Fluid Therapy and Transfusion Medicine Flashcards
Developing and implementing an appropriate fluid therapy plan includes what 6 things?
- Understand body fluid compartments
- Understand characteristics of different fluid types
- Consider rates of admin
- Consider route of admin
- Monitor effectiveness of achieving fluid therapy goals
- Recognize possible complications
Give some indications for fluid therapy
- Maintaining hydration
- Replacing fluid deficit (dehydration)
- Replacing ongoing losses
- Treating decreased oncotic pressure
- Treating hypovolemia
- Treating shock states
- Improving/increasing urine production
- Correcting acid-base balance or electrolyte disorders
- Maintaining IV access + delivering other medications
TBW
total body water
TBW is spread across ____ and ____ spaces. These spaces are separated by _____.
Intracellular fluid spaces
Extracellular fluid spaces
Cell membranes
ICF makes up __/__ of TBW
Intracellular fluid makes up 2/3 of total body water
ECF makes up __/__ of TBW
Extracellular fluid makes up 1/3 of total body water
ECF is spread across ____ and ____ spaces. These spaces are separated by _____.
Interstitial fluid spaces
Intravascular fluid spaces
Vascular endothelium + glycocalyx
ICF
intracellular fluid
ECF
extracellular fluid
ISF
interstitial fluid
IVF
intravascular fluid
ISF makes up __/__ of ECF
Interstitial fluid makes up 3/4 of extracellular fluid
IVF makes up __/__ of ECF
Intravascular fluid makes up 1/4 of extracellular fluid
Circulating blood volume:
Canines = ____ mL/kg
80-90 mL/kg
Circulating blood volume:
Felines = ____ mL/kg
40-60 mL/kg
Circulating blood volume:
Equines = ____ mL/kg
80 mL/kg
____ can move across all barriers based on concentration gradient
Water
_____ can move across the vascular endothelium freely but cannot move across the cell membrane without active transport
Electrolytes
When administering an electrolyte solution, ____ will remain in the vascular space and ____ will move into the interstitial space.
1/4 remains in vascular space
3/4 moves into interstitial space
_____ cannot readily move across the vascular endothelium and are relatively confined to the vascular space
Colloids
Administering colloids increases the _______ which causes fluid to move from the _____ space to the _____ space.
increases oncotic pressure of blood
moves fluid from ISF space to IVF space
a type of osmotic pressure that causes fluid to pull back into the capillary
Oncotic Pressure
electrolytes dissolved in water
Crystalloids
Can be used as transient fluid volume expanders
Crystalloid solutions
Why can crystalloid solutions be used as transient fluid volume expanders?
Electrolytes easily redistribute across the endothelium
crystalloid solutions that have an osmolality less than that of blood and provide water in greater proportion than electrolytes
Hypotonic Crystalloids
Hypotonic crystalloids cause a fluid shift from the ____ space to the ____ space > thus increasing _____ space volume.
from IVF to ISF > increase ISF volume
a condition characterized as having high blood sodium and free water loss
Hypernatremia
________ can be used to replace free water deficits or maintain hydration in patients with heart disease and kidney disease. Why?
Hypotonic Crystalloids > because these patients have a decreased tolerance for sodium
_______ can be used to treat hypernatremia
Hypotonic crystalloid
Why should hypotonic crystalloids NOT be used in fluid resuscitation?
Ineffective for expanding vascular volume
Give 4 examples of hypotonic crystalloid solutions
- Dextrose 5% in water (D5W)
- 0.45% NaCl
- Normosol M
- Plasmalyte 56
D5W
Dextrose 5% in water
D5W is a _____ solution
hypotonic crystalloid
0.45% NaCl is a _____ solution
hypotonic crystalloid
Normosol M is a _____ solution
hypotonic crystalloid
Plasmalyte 56 is a _____ solution
hypotonic crystalloid
crystalloid solutions that have an osmolality equal to that of blood and provide water in equal proportion to electrolytes
