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Clin Specialties - Surgery > Fluids Lecture > Flashcards

Fluids Lecture Flashcards

1
Q

What is the most common cause of electrolyte imbalances?

A

medications

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2
Q

What is acute vs chronic hyponatremia defined as?

A

hyponatremia <135 mEq/L

actue < 48 h
Chronic > 48 h

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3
Q

What does a pt with hyponatremia look like?

A

Well it depends on their volume status (hypovolemic, hypervolmeic, euvolemic)

Obtunded, coma, seizure, AMS, lethargy
Dizzy, N/V, confusion, muscle cramps
edema, lung crackles

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4
Q

ADH

A

Anti-diuretic hormone
also known as vasopressin

stimulated by the hypothalamus and released from the pituitary in response to low blood volume

increases H20 reabsorption

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5
Q

SIADH

A

too much ADH
too much water reabsorption (or pt is drinking enough water but the body is not responding appropriately)
leads to hyponatremia

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6
Q

How does aldosterone play a role in sodium balance?

A

when sodium is too low aldosterone is released from the adrenal cortex to increase sodium reabsorption

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7
Q

How does ANP play a role in sodium balance?

A

when blood volume is too high ANP is released from the atria to inhibit Na+/H20 reabsorption and thus decrease ADH and aldosterone release

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8
Q

What can cause hypovolemic hyponatremia?

A

vomiting/diarrhea

diuretics

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9
Q

What is the treatment for hypovolemic hyponatremia?

A

NS

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10
Q

What can cause euvolemic hyponatremia?

A

SIADH

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11
Q

What is the treatment for euvolemic hyponatremia?

A

free water restriction

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12
Q

What can cause hypervolemic hyponatremia?

A

CHF, ESRD, cirrhosis

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13
Q

What is the treatment for hypervolemic hyponatremia?

A

diuretics

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14
Q

What is the goal rate of replacing Na in a hyponatremic pt?

A

8-10 mEq/L in the first 24 hours

too fast and you could cause osmotic demyelination syndrome

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15
Q

What is hypernatremia?

A

Na > 145 mmol/L

intracellular volume depletion d/t loss of H20 and Na but more H20 than Na

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16
Q

What are the common sxs of hypernatremia?

A 
lethargy 
coma
seizure
muscle weakness
AMS
CNS and muscle dysfunction
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17
Q

What are the causes of hypernatremia?

A

water loss
-diarrhea, vomiting, sweating, diuretics, DI - diabetes insipidus

decrease H20 intake
-elderly bed bound pts that can’t get H20

increase Na intake
-hypetonic saline

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18
Q

What is free water deficit?

A

estimated amount of free H20 needed to correct hypernatremia

0.6 (men) or 0.5 (women) x kg (ideal body weight) x (actual sodium/ideal sodium (140) - 1)

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19
Q

How do you calculate free water deficit?

A

0.6 (men) or 0.5 (women) x kg (ideal body weight) x (actual sodium/ideal sodium (140) - 1)

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20
Q

Hypokalemia

A

K+ < 3.5 mmol/L

intracellular ion

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21
Q

What are some sxs of hypokalemia?

A

arrythmias, muscle weakness, diaphragm paralysis, ileus, vomiting

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22
Q

What are EKG findings of hypokalemia?

A

U waves
QT prolongation
flat/innverted T waves

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23
Q

What causes intracellular shift of K+ leading to hypokalemia?

A

insulin
Beta agonists
hyperventilation
alkalosis

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24
Q

What are extrarenal causes of hypokalemia?

