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Introduction to Anesthesia > Fluid Therapy and Replacement > Flashcards

Fluid Therapy and Replacement Flashcards

1
Q

Indications upon physical examination of hypovolemia

A

Abnormal skin turgor
Dehydration of mucous membranes
*Thready peripheral pulses
*Increased resting HR and BP
Orthostatic HR and BP changes upon changing from supine to sitting or standing position
*Decreased urinary flow rate

*“Many of these symptoms will be masked during anesthesia. Of these symptoms these are most reliable intraoperatively”

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2
Q

Indications of hypervolemia in patients with normal cardiac, hepatic and renal function

A

Increased urinary flow rate
Pitting edema
Late signs: tachycardia, tachypnea, elevated jugular PP, pulmonary crackles, wheezing, cyanosis, and pink, frothy pulmonary secretions

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3
Q

Laboratory signs of dehydration

A

Rising hematocrit and hemoglobin
Progressive metabolic acidosis
Urinary specific gravity > 1.010
Urinary Na+ < 10mEq/L
Urinary osmolality > 450mOsm/L
Hypernatremia
BUN-to-creatine ration > 10:1

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4
Q

What is the difference between crystalloids and colloids?

A
  • *Crystalloid solutions** are aqueous solns of ions (salts) with or without glucose
  • Rapidly equilibriate with and distribute throughout the entire extracellular fluid space
  • When given in sufficient amounts, are just as effective in restoring intravascular volume (3-4x more is needed usually)
  • IV half life 20-30 min
  • Large administrations (>4-5L) may contribute to tissue edema that can impair O2 transport
  • *Colloid solutions** also contain high-molecular-weight substances such as proteins or large glucose polymers (help to maintain oncotic pressure better)
  • Remain more intravascular
  • More efficient in restoring normal intravascular volume and CO
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5
Q

What is the preferred solution for hypochloremic metabolic alkalosis and for diluting RBC prior to transfusion?

A

Normal saline

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6
Q

What is hyperchloremic metabolic acidosis?

A

Hyperchloremic acidosis is a form of metabolic acidosis associated with a normal anion gap, a decrease in plasma bicarbonate concentration, and an increase in plasma chloride concentration

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7
Q

Indications for use of colloids

A
  1. Fluid resuscitation in patients with severe intravascular fluid deficit (ex. hemorrhagic shock) prior to the arrival of blood for transfusion
  2. Fluid resuscitation presence of severe hypoalbuminemia or conditions associated with large protien losses such as burns
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8
Q

Blood derived colloids

A

Albumin (5% and 25%)
Plasma protein fraction (5%) - contains a and B-globulins in addition to albumin (may cause hypotensive allergic reaction)

Both are heated to 60 degrees for at least 10 h to minimize risk of transmitting hepatitis and other viral disease.

IV Half-life = 16-24 hours

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9
Q

Synthetic colloids

A
  1. Gelatins - associated with histamine-released allergic reactions, not available in USA
  2. Dextrose starches (Dextran) - used as volume expander, reduces blood viscosity, von Wllebrand factor antigen, platelet adhesion, and RBC aggregation
    - Contraindicated in acute kidney injury and those at risk of kidney disease
    - Prevention of anaphylactic reactions by administration of Dextran I (Promit) prior to infusion
  • Hetastarch - great plasma expander and less expensive than albumin, can decrease von Willebrand factor antigen levels, may prolong prothrombin time, potentially nephrotoxic in ederly
  • Duration of volume expansion is 2-5 hours
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10
Q

Perioperative fluid therapy includes

A 
Normal losses (maintenance requirements)
Pre-existing fluid deficits
Surgical wound losses including blood loss
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11
Q

Estimation of maintenance fluid requirements

A

4-2-1 Rule

For the first 10kg = 4mL/kg/hr
For the next 10kg = 2mL/kg/hr
For each kg above 20kg = 1mL/kg/hr

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12
Q

Fully soaked “4x4” is considered to hold?

A

10mL of blood

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13
Q

Fully soaked “lap” may hold?

A

100-150mL of blood

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14
Q

Below a hemoglobin concentration of ___g/dL, the resting cardiac output increases to maintain normal oxygen delivery

A

7

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15
Q

Average blood volumes of Neonates (Premature, Full-term), Infants, Adults (Men, Women) in mL/kg?

