fluid therapy Flashcards
1
Q
Causes of intravascular volume depletion?
A
Prolonged GI loss chronic hypertension chronic diuretic use sepsis trauma
2
Q
If a patient has supine hypotension what does that tell you about their fluid?
A
implies blood volume deficit greater than 30%
3
Q
positive tilt test or orthostasis -how would you assess?
A
increased HR greater than 20 beats/min and decreased systolic BP greater than 20mmHg when the patient assumes a standing position.
4
Q
Is Hct a useful tool in determining hypovolemia?
what can a high Hct indicate?
A
No, hct is a poor indicator of blood volume.
High hct means the pt is dry.
5
Q
Azotemia?
A
nitrogenous products in blood
6
Q
low urine sodium concentration would be what measurement?
A
less than 20mEq for every 1000ml of urine
7
Q
What does metabolic acidosis reflect with low fluid volume?
A
reflects hypoperfusion due to sodium reabsorption
8
Q
Total body water is divided into?
A
ICF and ECF (PV+ISF)
9
Q
TBW contents varies with?
A
Age, Gender, Body Habitus
10
Q
57-60% of your body weight is what?
A
fluid!
11
Q
How much of your TBW is intracellular and extracellular?
A
40% intracellular and 20% extracellular
12
Q
extracellular is comprised of?
A
plasma, blood cell volume, and interstitial fluid
13
Q
distribution of electrolytes intracellular and extracellular of sodium, potassium, magnesium, and calcium?
A
extracellular sodium = 140
potassium = 4.5
magnesium = 2
calcium = 5
Intracellular sodium = 10
potassium = 150
magnesium = 40
calcium = 1
14
Q
Hypovolemia increses the risk of?
hypervolemia incerases the risk of?
A
hypovolemia = organ hypoperfusion hypervolemia = risk of pulmonary edema
15
Q
crystalloids come in what three tonicities?
A
hypo, iso, hyper
16
Q
why do anesthesia providers avoid crystalloids that have glucose in them?
A
+unnecessary hyperglycemia response
+iatrogenic hyperglycemia can induce osmotic duresis
+hyperglycemia can aggravate ischemic neurologic injury
17
Q
Primary crystalloids used in the OR?
A
LR and NS
18
Q
Would you use cyrstalloids to replace fluid if the losses required protein replacement?
A
No, crystalloids are appropriate for the maintenance and fluid replacement in the absence of specific fluid losses that require protein replacement.
19
Q
In what patients would crystalloids be the initial resuscitation fluid?
A
shock, burns, and head traumas
20
Q
What do you replace PRIMARY water losses with?
A
hypotonic solutions.
21
Q
water and electrolyte losses are replaced with which fluids?
A
isotonic electrolyte solutions
22
Q
Type A blood has what type of naturally occurring antibodies?
A
Anti-B
23
Q
Type O blood has what type of naturally occurring antibodies?
A
anti a and anti b
24
Q
AB blood has what naturally occurring antibodies?
A
NONE
25
Difference between a cross match and a type and screen?
cross match mixes donor blood with patient blood to check for agglutination and checks for igg antibodies.
screen looks for common antibodies
26
How long does it take to confirm ABO and Rh typing?
less than 5 min.
27
how long does it take to do a cross match for antibodies other than blood groups and low titer antibodies?
45 min.
28
Do we cross match for all surgeries?
Only preformed for surgical procedures with high possibility of transfusion
29
when does angulation occur when checking blood?
if the major or minor cross match is incompatible.
30
What immunoglobulin does the major crossmatch also check for?
Immunoglobulin G antibodies
31
In a trauma if you do not know the patients bloody type what will you do?
Use O Rh negative packed red cells (NOT WHOLE BLOOD)
32
Why is whole blood O neg for an unknown blood type not given?
may contain high titers of anti A and anti B hemolytic antibodies.
33
If you know the patients blood type what kind of blood can you give? (select two)
type specific NON crossmatched blood if available or O negative PRBC.