A

vomiting/diarrhea
laxatives
NG suction
dialysis

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25
KCl 10 mEq/hr IV changes serum K+ by how much?
0.1
26
Can you infuse K+ >20mEq/hr?
yes but you have to have a central line to do it
27
What are the risks of infusion with KCl?
pain | phlebitis
28
What is hyperkalemia?
>5.5 mmol/L
29
What are the sxs of hyperkalemia?
arryhthmias bradycardia hypoactive reflexes heart block
30
What are EKG findings of hyperkalemia?
peaked T waves QRS lengthening Sine waves
31
What are causes of hyperkalemia?
``` potassium sparing diuretics renal dysfunction acidosis hypoaldosteronism cell death (burns, chemo) drugs (NSAIDS, BB, ACEI, Bactrim) blood transfusions ```
32
What is the treatment for hyperkalemia if there are EKG findings?
CaCl or calcium gluconate
33
What are treatments for hyperkalemia that move potassium into the cell?
insulin/glucose sodium bicarb albuterol
34
What are ways to remove K+ from the body for hyperkalemia?
dialysis loop diuretics + isotonic fluids kayexalate
35
What percentage of body weight is water?
65-70%
36
>15% H2O loss
fatal
37
>10% H20 loss
mental and physical impairments
38
What are the sxs of moderate dehydration?
oliguria, dark urine, dry eyes
39
What are the sxs of severe dehydration?
``` anuria confusion tachycarida hypotension shock ```
40
What lab findings would you see with a dehydrated pt?
increased BUN/Cr ratio increased Cr hypernatremia Increased lactic acid
41
What is the first rule of fluid replacement?
If the gut works, USE IT | PO or NG
42
What are the different types of fluid replacements?
``` Crystalloid -isotonic -hypotonic -hypertonic Colloid Blood Products ```
43
What is the purpose of crystalloids?
increase ECF | electrolyte replacement
44
What are the types of isotonic crystalloid and what are they used for?
similar to blood plasma NS + LR uses: vomiting/diarrhea, hypovolemic shock
45
What are the types of hypotonic crystalloid and what are they used for?
causes fluid shifts from intravascular into intracellular 1/2NS uses: intracellular dehydration, hypERnatremia, DKA RISK: NEVER give to pts with risk of increased ICP or burn pts
46
What are the types of hypertonic crystalloids and what are they used for?
draws fluid into intravascular space "plasma expanders" 2%, 3%, 5%, 7%, 23%, NS (given in ICU) uses: cerebral edema, severe hyponatremia RISK: volume overload, pulmonary edema
47
What is the most common MAINTENANCE fluid used for healthy adults?
D51/2NS
48
What is the goal for urine output for a pt on fluid replacement?
0.5cc/kg/hr
49
Which fluid is most like blood serum?
LR 130 Na+ 109 Cl- 4 K+
50
What is D5W used for?
free water replacement | it is water + 50g Dextrose
51
What is the fast way to estimate daily maintenance IVF?
35cc/kg/day
52
What is the academic way to calculate daily maintenance IVF?
100/50/20 rule ``` 100cc/kg for first 10 kg (1000 cc) + 50cc/kg for second 10 kg (500cc) + 20cc/kg for remaining kg ``` or 1500 (for first 20 kg) + 20(IBW - 20kg)
53
Colloids function
draw fluid into intravascular space via oncotic pressure by having large molecules like albumin that con't cross cell membrane ex/ albumin blood products purpose: plasma expansion high volume fluid loss replacement adjunct
54
What are the advantages of colloid solutions?
3x more potent than crystalloids 1ml blood loss = 1ml colloid = 3ml crystalloids longer duration of action (expansion)
55
What are the uses of colloid solutions?
hypovolemic shock | burn resuscitation adjunct
56
Normal blood volume /kg
70ml/kg
57
Transfusion is rarely indicated if _______
>10 g/dl Hgb
58
O2 delivery can be maintained @ ________ Hb level
6-7 g/dl
59
Rh negative blood pts need......
Rh negative blood
60
Is whole blood used in the hospital setting?
no only in military increases blood volume by 10% in a nonbleeding pt
61
1 unit of PRBCs increases Hgb and HCT by how much?
Hgb 1g/dl HCT by 3% it takes 15 minutes for Hgb levels to equilibrate post transfusion
62
FFP
fresh frozen PLASMA (not platelets) increases coagulation factors by 8% uses: massive transfusion, DIC
63
Cryoprecipitate
fibrinogen + factor 8 + factor 13 + VWF + firbronectin uses: hemophilia, DIC, low fibrinogen
64
