Intraop Fluid Management Flashcards
What are insensible fluid loses?
Water loss through Urine Feces Sweat Respiratory tract (breathing)
How do you correct insensible fluid loses?
2ml/kg/hr of a crystalloid solution
What is third space fluid loss?
Redistribution of fluid from the intravascular space to the interstitial space.
When replacing third space fluid loss for minimal trauma, how much do you replace?
3-4 ml/kg
Knee/shoulder scope
Hernia repair
When replacing third space fluid loss for moderate trauma, how much do you replace?
5-6 ml/kg
When replacing third space fluid loss for severe trauma, how much do you replace?
7-8 ml/kg
Open belly
Open heart
Thoracic cases
3rd space losses become mobilized on about the ____ day post-op.
3rd
will start to shift back 3 days later
What patients will have trouble with the 3rd spacing mobilization on the third day?
CHF patients (may manifest as increased intravascular volume)
New Perioperative Goal-Directed Fluid Therapy (PGDT) utilizes
Utilize individualized hemodynamic end-points to support oxygen transport balance
If a patient has a HCT of 50 what does that mean?
fluid volume depleted (RBCs packed together)
Give fluid to bring back down to normal range
What mechanism supports PGDT?
Frank Sterling Mechanism
LVEDV – myocardial contractility
So an increased preload will increase myocardial contractility and thus > CO
What does a decreasing LVEDP signify?
hypovolemia
In PGDT, what are some ways we are measuring pulse contour?
Plethsmography variability index
Stroke volume variation
Systolic pressure variation
Pulse pressure variation
How do we measure real-time measures of LV function and aortic compliance
esophageal doppler and Echocardiography
When assessing the Frank Sterling Curve, how much fluid do you give?
Administration of small fluid bolus (200-250 mL) to assess Frank-Starling curve
What type of fluids are used intraoperatively to maintain normal body fluid composition and replace losses.
crystalloids
Crystalloids are effective at increasing the intravascular fluid volume, however, they only stay in the vasculature for about
20 minutes
The risk of ____ _____ increases if crystalloids administered in large volumes
pulmonary edema
Crystalloids are preferred in dehydrated states because they hydrate the entire
EVC (water and electrolytes)
Crystalloids cause hemodilution and
a loss of hydrostatic pressure
Sodium Chloride has equal concentrations of
Na and Cl
What type of solution is 3% saline and what is it used for?
Hypertonic
Used in trauma and head injury
Recommended for those at risk for cerebral edema, anuric or end stage renal failure.
Why do you avoid LR in DM?
Lactate metabolites are gluconeogenic
With LR, lactate metabolism can cause
alkalosis
Who do you NOT give LR to?
its with cerebral edema
Why don’t you hang LR with blood products?
LR contains Ca, so avoid with citrated transfusion products
What is the most isotonic balanced salt solution?
Plasmalyte
no lactate, no Ca
The volume of crystalloid used to replace intraoperative blood loss should be
three times the estimated blood loss.
Why do we NOT give glucose containing solutions during surgery?
Surgical stress response normally induces hyperglycemia.
What is the exception to when we would give a glucose containing solution
prevention of hypoglycemia in diabetic patients who have received insulin.
Colloids are large molecules that
do not readily cross the plasma membranes
What is the advantage of colloids in regard to disease transmission?
Lack of risk of disease transmission
Risk of transmitting hepatitis eliminated by heat
Pretreated to 60*C for 10 hours - Albumin
What is the disadvantage of colloids
Lack of oxygen-carrying capacity
Lack of coagulation factors
Increased cost
Large infusions of hetastarch can cause
dilution coagulopathy
Infusion of hetastarch can cause a decrease in ______ when administered in a volume greater than 1000mL in a 70kg individual.
Factor VIII
Large infusions of Dextran can cause a ______ _______ and has a large potential for
dilutional coagulopathy
anaphylactic/anaphylactoid reactions
Why can’t you cross match blood after infusion of dextran?
secondary to agglutination of red blood cells.
