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CRH II > Fluid Therapy > Flashcards

Fluid Therapy Flashcards

1
Q

what do fluid dynamics depend on?

A
  1. osmotic pressure
  2. oncotic pressure
  3. hydrostatic pressure: exerted by fluid pressing on capillary/cell walls
  4. reflection coefficient
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2
Q

describe fluid therapy

A
  1. replacement of losses
    -resuscitation
    -rehydration
    -ongoing excessive losses
  2. providing maintenance fluids
  3. as a vehicle for drugs and electrolytes
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3
Q

what are the 2 categories of fluids?

A
  1. crystalloids
    -isotonic replacement
    -maintenance
    -hypertonic
  2. colloids:
    -biologic
    -synthetic
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4
Q

describe crystalloids

A
  1. water-based solutions
  2. contain small osmotically active molecules which are permeable to membranes
  3. crystalloids redistribute!
    -less than 1/3 left in vascular space after 30-40 min = good for replacing vascular volume! but not so good for shock
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5
Q

how are crystalloids characterized?

A
  1. tonicity
  2. buffer content: acidifying versus alkalinizing
    -the only acidifying solution is normal saline
    -alkalinizing solutions have added buffers to increase pH
  3. electrolyte content
    -balanced versus unbalanced
    –balanced solutions have added electrolytes to closer mimic plasma composition

-replacement versus maintenance
–replacement solutions have a similar sodium content to that of normal (for replacement!)
–maintenance solutions are much lower in sodium (half strength of replacement) and contain electrolytes to maintain daily homeostasis

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6
Q

describe the 3 categories of tonicity

A
  1. isotonic: general use
  2. hypertonic: used for resuscitation, pulls fluid into vasculature
  3. hypotonic: free water replacement
    -5% dextrose: maintains some osmolality but is metabolized quickly so left with free water, used to treat hypernatremia SLOWLY
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7
Q

what is the most commonly used fluid solution!

A

isotonic, balanced, replacement crystalloid!!!

when in doubt reach for one of these

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8
Q

describe hypertonic crystalloids

A
  1. osmotic pull from interstitium
  2. hypertonic saline: primarily for resuscitation or for intracranial edema
  3. hypertonic bicarbonate: ONLY IN CALVES!!!!!!! with severe diarrhea!!!!
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9
Q

what are 2 contraindications of hypertonic saline?

A
  1. dehydration:
    -if interstitially dehydrated, nothing to pull fluid from, will just make patient salty
  2. hyper or hyponatremia (sodium derangement)
    -hyper: duh
    -hypo: don’t want to raise too fast and risk brain injury
    -how know? chronic vomiting or diarrhea = check first
    -HBC? probs normal before smacked by car so probs safe to use
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10
Q

give 5 potential side effects of hypertonic saline

A
  1. dehydration
  2. hypernatremia
  3. bradycardia: if give really fast, rapid increase in afterload/blood volume = reflex bradycardia
  4. hypotension
  5. bronchoconstriction: if give too fast

-give these nice and slow, over like 10-15 min as opposed to a rapid bolus

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11
Q

describe how to choose a crystalloid

A
  1. fluid plan
  2. serum sodium level
  3. acidemia versus alkalemia
  4. calcium levels
  5. concurrent drug therapy
    -precipitation = so so bad
  6. liver disease
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12
Q

what are 3 potential side effects of crystalloids?

A
  1. exceeding starling curve: giving more water will no longer result in an increase in stroke volume, leads to fluid overload
  2. fluid overload:
    -edema, effusion
    -GI stasis
  3. dilutional coagulopathy: harder time finding each other when so diluted = harder to clot, rare in animals
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13
Q

what is the primary difference between a replacement and a maintenance crystalloid solution?

A

sodium concentration!

