Lecture 5: Fluid, Electrolytes, Blood Replacement Flashcards by Lindsay Christ

What type of Hyponatremia shows S/S of dehydration such as decreased skin turgor and dry mucous membranes?

HYPOvolemic HYPOnatremia

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What type of Hyponatremia shows S/S of fluid overload such as edema and crackles?

HYPERvolemic HYPOnatremia

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A patient has Euvolemic Hyponatremia how will his PE look?

normal PE

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How can you differentiate Hypovolemic from Hypervolemic Hyponatremia based on labs?

Look at Urine Osm

Urine Osm will be more decreased in HYPERvolemic
Urine Osm could be high in HYPOvolemic

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How can you differentiate Euvolemic Hyponatremia from the other two?

The Urine Na will be majorly increased (> 30) in Euvolemic Hyponatremia

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How do you correct HYPOvolemic Hyponatremia?

replace their volum w/NS

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How do you correct Euvolemic Hyponatremia?

Restrict Free Water

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How do you correct HYPERvolemic Hyponatremia?

Diuretics

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What is the problem that occurs if you correct Hyponatremia too rapidly?

Who’s mainly at risk for this?

Osmotic Demyelination Syndrome

Na <105, alcoholics, cirrhosis, malnutrition, HYPOkalemia

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When do you use hypertonic saline for Tx in Hyponatremia?

Pts w/ life threatening Sxs (seizures)

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Which type of Hyponatremia can you correct more rapidly?

Acute Hyponatremia

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What are the causes of HYPERnatremia?

Water loss (diabetes insipidus
Reduced water intake 
Excess Na intake

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What is occuring in hypernatremia?

Intracellular volume depletion w/ loss of free water > Na loss

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What is the Tx for HYPERnatremia?

What is the Tx for unstable pts?

Replace the free water deficit w/D5W
- by NG tube or IV (gut always better)

Give NS until they stabilize then D5W

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Why must you only correct 1/2 of the free water deficit in the 1st 24 hrs for acute HYPERnatremia?

Corrected too rapidly –> cerebral edema

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What are the EKG findings of hypokalemia vs hyperkalemia?

HypoK - flat/inverted T waves, U waves

HyperK - peaked T waves (“tent of bananas”)

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What are the 4 major causes of hypokalemia? Others?

Insulin (pushes K into cells)
Metabolic Alkalosis
Hyperaldosteronism
(more aldost –> reabs more Na & excrete more K)
Decreased intake (malnutrition, EtOH, anorexia)

Others: diarrhea, profuse sweating, decreased intake (malnutrition, EtOH, anorexia)

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What is the general Tx approach for Hypokalemia?

Address underlying cause

Correct low Mg first!
Correct alkalosis
D/c offending meds (diuretic –> switch to K sparing)

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How do you Tx uncontrolled diabetics w/Hypokalemia?

Give K+ then insulin

- giving insulin first –> more hypokalemia b/c pushes it into cells

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What are some of the major causes of Hyperkalemia?

metabolic acidosis
Hypoaldosteronism
Drugs (K sparing diuretics, ACEs)

note: first two are the opposite of hypokalemia

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What is the Tx for hyperkalemia w/significant EKG findings?

CaCl or Ca gluconate IV

CALCIUM

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What is the the medications given for hyperkalemia?

Insulin (pushes K into cells) & glucose
Na bicarb
inhaled B2-agonists (albuterol)

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What is the Tx to remove K from the body in hyperkalemic pts?

Loop diuretics & isotonic fluids
Dialysis
Kayexalate

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What is the Tx to remove K from the body in hyperkalemic pts?

Loop diuretics & isotonic fluids
Dialysis
Kayexalate

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Signs/Sxs of dehydration (Mild -Severe) | - for reference

Mild: thirst, dry mouth, decr urine Mod: dry eyes, dry mouth, oliguira, decr urine, tachycardia Severe: tachycardic, oliguira to anuria, confusion, HoTN, shock

What labs values are increased in dehydration states?

BUN/Cr ratio Cr Lactic Acid will be HYPERnatremic

What crystalloid fluids are isotonic? 3 Uses?

NS, LR, D5W Uses: Hypovolemic shock (LR/NS), initial therapy for DKA, replacing fluids post-op

What crystalloid fluid is hypotonic? Where do hypotonic fluids go in the body?

1/2 NS (.45%) fluid goes from blood (intravascualar) --> intracellular/interstitial

Since hypotonic crystalloid fluids like 1/2 NS enter the cells when do you NOT want to give it?

pts w/risk of increased ICP --> cerebral edema pts w/liver failure, burns, trauma --> fluid leaves blood --> deplete their BV

3 Uses for hypotonic crystalloid solutions?

intracellular dehydration, HYPERnatremia, DKA

Where do crystalloid fluids that are hypertonic go in the body? Therefore what are its 2 uses?