34
When emergent releasing blood what type of blood is safer than O negative?
Type specific partially crossmatched is safer than O negative
35
Why is partially crossmatched safer than O neg?
O neg contains high titers of anti A anti B antibodies (specifically whole blood but ppt makes it sound like any O neg)
36
What changes the effectiveness of whole bloods ability to restore coagulation?
How long has it been stored? platelets begin to disappear soon after storage. Fresh whole blood is effective, but the key word is fresh.
37
Once you've given a few units of O neg blood to a trauma pt should you switch to another blood type?
it is advised to continue to give O neg until antibody panel can be evaluated
38
First sign of transfusion reaction under general anesthesia?
Hematuria, thus you must maintain urine output so you can see this as it occurs.
39
What is TRALI?
Acute lung injury syndrome or transfusion-related acute lung injury (TRALI)
40
When will TRALI resolve?
12-48 hours
41
What do you set the vent to for someone in ARDS?
HIGH PEEP, LOW VOLUME
42
Most common cause of bleeding after massive blood transfusion?
Dilutional coagulopathy
43
Most common acid base imbalance in relation to massive blood transfusion?
metabolic alkalosis
44
What is citrate intoxication?
calcium used as preservative in packed red blood cells, binds to calcium in blood and causes acute hypocalcemia
45
how much blood would you have to be giving to cause citrate intoxication?
transfusion rate exceeds 1 unit every 5 min.
46
what do you give if someone has citrate intoxication?
give calcium chloride as guided by ionized calcium level.
47
Tell me about a cell saver.
Cell saver filters out all the little particles from the surgery (knee/hip) and gives the blood back to the patient.
48
Normovolemic Hemodilution?
blood removed before surgery and the amount they take out is replaced with crystalloids (3:1) to keep volume. then the blood is given back, kept at room temp which is good for 6 hours, HCT is kept at 21-25%.
49
simplest technique for quantifying intraoperative blood loss?
visual estimation of blood loss
50
```
formula for Blood Volume in
adult male
adult female
obese
infant
full term
premature
```
Adult male: 75 ml X Wt in Kg
Adult female: 65 ml X Wt in Kg
Obese: 70 X Wt in Kg
Infant: 80 ml X Wt in Kg
Full term: 85 ml X Wt in Kg
Premature: 95 ml X Wt in Kg
51
formula for allowable blood loss?
EBV x (starting hct - target hct) / starting hct
52
ways to measure blood loss in the OR? (select three)
Measure suction containers (most common)
Fully soaked sponge (4 x 4) 10 ml of blood
Fully soaked lap sponge 100 – 150 ml of blood
53
what do you subtract from the EBL?
IRRIGATION (just ask the tech.)
54
how many ml of blood is a fully soaked sponge worth?
10ml
55
how many ml of blood is a fully soaked lap sponge worth?
100-150 (it is a range)
56
most accurate way to estimate blood loss in sponges and laps? typically only done in pediatrics.
weigh the sponge/laps
57
how do you determine partially soaked from fully soaked?
with your eyes, its all visualization (again best way would be to weigh but who has time for that?)
58
What lab should be used as a guide for determining blood replacement?
Hct
59
According to the book is CVP a reliable indicator of fluid loss?
Not reliable bc CVP may remain normal long after BP and HR have decreased.
60
surgery does what to the body causing a decrease in UOP?
surgery causes release ADH which causes a decrease in UOP.
61
Typically BP and HR will respond to intravascular decreases but in what patient population (choose 2) may this not be true? and the change in HR may not occur all together in patients on what medications?
elderly people and people on cardiovascular medications such as beta blockers.
beta blockers
62
According to the book does the third space even exist?
unlikely that the third space even exists, but we keep calculating it with our old school formulas.
63
what is the amount of fluid per kg per hr that is considered liberal fluid administration?
20ml/kg/hr
64
liberal fluid administration to a healthy patient would be a patient in what ASA classification?
