Patho: Fluid and Electrolyte Management Flashcards
1
Q
what percent of the body weight is water?
A
45-75% of body weight is water
2
Q
what influences the amount of water in a body?
A
age, gender, body mass composition
3
Q
The average man has with % of body water
A
55%
4
Q
the average women has what % of water?
A
45%
5
Q
an infant has what percent of body water?
A
80%
6
Q
why do infants have so much more water?
A
o Greater body surface area – can lose more water through evaporation
o When they sweat, they lose more water
o Higher metabolic rate
< renal function. Do not have reabsorption capacities, urinate a lot. Must keep hydrated!
7
Q
do obese people have more or less water?
A
Less
8
Q
____have the highest water
____ have the lowest amount of water
A
Highest in lean and young
Lowest in eldery and obese
(muscle contains > H2O), why males have more water than female. Lowest in elderly/obese.
9
Q
Distribution of total body water
A
Intracellular is 2/3, Extracellular is 1/3
Of the Extracellular fluid:Extravascular is ¾ and Intravascular is ¼
10
Q
how much water does a typical man that is 70 kg have
A
70 kg x .6 (average body % water) → 42L of water
28L is intracellular, 14 L is extracellular
11L is interstitial, 3 L is intravascular → Normal person has 5-6 L in intravascular space of blood cells and water, so 3L water, 2-3 blood cells.
11
Q
Composition of Fluid Compartments
-what determines water movement
A
Osmolarity determines water movement
12
Q
Na: ____mEq/L extracellular, ____ mEq/L intracellular
K: ____ mEq/L extracellular, ____ mEq/L intracellular
Calcium:____ mEq/L extracellular, ____ mEq/L intracellular
HCO3: ____ mEq/L extracellular, ____ mEq/L intracellular
A
Na: 140mEq/L extracellular, 10 mEq/L intracellular
K: 5 mEq/L extracellular, 141 mEq/L intracellular
Calcium: 5 mEq/L extracellular,
13
Q
If potassium lab comes back and is 10 & pt is asymptomatic what do you think?
A
lysis of RBC where cells lysed and released potassium. If this high, pt normally would be symptomatic
14
Q
If intracellular is 300mOsm and extracellular is 350mOsm, water shifts where?
A
outside of cell
15
Q
If intracellular is 300mOsm and extracellular is 250mOsm, water shifts?
A
inside of cell
16
Q
Shifting is based on mOsm
A
OUTSIDE of cell, ONLY measure OUTSIDE
17
Q
Composition of Fluid Compartments
o Composition maintained by:
o Movement of water is determined by:
o Solute concentration expressed as :
o Normal plasma osmolarity is:
A
o Composition maintained by selective permeability of cellular membranes
o Movement of water is determined by solute concentration
o Solute concentration expressed as milliosmoles (mOsm)
o Normal plasma osmolarity is 270-300mOsm/L
18
Q
Calculate osmolarity
A
2(Na + K) + Glucose/16 + BUN/2.8
19
Q
Explain Potassium levels if they are high or low
-First, know that Na is in charge of _______ and water movement and K is in charge of
A
Na: osmolarity
K: resting membrane potential
20
Q
if K is high, RMP will be:
What will increase K+ Levels?
what are symptoms of high K?
A
high, more excitable and easier to reach threshold leading to muscle twitches and increased heartbeat.
Spironolactone increases K – pee out more Na, reabsorb more K
-Monitor K often
muscle cramps
21
Q
If K is low, RMP will be
Where low K+ is Important with the heart, when K is low:
A
low and you need a stronger stimulus to reach threshold.
conduction in AV node is delayed resulting in slow heart rate.
22
Q
People with heart failure are often of Dig and Lasix why is this a bad combination?
oDigitoxin works by:
o Those with CHF also on diuretic such as Lasix that also does what to K+ levels?
A
Digoxin: Increase contractibility of the heart and slowing conduction through AV node decreasing HR → CHF
decrease K levels by bulk flow – double wammy, could have complete heart block. MONITOR K OFTEN IN THESE PATIENTS because you can put them in a complete heart block
23
Q
-
-
A
o kayexalate – bind up K and excrete through feces
o Insulin + glucose- push the K into the cells
o Calcium gluconate – works by increasing threshold levels so nerves and muscles are hyperexcitable. Normal stimulus needed now.
