Fluids and shock Flashcards
Major physiologic determinants of tissue perfusion are:
BP, Cardiac output
main sign of pre-shock/ compensated shock
tachycardia
symptoms of shock
Signs and symptoms of end-organ dysfunction
Symptomatic tachycardia, dyspnea, hypotension, cool clammy skin
Metabolic acidosis, oliguria, renal dysfunction
what type of shock?
Intravascular fluid loss due to:
Hemorrhagic cause
Nonhemorrhagic cause
Third spacing
hypovolemic
hypovolemic shock effect on cardiac output
decrease in preload (volume in LV at end of diastole)
fluid options for Nonhemorrhagic hypovolemic shock
1st line is crystalloids (NS, LR), 2nd line is colloids
class: recombinant factor 7a (novoseven), tranexamic acid
hemostatic agents
managment for internal bleeding
hemostatic agents, blood
how to reverse warfarin
4Factor PCC (prothrombin complex concentrate)/KCentra + vitamin K
how to reverse dabigatran
Idarucizumab/Praxbind or activated PCC
how to reverse Xarelto, Eliquis
Andexanet alfa or 4F PCC/KCentra
criteria for septic shock dx
Infection: Invasion of normally sterile tissue by organisms OR Bacteremia.
Organ dysfunction
SOFA (Sequential (sepsis-related) Organ Failure Assessment score
Score ≥ 2
qSOFA can identify patients at risk for sepsis
Score ≥ 2
Patients who require vasopressors despite adequate fluid resuscitation maintain MAP ≥ 65 mmHg
+
Lactate ≥ 2 mmol/L
septic shock is a type of ____ shock
distributive
major factor of distributive shock
massive vasodilation
3 keys points for mgmt of sepsis
Management requires these 3-things:
Early recognition and intervention (including administration of IV fluids (NS or LR) and vasopressors as needed)
Early administration of broad spectrum antibiotics (w/in 1 hr of arrival)
Source control
rate/amount of fluid restoration for sepsis
30mL/kg total bolus
Given in 500-1000mL bolus
Reassessment performed following each bolus
indication for vasopressors in sepsis
Recommended in patient with MAP < 60 – 65 mmHg after failed fluid resuscitation. Used when fluid resuscitation is inadequate to maintain blood pressure and prevent organ dysfunction in shock
central or peripheral line for vasopressors?
central
1st line vasopressor in septic shock
norepinephrine
add ___ to NE if persistent hypotension in septic shock
epi
1st line for shock caused by HF or resulted in HF
dobutamine (but Rarely used in septic shock – only when combined with multiple other vasopressors)
indication for corticosteroids in shock
Hemodynamic instability despite fluid and vasopressor therapy
IV hydrocortisone: 200 mg/day (50 mg q6h)
Wean from steroids when vasopressor therapy no longer required
stress ulcer prophylaxis in shock
Drugs that increase gastric pH
Famotidine (Pepcid®) or ranitidine (Zantac®): histamine receptor antagonist
Lansoprazole (Prevacid®) or pantoprazole (Protonix®): proton pump inhibitors
pts at risk for stress ulcers
Mechanical ventilation (> 48 hours)
Coagulopathic
Hypotensive
predominant ion in intracellular fluid
K
plasma w/o clotting factors
serum
predominant ion in interstitial fluid
Na
75% of oncotic pressure is from ____
albumin
brain structure regulating thirst
hypothalamus
should intake ___L of water, pee out ___L
2, 1.5
BUN/Cr ratio in prerenal azotemia / dehydration
> 20:1
20:1
HR and BP in dehydration
rapid HR, low BP
Aqueous solutions of mineral salts or other water soluble molecules
* Increases intravascular volume and intracellular volume
* Low tendency to stay in intravascular space
crystalloids
isotonic crystalloid; contains Na, Cl, K, Ca, lactate; prevents hyperchloremia acidosis
lactated ringers
NS overload can cause
overload can cause high Na, low K, metabolic acidosis, high Cl
3 contraindications for half normal saline
burns, trauma, cirrhosis
indications for half normal saline
hypernatremia, DKA
indications for Electrolyte-Free Water
o D5w: dextrose 5% In water, D10w: dextrose 10% in water
hypoglycemia, critically elevated serum osmolarity
contras for Electrolyte-Free Water
o D5w: dextrose 5% In water, D10w: dextrose 10% in water
edema, blood loss, hypovolemia
3% saline (or higher): causes volume expansion where?
larger volume expansion in intravascular space
severe hypovolemia / large quantity of fluid needed. use NS or LR?
LR (to prevent hypercholremic acidosis, AKI)
High concentration solutes and protein designed to keep fluids in intravascular space à “plasma expander”
* Large molecules/proteins suspended in solution
* Don’t diffuse out of blood stream into interstitial or intracellular space
* Draws fluid into bloodstream by oncotic pressure à increases oncotic pressure
colloids
class: Fresh frozen plasma or albumin (natural)
o Hespan or Dextran (synthetic)
colloids
pt w/ blood loss–what to give them?
blood
what fluid can reverese a coagulopathy (pre-procedural)?
fresh frozen plasma
quantity of fluid replacement for 68kg adult
For adults: Your patient weighs 68 kg
–First take 40 ml/hr
–Now add 68 ml/hr (this is the 1 ml/hr per kg of the patient’s weight )
Maintenance IV fluid rate is 40+68=108 ml/hr
quantity of fluid replacement for 25kg kid
Your patient weighs 25 kg (55 lbs):
-First 10 kg allow 4ml/kg/hr= 40 ml/hour
-Second 10 kg allow 2/mg/kg/hr=20 ml/hr
-Everything over gets 1 ml/kg/hr (in this case 5 more kg to make a total of 25 kg) SO…5 ml/hr
40 +20+5= 65ml/hr of chosen IV fluid for maintenance rate.
bolus rate for adults
1-2L at a time
bolus rate for CHF, ESRD
250-500cc, reassess every 2-5min
bolus rate for elderly, kids
also elderly, kids (bolus slowly over 30min-1hr, 10-20cc/kg). don’t give too much too fast to kids
what fluid to give burn pts
LR
when to refer burn pt
> 10% of BSA burned
when to give sodium bicarb in CKD metabolic acidosis
KDIGO suggests oral replacement when HCO3 concentrations are <22mEq
caution for sodium bicarb
Caution in patients who should maintain a low sodium diet
when to give bolus K+
never
antidote for KCl
hyaluronidase antidote
if giving pt PO KCl, also give ___
meal + full glass of water
caution for KCl
renal failure/insufficiency d/t risk of hyperkalemia
10 mEq of Kcl will increase serum K by ___
0.1
acute hyperkalemia management:
insulin, dextrose, albuterol. if also have EKG changes, give Ca gluconate
Gastrointestinal Cation Exchangers for Hyperkalemia – ok for renal impairment?
yes
preferred Gastrointestinal Cation Exchangers for Hyperkalemia
Lokelma (zirconium cyclosilicate)
§ Newer, preferred, works quickly (~1 hr)
§ May be used for chronic hyperkalemia of CKD/ESRD
contra for Gastrointestinal Cation Exchangers for Hyperkalemia
AVOID use in anyone w/ ileus, severe constipation, bowel obstruction or gastric motility disorders à risk of
intestinal necrosis!
indicatin for Potassium Bicarbonate
hypokalemia in pt w/ metabolic acidosis (Ex: diarrhea)
loop vs thiazide diuretic for CKD?
loop, esp if GFR<60