A

Neonates (Preterm) = 95mL/kg
Neonates (Full-term) = 85mL/kg
Infants = 80mL/kg

Adults (Men) = 75mL/kg
Adults (Women) = 65mL/kg

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16
Q

Estimating the amount of blood loss necessary for hematocrit to fall to 30%

A
  1. Estimate blood volume
  2. Estimate red blood cell volume (RBCV) at preoperative hematocrit (RBCVpreop)
  3. Estimate RBCV at hematocrit of 30% (RBCV30%)
  4. Calculate the RBCV lost when hematocrit is 30%
    RBCVlost = RBCVpreop - RBCV30%
  5. Allowable blood loss = RBCVlost x 3
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17
Q

An 85kg woman has a preoperative hematocrit of 35%. How much blood loss will decrease her hematocrit to 30%?

A

Estimated blood volume = 65mL/kg x 85kg = 5525mL

RBCV35% = 5525 x 35% = 1934mL

RBCV30% = 5525 x 30% = 1658mL

RBC loss at 30% = 1934 - 1658 = 276mL

Allowable blood loss = 3 x 276mL = 828mL

18
Q

Diffusion is the random movement of molecules due to kinetic energy, what does the rate depend on?

A

PERMEABILITY OF SUBSTANCE

CONCENTRATION DIFFERENCES

PRESSURE DIFFERENCES

ELECTRICAL POTENTIAL

19
Q

What is the difference between osmolality and osmolarity?

A

Osmolarity = #Osmoles/L

Osmolality = #Osmoles/kg of H2O

Normal human osmolality = 275-300mOsm/kg

20
Q

Differences between hypo/iso/hypertonic solutions?

A
21
Q

Body composition of fluids

A
22
Q

Total body water (TBW) content in Adults (Males, Females), Newborns, and Obese patients?

A
23
Q

What are differences between intracellular and extracellular fluid?

A

Intracellular
Comprises 2/3 total body water
Osmotic pressure determined by K+ (Na/K ATPase pump)
High protein content

Extracellular
Comprises 1/3 total body water
Osmotic pressure determined by Na+
Two compartments (Interstitial and intravascular or plasma)

24
Q

Common hypotonic solutions, uses, and risks?

A
  1. 25%, 0.45% Normal Saline
  2. 5% Dextrose

Uses:
Hypernatremia
Diabetic ketoacidosis
Hyperosmolar hyperglycemia

Risks:
Increase ICP
Worsen hypotension
Hyperglycemia
Hemolysis

25
Q

Common isotonic solutions, uses, and risks?

A

LR, 0.9% Normal saline
Normasol
Plasma-Lyte

Uses:
Replace extracellular volume

Risks:
Fluid overload
Caution in cardiac/renal patients

26
Q

What is the most physiological solution, what are considerations you should be aware of?

A

Lactated Ringers

Lactate is converted to bicarbonate (metabolic alkalosis)
Contains potassium (caution in renal patients, hyperkalemic, diabetics)
Contains calcium (DONT USE WITH BLOOD PRODUCTS)
27
Q

Consideration with Normal Saline?

A

Preferred use in renal patients, brain injury, BLOOD ADMINISTRATION

Contains no potassium

Greater than 4L can cause hyperchloremic metabolic acidosis

28
Q

Common hypertonic solutions, uses, and risks?

A

D5 Normal Saline/Lactated Ringers
3% Normal Saline (Neuro ICU)
Mannitol (0.25g/kg) used for nephrectomy

Uses:
Plasma expanders
Reduce cerebral edema

Risks:
Hyperchloremic metabolic acidosis
Pulmonary edema
IV Infiltration
Cellular dehydration

29
Q

Pulmonary artery catheter, uses and risks?

A
30
Q

What is a central venous catheter and what is it used for?

A
31
Q

What is pulmonary artery occlusive pressure (PAOP)?

A

Approximates LVEDP, normal is 8-12mmHg

<8 indicates hypovolemia (<15 in patients with poor ventricular compliance)
>18 may imply left ventricular overload
Can calculate CO with it and guide fluid therapy accordingly

32
Q

SVV vs. PPV

A
33
Q

What are pulse contour devices?

A
34
Q

Esophogeal doppler uses

A
35
Q

How can you estimate LV size?

A
36
Q

What is third space fluid loss?

A
37
Q

Surgical evaporative blood loss (open procedures)

A
38
Q

What is the “classic” fluid replacement approach?

A
39
Q

What is the “goal directed” fluid replacement approach?

A
40
Q

What is advanced recovery after surgery (ARAS)?

A
41
Q

Fluid considerations with kidney transplants and steep trendelenburg?

A

Introduction to Anesthesia (15 decks)

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