Isotonic Crystalloids
most commonly used crystalloid solutions
isotonic crystalloids
Isotonic crystalloids expand fluid volume in ______
ICF space + ECF space equally
______ solution does not alter the osmolality of the IVF space
Isotonic crystalloid
______ can be used for shock resuscitation, rehydration, and replacement of ongoing water/electrolyte losses
Isotonic crystalloids
_____ can be used to neutralize the acid-base balance of blood
Isotonic crystalloid
_____ has acidifying effects on the blood due to ____.
NS
High chloride content
_____ has alkalinizing effects on the blood due to _____.
BES
Sodium bicarbonate precursors
Give 4 examples of isotonic crystalloid solutions
- 0.9% NaCl (NS)
- Normosol R
- Plasmalyte 148
- Lactated Ringer solution (LRS)
NS
Normal Saline
LRS
Lactated Ringer Solution
BES
Balanced Electrolyte Solution
0.9% NaCl is a _______ solution
isotonic crystalloid
Normosol R is a _______ solution
isotonic crystalloid
Plasmalyte 148 is a _______ solution
isotonic crystalloid
Balanced electrolyte solutions are ______ solutions.
isotonic crystalloids
crystalloids that have an osmolality greater than that of blood and provide electrolytes in greater proportion than water
Hypertonic Crystalloids
Hypertonic crystalloids cause a fluid shift from the _____ space to the _____ space > thus increasing ______ volume.
from ISF to IVF space > increases IVF volume
______ can be used to aid in fluid resuscitation
Hypertonic crystalloids
______ can be used to treat head trauma/traumatic brain injury because _____
Hypertonic crystalloids > helps draw fluid out of cerebral interstitium > decrease intracranial pressure + increase blood volume + increase BP
Do NOT admin hypertonic saline faster than ____ - ____ mL/kg/min
0.5 - 1 mL/kg/min
Give 3 examples of hypertonic crystalloid solutions
- 3% hypertonic NaCl
- 7% hypertonic NaCl
- 23% NaCl diluted to no greater than 7.5%
3% hypertonic NaCl is a _______ solution.
hypertonic crystalloid
7% hypertonic NaCl is a _______ solution.
hypertonic crystalloid
23% NaCl diluted to no greater than 7.5% is a _______ solution.
hypertonic crystalloid
large molecules suspended in an isotonic crystalloid
Colloids
Why can colloids be used as prolonged fluid volume expanders?
Glycocalyx prevents movement of large molecules from IVF space
What are the 2 types of colloids solutions and which is preferred for long-term infusions?
- Natural - preferred for long-term infusions
- Synthetic
Give 2 examples of colloids
- Plasma
- Albumin
Plasma is a ______ solution
colloid
Albumin is a ______ solution
colloid
______ can be used as oncotic support for patients with hypoproteinemia
Colloids
Why aren’t synthetic colloids typically used?
May cause coagulopathy
the measurement of the concentration of particles in a solution
Osmolality
Normal plasma osmolality = ____ to _____ mOsm/L
280 - 310 mOsm/L
What are the 3 phases of fluid therapy?
- Resuscitation Phase
- Replacement Phase
- Maintenance Phase
the phase of fluid therapy aimed at restoring vascular volume in an effort to reverse hypovolemia and/or a shock state
Resuscitation Phase
Solution(s) used during the resuscitation phase of fluid therapy:
- Hypertonic crystalloids
- Colloids
reflects the increase in vascular volume for each 1 mL administered
Efficiency
What is the benefit of mixed resuscitation?
Total dose of each fluid can be reduced > thus side effects are diminished
The amount of fluid administered during the resuscitation phase is determined by:
1.
2.
- Amount of vascular volume lost
- Relative efficiency with which fluid expands in IVF space
How is a shock dose administered?
