blood

87
Q

Visual estimation of blood loss includes

A

floor and surgical drapes, suction containers (subtract irrigation fluid), soaked gauze 4x4, Ray-tech, soaked laparotomy pads, wet sponges

88
Q

Wet sponges equate to

A

20-30% of dry value

89
Q

Soaked laparotomy pads=

A

100-150 cc of blood

90
Q

Ray-tech equate to

A

10-20 cc of blood

91
Q

Soaked gauze 4x4 equate to

A

10 cc of blood

92
Q

The biggest reason to transfuse is to

A

maintain O2 carrying capacity of blood

93
Q

Most adults can tolerate (blood loss)

A

a 10% loss of EBV

94
Q

After a 15-20% loss of EBV

A

we should measure Hgb in healthy patients; earlier if comorbidities dictate

95
Q

Most providers are conservative with blood transfusion due to

A

risk of transfusion reaction and blood borne pathogens

96
Q

Transfusion of health patients tends to occur at

A

6-7 g/dL (Hct 18-21%)

97
Q

These patients may require higher hgb (10 g/dL) and Hct (30%)

A

elderly patients or patients with significant cardiovascular, pulmonary, or neurologic disease

98
Q

Transfusion should occur when

A

maintain normovolemia with crystalloid or colloid until danger of anemia outweighs risk of transfusion

99
Q

When replacing blood loss with crystalloid isotonic solution, replace in a

A

3:1 ratio- 3 mL crystalloid for 1 mL blood loss

100
Q

When replacing blood loss with colloid solution, replace in a

A

1:1- 1 mL colloid for each 1 mL blood loss

101
Q

When replacing blood with blood:

A

1:2- 1 mL PRBC for every 2mL blood loss

102
Q

Estimated blood volume in premature neonates is

A

95mL/kg

103
Q

Estimated blood volume in full term neonates is

A

85 mL/kg

104
Q

Estimated blood volume in infants is

A

80 mL/kg

105
Q

Estimated blood volume in children is

A

75 mL/kg

106
Q

Estimated blood volume in adult males is

A

75 mL/kg

107
Q

Estimated blood volume in adult females is

A

65 mL/kg

108
Q

Estimated blood volume in elderly males is

A

65 mL/kg

109
Q

Estimated blood volume in elderly females is

A

60 mL/kg

110
Q

Allowable blood loss is used to

A

determine how much blood you can lose to reach a particular hematocrit
helps anesthetist design appropriate plan and time to transfuse patient

111
Q

The allowable blood loss calculation is

A

Estimated blood volume x (pts starting HCT-allowable HCT)/ pts starting HCT

112
Q

In a healthy 75 kg male with HCT 40%, will allow his HCT to drop to 25%. What is his ABL?

A

ABL= EBV x (pts HCT- allowable HCT)/pts HCT
75 x 75= 5625 mL
5625 x .15/.4= ABL
844/0.4= 2110 cc

113
Q

Blood components include

A

PRBC, platelets, fresh frozen plasma, and cryoprecipitate

114
Q

Type specific compatibility testing is for

A

ABO-Rh typing only; 98.9% compatible

115
Q

Type and screen is done for

A

ABO-Rh type and screen for specific antibodies; commonly associated with non-ABO hemolytic reactions; 99.94% compatible

116
Q

Type and crossmatch is done to

A

confirm ABO-Rh typing (done in <5 minutes), detects antibodies to other blood groups, detects antibodies in low titers (may take up to 45 minutes)

117
Q

Massive transfusion is

A

replacement of patient’s total blood volume in <24 hours
acute administration of >1/2 the patient’s estimated blood volume in 3 hours or less
transfusion of 10 units of RBCs in 24 hours

118
Q

ASA guidelines regarding blood transfusion:

A

rarely indicated if Hbg >10 g/dL and almost always indicated if Hgb <6 g/dL
if Hgb is between 6-10 g/dL transfusion is based on the patient’s risk for complications and inadequate oxygenation
USE OF A TRANSFUSION TRIGGER OF HGB IS NOT RECOMMENDED

