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GP Final Exam > IV, Fluids, Blood > Flashcards

IV, Fluids, Blood Flashcards

1
Q

why are NPO guidelines enforced

A

due to risk of pulmonary aspiration

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2
Q

mendelson syndrome

A

acute chemical pneumonitis caused by the aspiration of stomach contents in patients under general anesthesia

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3
Q

Enhanced Recovery After Surgery (ERAS) related studies showed that a reduced fasting interval produced

A

lower residual gastric volume and higher gastric pH.

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4
Q

Prolonged fasting can contribute to

A

hypovolemia, hypoglycemia, and anxiety

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5
Q

adult traditional NPO guidelines

A

No solids for 8H pre-op

most medications can be continued with a small sip of water (excluding some cardiac and diabetic meds)

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6
Q

patients at ↑ risk for aspiration

A

Renal failure, hepatic dysfunction, ascites

Head injury, increased ICP, decreased LOC, cerebral palsy

Anorexia, esophageal disorders, diabetes, delayed gastric emptying, difficulty swallowing

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7
Q

pediatrics 2 hour NPO

A

clear liquids (water, apple juice, clear juice drinks, clear gelatin, clear broth, ice popsicles, and Pedialyte)

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8
Q

pediatrics 4 hour NPO

A

human breast milk

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9
Q

pediatrics 6 hours NPO

A

Infant formula, nonhuman milk, light meal:

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10
Q

pediatrics 8 hours NPO

A

“full” meal, carbonated drinks

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11
Q

ERAS

A

patient-centered, evidence-based, multidisciplinary team developed pathways for a surgical specialty and facility culture

goal: reduce the patient’s surgical stress response, optimize their physiologic function, and facilitate recovery

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12
Q

ERAS care pathways

A

form an integrated continuum, as the patient moves from home through the pre-hospital / preadmission, preoperative, intraoperative, and postoperative phases of surgery and home again.

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13
Q

ERAS program fasting recommendation

A

minimal fasting that includes a carbohydrate beverage two hours before anesthesia,

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14
Q

ERAS Program key elements

A

-pt/family education
-optimize pt prior to admission
-minimal fasting including carbohydrate beverage two hours before anesthesia
-multimodal analgesia with appropriate use of opioids when indicated
-return to normal diet and activities the day of surgery, and return home

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15
Q

4-2-1 Rule

A

guide for hourly maintenance

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16
Q

hourly fluid maintenance for 70kg patient

A
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17
Q

NPO deficit

A

Equals the number of hours the patient is NPO x the hourly maintenance rate
Example: 8 hr x 110 mL = 880 mL

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18
Q

NPO fluid administration

A

50% first hour

25% second hour

25% third hour

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19
Q

output

A

urine
respiratory tract
evaporative losses
losses due to wounds or bleeding
insensible losses

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20
Q

3rd space fluid losses

A

Tissue manipulation & surgical trauma supports movement of fluid from the ECF compartment into non-functional compartments

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21
Q

Small Incision/minimal trauma

A

4-6 ml/kg/hr

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22
Q

Moderate Incision/moderate trauma

A

6-8 ml/kg/hr

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23
Q

Large/Incision/severe trauma

A

8-10 ml/kg/hr

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24
Q

Major vascular case/extreme trauma

A

10-12 ml/kg/hr

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25
Q

crystalloids contain

A

electrolytes dissolved in water or dextrose and water

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26
Q

examples of crystalloids

A

0.9% NaCL

Lactated Ringers

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27
Q

natural or synthetic molecules, somewhat impermeable to vascular membrane; determine the colloid osmotic pressure that balances distribution of water b/t intravascular and interstitial spaces

A

colloids

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28
Q

examples of colloids

A

5% albumin

6% hydroxyethyl starch

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29
Q

used for most neurological or renal patients; blood administration

A

NaCl 0.9%

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30
Q

contains Mg, Acetate, Gluconate

A

plasmalyte

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31
Q

contains Na, Cl, K, Ca

A

Lactated ringers

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32
Q

contains 5 gm dextrose per liter

A

D5W

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33
Q

used for volume expansion; each has limitations

A

Dexran, hespan, hetastarch

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34
Q

Balance Salt Solutions (BSS) are fluids that have an electrolyte concentration similar to

A

ECF.