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14
Q

define colloid fluids

A

large molecules that are restricted to the plasma compartment = too large to leave, which is good because the fluid stays where you put it (great for shock)

provide oncotic pressure/support:
-innate: from the molecule itself
-gibbs-donan effect: molecule is negatively charged so attracts Na+ which attracts water

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15
Q

describe the available colloids

A
  1. biologic:
    -plasma
    -albumin: canine, human
  2. synthetic:
    -hydroxyethylstarches
    -gelatins
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16
Q

describe uses for plasma

A
  1. primary use is to provide clotting factors
    -but hard to find and expensive
  2. hypoalbuminemia: inefficient to treat, too expensive to provide enough albumin most times unless animal super small or not crazy losses
  3. providing immunoglobulins
    -primarily foals who fail passive transfer
    -or puppies and kittens
    -early calves!!
17
Q

describe potential side effects of plasma

A
  1. transfusion reactions
  2. fluid overload: colloids stay where you put them, so is hard to redistribute large volumes to vascular space
18
Q

describe the 5 functions of albumin

A
  1. contributes 80% of oncotic pressure
  2. drug carrier
  3. bilirubin and FFA carrier
  4. anti-inflammatory
  5. anti-coagulant
19
Q

describe albumin replacement

A
  1. need species-specific bc very immunogenic
    -only canine available
  2. human albumin also available
20
Q

describe uses for albumin

A
  1. treat severe hypoproteinemia (primarily in dogs)
  2. shock poorly responsive to crystalloids
    -but takes a whole to reconstitute so not very practical for ER unless last option left
21
Q

describe the possible side effects of albumin

A
  1. fluid overload: very concentrated product will pool fluid and is hard to redistribute
  2. tranfusion reactions:
    -ESPECIALLY with human product!
    -facial edema, anaphylaxis, vomiting, fever, delayed immune-mediated disease, death
22
Q

describe synthetic colloids

A

hydroxyethylstarches (HES)
-polysaccharide similar to glycogen, primarily amylopectin

-the larger the molecule the longer the half life

-degree of substitution: average number of hydroxyethyl groups per glucose unit within the polymer (hetastarch, pentastarch, etc.)

23
Q

describe uses for hydroxyethylstarch

A
  1. plasma volume expansion
    -resuscitation
    -vascular leak: septic patients have pulled apart endothelium (changed reflection coefficient; so large molecules are more likely to stay in vascular space than smaller)
  2. oncotic support
    -hypoproteinemia
24
Q

describe 6 potential side effects of HES

A

septic patients are far more likely to experience side effects!!

  1. fluid overload:
    -if using a lot of colloids early in resuscitation plan, will drop subsequent crystalloid rate by 1/2 to see how body will handle it at first
  2. anaphylactoid reaction: not IgE mediated but something that resembles histamine release
  3. pruritis: molecules hang out in tissues for a long time, less intense in vet med
  4. coagulopathy
    -platelets: coats platelets = can’t adhere to each other
    -vWF, VIII
    -dilutional
    -if a patient has low platelets or rodenticide tox or some other coagulopathy defect, DONT USE
  5. acute kidney injury
    -dose dependent, very bad in humans, not usually seen in animals but still beware
  6. increased mortality:
    -if on cardiac bypass or septic
25
Q

what are the 4 parts of a fluid therapy plan

A
  1. resuscitation
  2. rehydration
  3. maintenance
  4. ongoing losses
26
Q

describe resuscitation

A
  1. must be completed FIRST before considering the rest of the plan
  2. fluids for this:
    -isotonic replacement crystalloids: REPLACEMENT FLUIDS ONLY
    -do NOT use maintenance solutions for shock!!!!!!

-hypertonic saline: 7.2% (8x normal saline sodium concentration) is most common, super salty

-colloids: HES, sometimes plasma or albumin

-RBCs: for severe anemia

27
Q

describe use of isotonic replacement colloids in resuscitation

A
  1. give 1/4 to 1/3 of TOTAL shock dose over 15 minutes or more conservative as needed (murmur, etc.)
    -cat/camelid: 50-60ml/kg total, 10-15ml/kg shock bolus
    -dog, ruminant, horses: 90 ml/kg total, 20-30ml/kg shock bolus
    -birds: 60-120 ml/kg total, 10-15 ml/kg shock bolus
    -reptiles: 70 ml/kg total, 10 ml/kg shock bolus
    -MEMORIZE above numbers
    -total shock dose is approx patient blood volume, give a 1/4-1/3 for shock bolus and then monitor
  2. beware of redistribution: if hypovolemic, really want it to stay in vascular space but it will try to get out to interstitium and could reshock, so recheck and continue monitoring as needed
28
Q

