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APA 1 > Intraop Fluid Management > Flashcards

Intraop Fluid Management Flashcards

1
Q

What are insensible fluid loses?

A 
Water loss through
Urine
Feces
Sweat
Respiratory tract (breathing)
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2
Q

How do you correct insensible fluid loses?

A

2ml/kg/hr of a crystalloid solution

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3
Q

What is third space fluid loss?

A

Redistribution of fluid from the intravascular space to the interstitial space.

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4
Q

When replacing third space fluid loss for minimal trauma, how much do you replace?

A

3-4 ml/kg

Knee/shoulder scope
Hernia repair

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5
Q

When replacing third space fluid loss for moderate trauma, how much do you replace?

A

5-6 ml/kg

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6
Q

When replacing third space fluid loss for severe trauma, how much do you replace?

A

7-8 ml/kg

Open belly
Open heart
Thoracic cases

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7
Q

3rd space losses become mobilized on about the ____ day post-op.

A

3rd

will start to shift back 3 days later

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8
Q

What patients will have trouble with the 3rd spacing mobilization on the third day?

A

CHF patients (may manifest as increased intravascular volume)

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9
Q

New Perioperative Goal-Directed Fluid Therapy (PGDT) utilizes

A

Utilize individualized hemodynamic end-points to support oxygen transport balance

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10
Q

If a patient has a HCT of 50 what does that mean?

A

fluid volume depleted (RBCs packed together)

Give fluid to bring back down to normal range

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11
Q

What mechanism supports PGDT?

A

Frank Sterling Mechanism

LVEDV – myocardial contractility

So an increased preload will increase myocardial contractility and thus > CO

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12
Q

What does a decreasing LVEDP signify?

A

hypovolemia

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13
Q

In PGDT, what are some ways we are measuring pulse contour?

A

Plethsmography variability index
Stroke volume variation
Systolic pressure variation
Pulse pressure variation

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14
Q

How do we measure real-time measures of LV function and aortic compliance

A

esophageal doppler and Echocardiography

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15
Q

When assessing the Frank Sterling Curve, how much fluid do you give?

A

Administration of small fluid bolus (200-250 mL) to assess Frank-Starling curve

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16
Q

What type of fluids are used intraoperatively to maintain normal body fluid composition and replace losses.

A

crystalloids

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17
Q

Crystalloids are effective at increasing the intravascular fluid volume, however, they only stay in the vasculature for about

A

20 minutes

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18
Q

The risk of ____ _____ increases if crystalloids administered in large volumes

A

pulmonary edema

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19
Q

Crystalloids are preferred in dehydrated states because they hydrate the entire

A

EVC (water and electrolytes)

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20
Q

Crystalloids cause hemodilution and

A

a loss of hydrostatic pressure

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21
Q

Sodium Chloride has equal concentrations of

A

Na and Cl

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22
Q

What type of solution is 3% saline and what is it used for?

A

Hypertonic

Used in trauma and head injury
Recommended for those at risk for cerebral edema, anuric or end stage renal failure.

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23
Q

Why do you avoid LR in DM?

A

Lactate metabolites are gluconeogenic

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24
Q

With LR, lactate metabolism can cause

A

alkalosis

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25
Q

Who do you NOT give LR to?

A

its with cerebral edema

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26
Q

Why don’t you hang LR with blood products?

A

LR contains Ca, so avoid with citrated transfusion products

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27
Q

What is the most isotonic balanced salt solution?

A

Plasmalyte

no lactate, no Ca

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28
Q

The volume of crystalloid used to replace intraoperative blood loss should be

A

three times the estimated blood loss.

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29
Q

Why do we NOT give glucose containing solutions during surgery?

A

Surgical stress response normally induces hyperglycemia.

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30
Q

What is the exception to when we would give a glucose containing solution

A

prevention of hypoglycemia in diabetic patients who have received insulin.

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31
Q

Colloids are large molecules that

A

do not readily cross the plasma membranes

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32
Q

What is the advantage of colloids in regard to disease transmission?