1 and 2
65
liberal fluid administration decreases what? (choose two)
decreases nausea and vomiting and improves pain control according to the book
66
What fluid replacement should be avoided in sepsis patients?
HES should be avoided in patients who are septic, increases death rate.
67
what patient population should you not give albumin to?
traumatic brain injury
68
What is HES half life and what does that mean in terms of reactions?
half life is 17 days which means a reaction can occur 2 weeks later.
69
most common complication with HES is?
pruritus
70
what colloid should critically ill patients not receive?
HES, increases critically ill patients mortality and RRT (not good for renal patients.)
71
what colloid is known to be good for vascular surgery?
dextran 40
72
what does dextran 40 specifically do to RBC and platelets?
reduces RBC aggregation and platelet adhesiveness.
73
why is dextran less used today for hypovolemia?
bc hemodilatation does a better job with increasing blood flow. (crystalloids)
74
what risk do colloids carry that crystalloids do not? (this risk is less with colloids than with blood)
allergic reaction can occur, fewer risks than blood.
75
what sign of hypovolemia according to the book is an insensitive and non specific indicator?
tachycardia, especially if the patient is inhaling volatile anesthetics.
76
transfusion threshold for patients considered at risk for ischemia?
10g/dL may be justified.
77
A HEALTHY patient may lose up to what percentage of their blood volume before s/s appear (tachycardia and hypotension)
up to 20% for healthy patient. (typically at least 10% in less healthy ppl)
78
at what percentage of ACUTE BLOOD volume lost does the body typically need more than crystalloids for oxygen carrying abilities.
30% acute blood loss
79
According to the book, with acute blood loss what blood may you want to choose over another?
whole blood may be preferable to PRBC when replacing blood losses that exceed 30% of blood volume.
80
according to PPT what percentage of loss should be considered for replacement?
15%
81
what is the "guideline" for when to replace loss with blood? (bc the decision to transfuse is never taken lightly.)
Once anemia risk is greater than risk of transfusion, blood loss is replaced with blood to maintain
82
In surgery we are typically dealing with acute blood loss, what type of blood counts would make a low blood count a different story?
people with chronically low blood counts.
83
once anemia risk is greater than risk of transfusion what levels (h/h counts) are you trying to maintain?
Hgb 7-8
| Hct 21-24%
84
Any healthy patient with an acute blood loss with a Hgb of ?? or lower needs to be transfused
6
85
Less than ?? g/dl causes increases in Cardiac Output to maintain O2 delivery to the tissues
7
86
?? g/dl is necessary for elderly patients, patients with CAD, and pulmonary disease
10
87
Certain disease processes may require transfusion at a higher Hgb
name some of them...
```
COPD
CAD
Angina within 24 hours
MI within 6 weeks
EKG indicative of acute ischemia or acute MI syncope
Dyspnea
```
88
at what age do you have decreased 02 carrying capacity of hgb, typically
75 y.o
89
How do you measure that intraoperative blood replacement has been adequate?
improvements in B/P, HR, U/O, Arterial Oxygenation, and pH
90
After blood replacement if parameters being monitored return to normal levels you may consider checking what to see if further therapy is needed?
H/H
91
RATIO of blood replacement is what with PRBC, crystalloids, colloids?
PRBC 1:1
crystalloids 3:1 (LR or NS)
colloids 1:1
92
Whole blood if over 24 hours old?
no viable platelets, and factors V and VIII are markedly reduced
93
When is Whole blood indicated
acute blood loss >30% of EBV
94
ml of whole blood in a bag?
450ml blood with 63ml anticoagulant
95
apprx ml of RBC in PRBC?
250-300
96
Do PRBC restore 02 carrying capacity and do they contain any plasma proteins important to coagulation?
yes, they restore 02 carrying capacity but they do not contain any plasma proteins important to coagulation.
97
Does PRBC have plasma?
plasma removed in PRBC which removes factor 1 (fibrenogen) V and VIII
98
HCT of PRBC?