A fraction of the shock dose is given over a short period of time > then patient response is monitored
Using the traditional approach, a _____ bolus is given over _____ minutes
larger bolus is given over 15-20 minutes
Using the restricted approach, a _____ bolus is given over _____ minutes
smaller bolus is given over 20-30 minutes
the phase of fluid therapy that involves correction of lost body fluids and electrolytes
Replacement Phase
Solution(s) used during the replacement phase of fluid therapy:
Isotonic crystalloid
Goal = to restore euhydration within _____ of initiating fluid therapy
24 hours
normal hydration
Euhydration
Replacement Fluid Rate = ___________
Replacement Fluid Rate = Dehydration + Ongoing Losses + Maintenance
Dehydration = ___________
Dehydration = Fluid Deficit [L] / Hours fluid will be administered
Initial Bolus = ___________
Initial Bolus [mL] = Standard Bolus Rate for Species + Fluid [mL/kg] x BW [kg]
Fluid Deficit = ____________
Fluid Deficit [L] = BW [kg] x Estimated % Dehydration [as decimal]
dehydration in which there is minimal loss of skin turgor, mucous membranes are moderately dry, and the eyes are normal
Mild Dehydration (5%)
dehydration in which there is moderate loss of skin turgor, dry mucous membranes, pulse is weak and rapid, and enophthalmos is observed
Moderate Dehydration (8%)
dehydration in which there is significant loss of skin turgor, tachycardia, weak pulse and hypotension, considerable mucous membrane dryness, severe enophthalmos, and CNS effects
Severe Dehydration (10%)
The length of time a fluid deficit is replaced depends on ______
Clinical situation
Normal to minimal fluid loss is replaced over _____.
4-24 hours
Chronic fluid loss is replaced over _____.
12-24 hours
Ongoing Losses = _____________
Ongoing Losses [mL/hr] = Fluid loss over a period of time [mL] / # hours over which it occurred [hrs]
Ongoing losses include:
1.
2.
3.
4.
5.
- Vomiting
- Diarrhea
- Bleeding
- Panting
- Inappropriate urinary losses
Why are linear calculations not as accurate when determining maintenance fluid rates?
Doesn’t take into account impact of body surface area-to-volume ratio on metabolic rate
Ex: Underestimates for small patients and Overestimates for large patients
Allometric calculation for:
Canines = ________
Felines = ________
Canines = (132 x BW^(3/4)) / 24 hrs
Felines = (80 x BW^(3/4)) / 24 hrs
Maintenance fluid rate for normal adult equines is ____ mL/kg/day.
40-60 mL/kg/day
Maintenance fluid rate for normal neonatal equines is ____ mL/kg/day.
90 mL/kg/day
the phase of fluid therapy after dehydration has been corrected and there are no more ongoing losses
Maintenance Phase
Solution(s) used during the maintenance phase of fluid therapy:
Isotonic crystalloids
Hypotonic crystalloids
Methods of IV fluid therapy administration:
1.
2.
- Gravity-Fed System
- Fluid Pump
a device used to clamp just below the fluid bag in order to prevent any more than 150 mL of fluid being delivered unless it is refilled
Buretrol Device
Drip rate is based on:
1.
2.
- Desired infusion rate
- Size/delivery rate of the drip set (# drops/mL)
Calculate the drip rate for a prescribed infusion rate of 100 mL/hr with a drip set that has a delivery rate of 10 drops/mL
Drip Rate = 1 drop every 5 sec
100 mL/1 hr x 1 hr/60 min
100 mL/60 min = 1.66 mL/1 min
1.66 mL/1 min x 1 min/60 sec
1.66 mL/60 sec = 0.02 mL/1 sec
0.02 mL/1 sec x 10 drops/1 sec
0.2 drops/1 sec x 5/5
1 drop/5 sec
IV fluid therapy is typically administered to large animals via a _______
Gravity-fed system
a device that can be programmed to infuse a specific volume of fluid over a set amount of time, but maxes out at 1 liter per hour
Volumetric Pump
a device that can be programmed to infuse fluids at very low rates, especially less than 2 mL per hour
Syringe Pump
What are some clinical applications for SC administration of fluid therapy?
- Reverse mild to moderate dehydration
- Prevent development of dehydration in patients not eating/drinking
- Home fluid therapy
What are some clinical applications for IV administration of fluid therapy?