A

Lack of risk of disease transmission
Risk of transmitting hepatitis eliminated by heat
Pretreated to 60*C for 10 hours - Albumin

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33
Q

What is the disadvantage of colloids

A

Lack of oxygen-carrying capacity
Lack of coagulation factors
Increased cost

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34
Q

Large infusions of hetastarch can cause

A

dilution coagulopathy

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35
Q

Infusion of hetastarch can cause a decrease in ______ when administered in a volume greater than 1000mL in a 70kg individual.

A

Factor VIII

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36
Q

Large infusions of Dextran can cause a ______ _______ and has a large potential for

A

dilutional coagulopathy

anaphylactic/anaphylactoid reactions

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37
Q

Why can’t you cross match blood after infusion of dextran?

A

secondary to agglutination of red blood cells.

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38
Q

The fractionated blood product is produced from

A

pooled human plasma

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39
Q

What is the molecular weight of albumin

A

65-69 kDa

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40
Q

T/F: Albumin carries an anaphylaxis risk

A

True

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41
Q

Albumin is a carrier for protein bound substances such as

A

Drugs, elextrolytes, enzymes, hormones

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42
Q

What is the Donnan Effect?

A

albumin binds ions which increases plasma osmolality and intravascular volume

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43
Q

What is 5% albumin used for?

A

Used for rapid expansion of intravascular fluid volume.

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44
Q

What is 25% albumin used for?

A

Primary indication is for hypoalbuminemia

very concentrated, will pull massive amounts of fluid

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45
Q

Clinical assessment of intraop blood loss

A

Tachycardia
Hypotension
Decrease CVP
Decrease mixed venous oxygen

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46
Q

A urine output of ______ mL/kg/hr is typically indicative of an adequate intravascular fluid volume.

A

0.5 - 1

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47
Q

True or False: Administration of diuretics will interfere with the utility of intraoperative urine output as a measure of fluid volume.

A

True

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48
Q

Systolic BP variation greater than ______, indicates hypovolemia

A

10

8-10 is normal

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49
Q

Young healthy patients may lose ____% of circulating blood volume without demonstrating clinical signs.

A

20%

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50
Q

Vasoconstriction of ______- and _______ _________ vessels occurs in response to blood loss. A blood volume loss of approximately ____% can be masked by this compensatory response.

A

splanchnic

venous capitance

10%

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51
Q

What is the primary indication for a blood transfusion?

A

to increase the oxygen carrying capacity of the blood

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52
Q

Transfusion is almost always justified when Hgb is less than ____ g/dL. HCT ____

A

6

18

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53
Q

Transfusion is rarely justified when Hgb is greater than ___g/dL. HCT ___

A

10

30

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54
Q

Management of acute hemorrhage should be managed with what? And what type?

A

Blood (NOT crystalloids)

Whole blood is preferred to PRBCs in these situations to expand the circulating blood volume and the red cell volume.

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55
Q

Why doe you not want to use crystalloids when replacing volume for acute hemorrhage?

A

Administration of crystalloid volumes necessary to replace the intravascular fluid loss will result in an inadequate oxygen-carrying capacity of the blood.

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56
Q

What is the risk of transfusing patients who have not had blood typing done or who have had it done incorrectly and the blood is incompatible

A

transfusion reaction

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57
Q

Crossmatching of blood is accomplished by incubating the recipient’s ______ with the donor’s ______.

A

plasma

RBCs

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58
Q

Crossmatching is a 3 step process that takes approx _____ minutes

A

45

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59
Q

In emergent situations, admin the universal donor blood, which is

A

O- negative PRCs

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60
Q

O neg blood lacks __, ___, and ____ antigens.

Will not be hemolyzed by anti-A, anti-B antibodies that may be present in the patient’s blood.

A

A, B, Rh(D)

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61
Q

What blood type is the universal recipient?

A

AB positive

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62
Q

After a pt received emergency O neg blood and continues to receive O-neg, what is the risk

A

minor hemolysis and hyperbilirubinemia.

63
Q

After a patients received O neg blood then receives type specific, what is the risk

A

Concern that transfusion of patient’s type specific blood may now result in major intravascular hemolysis of O-negative blood by increasing titers of transfused anti-A and anti-B antibodies.

64
Q

What is type specific blood?

A

Blood that has only been typed for the A, B, and Rh antigens.

