Fluids and Blood (Connie) Flashcards

Question

Osmolarity

Answer 1

The number of osmoles per liter of a solvent

Answer 2

serum levels

Answer 3

* focused on treating underlying cause * **Rapid correction of hyponatremia may lead to osmotic demyelination syndrome** ("locked-in" syndrome, acute paralysis, inability to speak, issues with myocardial contractility)

Answer 4

* Primary intracellular cation * Role in electrical conduction, acid-base balance, and metabolism * Serious issues from fluctuation * Diet as main source * Imbalance affects several body systems * Chemistry panel as diagnostic test * Determining reason for alteration

Answer 5

**Pathophysiologic** (which is what it refers to when we say the body couldn't compensate any longer)

Answer 6

Increase excretion Treatment of acidosis

Answer 7

Increasing potassium Oral or intravenous administration

Answer 8

Initial resuscitation fluid \*If you give too much NS it may cause hyperchloremic metabolic acidosis & may contribute to perioperative acute kidney injury) LR and PlasmaLyte

Answer 9

Albumin (fluid resuscitation in hemorrhagic shock and in the presence of hypoalbuminemia or in conditions where there is large protein loss) Which patients have large protein loss? Burns and septic

Answer 10

* Polysaccharide (6% and 10% solution) * Volume expansion * Acute normovolemic hemodilution * Improve blood rheology •Side effects = Coagulopathy (dose-dependent decrease in factor VIII and vWF)

Answer 11

**Water soluble glucose polymer** •Clinical use * Colloid osmotic pressure of 350 mOsm/L * Remains in intravascular space for 12 hours * Replacement of intravascular volume •Side effects * Allergic reactions * Increased bleeding time (decreases platelet adhesion) * Non-cardiogenic pulmonary edema

Answer 12

RBC = 0- (because it does not contain any antigens) Plasma = AB+ (also no antibodies)

Answer 13

RBC = AB+ Plasma = O-

Answer 14

Whether the patient is euvolumic, hypovolemic or hypervolemic

Answer 15

hyponatremia

Answer 16

* Intracellular cation mostly stored in bone and muscle * Functions of magnesium (regulates many of the biochemical reactions in the body such as protein synthesis, muscle and nerve function, helps control blood glucose levels, BP regulation) * Diet as main source _Clinical manifestations_ * Neuromuscular and cardiovascular system effects Diagnostic procedures * History, physical exam, blood chemistry

Answer 17

\> 3.0 mg/dL ## Footnote Results from renal failure or excessive intake Treatment = Diuretics and IVF administration You'll see loss of DTR (deep tendon reflex)

Answer 18

\<1.8 mg/dL Inadequate intake or decreased absorption Treatment Oral or IV replacement

Answer 19

Hypertension

Answer 20

surface markers on our RBC The ABO antigens are sugars The RhD antigen is a very large protein

Answer 21

45 minutes

Answer 22

* Type-specific partially crossmatched blood * Type-specific uncrossmatched blood * Type O uncrossmatched blood (remember that the PRBCs will contain some of the anti-A and anti-B antibodies found in the plasma of type O blood **•After two or more units of type O blood are transfused, you must continue to use type O blood even if the patient is identified to be a different blood type.** •Once is has been identified that the transfuse anti-A and anti-B antibodies have decreased to a safe level, you may give the patient type specific blood.

Answer 23

PRBC: FFP: Platelet at a 1:1:1 ratio

Answer 24

1 gm during transfusion then 1 gm q8 hours \*TXA has proven NOT to increase clotting post-op (that was an old concern)

Answer 25

One round = 6 units PRBC Give 1 gm calcium chloride or 3 gm calcium gluconate Calcium chloride delivers 3 times more elemental calcium than calcium gluconate. You prefer to administer intravenous calcium gluconate over calcium chloride because it causes less tissue necrosis if extravasated.

Answer 26

Avoid acidosis – treat with standard approaches Avoid hypothermia Hemodynamic management Source control

Answer 27

Components: RBCs Indications: RBC replacement Key Points: Hbg \>10 rarely indicated, Hgb \<6 tranfusion is often indicated

Answer 28

Components: RBCs, WBCs, Plasma, Platelet debris & Fibrinogen Indications: RBC replacement & Blood volume replacement Key Points: Rarely used in the OR

Answer 29

**Components**: All coagulation factors, Fibrinogen & Plasma proteins **Indications**: Coagulopathy, Warfarin reversal, AT III deficiency, Massive transfusion, DIC, C1 esterase deficiency (causes angioedema) **Key Points**: Warfarin reversal = **5-8 mL/kg** Coagulopathy = **10-20 mL/kg** **Complete transfusion within 24 hours of thawing**

Answer 30

Hypocalcemia (Because bags of blood contain citrate which binds to calcium).