70-80%
99
1 UNIT of PRBC will raise the Hgb by what? and the HCT by what?
raise hgb by 1 gm/dl
| raise the Hct by 3% (which is 3g/dl)
100
what do you treat thrombocytopenia with?
platelets
101
general PLT count needed to be able to infuse plateletes?
less than 50k
102
one unit of PLT increases the patients PLT count by how much?
5-10k
103
FFP what would you give it for? (7 possible reasons 5 in ppt lol)
high PT PTT
```
restores coagulation factors lost with hemodilution
heparin resistance
TRALI!
coumadin reversal
coagulopathies (deficiencies)
volume expansion
```
104
what is the shelf life for FFP?
1 year
105
What exactly is in FFP
All coagulation factors except platelets are present.
106
Dose for FFP
10-15ml/kg
107
what does the PT or PTT have to be in order to need FFP?
PT and PTT needs to be 1.5 times greater than preoperative level.
108
what viral risk do you run when giving FFP?
Hepatitis
109
what is cryoprecipitate?
Fraction that precipitates when plasma is thawed
110
what is cryoprecipitate useful in treating?
Useful in treating Hemophilia A (high amount of factor VIII) XIII, factor 1 (fibrenogen) and vWD
Used to treat hypofibrinogenemia
111
what all does cryoprecipitate contain?
Cryoprecipitate contains factor VIII, XIII, vonWillebrand Factor, and fibrinogen(I)
112
When do we most often use cryoprecipitate?
DIC and open hearts
113
in the OR first place you look for a transfusion reaction would be?
urine, looking for hematuria
| fever is a later sign and hard to assess under GA
114
What typically causes a transfusion reaction?
ABO incompatibility resulting in hemolysis
115
what is TRALI?
TRALI-transfusion related acute lung injury (2nd most common cause of morbidity and mortality.)
Manifests as an acute respiratory distress syndrome within a few hours of transfusion.
116
awake symptoms of hemolytic reaction are masked by GA which would be lumbar and sternal pain, fever, chills, dyspnea, skin flushing , so what you will see is? (select 4)
increased temp
tachycardia
hypotension
hemoglobinuria
Acute renal Failure secondary to breakdown products of RBCs
IF YOUR PATIENT GOES INTO RENAL FAILURE THEN YOU MISSED ALL THE SIGNS.
117
If your patient is having a hemolytic transfusion reaction: treatment would be?
Discontinue transfusion
Maintain urinary output with crystalloids, mannitol, and/or furosemide
NaHCO3 may help to alkalinize the urine and theoretically improve solubility of hemoglobin degradation products
Corticosteroids are controversial
118
when would you give 5% albumin?
5% Isotonic for rapid expansion of intravascular fluid volume
119
When is 25% albumin indicated?
hypoalbuminemia
120
ratio of replacement with 5% albumin?
1:1
121
replacement ratio with 25% albumin?
Albumin : 25 % salt poor 100 ml replaces 500 ml of blood loss by pulling fluids from the interstitial spaces
122
does albumin provide clotting factor?
NO, does not provide any clotting factors.
123
Should critically ill patient's have albumin?
Increased mortality when administered to critically ill patients
124
What is plasmanate?
made from human plasma
125
what does pasmanate treat?
Shock due to burns, crushing injuries, abdominal emergencies and other cases where plasma (not necessarily RBC) is lost
126
giving plasmanate with hemorrhagic shock, whats specific?
plasmanate Can be given but may need to be followed by blood transfusions
127
with hemolytic/hemorrhagic shock you need?
RBC's
128
what does plasmanate do?
Increases blood volume which can last up to 48 hours.
129
plasmanate can have what protein disease?
Prion protein, Cruetzfeldt-jakob Disease (when from plasmanate it is acquired CJD specifically medical procedure aquired)
130
use what filter with blood?
170 um filter
131
FFP contains all coagulation factors except?
platelets
132
FFP used to reverse? (select 3)
warfarin therapy, correction of known cagulation factor deficiencies, and in massive blood transfusions
133
what two types of patients is cryoprecipitate good for?
DIC and open hearts