65
Q

The chance of a significant hemolytic transfusion reaction is following type specific blood

A

1:1,000

66
Q

What is type and screen

A

In addition to being typed for A, B, and Rh antigens, is screened for the most common antibodies.

67
Q

Is a type and screen unit of blood matched to a specific pts blood?

A

No

Allows for a unit of blood to be available for more than one patient.

68
Q

What type of blood is ordered for surgical procedures where the risk of transfusion is remote.

A

Type and screen

69
Q

The chance of significant hemolytic reaction with typed and screened blood is

A

1 in 10,000

70
Q

the cross match is performed, we are now looking for

A

antibodies

71
Q

What 3 preservatives are added to donated blood?

A

phosphate, dextrose, and adenine.

72
Q

What does phosphate do when preserving blood?

A

acts as a buffer

73
Q

What does dextrose do when preserving blood?

A

provides energy to the red blood cells.

74
Q

What does adenine do when preserving blood?

A

allows RBCs to resynthesize adenosine triphosphate to fuel their metabolic requirements and increase their survival time in storage.

75
Q

How long can blood be stored?

A

21-35 days

76
Q

Duration of blood storage is determined by the requirement that at least ___% of the red blood cells be viable for more than 24 hours after transfusion.

A

70

77
Q

Blood is stored at a temperature of ___ to ____C. (33-42* F)

A

1C to 6C (33-42* F)

78
Q

Why is blood stored cold?

A

slows down the rate of glycolysis in red blood cells and increases their survival time in storage

79
Q

In a given unit of whole blood the volume of blood is ____ml, the volume of citrate-containing preservative is ___ml and the hematocrit is about ____%.

A

450
65
40

80
Q

We do not type and cross for

A

albumin and FFP

81
Q

One unit of packed red blood cells has a volume of ___ mL and a hematocrit of ___%

A

300

70

82
Q

PRBCs augment the

A

oxygen-carrying capacity of the blood.

83
Q

Hemoglobin concentrations will increase by approximately __g/dL per unit PRBC in a 70kg adult.

A

1

84
Q

When are PRBCs indicated

A

anemia that is not associated with acute hemorrhage or shock.

85
Q

PRBCs can be administered with a _____ or ______ solution

A

crystalloid or colloid

86
Q

Why do you NOT use hypotonic solutions with blood admin?

A

Hypotonic solutions include glucose-containing solutions and Plasmanate.

Can result in RBC swelling and cell lysis.

87
Q

Why don’t you infuse LR with blood?

A

LR contained Ca. Ca can cause clotting

88
Q

What are the advantages of infusing PRBC’s?

A

Decreased potential for citrate toxicity with PRBC transfusion as compared to whole blood transfusion.

Decreased risk of allergic reaction with PRBC transfusion as compared to whole blood transfusion related to decreased volume of plasma that is infused with PRBC’s.

89
Q

Administration of platelets during surgery is usually indicated for platelet counts less than ____ cells/mm3.

A

50,000

90
Q

The platelet count will increase by _____ to _____ cells/mm3 with each unit of platelets administered to the 70kg adult.

A

5,000 to 10,000

91
Q

During surgery, when would you be more likely to transfuse platelets at a higher count?

A

In situations of surgical trauma, bleeding into the brain, eye, or airway, the transfusion of platelets at a higher platelet count may be warranted.

92
Q

Do platelets need to be type and crossed?

A

yes

93
Q

What is the risks of transfusing platelets

A

transmission of viral diseases
Bacterial infection 1:12,000
Platelet related sepsis

94
Q

The plasma is frozen within __ hours of collection.

A

6

95
Q

FFP contains all the plasma proteins and all coagulation factors except

A

platelets

Includes factors V and VIII.

96
Q

When is FFP indicated?

A

When PT/PTT 1.5 times greater than normal and there is a clinical indication to be transfused.

Reversal of Coumadin

correction of known factor deficiency

97
Q

Risks associated with transfusion of FFP

A

Sensitization to foreign proteins.

Transmission of viral diseases.

Allergic reactions.

98
Q

How do we get cry

A

The plasma fraction that precipitates when fresh frozen plasma is thawed.