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35
Q

Contains more chloride than ECF

A

Normal saline solution

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36
Q

Good choice for renal (diabetic) and neurosurgical patients

A

Normal saline

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37
Q

too much NaCl can cause

A

hyperchloremic-induced metabolic acidosis

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38
Q

LR’s contain

A

contains dextrose, K, Ca, Na, and Lactate

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39
Q

Prevention of hypoglycemia in neonates and pediatric patients

A

Dextrose containing solutions

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40
Q

Used in conjunction with insulin infusions

A

dextrose containing solutions

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41
Q

Hyperglycemia is associated with

A

increased risk for ischemic neurologic injury.

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42
Q

Beneficial in fluid resuscitation from shock/trauma and major surgical Losses

A

hypertonic saline

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43
Q

hypertonic saline indications

A

Major surgical procedures: aortic, radical cancer surgeries
Shock
Slow correction of hyponatremia
TURP syndrome
Reduce perioperative edema
Reduce ICP

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44
Q

hypertonic saline effects

A
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45
Q

Pooled plasma in saline

A

albumin

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46
Q

albumin characteristics

A

Highly soluble, globular protein, accounting for 70-80% of the colloid osmotic pressure of plasma

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47
Q

5% albumin can be used for

A

rapid intravascular volume expansion

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48
Q

25% albumin can be used for

A

hypoalbuminemia

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49
Q

Has an intravascular half-life of >24 hours

A

albumin

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50
Q

Most perioperative volume deficits are

A

extracellular fluid

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51
Q

Crystalloid solutions eventually equilibrate ____________ therefore ____________

A

between plasma & interstitial space therefore more is needed to maintain intravascular volume

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52
Q

ABO compatibility for albumin and plasma

A

not needed

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53
Q

Albumin heat treated at 60 degrees C for 10 hours eliminates

A

possibility of transmission of blood-borne disease

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54
Q

do albumin and plasma derivatives contain coagulation factors

A

no

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55
Q

Associated with increased mortality in critically ill patients

A

albumin and plasma derivatives

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56
Q

synthetic plasma expanders

A

dextran, Hetastarch, Voluven, Hextend, Hespam

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57
Q

Composed of polymerized glucose molecules

A

dextran

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58
Q

dextran Intravascular half-life

A

6 hours

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59
Q

potential complications of dextran

A
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60
Q

synthetic polymer

A

Hextend and Hespan

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61
Q

intravascular half life of Hextend and Hespam

A

more than 24 hours

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62
Q

Hextend/Hespan infusion max

A

Infuse no more than 1000 cc (20 ml/kg/day)

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63
Q

higher volumes of Hextend/Hespan

A

can result in bleeding complications d/t decreased factor VIII/vWf, platelet defects, fibrin clots

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64
Q

Anaphylactoid reactions have been reported with both

A

dextran and hetastarch, but much rarer with hetastarch

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65
Q

ultimate goal of blood transfusion is to

A

maintain oxygen-carrying capacity to the tissues

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66
Q

for blood loss you can replace with

A

crystalloids or colloids to maintain intravascular volume until risk of anemia outweighs the risk of the blood transfusion

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67
Q

healthy patient without cardiac disease can usually tolerate decrease in Hgb and Hct to

A

Hgb to 7 - 8g/dL or a Hct 21-24%

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68
Q

When Hgb is less than 7 g/dL

A

the resting cardiac output increases to maintain normal O2 delivery ➔ myocardial strain.