119
Q

Risks associated with blood product administration include

A

infections (hepatitis B or C, HIV, bacterial sepsis)
allergic reactions/ febrile reactions
TRALI- lung injury, noncardiogenic pulmonary edema
Hemolytic reactions
Acute hypotensive transfusion reaction
metabolic complications- decreased pH (lactate production) and increased potassium (cell lysis, increased with storage)

120
Q

Complications associated with blood transfusion:

A

coagulopathy- usually occurs only after massive transfusion
dilutional thrombocytopenia- responds well to platelet transfusion
low factors V and VIII- stored blood factors may be 15-20% of normal
DIC- activation of clotting system–> microvascular fibrin deposition–> activation of fibrinolysis

121
Q

Transfusion alternatives include

A

autologous blood, cell saver, and acute normovolemic hemodilution

122
Q

1 unit PRBCs will increase hemoglobin

A

1 g/dL and Hct 2-3% in adults

123
Q

10 mL/kg transfusion of RBCs will increase Hgb by

A

3 g/dL and Hct by 10%

124
Q

Citrate toxicity is due to

A 
citrate preservatives (used as an anticoagulant in stored blood) may bind to and chelate calcium
-empiric administration of calcium is not warranted unless ionized calcium levels are low
125
Q

Clinically significant hypocalcemia resulting in cardiac depression

A

does not occur in most normal patients unless the transfusion rate exceeds 1 unit every 5 minutes

126
Q

In one unit of PRBC, the hematocrit is

A

70%

127
Q

PRBCs should be

A

reconstituted with 0.9% normal saline

calcium in LR may cause blood to clot by reversing anticoagulant effect of citrate

128
Q

PRBCs considerations

A

further testing if antibodies present or patient has had numerous blood products
type specific ABO and Rh factor alone is sufficient in 98.9% of patients (incompatibility seen in 1 in 1000)

129
Q

Complications from autologous blood include

A

anemia, preop myocardial ischemia from the anemia, administration of the wrong unit (1 in 100,000)
need for more frequent blood transfusion
febrile and allergic reactions

130
Q

Cell saver is the

A

salvage of blood from the surgical site
blood is processed washed and separated
red cells are transfused back

131
Q

Contraindications to cell saver include

A

surgery with wounds contaminated with bacteria, amniotic fluid, malignant cells or patients with sepsis, chemical contaminants

132
Q

Acute normovolemic hemodilution is when

A

blood is removed from patient
Replace blood volume lost with crystalloid or colloids
after surgical blood loss has slowed or stopped, patient’s blood transfused back to patient

133
Q

Uses for platelets include

A

thrombocytopenia, dysfunctional platelets, active bleeding, platelet count <50,000

134
Q

Volume of platelets is

A

200-400 cc

135
Q

One unit increases platelet count

A

7000-10,000 one hour after transfusion

136
Q

The incidence of platelet related sepsis is

A

1 in 12,000

137
Q

The incidence of bacterial contamination risk is

A

1 in 2000

138
Q

One unit of platelets is

A

obtained by centrifuging a single unit

139
Q

Fresh frozen plasma contains

A

clotting factors and plasma proteins (no platelets)

140
Q

The volume of FFP is

A

200-250 cc

141
Q

FFP must be

A

ABO compatible

142
Q

Uses of FFP include

A

urgent reversal of warfarin, known coagulation factor deficiencies, correction of microvascular bleeding in the presence of increased PT or PTT
correction of microvascular bleeding in the patient transfused with more than one blood volume when PT and PTT cannot be obtained in a timely fashion

143
Q

Each unit of FFP increases clotting factor level by

A

2-3%

144
Q

FFP is contraindicated for

A

augmentation of plasma volume or albumin concentration

145
Q

Cryoprecipitate is derived from

A

precipitate remaining after FFP is thawed

146
Q

Cryoprecipitate contains

A

factor VIII (hemophilia A), fibrinogen, vWF, XIII,

147
Q

Cryoprecipitate is used in the treatment of

A 
von Willebrand's disease
fibrinogen deficiencies (ex massive transfusion)
148
Q

Cryo should be

A

administered through a filter rapidly and complete within 6 hours
ABO compatible

N928 Basic Principles of Anesthesia (16 decks)

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