99
Q

Cyro contained high concentrations of

A

Factor 8

von Willebrand factor

Factor 13 - Fibrinogen & Fibronectin

100
Q

Indications for Cryo

A

Factor VIII deficiency (hemophilia A)

von Willebrand factor deficiency

Fibrinogen deficiency

101
Q

What is the most frequently occurring transfusion reaction

A

Febrile transfusion reaction

102
Q

S/S of febrile transfusion reaction

A 
Fever
Chills
Headache
Myalgia
Nausea
Nonproductive cough
103
Q

How is a a febrile transfusion reaction is distinguished from a hemolytic transfusion reaction

A

by evaluating the patient’s serum and urine for hemolysis.

104
Q

What is the treatment for febrile transfusion reaction?

A

slowing the rate of the transfusion and administering antipyretics.

105
Q

What causes an allergic transfusion reaction to occur?

A

Occur due to presence of incompatible plasma proteins in the donor blood.

106
Q

S/S of allergic transfusion reactions

A

Urticaria
Pruritus
Occasional facial swelling

107
Q

Treatment of allergic transfusion reaction is through the IV administration of

A

antihistamines

108
Q

Severe anaphylactic reactions (without RBC destruction) occur due to transfusion of ____ to patient’s who are ____ deficient.

A

IgA

IgA

109
Q

How do you differentiate between allergic reaction and hemolytic reaction

A

by checking the urine and plasma for free hemoglobin.

110
Q

Why do a hemolytic transfusion reaction occur?

A

Transfused donor cells are attacked by the recipient’s antibody and compliment, resulting in intravascular hemolysis.

111
Q

As little as ___mL of donor blood can result in a hemolytic transfusion reaction, which can be fatal.

A

10

The severity of a transfusion reaction is proportional to the volume of transfused blood.

112
Q

Hemolytic transfusion reactions may result in

A

renal failure and DIC.

113
Q

S/S of hemolytic transfusion reactions

A 
Fever
Chills
Chest pain
Hypotension
Nausea
Flushing
Dyspnea
Hemoglobinuria
114
Q

All clinical signs are masked by anesthesia except

A

hemoglobinuria and hypotension.

115
Q

How do you directly diagnose hemolytic transfusion reaction?

A

direct antiglobulin test.

116
Q

During a hemolytic transfusion reaction, Plasma bilirubin concentration will peak at ____ hours after starting the blood transfusion.

A

3-6

117
Q

During a hemolytic transfusion reaction, Hemoglobinuria or hemolysis in the presence of a transfusion should be treated as a hemolytic transfusion reaction until

A

proven otherwise.

118
Q

Treatment for hemolytic transfusion reaction

A

STOP the transfusion

Prevent renal failure by maintaining UOP at 100mL/hr through the administration of LR and mannitol and/or furosemide.

119
Q

What can be used in hemolytic transfusion reactions to alkalinize the urine?

A

Bicarbonate

120
Q

What do you do with united blood when a patient had a hemolytic transfusion reaction

A

Return unused blood to blood bank along with a repeat type and crossmatch sample from the patient.

121
Q

pH of a unit of blood is about ___ after collection and is ____ after being stored for 21 days.

A
  1. 1
  2. 9

(becomes more acidic as it sits there)

122
Q

Why does banked blood become more acidic while it sits on the shelf?

A

high PCO2 of stored blood and to the addition of acidic preservatives

123
Q

Why does arterial pH increase with blood transfusion when you are giving blood that is more acidotic?

A

elevated PCO2 of blood is quickly corrected

blood products contain the preservative citrate that metabolizes to bicarbonate upon transfusion. The increased bicarbonate levels increase the arterial pH of the recipient

124
Q

Do potassium levels raise with the admin of blood?

A

Serum K+ levels rarely increase with blood transfusion. (diluted)

Potassium concentration in blood stored for 21 days may be as high as 20-30mEq/L.

125
Q

Banked blood causes _______ concentrations of 2,3-diphosphoglycerate are associated with a shift of the oxyhemoglobin dissociation curve to the ____ and an ______ in the affinity of Hgb for O2.

A

decreased

left

increase

126
Q

What does citrate in the blood do to Ca?

A

Citrate binds to Ca in that body ( this is usually offset by Ca mobilization from the bones).