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69
Q

what is hgb limit for elderly/ those with cardiac/pulmonary disease

A

Generally, 9 - 10 g/dL is limit for elderly and those with existing cardiac/pulmonary disease

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70
Q

soaked 4x4 contains approx

A

10 mL blood

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71
Q

soaked lap sponge contains

A

approx 100 mL of blood

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72
Q

what else to assess for blood loss

A

the suction canister, amount of irrigation used, blood lost in the surgical drapes, on the floor, and on the surgical team’s garments

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73
Q

fluid replacement ratio with crystalloids

A

blood loss 3:1

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74
Q

fluid replacement ratio with colloids

A

blood loss 1:1

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75
Q

Morbidity & mortality rates – generally not affected until

A

the Hgb drops below 7 g/dL – where the resting CO ↑ significantly to maintain normal O2 delivery

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76
Q

Factors that effect O2 delivery

A

Inability to increase CO
Shifts to the oxyhemoglobin curve
Inadequate oxygenation
Abnormal Hgb

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77
Q

In adults, ____________ is an insensitive, nonspecific indicator of hypovolemia

A

tachycardia

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78
Q

In patients on inhaled anesthetics, maintenance of adequate BP implies

A

adequate intravascular volume

79
Q

CVP should be

A

6-12 mmHg

80
Q

Strongly suggest adequate fluid replacement

A

Preservation of BP and a CVP of 6 - 12 mmHg

81
Q

In procedures with large fluid losses, ____________ is more accurate at estimating BP than indirect measures

A

an arterial line

82
Q

Variations in the a-line waveform during positive pressure ventilation may indicate

A

hypovolemia

83
Q

premature neonate estimated blood volume (EBV)

A

95 mL/kg

84
Q

term neonate estimated blood volume (EBV)

A

85 mL/kg

85
Q

infants and children estimated blood volume (EBV)

A

80 mL/kg

86
Q

adult male estimated blood volume (EBV)

A

75 mL/kg

87
Q

adult female estimated blood volume (EBV)

A

65 mL/kg

88
Q

allowable blood loss formula

A
89
Q

Antibodies (anti-A, anti-B) are formed whenever

A

membranes lack A and/or B antigens

90
Q

antigens on erythrocyte membranes

A

A, B, Rh

91
Q

erythrocyte antibodies are capable of causing

A

rapid intravascular destruction of erythrocytes that contain the corresponding antigens

92
Q

Red cell membranes contain at least

A

300 different antigenic systems

93
Q

Chromosomal locus produces

A

3 alleles

94
Q

each allele represents

A

an enzyme that modifies a cell surface glycoprotein, producing a different antigen

95
Q

80-85% of caucasians have

A

the D antigen

96
Q

individuals that lack the D antigen

A

Rh-

97
Q

t/f you can’t develop antibodies against the D antigen

A

false, you can develop antibodies against the D antigen after exposure to a previous Rh-positive transfusion or pregnancy (Rh-negative mother delivering an Rh-positive baby)

98
Q

ABO blood grouping

A
99
Q

ABO-Rh typing only 99.8% compatible

A

type specific; 5-15 minutes

100
Q

type and screen

A

ABO-Rh and screen; 99.94% compatible

101
Q

screen process of type and screen

A

indirect coombs test

detects presence of antibodies in serum that are most commonly associated with non-ABO hemolytic reactions

102
Q

how long does type and screen take

A

15-45 minutes

103
Q

type and cross match

A

ABO-Rh, screen, and crossmatch; 99.95% compatible

104
Q

type and cross match takes how long

A

at least 45 minutes

105
Q

Confirms ABO-Rh typing (in < 5 min)
Detects antibodies to other blood group systems
Detects antibodies in low titers or those that do not agglutinate easily

