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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
Q

KCl 10 mEq/hr IV changes serum K+ by how much?

A

0.1

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26
Q

Can you infuse K+ >20mEq/hr?

A

yes but you have to have a central line to do it

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27
Q

What are the risks of infusion with KCl?

A

pain

phlebitis

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28
Q

What is hyperkalemia?

A

> 5.5 mmol/L

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29
Q

What are the sxs of hyperkalemia?

A

arryhthmias
bradycardia
hypoactive reflexes
heart block

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30
Q

What are EKG findings of hyperkalemia?

A

peaked T waves
QRS lengthening
Sine waves

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31
Q

What are causes of hyperkalemia?

A 
potassium sparing diuretics 
renal dysfunction 
acidosis 
hypoaldosteronism 
cell death (burns, chemo) 
drugs (NSAIDS, BB, ACEI, Bactrim) 
blood transfusions
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32
Q

What is the treatment for hyperkalemia if there are EKG findings?

A

CaCl or calcium gluconate

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33
Q

What are treatments for hyperkalemia that move potassium into the cell?

A

insulin/glucose
sodium bicarb
albuterol

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34
Q

What are ways to remove K+ from the body for hyperkalemia?

A

dialysis
loop diuretics + isotonic fluids
kayexalate

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35
Q

What percentage of body weight is water?

A

65-70%

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36
Q

> 15% H2O loss

A

fatal

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37
Q

> 10% H20 loss

A

mental and physical impairments

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38
Q

What are the sxs of moderate dehydration?

A

oliguria, dark urine, dry eyes

39
Q

What are the sxs of severe dehydration?

A 
anuria 
confusion 
tachycarida
hypotension 
shock
40
Q

What lab findings would you see with a dehydrated pt?

A

increased BUN/Cr ratio
increased Cr
hypernatremia
Increased lactic acid

41
Q

What is the first rule of fluid replacement?

A

If the gut works, USE IT

PO or NG

42
Q

What are the different types of fluid replacements?

A 
Crystalloid 
-isotonic
-hypotonic
-hypertonic
Colloid
Blood Products
43
Q

What is the purpose of crystalloids?

A

increase ECF

electrolyte replacement

44
Q

What are the types of isotonic crystalloid and what are they used for?

A

similar to blood plasma

NS + LR

uses: vomiting/diarrhea, hypovolemic shock

45
Q

What are the types of hypotonic crystalloid and what are they used for?

A

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
Q

What are the types of hypertonic crystalloids and what are they used for?

A

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
Q

What is the most common MAINTENANCE fluid used for healthy adults?

A

D51/2NS

48
Q

What is the goal for urine output for a pt on fluid replacement?

A

0.5cc/kg/hr

49
Q

Which fluid is most like blood serum?

A

LR
130 Na+
109 Cl-
4 K+

50
Q

What is D5W used for?

A

free water replacement

it is water + 50g Dextrose

51
Q

What is the fast way to estimate daily maintenance IVF?

A

35cc/kg/day

52
Q

What is the academic way to calculate daily maintenance IVF?

A

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
Q

Colloids function

A

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
Q

What are the advantages of colloid solutions?

A

3x more potent than crystalloids

1ml blood loss = 1ml colloid = 3ml crystalloids

longer duration of action (expansion)

55
Q

What are the uses of colloid solutions?

A

hypovolemic shock

burn resuscitation adjunct

56
Q

Normal blood volume /kg

A

70ml/kg

57
Q

Transfusion is rarely indicated if _______

A

> 10 g/dl Hgb

58
Q

O2 delivery can be maintained @ ________ Hb level

A

6-7 g/dl

59
Q

Rh negative blood pts need……

A

Rh negative blood

60
Q

Is whole blood used in the hospital setting?

A

no
only in military

increases blood volume by 10% in a nonbleeding pt

61
Q

1 unit of PRBCs increases Hgb and HCT by how much?

A

Hgb 1g/dl
HCT by 3%

it takes 15 minutes for Hgb levels to equilibrate post transfusion

62
Q

FFP

A

fresh frozen PLASMA (not platelets)

increases coagulation factors by 8%

uses: massive transfusion, DIC

63
Q

Cryoprecipitate

A

fibrinogen + factor 8 + factor 13 + VWF + firbronectin

uses: hemophilia, DIC, low fibrinogen

64
Q

When do you give platelets?