The fractionated blood product is produced from
pooled human plasma
What is the molecular weight of albumin
65-69 kDa
T/F: Albumin carries an anaphylaxis risk
True
Albumin is a carrier for protein bound substances such as
Drugs, elextrolytes, enzymes, hormones
What is the Donnan Effect?
albumin binds ions which increases plasma osmolality and intravascular volume
What is 5% albumin used for?
Used for rapid expansion of intravascular fluid volume.
What is 25% albumin used for?
Primary indication is for hypoalbuminemia
very concentrated, will pull massive amounts of fluid
Clinical assessment of intraop blood loss
Tachycardia
Hypotension
Decrease CVP
Decrease mixed venous oxygen
A urine output of ______ mL/kg/hr is typically indicative of an adequate intravascular fluid volume.
0.5 - 1
True or False: Administration of diuretics will interfere with the utility of intraoperative urine output as a measure of fluid volume.
True
Systolic BP variation greater than ______, indicates hypovolemia
10
8-10 is normal
Young healthy patients may lose ____% of circulating blood volume without demonstrating clinical signs.
20%
Vasoconstriction of ______- and _______ _________ vessels occurs in response to blood loss. A blood volume loss of approximately ____% can be masked by this compensatory response.
splanchnic
venous capitance
10%
What is the primary indication for a blood transfusion?
to increase the oxygen carrying capacity of the blood
Transfusion is almost always justified when Hgb is less than ____ g/dL. HCT ____
6
18
Transfusion is rarely justified when Hgb is greater than ___g/dL. HCT ___
10
30
Management of acute hemorrhage should be managed with what? And what type?
Blood (NOT crystalloids)
Whole blood is preferred to PRBCs in these situations to expand the circulating blood volume and the red cell volume.
Why doe you not want to use crystalloids when replacing volume for acute hemorrhage?
Administration of crystalloid volumes necessary to replace the intravascular fluid loss will result in an inadequate oxygen-carrying capacity of the blood.
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
transfusion reaction
Crossmatching of blood is accomplished by incubating the recipient’s ______ with the donor’s ______.
plasma
RBCs
Crossmatching is a 3 step process that takes approx _____ minutes
45
In emergent situations, admin the universal donor blood, which is
O- negative PRCs
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, B, Rh(D)
What blood type is the universal recipient?
AB positive
After a pt received emergency O neg blood and continues to receive O-neg, what is the risk
minor hemolysis and hyperbilirubinemia.
After a patients received O neg blood then receives type specific, what is the risk
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.
What is type specific blood?
Blood that has only been typed for the A, B, and Rh antigens.
The chance of a significant hemolytic transfusion reaction is following type specific blood
1:1,000
What is type and screen
In addition to being typed for A, B, and Rh antigens, is screened for the most common antibodies.
Is a type and screen unit of blood matched to a specific pts blood?
No
Allows for a unit of blood to be available for more than one patient.
What type of blood is ordered for surgical procedures where the risk of transfusion is remote.
Type and screen
The chance of significant hemolytic reaction with typed and screened blood is
1 in 10,000
the cross match is performed, we are now looking for
antibodies
What 3 preservatives are added to donated blood?
phosphate, dextrose, and adenine.
What does phosphate do when preserving blood?
acts as a buffer
What does dextrose do when preserving blood?
provides energy to the red blood cells.
What does adenine do when preserving blood?
allows RBCs to resynthesize adenosine triphosphate to fuel their metabolic requirements and increase their survival time in storage.
How long can blood be stored?
21-35 days
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.
70
Blood is stored at a temperature of ___ to ____C. (33-42* F)
1C to 6C (33-42* F)
Why is blood stored cold?
slows down the rate of glycolysis in red blood cells and increases their survival time in storage
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 ____%.
450
65
40
We do not type and cross for
albumin and FFP
One unit of packed red blood cells has a volume of ___ mL and a hematocrit of ___%
300
70
PRBCs augment the
oxygen-carrying capacity of the blood.