- Fluid resuscitation
- Intraoperative fluid therapy
- Use in anesthetized patients
- Significant dehydration + ongoing losses replacement
- General use for critically ill patients
Contraindications for SC administration of fluid therapy
- Severe dehydration
- Significant electrolyte imbalances
- Hypovolemia or hypotension
- Large animals
SC administration of fluid therapy should use _____ fluids with an osmolality _____.
Isotonic
Equal to that of the ECF
Total fluid volume to be given should be administered in as many different places as possible when using the ______ route.
SC
IO fluid therapy administration sites include:
1.
2.
3.
4.
- Tibial tuberosity
- Trochanteric fossa of the femur
- Iliac wing
- Greater tubercle of the humerus
an infection in a bone
Osteomyelitis
Meds safe for _____ are safe for IO administration
IV
Enteral administration of fluid therapy at scheduled intervals should be given every ______ hours
2-4 hours
Give 2 contraindications for enteral administration of fluid therapy
- Patients in shock
- Abnormally functioning GI tract
low blood potassium levels
hypokalemia
a condition characterized by excessive urination following the relief of a urinary obstruction
Postobstructive diuresis
a condition caused by a pituitary gland tumor that secretes excessive ACTH which leads to increased cortisol secretion from the adrenal glands
Hyperadrenocorticism (Cushing Disease)
a condition in which the body can no longer produce enough insulin which leads to the breakdown of fat for energy and a dangerous buildup of ketones in the bloodstream
Diabetic ketoacidosis
a condition in which the adrenal glands produce too much of the steroid hormone that helps regulate sodium and potassium in the blood
Primary hyperaldosteronism (Conn’s Syndrome)
a steroid hormone that helps regulate sodium and potassium in the blood
Aldosterone
Potassium admin maximum = _____ mEq/kg/hr
0.5
What kind of effects will you see if potassium is administered faster than 0.5 mEq/kg/hr?
Cardiac effects
Hypokalemia can be treated with _____ and ______
Potassium chloride (KCl) and Potassium phosphates (K+)
low blood glucose levels
Hypoglycemia
the inability of the liver to perform its normal synthetic and metabolic functions
Hepatic insufficiency
a condition in which damage to the adrenal glands causes them to not produce enough cortisol and aldosterone
Hypoadrenocorticism (Addison Disease)
a condition in which chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body and can lead to a cascade of organ failure
Sepsis
a tumor that forms in the pancreas and produces an excess amount of insulin
Insulinoma
a condition in which a tumor overproduces incompletely processed insulin-like growth factor 2 (IGF-2) which leads to stimulation of insulin receptors and increased glucose utilization
Non-islet Cell Tumor Hypoglycemia (NICTH)
a condition in which the animal exerts itself in strenuous exercise and rapidly depletes their blood glucose before their reserves can be remobilized or released from glycogen storages from the muscles and liver
“Hunting Dog Hypoglycemia”
lack of muscle coordination and control
Ataxia
Hypoglycemia is treated with an IV administration of dextrose at a rate of ____ mL/kg
0.5-1 mL/kg
Stock dextrose (___%) should be diluted to a ____% solution to prevent _____.
Stock dextrose (50%) should be diluted to a 25% solution to prevent phlebitis.
Making a Dextrose-Containing Solution =
(Desired concentration [%] x Desired volume [mL]) / Stock concentration of dextrose
Only when severe can metabolic acidosis be treated with _____.
sodium bicarbonate
Only when severe can hyperkalemia be treated with _______.
sodium bicarbonate
dangerously low blood pH levels due to increased hydrogen ions
Acidemia
What are 3 contraindications for adding sodium bicarbonate to a fluid therapy solution?
- Respiratory acidosis
- Hypoventilation
- Hypercapnia
a condition characterized by an accumulation of carbon dioxide in the body due to inadequate ventilation
Respiratory acidosis
a condition characterized by inadequate ventilation which leads to low blood oxygen levels and high blood carbon dioxide levels
Hypoventilation
a condition characterized by a high partial pressure of carbon dioxide (PaCO2) in the blood
Hypercapnia
Monitoring during the resuscitation phase is geared toward assessing:
- Cardiovascular stability
- Blood volume
- Perfusion parameters
Efforts should be made to normalize/maintain systolic BP between _____ and ____ mm Hg during the resuscitation phase
110-140 mm Hg
It’s beneficial to target a lower minimally acceptable systolic BP (___ to ___ mm Hg) in cases of ______ to prevent _____.
