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Fluid Management > Intraoperative Fluid Mgmt > Flashcards

Intraoperative Fluid Mgmt Flashcards

1
Q

% Total Body Water

A

80% Newborn, Adults 60-70%, obese=lower%, lean=higher%

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2
Q

Fluid Compartments and %

A

2 main compartments: intracellular and extracellular. ICF 2/3, ECF 1/3, ECF 1/3 plamsa fluid, 2/3 interstitial fluid

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3
Q

Std 70kg patient water composition

A

70gk - 60% water = 42 total liters, 28L ICF, 14L ECF –> 4.5L plasma, 9L interstitial

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4
Q

Mean of regulation of fluid compartments / separation of compartments

A

Diffusion, Filtration, Osmosis / ICF to ECF by cell membrane, IVF to ISF by capillary membrane

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5
Q

Diffusion / Filtration / Osmosis

A

Movement of molecules among each other / transfer of water/dissolved substance from high to low pressure / water shifting thru semipermeable membrane to reach equilibrium

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6
Q

What is diffusion?

A

Movement of molecules among each other in liquids.

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7
Q

What is filtration?

A

Transfer of water from region of high pressure to low pressure

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8
Q

What is osmosis?

A

Water shifting through semi permeable membrane from area of low solute to high solute concentration unto equilibrium reached. Generated osmotic pressure. Relates to tonicity.

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9
Q

ECF and ICF osmolalities

A

Equilibrate within minutes. # of osmo active substances remains constant or moves across membrane and being water with is to maintain equilibrium.

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10
Q

Osmotically active substances

A

ECF –> sodium, chloride, bicarb.

ICF –> potassium, phosphates, mag, proteins.

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11
Q

Intracellular fluid lytes

A

Cations are potassium and mag. Anions are proteins and phosphates.

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12
Q

Sodium potassium pump

A

Counter acts sodium desire to move inside cell. Energy requiring exchange of three sodium for two potassium. Uses ATP-ase. Also
Maintain intra cell potassium for RMP and nerve conduction.

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13
Q

Net Capillary and lymphatics

A

Capillary filtration depends on cap permeability and imbalance of hydrostatic and colloidal pressures. Cap filtration is 2ml/min. Cap filtrate them enters lymphatic circulation.

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14
Q

Lymphatic characteristics

A

Receives cap filtrate via highly perm lymph caps, carries in unidirectional manner d/t valves thru right lymph or thoracic duct to venous sys via contraction of vessels or muscles.

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15
Q

What are starling forces?

A

Forces/pressures that determine mvmt of fluid across cap membrane. Capillary hydrostatic and plasma colloid osmo pressure. ISF hydrostatic and colloid osmo pressure.

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16
Q

Electrolyte composition.

A 
ICF = lots of potassium, mag, phosph/sulf and protein 
ECF/plasma = high sodium, bicarb chloride, calcium, organic acids, some protein but less than ICF. Plasma>ISF
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17
Q

Summary of fluid movement between compartments.

A

ICF to ECF is based on osmotic gradient reg by sodium and potassium conc. IVF to ISF is based on plasma proteins, filtration pressure and cap permeability.

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18
Q

What is tonicity?

A

Deals with how a solution affects a cells volume. Water flows OUT of cell in hypertonic area, INTO cell in hypotonic area. Body adjusts better to chronic tonicity changes more than acute. IVF + salt = cell shrinks. IVF - salt = cell swells.

19
Q

Types of hypervolemia

A

Isotonic hypervolemia has no ICF shifts, excess isotonic admin. Hypotonic hypervolemia is result of excess hypotonic admin lacking of normal lytes.

20
Q

Hypotonic hypervolemia characteristics.

A

Leads to sig hyponatremia and low osmo (tonicity decr). Leads to CHF and cerebral edema. Examples: turp fluid flush being absorbed, anesthetic agents incr ADH secretion.

21
Q

Types of Hypovolemia.

A

Isotonic hypovolemia has no ICF shifts. Decr in volume, no composition change. Hypertonic had loss of mostly free water from IVF. Hypotonic had loss of composition with more lytes lost.

22
Q

Isotonic volume contraction (hypovolemia)

A

Fluids and lytes lost together. There is no intra cell fluid shifts. Most common fluid issue. Causes: diuretics vomiting excess urine loss hemorrhage 3rd spacing.

23
Q

Hypertonic dehydration (contraction)

A

Loss of water leading to contraction of IVF, then become hypertonic. Leads to hypernatremia and pulls water from ICF. Causes include evaporative and insensible losses, inadequate free water.