Hemoglobin concentrations will increase by approximately __g/dL per unit PRBC in a 70kg adult.
1
When are PRBCs indicated
anemia that is not associated with acute hemorrhage or shock.
PRBCs can be administered with a _____ or ______ solution
crystalloid or colloid
Why do you NOT use hypotonic solutions with blood admin?
Hypotonic solutions include glucose-containing solutions and Plasmanate.
Can result in RBC swelling and cell lysis.
Why don’t you infuse LR with blood?
LR contained Ca. Ca can cause clotting
What are the advantages of infusing PRBC’s?
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.
Administration of platelets during surgery is usually indicated for platelet counts less than ____ cells/mm3.
50,000
The platelet count will increase by _____ to _____ cells/mm3 with each unit of platelets administered to the 70kg adult.
5,000 to 10,000
During surgery, when would you be more likely to transfuse platelets at a higher count?
In situations of surgical trauma, bleeding into the brain, eye, or airway, the transfusion of platelets at a higher platelet count may be warranted.
Do platelets need to be type and crossed?
yes
What is the risks of transfusing platelets
transmission of viral diseases
Bacterial infection 1:12,000
Platelet related sepsis
The plasma is frozen within __ hours of collection.
6
FFP contains all the plasma proteins and all coagulation factors except
platelets
Includes factors V and VIII.
When is FFP indicated?
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
Risks associated with transfusion of FFP
Sensitization to foreign proteins.
Transmission of viral diseases.
Allergic reactions.
How do we get cry
The plasma fraction that precipitates when fresh frozen plasma is thawed.
Cyro contained high concentrations of
Factor 8
von Willebrand factor
Factor 13 - Fibrinogen & Fibronectin
Indications for Cryo
Factor VIII deficiency (hemophilia A)
von Willebrand factor deficiency
Fibrinogen deficiency
What is the most frequently occurring transfusion reaction
Febrile transfusion reaction
S/S of febrile transfusion reaction
Fever Chills Headache Myalgia Nausea Nonproductive cough
How is a a febrile transfusion reaction is distinguished from a hemolytic transfusion reaction
by evaluating the patient’s serum and urine for hemolysis.
What is the treatment for febrile transfusion reaction?
slowing the rate of the transfusion and administering antipyretics.
What causes an allergic transfusion reaction to occur?
Occur due to presence of incompatible plasma proteins in the donor blood.
S/S of allergic transfusion reactions
Urticaria
Pruritus
Occasional facial swelling
Treatment of allergic transfusion reaction is through the IV administration of
antihistamines
Severe anaphylactic reactions (without RBC destruction) occur due to transfusion of ____ to patient’s who are ____ deficient.
IgA
IgA
How do you differentiate between allergic reaction and hemolytic reaction
by checking the urine and plasma for free hemoglobin.
Why do a hemolytic transfusion reaction occur?
Transfused donor cells are attacked by the recipient’s antibody and compliment, resulting in intravascular hemolysis.
As little as ___mL of donor blood can result in a hemolytic transfusion reaction, which can be fatal.
10
The severity of a transfusion reaction is proportional to the volume of transfused blood.
Hemolytic transfusion reactions may result in
renal failure and DIC.
S/S of hemolytic transfusion reactions
Fever Chills Chest pain Hypotension Nausea Flushing Dyspnea Hemoglobinuria
All clinical signs are masked by anesthesia except
hemoglobinuria and hypotension.
How do you directly diagnose hemolytic transfusion reaction?
direct antiglobulin test.
During a hemolytic transfusion reaction, Plasma bilirubin concentration will peak at ____ hours after starting the blood transfusion.
3-6
During a hemolytic transfusion reaction, Hemoglobinuria or hemolysis in the presence of a transfusion should be treated as a hemolytic transfusion reaction until
proven otherwise.
Treatment for hemolytic transfusion reaction
STOP the transfusion
Prevent renal failure by maintaining UOP at 100mL/hr through the administration of LR and mannitol and/or furosemide.
