Lecture 3: Fluid Management

Question 1

Steps in Acid Base interpretation

Answer 1

is it life threatening?
acidemic or alkalemic?
acute respiratory?
chronic respiratory vs acute metabolic?
if acute metabolic, resp compensation?
anion gap present?
is clinical presentation consistent with interpretation?

Question 2

Anion gap equation

Answer 2

Na - (Cl + HCO3)
3-11 normal
>12 resp acidosis

Question 3

Respiratory acidosis

Answer 3

PaCO2 > 45 pH < 7.35
compensated with renal retention of HCO3
decreased contractility, SVR
increased PVR
treatment: mech vent, HCO3, improve pulm function

Question 4

Respiratory alkalosis

Answer 4

PaCO2 < 35 pH > 7.45

results in hypokalemia, hypocalcemia, dysrhythmias, bronchoconstriction, cerebrovascular constriction, hypotension

Question 5

Metabolic acidosis

Answer 5

HCO3 < 21 pH < 7.35
decreased contractility, SVR
increased PVR
treatment: IV fluid, HCO3

Question 6

Metabolic alkalosis

Answer 6

HCO3 > 27 pH > 7.45

treatment IV fluid, KCl

Question 7

Base Excess

Answer 7

deviation of HCO3
0 normal
-2 - < 0 metabolic acidosis (base deficit)
> 0 - +2 metabolic alkalosis (base excess)

Question 8

Who has more water weight?

Answer 8

Infants, men

Question 9

Body fluid distribution

Answer 9

Of weight
60% TBW
40% intracellular
20% extracellular - 4% plasma, 16% interstitial

Question 10

Most oncotically active part of ECV?

Answer 10

Albumin

Question 11

healthy adult fluid requirements

Answer 11

2500ml/day

Question 12

Maintenance fluid calculations

Answer 12

4 ml/kg/hr for 1st 10kg
2 ml/kg/hr for 2nd 10kg
1 ml/kg/hr for each additional kg

Question 13

NPO fluid deficit calculation

Answer 13

maintenance fluid rate x hours NPO

Question 14

Fluid deficit replacement strategy

Answer 14

1/2 in 1st hr
1/4 in 2nd hr
1/4 in 3rd hr

Question 15

Blood soaked 4x4 volume

Answer 15

~10 ml

Question 16

Blood soaked laparotomy pad

Answer 16

100-150 ml

Question 17

Blood spill amounts

Answer 17

1 in = 5 ml
2 in = 20 ml
3 in = 45 ml
4 in = 80 ml

Question 18

EBV for premature, term

Answer 18

95 ml/kg

85 ml/kg

Question 19

EBV for infant, child

Answer 19

80 ml/kg

70 ml/kg

Question 20

EBV for adult male, female

Answer 20

75 ml/kg

65 ml/kg

Question 21

Allowable blood loss equation

Answer 21

ABL = EBV x (starting Hct - allowable Hct) / starting Hct

Question 22

Evaporation loss estimations

Answer 22

Short case: 0-2 ml/kg/hr
moderate uncomplicated: 3-5 ml/kg
severe: 6-9 ml/kg
emergency 10-15 ml/kg

Question 23

Blood loss replacement ratios

Answer 23

crystalloid 3: 1

colloid 1:1

Question 24

Fluid therapy philosophy

Answer 24

avoidance of sodium and water overload

Question 25

Goal directed fluid therapy

Answer 25

estimating based on changes to:
Stroke volume variation
pulse pressure variation
systolic pressure variation

Question 26

Lactated Ringers components

Answer 26

closely resembles plasma
has lactate that converts to HCO3 to buffer
has Ca

Question 27

Normal Saline large dose

Answer 27

should switch to something else due to chloride content = acidosis

Question 28

Normosol-R

Answer 28

has Mg, acetate

no Ca

Question 29

D5W calories

Answer 29

170-200/L

Question 30

Hypertonic solution uses

Answer 30

used for slow resuscitation

Question 31

Colloid half life

Answer 31

16 hrs, as short as 2-3 hrs

Question 32

Albumin risks, sizes, oncotic pressure

Answer 32

allergic reaction, 5%/25% molecular size, 20 pressure

Question 33

Dextran components

Answer 33

water soluble glucose polymers

Question 34

Dextran 70 use

Answer 34

volume expansion

Question 35

Dextran 40 use

Answer 35

prevents thrombosis

less viscosity, good for microvascular cases

Question 36

Dextran side effects

Answer 36

anaphylactic reaction, platelet inhibition, pulm edema, crossmatching problems

Question 37

Hetastarch components, problems, max dose, oncotic pressure

Answer 37

plant starch
as effective as albumin, less expensive
issues with coagulopathy w/ dilutional thrombocytopenia
max dose < 20 mg/kg/day
30 oncotic pressure

Question 38

Benefits of crystalloids

Answer 38

equally effective as colloid for volume
supports U/O better
less side effects
inexpensive

Question 39

Benefits of colloids

Answer 39

better at restoring severe volume deficits
longer half life
better for low protein
less tissue edema

Question 40

Blood therapy indication

Answer 40

Mainly to increase oxygen carrying capacity

Question 41

ASA 2006 guidelines for blood transfusion

Answer 41

rarely indicated for Hgb > 10
always indicated for Hgb < 6
use of trigger not recommended
when appropriate use autologous blood, cell saver, normovolemic dilution

Question 42

Normovolemic dilution

Answer 42

giving large volume before case to prevent loss of RBCs

Question 43

Blood administration risks

Answer 43

Hep B, C, HIV, Sepsis, allergic reaction, lung injury, hemolytic reaction, pulm edema

Question 44

PRBC type, Hct, toxicities

Answer 44

ABO Rh factor, 70% Hct, citrate toxicity - hypocalcemia

Question 45

Autologous Blood requirement, risks

Answer 45

pt’s own blood, must have Hgb 11 to give

human error, infection

Question 46

Platelet indication, volume, increased count, risk

Answer 46

<50k, 200-250 ml volume
increases count 7-10k
bacterial risk (not stored cold)

Question 47

FFP indications, requirement, risk, increased count

Answer 47

replaces all coag factors except platelets
must be ABO compatible
reverses warfarin
give after multiple PRBCs
risk: acute lung injury
2-3% increased clotting factors per unit

Question 48

Cryo components, administration

Answer 48

factor VII, XIII, fibrinogen, von Willebrands

quickly give 200ml/hr