describe the use of hypertonic saline for resuscitation

A
  1. use for severe shock, traumatic brain injury, or for small volume resuscitation of very large patients
  2. bolus size = 3-5 ml/kg
  3. repeat once, if necessary
    -recheck sodium if you want to give more
  4. DONT USE IF: severe dehydration or severe sodium derangement
29
Q

describe use of HES in resuscitation

A
  1. for hypoproteinemic or decompensatory shock failing fluids alone
  2. bolus of approx 5ml/kg
    -up to 15ml/lg in cats and camellids
    -up to 20 ml/kg in dogs, horses, ruminants, most others
30
Q

describe maintenance needs

A
  1. to maintain homeostasis
    -normal losses: so use lower sodium fluids
  2. optimally replaced using maintenance crystalloids
    -sometimes use replacement crystalloids fro simplicity (one bag versus multiple) but NOT if heart disease (use low sodium), renal insufficiency (use maintenance solution for sure)
  3. 50ish ml/kg/day for most
    -40-50 for cats and camellids
    -50-60 for most others
    -NEONATES much higher!! can’t concentrate urine yet so need 2-3x adult rate!
31
Q

describe the tonicity of losses and the fluid of choice to replace losses/rehydration

A

losses are generally high in sodium and electrolytes so use balanced, isotonic, replacement crystalloids for rehydration/replacement!

32
Q

describe assessment of dehydration

A
  1. cannot detect less than 5% dehydration in ANY patient!!
  2. so if you detect any signs of dehydration, they are AT LEAST 5% dehydration
  3. for dehydration replacement, take weight in kg x % dehydration (ex. 16kg x 0.1 for 10% dehydration) and replace over 12-24 hours
  4. if less than 5% dehydrated and treating as outpatient, can utilize SQ fluid option
    -top out at 20ml/kg in any one admin, reassess and readmin PRN

for the rest, will have a chart on an exam :)

33
Q

describe HES for non-shock use

A
  1. hypoprotenemia
  2. hetastarch: 1ml/kg/hr, 20 ml/kg/day
  3. tetrastarch: up to 50ml/kg/day
    -much smaller molecule so excreted more rapidly so higher dose
34
Q

describe ongoing losses

A
  1. EXCESSIVE losses
    -vomiting/reflux, diarrhea
    -urinary losses
    -third spacing
  2. quantify losses
    -measure
    -estimate amount loss: 1 gram = 1ml with a pee pad
    -weigh animal, more common in large animal (rapid changes in body weight are water changes)
  3. generally, losses are high in electrolytes, so use REPLACEMENT crystalloids
35
Q

describe the routes of fluid admin

A
  1. enteral
    -voluntary
    -tube/gavage
  2. per rectum: horses, ruminants
  3. subcutaneous
  4. intraperitoneal/intracoelomic
  5. IV
  6. interosseous
36
Q

describe potassium supplementation

A
  1. for all hypokelamic patients
  2. for normokalemic patients especially if not eating
  3. based on serum K+ level
  4. Kmax is 0.5mEq/kg/hr
37
Q

describe dextrose supplementation

A
  1. to prevent or treat hypoglycemia
  2. bolus if severely hypoglycemic
    -0.25-0.5g 50% dextrose/kg diluted
  3. CRI
    -usually 2.5 or 5%
    -solution is now hypertonic if added to replacement solution
    –use a central catheter if >5%
  4. not enough to meet caloric needs!
38
Q

describe bicarbonate administration

A
  1. for SEVERE METABOLIC acidosis
    -NEVER respiratory acidosis
  2. controversial; treat the underlying cause of acidosis first
  3. indications:
    -pH <7.1
    -bicarbonate of <8-12mEq/L
    -symptomatic
  4. administer SLOWLY IV
  5. complications:
    -paradoxic CNS acidosis
    -hypernatremia
    -hypokalemia
    -worsening intracellular acidosis

CRH II (26 decks)

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