Answer 31

Components: Platelets _Indications_: * \< 50,000 µL * Invasive procedures, neuraxial blockade or most surgeries (\< 100,000 µL) * Eye and neurosurgery * Qualitative platelet defect * TEG Key Points: * 1 pack per 10 kg/wt. * Stored at room temp for 5 days * Highest risk of bacterial contamination * Recommended to not go through a blood warmer

Answer 32

**Components**: Fibrinogen, Factor 8, Factor 13 & vWF **Indications**: * Fibrinogen deficiency * \< 80 – 100 mg/dL * vWB disease * Hemophilia **Key Points**: * 5 bag pool * Administer through filter * Complete infusion within 6 hours of thawing

Answer 33

**_Observed under anesthesia_** = Hemoglobinuria, Hypotension & Bleeding Masked by anesthesia * Fever ? * Chills * Chest pain * Dyspnea * Nausea * Flushing ?

Answer 34

* Free hemoglobin precipitates in the renal tubules = mechanical obstruction * Acidic urine increases precipitation

Answer 35

•Erythrocin is released from the RBC and activates the intrinsic clotting cascade Lab abnormalities reflect consumption of clotting factors and enhanced fibrinolysis: **DECREASED platelets, fibrinogen, prothrombin, factor 5, 8, 13 and INCREASED fibrin degredation products**

Answer 36

* Free hemoglobin activates the the kallikrein system = bradykinin * Vasodilation

Answer 37

* Stop transfusion * Maintain UOP (need to make sure the kidneys are getting perfusion) * IVF * Mannitol (add Lasix if IVF and mannitol fail to provide adequate response) * Alkalinize the urine with NaHCO3 (Sodium Bicarbonate) * Send urine and plasma hemoglobin samples to blood bank * Check platelets, PT and fibrinogen * Send unused blood to blood bank (recheck cross match) * Support hemodynamics

Answer 38

* **Alloimmunization** (platelets – Leukocytes - RBC) (your body gains immunity against your own cells) * **HLA – antigens (**Granulocyte – platelet – RBC specific) * **Allergic reactions** * **Febrile reactions** * **ABT** (**allogenic blood transfusions**)– related mortality (**TRALI – TAS – HTRs – TTI**) *TAS = transfusion associated sepsis, HTR = hemolytic transfusion reaction, TTI = transfusion transmitted infections* * **Intravascular hemolysis** – coagulopathy – renal impairment and failure - death

Answer 39

**Transfusion Related Acute Lung Injury** Can occur from all plasma containing blood products (HLA antibodies). Can also occur from storage of banked blood which develops biologically active lipids which can go across the vessels into the lung vessels and draw fluid into it. * Non-cardiogenic pulmonary edema * Typically seen 1-2 hours post-transfusion * Symptoms = Dyspnea -cough - fever

Answer 40

TACO = transfusion associated circulatory overload * Volume overload * Cardiogenic pulmonary edema * Multiparous donors become HLA sensitive (thus they're at higher risk)

Answer 41

**ABO antigens and/or antibodies to other RBC antigens.** ## Footnote Can be Acute = 24 hours or Delayed \> 24 hours If it's Non-ABO = RBC antibodies (Jkb, Jka, Kell, Fya, Fyb, E, Jsa, I) Usually due to exposure (can occur during pregnancy as well).

Answer 42

#1 Cytomegalovirus (CMV) (prevent with leukoreduction) #2 Hepatitis B #3 Hepatitis C #4 HIV Human T-cell lymphotropic virus (HTLV)

Answer 43

RBCs and platelets

Answer 44

**Transfusion Related Immunomodulation** APCs (Antigen Presenting Cells) and plasma. Can cause: * Non-specific immunosuppression * Antigen-specific immunosuppression * Impaired T-cell mediated immunity * Decreased macrophage * Altered cytokine Renal allografts – better outcomes Tumor recurrence (occurs when pt received blood during the tumor removal case) Reduction in survival

Answer 45

WBCs – HLA – CD4 – Helper T-cell

Answer 46

**Adapt appropriately**. Even though oxygen carrying capacity is decreased, tissue oxygenation is preserved at Hgb levels below 10. THESE MACHANISMS ARE WHY THIS HAPPENS: **Shift in oxyhemoglobin dissociation curve to the right** which increases synthesis of 2,3-DPG (diphosphoglycerate). **Hemodynamic alterations** (increased CO) **Microcirculatory alterations** = **Vascular tone-** Helps drive bringing the blood to the tissues in need. **Renin-angiotensin-aldosterone system-** promotes better BP responses and helps absorb Na in water so that we have more volume in vasculature

Answer 47

To unload O2 off of cells into the tissues.