It’s beneficial to target a lower minimally acceptable systolic BP (90 to 100 mm Hg) in cases of ongoing hemorrhage to prevent worsening bleeding.
a condition characterized by the moderate buildup of lactic acid in the blood when the tissues do not get enough oxygen
Hyperlactemia
Monitoring during the replacement phase is geared toward assessing:
Hydration
The goal during the resuscitation phase is to ______ and ______.
restore vascular volume and tissue perfusino
a condition characterized by high sodium levels in the blood which typically results from free water losses, inadequate water intake, or sodium overload
Hypernatremia
Change in body weight of ____ kg correlates to ___ L of body water
1 kg = 1 L
a condition in which there is a decrease in coagulation factors and platelets when blood is replaced by fluids that do not contain these components
Dilution coagulopathy
What are 3 signs of volume overload due to fluid therapy?
- Pulmonary edema from overload of the left side of the heart
- Cavitary Effusion
- Peripheral edema
fluid collection in a body cavity or joint
Cavitary Effusion
Physical exam findings when blood loss is >30% of blood volume includes:
- Pale mucous membranes
- Tachycardia
- Tachypnea
- Lethargy
- Cold extremities
- Hypotension
- Increased blood lactate concentrations
- Sweating + Colic (horses)
Give some indications for a blood transfusion
- Chronic and hemolytic anemia
- Acute hemorrhage
Give some indications for a platelet transfusion:
- Severe thrombocytopenia + life-threatening hemorrhage
- Severe thrombocytopenia + necessary surgery
Platelet counts should be ____ μL in cats and ____ μL in dogs.
Cats = 10,000 μL
Dogs = 20,000 μL
Give some indications for a plasma transfusion:
- Coagulopathy
- Hypoalbuminemia
- FTP
- IgG concentration <800 mg/dL in foals older than 12 hrs
- TP concentration <5.5 g/dL in calves older than 12 hrs
There is no true “universal” blood type known in _____.
horses
Ideal equine blood donors are _____ negative
Aa or Qa
How can you increase the likelihood that two horses have a similar blood type when considering blood donation?
Choose donor of same breed
Ideal bovine blood donors are _____ negative
factor J
What happens if a canine blood recipient that has anti-DEA 1.1 antibodies is transfused with DEA 1.1 positive blood?
Agglutination and hemolysis
Canine blood typing can be done using:
1.
2.
- Canine rapid blood typing cards
- Immune-chromatographic test kits
If a canine blood sample does not agglutinate on the DEA 1.1 rapid blood typing card > the pet is ______
DEA 1.1 negative
Universal canine blood donors are only positive for ______ antigen.
DEA 4
Dogs that can be used in a blood donor program include:
1.
2.
- Positive for DEA 4 + negative for all other DEAs > can donate to all dogs
- Positive for DEA 1.1 > can donate to DEA 1.1 positive
_____ do NOT have typically have naturally occurring antibodies to the blood type they do not have
Dogs
the most common feline blood type, especially for domestic shorthair and domestic long-hair breeds
Type A
the less common feline blood type, but is seen more frequently in some breeds such as Devon Rex, British Shorthair, Abyssinian, Persian, Himalayan, and Sphinx
Type B
the universal recipient feline blood type
AB
_____ HAVE naturally occurring alloantibodies to the blood type they do not have
Cats
Canine blood typing can be done using:
1.
2.