When do you give platelets?
for actively bleeding thrombocytopenic pts includes FFP in it
65
What Hgb level typically warrants transfusion?
<7 g/dL
66
JAMA guidelines for blood transfusion
Hgb < 8 for ortho, cardiac surgery or CV disease Hgb < 7 for hospitalized pt Hgb < 6 everyone getting blood
67
What are the different hemorrhage classifications?
1 - <15% blood loss --tx. minimal treatment 2 - 15-30% blood loos ---tx. IVF 3 - 30-40% blood loss - tx. IVF + RBC 4 - > 40% blood loss - tx. aggressive
68
What is the normal range for platelet levels?
150,000-450,000 (150-450)
69
What platelet value warrants platelet transfusion?
<50,000/mm3 exception: cardiac/neurologic/ophthalmologic producers and pts with CNS bleeding, DIC, or multiple traumas, the number is 100,000
70
Pt are at risk of spontaneous hemorrhage if their platelet levels are below.....
12,000.mm3
71
1 unit of platelets increases plts by.....
30,0000
72
What are tests that can tell you platelet function?
VerifyNow PFA100 TEG
73
What are causes of platelet dysfunction?
``` DIC ITP Infections hypersplenism EtOH pregnancy TTP, HUS VWD malignancies nutrient deficiency ```
74
What is the most common transfusion hazard?
allergic reaction to donor proteins treat with benadryl or atarax (hyrdoxyzine)
75
What can occur immediately if a pt was transfused with the wrong blood product?
immediate acute hemolytic reactions fever, hypotension, dyspnea, flushing, N/V, anxiety, DIC, hematuria, ATN dx: positive direct antiglobin test
76
How do you treat immediate acute hemolytic reactions?
STOP the transfusion give mannitol monitor for DIC cross and match and transfuse appropriate blood
77
TRALI vs TACO
TRALI has fever TACO has increase BNP
78
TRALI
transfusion related acute lung injury immune response most commonly with FFP donor antibodies attack neutrophils in the lungs --ARDS sxs: fever (30 min - 6h), hypotension, dyspnea CXR: white out tx: supportive, self-limited, resolve fairly quickly
79
TACO
transfusion associate circulatory overload acute congestive HF secondary to transfusion fluid overload RF: extremes in age, hx CHF prevention: slow deliveries Tx: lasixs
80
What is the treatment for TACO?
lasixs
81
Massive Blood Transfusion
total blood volume replaced in 24 hours or half total blood volume replaced in 1 hr
82
1:1:1
massive blood transfusion protocol 1 unit pRBCs : 1 unit platelets: 1 unit FFP -->repeat
83
What are the risks of massive blood transfusion?
``` coagulopathy (d/t dilution) hypothermia acidosis hyperkalemia hypocalcemia hypervolemia ```
84
What can cause coagulopathy?
``` DIC anemia hypothermia acidosis HIT dilution ```
85
DIC
causes: sepsis, trauma, malignancy complications: bleeding, thrombosis, end organ damage, purpura fulminans dx: thrombocytopenia, increase in PT/PTT/D-dimer, decrease in fibrinogen
86
How do you treat DIC if there is active bleeding?
give platelets
87
How do you treat DIC if there is active thrombosis?
Heparin
88
How do you treat DIC if there is increase PT or decrease fibrinogen?
FFP or cryoprecipitate
89
What is the major laboratory difference between ITP, TTP, and DIC?
DIC has a decrease in fibrinogen while ITP and TTP have normal fibrinogen
90
HIT
heparin induced thrombocytopenia occurs 5+ days post initial treatment tx: stop heparin and switch to argatroban then switch to warfarin
91
4Ts to calculate risk of HIT
thrombocytopenia timing of platelet fall thrombosis cause of thrombocytopenia 0-3 low 6-8 high
92
A pt with normal electrolytes is being admitted to your service. What kind of fluids might you give this pt and how do you determine how much to give?
Maintenance IVF 100/50/20 rule based on IBW (kg) the most common maintenance fluid used in a healthy adult is D51/2NS
93
A pt with Na ~150 mmol/L is being admitted to your service. What kind of fluids will you give this pt and how do you determine how much and what rate?
treating hypernatremia requires you go slow in efforts not to avoid cerebral edema and seizures this is done by using the free water deficit equation to determine how much D5W to give this pt the goal is to decrease 10mEq/24hr

Clin Specialties - Surgery (11 decks)

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