A

type and cross match

106
Q

always want to use ____________ for transfusion

A

type and cross-matched blood

107
Q

if an emergency arises can use ____________

A

type-specific, uncross-matched blood

108
Q

last resort for transfusion in emergency

A

O negative

109
Q

packed RBCs contain

A

RBC’s, WBC’s, platelets, reduced plasma

110
Q

Used to restore oxygen-carrying capacity and for controlled surgical blood Loss

A

PRBCs

111
Q

usually contain a volume btwn 250-350 mL

A

PRBCs

112
Q

Washed PRBCs

A

complete removal of plasma and are generally used for neonatal transfusions or patients with a history of severe transfusion reaction, immunocompromised patients

113
Q

NS is added to PRBCs to

A

decrease viscosity

114
Q

PRBC hematocrit is

A

70%

115
Q

filter for PRBCs

A

170 micronfilter to trap clots & debris

116
Q

1-unit PRBC increase:

A

Hgb by 1 gm/dL

Hct by 2-3%

117
Q

PRBC tubing should contain 170 - 230 mm filter to

A

trap clots and debris (degenerated platelets, leukocytes, fibrin)

118
Q

what temp should PRBCs be warmed to

A

37º C

119
Q

Hypothermic effects and low levels of 2,3 DPG in stored blood cause

A

leftward shift of oxy Hgb dissociation curve ➔ tissue Hypoxia

120
Q

Glucose solutions with PRBCs may cause

A

RBC hemolysis

121
Q

LR contains ____________ and may induce ____________

A

calcium; clot formation

122
Q

what is compatible with PRBCs

A

NS, albumin, and FFP are all compatible with PRBC

123
Q

whole blood is what % hgb

A

40%

124
Q

Used primarily in hemorrhagic shock (massive blood Loss; >25% of EBV)

A

whole blood

125
Q

whole blood contains

A

all factors (RBC’s, WBC’s, platelets, plasma, including factors V and VIII)

126
Q

a unit of whole blood will raise Hct ____________ and Hgb ____________

A

Hct 3-4% and Hgb 1 gm/dL

127
Q

platelet activity after 24 hrs of storage

A

less than 5%

128
Q

whole blood volume

A

450 - 500 mL

129
Q

Not economical for routine use due to blood shortages

A

whole blood

130
Q

Increased risk of allergic transfusion reaction

A

whole blood

131
Q

If type known, an abbreviated crossmatch can be done in

A

5 min to confirm ABO compatibility (type specific)

132
Q

O Rh-negative

A

universal donor

133
Q

If > 2 units of ____________ given, screen recipient’s blood for antibodies before own type given

A

O Rh-negative

134
Q

can you give O+ to women of childbearing age

A

NO

135
Q

If > 10 units of O-

A

continue giving

136
Q

when can you go back to type specific blood after O- transfusion

A

in 3-4 months (RBC last ~ 120 days)

137
Q

FFP contains

A

plasma proteins and clotting factors (NO PLATELETS)

138
Q

Utilized in coagulation deficiencies, reversal of warfarin therapy and microvascular bleeding

A

FFP

139
Q

1 unit of FFP will increase clotting factors by

A

3%

140
Q

Hypernatremia could result from

A

massive transfusion of FFP

141
Q

plt less than 50,000

A

thrombocytopenia

142
Q

1 unit of Platelet concentrate increases platelet count by

A

5,000 to 10,000

143
Q

The presence of ____________ poses a risk of transfusion reaction

A

plasma

144
Q

Fraction of plasma that precipitates once FFP is thawed

A

cryoprecipitate

145
Q

contains high concentrations of Factor VIII to treat Hemophilia A

A

cryoprecipitate

146
Q

contains high concentrations of fibrinogen to treat Hypofibrinogenemia

A

cryoprecipitate

147
Q

Most common with a 1% incidence

A

febrile reaction

148
Q

febrile reaction

A

Increase in temperature by 1 degree C

149
Q

2nd most common transfusion reaction

A

allergic

150
Q

Pruritus, hives increase in temperature

A

allergic reaction

151
Q

ABO incompatibility can cause

A

hemolytic reaction

152
Q

1 in 6000 transfusions

A

hemolytic reaction

153
Q

Fatal in 1 in 100,000

A

hemolytic reaction

154
Q

Patient “mis-identification” is the common cause

A

hemolytic reaction

155
Q

presumptive diagnosis for transfusion reaction

A

Free Hgb in urine & plasma

156
Q

steps to take if a transfusion reaction is suspected:

A
157
Q

infection risk with transfusions

A
158
Q

complications with transfusion reactions

A
159
Q

Storage temp for blood:

A

1 – 6 degrees C to slow glycolysis

160
Q

Biochemical changes in stored blood

A
161
Q

citrate (preservative)

A

anticoagulant that binds with ionic calcium; prevents clotting

162
Q

phosphate preservative

A

acts as buffer

163
Q

dextrose preservative

A

substrate used for glycolysis of RBC for energy

164
Q

CPD (citrate-phosphate-dextrose) shelf life

A

21 days

165
Q

CPDA (citrate-phosphate-dextrose-adenine) includes

A

adenine (adenosine) for incorporation into ATP and extra glucose to prolong storage; most common

166
Q

CPDA shelf life

A

35 days

167
Q

CPDA Hct

A

70-80%

168
Q

Citrate intoxication is from

A

the addition of CPD as preservative for stored blood; can occur with rapid transfusion (>150ml/min)

169
Q

how is citrate metabolized

A

by the liver

170
Q

if rate of transfusion exceeds 1 unit of blood per minute in an adult, decreased ____________ may result

A

calcium

171
Q

Due to accumulation of citrate-chelating serum calcium

A

citrate intoxication

172
Q

citrate intoxication is more likely to effect

A

Pediatric patients and those with liver disease are more likely to become intoxicated

173
Q

Symptoms of Citrate Intoxication

A
174
Q

Treatment of Citrate Intoxication

A

Calcium or magnesium

Citrate will be metabolized quickly in Kreb’s cycle so symptoms may abate before treatment needed

Supportive treatment

175
Q

Blood routinely screened for

A

HIV 1/2
Hepatitis B and C
Hepatitis C (nonA/nonB): most symptomatic (90%)
HTLV1/2 (human T-cell lymphocytic virus)
Syphilis

176
Q

most commonly transmitted virus via blood

A

CMV

177
Q

CMV negative blood should be used for

A

immunocompromised like BMT or organ transplants; infants;

178
Q

TRALI

A

non-cardiogenic form of pulmonary edema associated with blood product administration.

179
Q

when does TRALI occur most frequently

A

with RBCs, FFP, and platelets

180
Q

TRALI incidence

A

1 in 5000 units transfused

181
Q

TRALI mortality rate

A

5 to 8%

182
Q

clinical appearance is similar to adult respiratory distress syndrome (ARDS)

A

TRALI

183
Q

TRALI symptoms usually begin

A

within 6 hours after the transfusion

184
Q

TRALI symptoms

A

the patient develops dyspnea, cyanosis, chills, fever, hypotension and noncardiogenic pulmonary edema

185
Q

TRALI CXR reveals

A

bilateral infiltrates

186
Q

severe ____________ can develop from TRALI

A

pulmonary insufficiency

187
Q

TRALI treatment

A

largely supportive

188
Q

what should happen to the transfusion during TRALI

A

should be stopped

189
Q

TRALI vent support

A

usually with a low tidal volume strategy to prevent barotrauma

190
Q

Seen with massive transfusions > 1 EBV (or >10 units)

A

dilutional coagulopathy

191
Q

dilutional coagulopathy symptoms

A
192
Q

Treatment for Dilutional Coagulopathy

A
193
Q

Alternatives to Traditional Blood Transfusion Therapy

A

GP Final Exam (3 decks)

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