Extravascular --> intravascular (plasma expanders) Uses: Severe Hyponatremia, cerebral edema --> to remove fluid from cells

What must you watch for when giving NS?

Hypercholermic acidosis - b/c it has higher levels of Cl than the body

What is the makeup of colloid solutions, therefore where in the body do they go?

Large molecules --> cant cross cell mem --> stay in intravascular space --> volume expanders

Since colloid solutions are volume expanders what are their 2 uses? Examples?

hypovolemic shock, adjunct for burn resuscitation Ex: blood products, albumin

What is the most commonly used maintenance fluid for a normal adult patient?

1/2 NS

What formula is used to calculate IVF maintenance? What is the alternative method based on?

Holiday Segar formula (100/50/20 rule) Alt based on IBW: 35 cc/kg/day

What is the fastest method of increasing the O2 carrying capacity to the blood?

Giving Blood products

Unconscious man comes into the ER after suffering severe blunt forced trauma in a MVA and needs blood products immediately to replace lost volume, what type of blood can you give him?

O- or O+ For women give only O- due to the Rh antigen

What is the difference for type and screen vs type and cross blood?

Screen: only determines ABO, Rh type, faster results Crossmatch: recipient serum is tested against the donor's RBCs, slower results, more specific match

What are the 5 choices of blood products?

1. Whole blood 2. pRBCs 3. FFP 4. Cryoprecipitate 5. Platelets

What is removed from pRBCs and what is it used for?

platelets removed use: incr O2 carrying capacity to tissues

What is different in FFP from cryoprecipitate? | Uses for FFP?

FFP has all coag/clotting factors (cryo only has some), contains plasma proteins Use: Elevated INR (d/t liver failure, warfarin, massive transfusion, DIC)

What are the clotting factors in cryoprecipitate? Uses?

Fibrinogen, Fibronectin, Factor 8 & 13, vWF Uses: Hemophilia, decr fibrinogen (DIC), uremic bleeding

When giving platelets, what are you also giving? Uses?

also giving FFP b/c plts are suspended in plasma Uses: active bleeding, pre-op surgery

When giving 1 unit pRBCs how will the Hb and Hematocrit be affected? If the expected response doesnt occur what does it suggest?

Increase Hb by 1 Increase Hematocrit by 3% Doesnt occur --> active bleed

In general when is transfusion of RBCs needed?

<8 if having surgery | <7 if hospitalized

In general when is transfusion of platelets needed? What level of platelets put you at risk for spontaneous hemorrhage?

general transfuse when platelets < 50,000 risk of spont hemorrhage when platelets <12, 000 note: norm = 150,000-400,000

A patient comes in for a transfusion, but you know he has had an allergic rxn in the past to it, what can you give him prior to the infusion to prevent an allergic rxn?

Antihistamines or steroids | Benadryl or Atarax

What is the cause of immediate acute hemolytic rxns? Major complication? What is seen on lab values?

transfuse an non-compatible blood type complication: Renal failure (caused by RBC destruction) Labs: decr haptoglobin, incr indirect bili/LDH

A patient has is receiving a transfusion when he starts feeling feverish, has HoTN and becomes tachycardic, is flushed and has severe anxiety all of a sudden - what is the best test to confirm the Dx and Tx?

DAT - will be + --> immediate transfusion rxn Tx: stop transfusion, give mannitol and monitor

What is TRALI? What is it most commonly caused by? Tx?

Transfusion Related Acute Lung Injury MC cause = FFP infusion self-limited, resolves --> supportive tx

What is the major complication in TRALI and how is it Dx?

ARDS | Dx: CXR = white out

What is TACO? What does it cause? | Tx?

Transfusion Associated Circulatory Overload causes: CHF Tx: Lasix --> remove fluid

What are the major differences b/t TRALI and TACO?

TRALI - FEVER, BNP norm | TACO - NO fever, BNP ELEV

What is the common formula for massive transfusions?

1:1:1 1 unite pRBCs: 1 unit plt: 1 FFP

What is the key lab value that indicates DIC?

DECREASED Fibrinogen (usually) Also see: increased PT, PTT, D-dimer

Patient Dx w/DIC is actively bleeding, what is the Tx?

Platelets

Patient Dx w/DIC has active thrombosis, what is the Tx?

Heparin (decreases clotting)

Patient Dx w/DIC has elevated PT or fibrinogen, what is the Tx?

FFP or cryoprecipitate (to make them clot)

What are the low platelet counts in HIT usually triggered by and what is the main complication of HIT?

Heparin or Lovenox Complication = thrombosis

A patient taking Heparin after his hip replacement presents w/enlargement of a clot diagnosed after his surgery, what is the most likely Dx and how do you Dx it?

HIT Dx: Thrombocytopenia 5+ days after exposure, check HIT panel/SRA

Tx for HIT?

STOP HEPARIN Start on different anticoag: *Fondaparinux* or Argatroban