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Anesthesiology 398 and 466 > Lecture 12 Intra-operative Fluid therapy & Peri-Anesthetic Complications > Flashcards

Lecture 12 Intra-operative Fluid therapy & Peri-Anesthetic Complications Flashcards

1
Q

Why do IV fluids during anesthesia?

A
  1. —Maintain intra-vascular volume
    • —Animals are fasted, unlikely to drink for several hours post-op
    • —Replace fluid losses during anesthesia
      • —Evaporation, respiratory, hemorrhage, urine/sweat
  2. —Compensate for vasodilation effects of anesthetic drugs, support CO/tissue perfusion
    • DO2 = CO x CaO2
  3. —Maintain acid/base & electrolyte normality
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2
Q

What are different reasons why you would change different types of fluids

A
  1. —Fluid/Cardiovascular status
  2. —Electrolyte & acid/base
  3. —Albumin, Colloid oncotic pressure (COP)
  4. —Glucose
  5. —Correct/stabilize pre-op to ↓drug induced hypotension & anesthetic risk
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3
Q
  1. What is the target MAP during anesthesia?
  2. SAP
  3. HR
A
  1. —MAP > 60 mmHg,
  2. SAP > 90 mmHg
  3. —HR
    • 60-110 bpm dogs,
    • 120-160 bpm cats
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4
Q
  1. Target Values for Perioperative plasma albumin?
  2. Colloid oncotic pressure
  3. TP
A
  1. —Plasma albumin >2.0 g/dl
  2. —Colloid Oncotic Pressure 15-20 mmHg
  3. —TP > 3.5 g/dl
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5
Q
  1. Target Values for Perioperative PCV?
  2. Lactate
  3. Base deficit
  4. Central venous pressure
A
  1. —PCV > 25-30%
  2. —Lactate < 2 mmol/L
  3. —Base deficit +4 to – 4 mmol/L
  4. —Central venous pressure 6-8 cmH2O
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6
Q

What is a Crystalloid

A

—contain ions/solutes that distribute to all body fluid compartments, are isotonic, composition similar to extra-cellular fluid (ECF)

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7
Q

What are the 4 crystalloids and what do they contain?

A
  1. —Lactated Ringer’s (LRS)
    • —Na = 130, Cl = 109, K = 4,
    • *Ca = 2.7,* lactate
  2. —Plasmalyte A or Normosol-R
    • —Na = 140, Cl = 98, K = 5,
    • *Mg = 3, *Acetate & Gluconate
  3. —.9% Sodium Chloride
    • —Na = 154, Cl = 154
    • —No K+, indicated in hyperkalemia, no base => ‘acidifying’
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8
Q

Which crystalloids are better for liver patients?

A

—Plasmalyte A or Normosol-R

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9
Q
  1. What is the historic intraoperative fluid rate?
  2. Fluid rate now for normovolemic patients?
A
  1. —Historically, 5-10 ml/kg/hr recommended
  2. Now:
    • —5ml/kg/hr for first hour,
    • —2.5ml/kg/hr thereafter

Note: —Restrictive IV fluids NOT appropriate for critical patients

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10
Q

What are the downfalls of using the old 5-10ml/kg/hr fluid rate?

A
  • Median urine output ~0.5 ml/kg/hr
  • —Fluid retention 1 -2 liters in 30kg dog/4hrs
  • —Gain in body weight of > 1.0 kg
  • —PCV ↓ to 29-33, TP ↓ 4.5 – 5.1
  • —30-45min after crystalloid, 30% in vascular space, 70% excreted by kidney or into ECF (fluid retention)
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11
Q
  1. What are synthetic colloids?
  2. Used for?
A
  1. —Contain large MW molecules that stay in vascular space,
  2. exert colloid oncotic pressure
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12
Q

What are the 2 synthetic colloids

A
  1. Hydroxyethylstarch (Hetastarch)
  2. Hypertonic Saline – 7.5% NaCl
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13
Q

What are 4 side effects of synthetic colloids

A
  1. —Fluid overload
  2. —Coagulopathies
  3. —Anaphylactic reactions
  4. —Renal dysfunction
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14
Q

What are the 4 starling forces

A
  1. Pc = capillary hydrostatic pressure
  2. Pi = interstitial fluid hydrostatic pressure
  3. πp = plasma protein oncotic pressure
  4. πi = interstitial protein oncotic pressure
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15
Q

—If πp < πi => fluid moves out of vessels => edema

—Albumin provides ~80% of plasma oncotic pressure

A
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16
Q
  1. What is the half life of Hydroxyethylstarch (Hetastarch)
  2. What are the different rate options and when would you use them?
A
  1. ½ life 12-24hrs
  2. Fluid rates:
    • —Maintenance in hypoalbuminemic patients
      • —1-2 ml/kg maintenance
    • —Hypotension or 10-20% blood loss
      • — bolus 5-20ml/kg
    • —Up to 20ml/kg/day
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17
Q
  1. Hypertonic Saline (7.5% NaCl) use?
  2. How does it do what it does
A
  1. ↑ blood volume & blood pressure
  2. By:
    • —Draws water from interstitial space
    • —venoconstriction of large veins
    • —↑coronary/cerebral blood flow
    • —↑ inotropy by ↑cardiac intra-cellular Ca2+
18
Q

Side effects of using Hypertonic Saline ,7.5% NaCl

A
  1. —Hypernatremia,
  2. hypokalemia,
  3. hemolysis,
  4. hemodilution
19
Q

What are the peri-anesthetic complications

A
  1. —Cardiovascular*
    • —Hemorrhage, hypotension, arrhythmias, cardiac arrest
  2. —Respiratory insufficiency*
    • —Hypoventilation, hypoxemia
    • —Upper Airway Obstruction
  3. —Hypothermia/Hyperthermia
  4. —Gastroesophageal Reflux/Aspiration
  5. —Equine => post anesthetic myopathy/neuropathy
  6. —Ruminants => aspiration of ruminal contents
20
Q

The Key to avoiding peri-anesthetic complications is to

A
  • —anticipate possible concerns => anesthesia work-up
    • —Have an action plan should these complications arise
21
Q

Majority of peri-operative mortality occurs at what hours?