What can be used in hemolytic transfusion reactions to alkalinize the urine?
Bicarbonate
What do you do with united blood when a patient had a hemolytic transfusion reaction
Return unused blood to blood bank along with a repeat type and crossmatch sample from the patient.
pH of a unit of blood is about ___ after collection and is ____ after being stored for 21 days.
- 1
- 9
(becomes more acidic as it sits there)
Why does banked blood become more acidic while it sits on the shelf?
high PCO2 of stored blood and to the addition of acidic preservatives
Why does arterial pH increase with blood transfusion when you are giving blood that is more acidotic?
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
Do potassium levels raise with the admin of blood?
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.
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.
decreased
left
increase
What does citrate in the blood do to Ca?
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
Hypocalcemia can result in
hypotension, a narrow pulse pressure, and elevated central venous pressure.
shortened PR interval and a prolonged QT interval.
Transmission of viral diseases from blood transfusion
HIV
Hepatitis
Cytomegalovirus
(HIV) 1:1million
Hepatitis virus – 1:60,000
Cytomegalovirus (highest**)
What are microaggregates in whole blood?
platelets and leukocytes.
spontaneously form during storage
What is the concern with microaggregates?
will enter the recipient’s blood, accumulate in the lungs, cause vascular obstruction, and contribute to ARDS.
Who blood should be infused through a filter to decrease transmission microaggregates, what is the standard filer size and the preferred filter size
Standard filters 170-um diameter
Preferred 10- to 40-um (gets more microaggregates out)
What are complications of giving cold blood?
Cardiac irritability, shivering, increased O2 demand
What temp do we admin blood when going through blood warmers?
Confirm that it is warmed to 37-38*C because red blood cells hemolyze if overheated.
How do you get dilution thrombocytopenia and how is it manifested?
dilution of clotting factors (giving just PRBCs and not platelets)
as hematuria, gingival bleeding, and spontaneous oozing from all puncture sites, IV starts etc.
What are the labs for DIC
Prolonged prothrombin time
Prolonged partial thromboplastin time
Decrease in serum fibrinogen
Increase in level of fibrin split products.
Treatment of DIC?
TREAT UNDERLYING CAUSE
Administer platelets and FFP
What is TRALI
Transfusion-related acute lung injury
Acute, noncardiogenic pulmonary edema associated with dyspnea and arterial hypoxemia that occurs within six hours of transfusion.
What is the treatment for TRALI?
Treatment is supportive.
Most episodes of transfusion-related acute lung injury spontaneously recover.
Immunosuppressive is related to the volume of ______ transfused
plasma
T/F: whole blood has a greater suppressive effect than PRBC’s
true, because it has more plasma
When would immunosuppressive be beneficial?
When would it be a concern?
beneficial to transplant patients
concern for those with malignancy
When should autologous blood be considered?
when significant surgical blood loss is anticipated.
decreased risk of complications
Intra-op salvage has to be from a
clean wound
Contraindications to intra-op salvage (cell saver)
Malignancy
Presence of blood-borne disease
Blood contaminated with bowel contents
What is the blood mixed with so it doesn’t clot when using a cell saver?
heparinized saline
Hematocrit of “cell saver” blood is _____% and the pH is _____
50-60%
alkaline
What are some complications of intraop salvage?
Dilutional coagulopathy (only giving back PRBCs, no clotting factors) Re-infusion of blood treated with Acs Hemolysis Air embolism Fat embolism Sepsis DIC
Contraindications of hemodilution
Anemia
Severe cardiac disease
Severe neurologic disease
For hemodilution, the withdrawn blood is stored in the operating room at _____ in a sterile blood bag with _______
room temp
anticoagulants.
When is hemodilution blood infused back to the patient?
after major blood loss has ceased
Advantages of hemodilution
Less expensive than autologous blood
Does not require patient’s cooperation
Has platelet and coagulation factor activity that is lost is stored autologous blood.
Strong recommendations for transfusion
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
Massive transfusion protocol
1:1:1
FFP:Platelets:PRBCs