- Feline rapid blood typing cards
- Immune-chromatographic test kits
- Cross matching
detects agglutination reactions between the donor’s RBCs and the recipient’s plasma
Major Cross-Matching
detects agglutination reactions between the donor’s plasma and recipient’s RBCs
Minor Cross-Matching
The max blood donation for canines is _____ mL/kg of BW (or _____ of blood volume)
13-17 mL/kg BW
(or 15-20% of blood volume)
The max blood donation for felines is _____ mL/kg of BW (standard blood volume collected is _____ mL)
11-15 mL/kg BW
50-70 mL standard collected
The max blood donation for equines is _____ mL/kg of BW (or _____ of blood volume)
16 mL/kg BW
(or 20% of blood volume)
Always use ______ BW when calculating max blood collection volume in all species
Lean
If 20% of blood volume is collected > replace ______ mL/kg of IV crystalloid
20-40 mL/kg
If blood will be transfused immediately > use ______ as the anticoagulant
sodium citrate
If blood will be stored > use ______ or ______ as the anticoagulant
Citrate-phosphate-dextrose
or
Citrate-phosphate-dextrose-adenine
plasma that is used within 8 hours of collection
Fresh Plasma
plasma that is placed in a freezer within 8 hours of collection and that is less than 1 year old
Fresh Frozen Plasma (FFP)
FFP should be stored at ____ºF
≤ 0ºF
FFP must be used within _____ to ensure optimal ______ activity
1 year
clotting factor
plasma that is frozen longer than 8 hours after collection or FFP that is older than 1 year of age
Frozen Plasma
If plasma is thawed but not needed > you can refreeze it within _____ of thawing
1 hour
PRBCs
packed red blood cells
When separating blood components, blood should be centrifuged at ____ºF with a relative centrifugal force of _____ g for ____ minutes
centrifuged at 39.2ºF with a relative centrifugal force of 5000x g for 5 minutes
Why should refrigerated blood be transfused directly? What is an exception?
Warming may deteriorate RBCs
Exception = hypothermic patients
______ prevents inadvertent infusion of blood clots
In-Line Filter
Do NOT admin blood concurrently with ______ or ______ solutions
hypertonic or hypotonic
Do NOT admin blood with _______ containing solutions. Why?
Calcium - calcium can overwhelm the citrate anticoagulant and activate the coagulation cascade
Blood Transfusions:
Give ____ mL/kg over the first ____ minutes and increase afterward as needed
0.3 mL/kg over the first 20-30 minutes
Blood Transfusions:
Do NOT exceed ____ mL/kg/hr in patients with significant cardiac disease
2-4 mL/kg/hr
Blood Transfusion Volume (mL) =
(BW [kg]x Blood Volume [mL/kg] x (Desired PCV −Actual PCV)) / (Donor PCV)
Goals for Acute Hemorrhage Blood Loss
1. Replace ____% of blood lost
2. Increase PCV ___%
3. Reverse clinical signs that prompted the transfusion to begin with
- Replace 25-50% of blood lost
- Increase PCV 10%
- Reverse clinical signs that prompted the transfusion to begin with
Guideline for RBC Transfusion (Canines):
____ mL/kg of whole blood OR ____ mL/kg of PRBCs will raise PCV by 1%
2 mL/kg of whole blood OR 1-1.5 mL/kg of PRBCs will raise PCV by 1%
Guideline for amount of plasma needed to treat coagulopathy:
Canines = _____ mL/kg
10-15 mL/kg
Guideline for amount of plasma needed to treat coagulopathy:
Felines = _____ mL/kg
5-8 mL /kg
Guideline for amount of plasma needed to treat coagulopathy:
Equines = ____ L increments “to effect”
1 L increments “to effect”
treatment is continued until the desired effect is achieved
“To effect”
a skin condition characterized by redness or rash resulting from increased blood flow in the superficial capillaries
Erythema
a skin condition characterized by itchy red welts or lumps on the skin
Urticaria
medical term for itching
Pruritus
a severe, life-threatening allergic reaction
Anaphylaxis
an allergic reaction that involves antibody mediated destruction of cells and develops during or within hours of the transfusion
Cytotoxic (Type II) Hypersensitivity Reaction
a reactions that can occur longer than 24 hours after a transfusion and can result in RBC lysis
Delayed Hemolytic Transfusion Reactions
Most common blood transfusion reaction seen in vet med
Nonhemolytic Immune Reaction
a nonimmune acute reaction that can occur with large or rapidly delivered volumes of blood products, especially normovolemic patients
Transfusion-Associated Circulatory Overload (TACO)