A

for actively bleeding thrombocytopenic pts

includes FFP in it

65
Q

What Hgb level typically warrants transfusion?

A

<7 g/dL

66
Q

JAMA guidelines for blood transfusion

A

Hgb < 8 for ortho, cardiac surgery or CV disease
Hgb < 7 for hospitalized pt
Hgb < 6 everyone getting blood

67
Q

What are the different hemorrhage classifications?

A

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
Q

What is the normal range for platelet levels?

A

150,000-450,000 (150-450)

69
Q

What platelet value warrants platelet transfusion?

A

<50,000/mm3

exception: cardiac/neurologic/ophthalmologic producers and pts with CNS bleeding, DIC, or multiple traumas, the number is 100,000

70
Q

Pt are at risk of spontaneous hemorrhage if their platelet levels are below…..

A

12,000.mm3

71
Q

1 unit of platelets increases plts by…..

A

30,0000

72
Q

What are tests that can tell you platelet function?

A

VerifyNow
PFA100
TEG

73
Q

What are causes of platelet dysfunction?

A 
DIC
ITP
Infections
hypersplenism 
EtOH
pregnancy 
TTP, HUS 
VWD 
malignancies 
nutrient deficiency
74
Q

What is the most common transfusion hazard?

A

allergic reaction to donor proteins

treat with benadryl or atarax (hyrdoxyzine)

75
Q

What can occur immediately if a pt was transfused with the wrong blood product?

A

immediate acute hemolytic reactions

fever, hypotension, dyspnea, flushing, N/V, anxiety, DIC, hematuria, ATN

dx: positive direct antiglobin test

76
Q

How do you treat immediate acute hemolytic reactions?

A

STOP the transfusion
give mannitol
monitor for DIC
cross and match and transfuse appropriate blood

77
Q

TRALI vs TACO

A

TRALI has fever

TACO has increase BNP

78
Q

TRALI

A

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
Q

TACO

A

transfusion associate circulatory overload
acute congestive HF secondary to transfusion

fluid overload

RF: extremes in age, hx CHF

prevention: slow deliveries

Tx: lasixs

80
Q

What is the treatment for TACO?

A

lasixs

81
Q

Massive Blood Transfusion

A

total blood volume replaced in 24 hours
or
half total blood volume replaced in 1 hr

82
Q

1:1:1

A

massive blood transfusion protocol

1 unit pRBCs : 1 unit platelets: 1 unit FFP –>repeat

83
Q

What are the risks of massive blood transfusion?

A 
coagulopathy (d/t dilution) 
hypothermia
acidosis 
hyperkalemia
hypocalcemia
hypervolemia
84
Q

What can cause coagulopathy?

A 
DIC
anemia
hypothermia
acidosis 
HIT
dilution
85
Q

DIC

A

causes: sepsis, trauma, malignancy
complications: bleeding, thrombosis, end organ damage, purpura fulminans
dx: thrombocytopenia, increase in PT/PTT/D-dimer, decrease in fibrinogen

86
Q

How do you treat DIC if there is active bleeding?

A

give platelets

87
Q

How do you treat DIC if there is active thrombosis?

A

Heparin

88
Q

How do you treat DIC if there is increase PT or decrease fibrinogen?

A

FFP or cryoprecipitate

89
Q

What is the major laboratory difference between ITP, TTP, and DIC?

A

DIC has a decrease in fibrinogen while ITP and TTP have normal fibrinogen

90
Q

HIT

A

heparin induced thrombocytopenia

occurs 5+ days post initial treatment

tx: stop heparin and switch to argatroban then switch to warfarin

91
Q

4Ts to calculate risk of HIT

A

thrombocytopenia
timing of platelet fall
thrombosis
cause of thrombocytopenia

0-3 low
6-8 high

92
Q

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?

A

Maintenance IVF
100/50/20 rule based on IBW (kg)

the most common maintenance fluid used in a healthy adult is D51/2NS

93
Q

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?

A

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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