Answer 48

DO2 = delivery of oxygen VO2 = utilization of that oxygen

Answer 49

**Delivery**. Stored RBCs contain: * low p50- shifting the oxygen dissociation curve to the left * Depletion of 2,3 DPG * Depletion of ATP (which undergoes anaerobic metabolism which causes bad changes) **Oxygen Utilization** * Very few studies can confirm improved hemodynamics and O2 transport parameters in critically ill patients after receiving RBCs

Answer 50

**Metabolic acidosis** * Lactate increased = 1.6 - 30.1 mmol/L * K+ increased = 3.9 - 80 mEq/L * Increased Free Hemoglobin (a marker for hemolysis which can cause problems which vascular tone) * pH decreased = 7.2 - 6.6 * 2,3-DPG decreased * ATP decreased * GSH (glutathione) is decreased (this decreases your ability for the vasculature to expand) * Ionized Calcium and magnesium = 0 * (SNO-Hb decreased)

Answer 51

Modulates vascular tone

Answer 52

* Hemolysis * Membrane area decreases * Osmotic fragility * RBC adhesion * 30% DOA (dead on arrival) * Deformability decreases only good for 42 days

Answer 53

**Hemoglobin oxidation which leads to Hemoglobin denaturation & Lipid peroxidation** (production of free radicals) •Bioactive Substances (they're all bad) * Cytokines * Histamines * Lipids * Soluble HLA

Answer 54

* Hemorrhagic shock * Critically ill do not tolerate anemia Goal to Increase DO2 and Increase VO2

Answer 55

**Increase Oxygen Delivery!!** ## Footnote Study done by Suttner et al. (2004) The influence of allogeneic RBC transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery •O2 - not the blood transfusion increased tissue oxygen levels

Answer 56

* Reduce hemolysis * Reduce dead-on-arrival RBC (Iron toxicity, Vasoconstriction via NO scavenging) * Maintain deformability / prevent aggregation (prevent capillary blockage) * Maintenance of high ATP – 2,3, DPG – SNO-hb * Minimize oxidative damage * Prevent release, and/or remove bio-active substances * Prevention of TRALI * Leukoreduction, irradiation, pathogen-reduction, etc.

Answer 57

**_Clinical uses_** = Platelet count \< 50,000 or Known platelet dysfunction (TEG) **_General Facts_** * Multiple or single donors * **One unit increases platelet count by 5000-10,000 cells/mL3** * Platelets loose ability to aggregate when refrigerated * A typical pack of platelets includes 6 units * **Stored at room temperature** 20 – 24 degrees C – 5 days (because they can't aggregate appropriately at other temps) * **Risk for bacterial growth & Sepsis.** (because they need to be stored at room temp)

Answer 58

_Clinical uses_ * PT \> 1.5 times normal (18) * PTT \> 1.5 times normal (55-60) * Coagulation factor assay of \< 25% activity (TEG) _Other reasons to give_ * Urgent reversal of warfarin therapy * Antithrombin deficiency (requiring heparin) * Massive blood transfusions (\> 5000 mL)

Answer 59

Warfarin reversal Antithrombin deficiency

Answer 60

anticoagulation and Heparin admin Therefore, the deficiency of AT III would explain a patient's lack of response to Heparin therapy.

Answer 61

Activated clotting time

Answer 62

Antihemophiliac factor (VIII) _Clinical uses_ * Treatment of hemophilia A * Von Willebrand’s disease * Massive transfusion with fibrinogen concentrates * Consumption coagulopathy What's a benefit of Cryo? It's not a lot of volume

Answer 63

0.3 mcg/kg

Answer 64

**Desmopressin Acetate** Twofold to 20-fold **increase in factor VIII** Speeds up activation of factor X by factor IXa * Stimulates release of vWF * Releases tPA * Releases prostacyclin Used for: Hemophilia A and vWF & ASA induced platelet dysfunction

Answer 65

Factor I Dose: 70 mg/kg Adverse reaction = HA – erythema – N&V – fever – weakness

Answer 66

Factor IX (II, VII, X) Used in hemophilia B Reversal of anticoagulant agents (warfarin)

Answer 67

Approved for hemophilia patients Enhances thrombin generation on activated platelets Cost – exorbitant $15,000.00 Thrombotic complications

Answer 68

100 mg/kg (max 5g) over 15 min (load) 10 mg/kg/hr throughout surgery 1604 mL versus 2312 mL

Answer 69

* Synthetic lysine inhibitors of plasminogen * Significant reductions in blood loss and transfusion requirements * Reduced perioperative blood loss * Decreased autologous blood donation * Transfusion of blood products * Overall costs and complications

Answer 70

Competitive inhibitor of plasminogen activator Significantly reduced intraoperative bleeding by a mean of 408 mL Decreased the probability of receiving blood transfusion by 49% The rate of DVT was not affected by the use of TXA when compared to controls

Answer 71

**Preoperative blood donation** * Hgb not less than 11 g/dL or Hct 33% * May donate 10.5 mL/kg **Intraoperative blood collection** * Cell saver – shed blood * Lacks coagulation properties **Postoperative blood collection** * Shed blood * Coagulation/fibrinolysis/hemolysis

Answer 72

Technique that involves removing whole blood from patient shortly after induction. Overall goal = decreasing blood viscosity. Benefits = Conserved RBC Mass, Improved Oxygenation, Preservation of Hemostasis, Improves rheology (tissue perfusion) _Criteria_ * High likelihood of transfusion * Hb \> 12 * No significant comorbidities * Absence of infection

Answer 73

immunosuppression and adverse outcome

Answer 74

**Pre-operative anemia** (She gave the example of cancelling an urgent but not emergent case so that the patient can go to the clinic and receive IV iron and epogen and then come back to have their surgery done).