Admin Ca will large amounts of blood transfusions

127
Q

Hypocalcemia can result in

A

hypotension, a narrow pulse pressure, and elevated central venous pressure.

shortened PR interval and a prolonged QT interval.

128
Q

Transmission of viral diseases from blood transfusion
HIV
Hepatitis
Cytomegalovirus

A

(HIV) 1:1million

Hepatitis virus – 1:60,000

Cytomegalovirus (highest**)

129
Q

What are microaggregates in whole blood?

A

platelets and leukocytes.

spontaneously form during storage

130
Q

What is the concern with microaggregates?

A

will enter the recipient’s blood, accumulate in the lungs, cause vascular obstruction, and contribute to ARDS.

131
Q

Who blood should be infused through a filter to decrease transmission microaggregates, what is the standard filer size and the preferred filter size

A

Standard filters 170-um diameter

Preferred 10- to 40-um (gets more microaggregates out)

132
Q

What are complications of giving cold blood?

A

Cardiac irritability, shivering, increased O2 demand

133
Q

What temp do we admin blood when going through blood warmers?

A

Confirm that it is warmed to 37-38*C because red blood cells hemolyze if overheated.

134
Q

How do you get dilution thrombocytopenia and how is it manifested?

A

dilution of clotting factors (giving just PRBCs and not platelets)

as hematuria, gingival bleeding, and spontaneous oozing from all puncture sites, IV starts etc.

135
Q

What are the labs for DIC

A

Prolonged prothrombin time
Prolonged partial thromboplastin time
Decrease in serum fibrinogen
Increase in level of fibrin split products.

136
Q

Treatment of DIC?

A

TREAT UNDERLYING CAUSE

Administer platelets and FFP

137
Q

What is TRALI

A

Transfusion-related acute lung injury

Acute, noncardiogenic pulmonary edema associated with dyspnea and arterial hypoxemia that occurs within six hours of transfusion.

138
Q

What is the treatment for TRALI?

A

Treatment is supportive.

Most episodes of transfusion-related acute lung injury spontaneously recover.

139
Q

Immunosuppressive is related to the volume of ______ transfused

A

plasma

140
Q

T/F: whole blood has a greater suppressive effect than PRBC’s

A

true, because it has more plasma

141
Q

When would immunosuppressive be beneficial?

When would it be a concern?

A

beneficial to transplant patients

concern for those with malignancy

142
Q

When should autologous blood be considered?

A

when significant surgical blood loss is anticipated.

decreased risk of complications

143
Q

Intra-op salvage has to be from a

A

clean wound

144
Q

Contraindications to intra-op salvage (cell saver)

A

Malignancy
Presence of blood-borne disease
Blood contaminated with bowel contents

145
Q

What is the blood mixed with so it doesn’t clot when using a cell saver?

A

heparinized saline

146
Q

Hematocrit of “cell saver” blood is _____% and the pH is _____

A

50-60%

alkaline

147
Q

What are some complications of intraop salvage?

A 
Dilutional coagulopathy (only giving back PRBCs, no clotting factors)
Re-infusion of blood treated with Acs
Hemolysis 
Air embolism
Fat embolism
Sepsis
DIC
148
Q

Contraindications of hemodilution

A

Anemia
Severe cardiac disease
Severe neurologic disease

149
Q

For hemodilution, the withdrawn blood is stored in the operating room at _____ in a sterile blood bag with _______

A

room temp

anticoagulants.

150
Q

When is hemodilution blood infused back to the patient?

A

after major blood loss has ceased

151
Q

Advantages of hemodilution

A

Less expensive than autologous blood
Does not require patient’s cooperation
Has platelet and coagulation factor activity that is lost is stored autologous blood.

152
Q

Strong recommendations for transfusion

A 
HGB < 7 if > 65 and Pulm/CV disease
HGB < 6 if CV bypass
Loss of 30% blood volume or 1500cc
Platelet count <50,000
FFP: INR >2, PT/PTT >1.5 times normal
Cryo: fibrinogen <80-100
153
Q

Massive transfusion protocol

A

1:1:1
FFP:Platelets:PRBCs

APA 1 (7 decks)

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