24
Q

Causes of fluid loss

A

GI loss, fever, burns, evaporation, peritonitis, diuretics, inhale dry gas. Majors: blood loss, fluid shifts (both isotonic losses). 3rd spacing is redistr of IVF to ISF, replace with balanced salts.

25
Q

Hypovolemia signs

A

Tachycardia, ortho statics, flat neck veins when supine, decr CVP, decr UOP, dry membranes, CV collapse.

26
Q

Effects of general anesthesia

A

Vasodilation exposes/exacerbates hypovolemia. Decreased ANP, increased ADH, RASS activation and stress response.

27
Q

Types of Intraop fluid loss

A

Observed blood loss #1. Hidden blood loss. Third space loss #2. All are isotonic losses. Evaporation for exposed surfaces (free water loss).

28
Q

Effects of regional anesthesia

A

Blocks SNS nerves causing vasodilation and hypotension.

29
Q

Causes of 3rd spacing.

A

Damage to cap membrane = leaking and/or loss of albumin = ISF protein wins and pulls fluid in to ISF. Trauma, surgery, burns, bowel obs, sepsis, pancreatitis, ascities.

30
Q

Characteristics is third space loss

A

Fluid shift from IVF to ISF. Traumatized tissue (surg manipulation) becomes edematous d/t leaky caps. Loss is isotonic and replaced with balanced salt solution. 3rd spacing mobilizes day 3.

31
Q

Types of IV fluids

A

Isotonic - comp same as plasma, stays in IVF. Hypotonic - less diluted then plasma, moves into cell. Hypertonic - more solutes than plasma, pulls water from cell.

32
Q

Crystalloids vs Colloids

A

Crystalloids are cheaper, but dilute plasma proteins and dont stay in IVF (25min), diffuse thru cap membrane. Colloids have sustained time (3-6hrs) in IVF, dont diffuse thru cap membrane. Expensive and poss cause coagulopathy.

33
Q

D5W characteristics

A

Dextrose metabolized, leaving free water infusion. Useful in cases of Na restriction or replacement of free water loss. Pt maybe on insulin in need of dextrose supplement.

34
Q

LR characteristics

A

Most common fluid in OR, most physiologic solution in large volumes. Lactate metab to bicarb in liver (dont give to liver pts). Contains K (dont give the renal pts). Contains Ca so is not suitable for blood products.

35
Q

NS characteristics

A

Pref for NSurg pts, blood component therapy. Large volumes cause dilution and hyperchloremic acidosis as Cl- stays in and Bicarb secreted out to maintain electro-neutrality.

36
Q

Colloids

A

Large MW product, cannot traverse cap membrane. Influence colloid osmotic pressure which retains fluid in IV space. IVF half life of 3-6 hours. 5% is isotonic, 25% is “salt poor” and expands IVF 5X its volume, useful for excess ECF.

37
Q

Synthetic Colloids

A

Made from corn/starch. Hespan/Hetastarch. Max dose of 10-15 ml/kg. Causes coagulopathy via fibrin inh/platelet dysfxn, lacks calcium and buffers. Remains in IVF for 24-36 hours. Dextran 40/70 primes bypass pump.

38
Q

Isotonic Infusion

A

No osmotic gradient created. Delivered to ECF and stays in ECF. 1/3 to IVF, 2/3 to ISF.

39
Q

Hypotonic Infusion

A

Treats hypertonic volume contraction (free water loss “dehydration”). Infusion creates gradient and distribution follows rule of 3rds. 2/3 ICF, 1/3 ECF (1/3 IVF, 2/3 ISF). Infusion must be done slowly d/t fluid shifts –> cerebral edema via decr serum osmo –> water shift into cells/swells.

40
Q

Intraop Fluid Replacement

A

Maintenance - done hourly Defecit - done w/i first 3 hours Surgical Loss (Actual blood loss/3rd space loss/Evap Loss) - replace as needed with correct fluid

41
Q

What is seen with excess isotonic infusions?

A

Healthy w/o significant incr in CVP. Will show diuresis or ISF edema.

42
Q

Maintenance Calculation

A

4ml/kg/hr first 10kg / 2ml/kg/hr second 10kg / 1ml/kg/hr for remaining kg. Based on IBW.

43
Q

Deficit Calculation

A

Maint rate x hours of NPO status. Consider overnoc IV therapy, bowel prep etc. Replace over 3 hours (1/2, 1/4, 1/4).

44
Q

3rd Space loss

A

Minimal (hernia) 3-4ml/kg/hr Mod (total abdo hyst) 5-6ml/kg/hr Severe (bowel rsxn) 7-8(or10) ml/kg/hr. Infused hourly

Fluid Management (1 decks)

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