A

—within 1st 3 hours

22
Q
  1. What is the equation for delivery of oxygen to tissues?
  2. equation for Cardiac output
A
  1. DO2 = CO x CaO2
    • CO= cardiac output
    • Ca02= content of oxygen in the blood
  2. CaO2 = HbO2 + PaO2
23
Q
  1. If you have a normal awake animal with PCV of 20 (anemic) what will compensate?
  2. Why is anesthesia bad for these patients?
A
  1. —compensate for ↓ O2 content (RBC) by ↑ CO
    • —by ↑ HR & vasoconstriction
  2. —Anesthesia interferes with ability to compensate
    • ↓ HR & causing vasodilation
24
Q
  1. What do you do if a patient’s PCV is <20 if you plan on anethetizing
  2. PCV 20-30
  3. PCV > 30
A
  1. —PCV < 20 => transfusion recommended
  2. —PCV 20-30 => maybe
    • —depends on organ reserve, expected losses, chronicity/regeneration
  3. —PCV > 30 => no transfusion
25
Q

What are Cases of ‘expected’ Intra-op blood loss

A
  1. —Splenectomy
  2. —Liver biopsy/Liver lobectomy
    • —Prolonged Pt/Ptt should be corrected pre-op
  3. —Ventral slot
  4. —Limb amputation
  5. —Large tumor removal
  6. —Not expected cases:
    • OHE (drop ovarian pedicle),
    • TPLO, cutting popliteal artery
26
Q
  1. What does anesthesia do to —PCV, TP, colloid oncotic pressure (COP)
  2. Why is this important to know?
A
  1. —decreases PCV, TP, COP
  2. —Take PCV, TP or COP after induction
27
Q

How do you prepare for intra-op Blood Loss

A
  1. —Calculate total blood volume, allowable loss
  2. —Quantitate blood loss intra-operatively
  3. —Replace fluid/blood as indicated
28
Q
  1. How do you calculate total blood volume in dog?
  2. Cat?
A
  1. —Dog 90ml/kg
  2. —cat 70ml/kg
29
Q

How do you Calculate Allowable Blood Loss

(ask professor)

A
  • Calculate 10, 20 & 30% of total blood volume
  • Total blood volume x (0.1, 0.2 or 0.3) x 100
30
Q

26

(ask professor)

A
31
Q
  1. At what % of blood loss will you see clinical signs
  2. What clinical signs?
A
  1. May see clinical signs ≥ 10% loss
  2. Hypotension, +/- tachycardia
32
Q
  1. As As CO ↓ because of blood loss, what will happen to anesthetic depth
  2. What do you do with vaporizer
  3. When do you replace loss?
A

As CO ↓

  1. anesthetic depth will ↑
  2. ↓ vaporizer setting
  3. Replace loss as it occurs
33
Q
  1. How much blood does a q-tip hold?
  2. —4x4 sponge
  3. —Lap sponge
  4. —Weight 1gm = how many mls?
A
  1. —Q-tip .1ml
  2. —4x4 sponge 5-15ml
  3. —Lap sponge 50ml
  4. —Weight 1gm = 1ml
34
Q

How do you use the suction cannister to quantitate blood loss?

A
35
Q
  1. If you have a 10-15 % blood loss what fluid do you use?
  2. 15-25%
  3. 25-30%
A
  1. —10 - 15%
    • replace with crystalloid, 3 x mls lost
      • Because crystalloid will move out of vasculature
  2. —15 - 25%
    • crystalloid + colloid
  3. —>25 - 30%
    • whole blood or packed RBCs + colloid (plasma and/or hetastarch)
36
Q
  1. What does whole blood contain
  2. At what % of blood loss would you use it?
A
  1. Contains:
    • —RBC
    • protein
    • platelets
    • clotting factors
  2. —Severe >30-50% blood loss
37
Q
  1. What is the PCV of packed RBCs?
  2. When do you use it?
A
  1. PCV 80-90%
  2. —Less severe blood loss or + plasma for severe blood loss
38
Q

What is the calculation on how much blood to give?

A

milliters blood required =

Blood Vol. X (desired PCV– recipient PCV*) / Donor PCV

39
Q

*takes up to __ hrs for redistribution after acute hemorrhage

A

24

40
Q
  1. What does —Fresh Frozen Plasma contain?
  2. When would you use it?
  3. Need low or high doses?
A
  1. Contains:
    • —Albumin
    • plasma proteins
    • clotting factors
  2. —Use it when:
    • Hypoalbuminemia (along with colloids)
    • prolonged clotting times
  3. —Need high doses
    • —45ml/kg to raise albumin 1g/dl
41
Q

Can you get albumin alone?

A

Yes! —Canine/Human Albumin

Anesthesiology 398 and 466 (22 decks)

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