24
Q
What are ways to regulate volume?
A
o Antidiuretic Hormone (Arginine-Vasopressin) regulates plasma osmolarity
o Renin/angiotensin/aldosterone system
o Baroreceptors (aortic arch, carotid bodies)
o Stretch receptors (atrium, juxtaglomerular apparatus)
o Cortisol
25
Explain how ADH regulates Volume (Arginine-Vasopressin)
- how does ADH work?
- ADH if high osmolarity?
- ADH if low osmolarity ?
•ADH comes from neurons from the hypothalamic area in the brain – neurons in hypothalamus send axon down and ADH released from Pit gland into the bloodstream
* Neurons in brain sense osmolarity.
* If high osmolarity, releases ADH so you reabsorb H2O bringing OSM down
oADH goes to distal tubule collecting duct allowing production of more water channels so H2O can be reabsorbed based on OSM of distal tubule
•If low osmolarity, no action potentials or ADH released, do not reabsorb H2O
26
Explain how the Renin/angiotensin/aldosterone system works to regulate Volume
You have low volume so low GFR, since the fluid is moving so slow alot of Na+ is able to be reabsorbed in the proximal tubule, so by the time the fluid gets to the distal tubule the low Na+ levels are sensed by the macula densa cells (so it thinks GFR is low, so it needs to do something to increase filtration)
1: sends signal to afferet arterole to dilate to increase blood flow to increase GFR
2: produces prostalandins that go the JG and cause the release of renin
Renin
will do all that it can to get pressure and volume back up to perfuse the kidney:angitoteninofent --> angiotensin I--> Angiotensin II ( in the lungs) direct vascular effects and causes aldosterone release, (tubules of kidney > reabsorption of Na and H20 to increase bp
JG apparatus: Contains the macula densa and Juxtrartiral cells
27
Explain how the Baroreceptors (aortic arch, carotid bodies) work to regulate Volume
-
When BP bottoms out the Barro receptors sence that and send info up to the brainstem and causes
1: SNS activation to increase Vasoconstriction
2: JG cells to increase Renin
• JG cells under regulation of baroreceptors in the SNS
oDo not need Macula densa to play a role for renin release
28
why is it important that the kidney regulates flow when pressure is low?
to regulate perfusion to the nephron
29
Fluid and electrolyte replacement considerations- when it comes to Sxr
Maintenance:
Resuscitation:
Replacement:
o Maintenance: Amount of fluid/ions you need to maintain homeostasis when not eating
Could be through urinating, sweating, defecating
o Resuscitation: Repair imbalances that are already present
•When they hit ER, if NPO or vomiting for 12 hrs prior to sx must be caught up
•Take bowel prep into consideration here
oReplacement: Provide for ongoing loss that occur during surgery
2 major things:
1:Blood loss (measurable)
2: third space loss (extreme swelling after major surgery from tissue and vascular damage where vessels become leaky). Fluid accumulates into interstitial space.
30
how to determine Maintenance
| In adults: approximaently ___ is maintenace
•In adults: Approximately 1.5ml/kg/hr
o Maintenance requirements (4-2-1 rule) PER HOUR
•4ml/kg/hr for first 10kg
•2ml/kg/hr for the second 10kg
•1ml/kg/hr for the remaining kg
o Maintenance requirements (100-50-20 rule) PER 24 HOURS
•100ml/kg for first 10kg
•50ml/kg for next 10kg
•20ml/kg for each remaining kg
31
If a patient has a fever what happeneds to maintenance value?
•Must adjust for fever and high ambient temperatures, fever may often require an additional 500ml of salt free water per day
32
Example of a 90 Kg man and the 4-2-1 Maintenance requirements?
4x10)+ (2x10) + (70x1) = 130ml/hr needed
You usually order a 1L of 0.45% NaCl with 20 KCL @ 125 ml/hour, this is close to the 130 for the normal 90kg man, so if you had a 1 L bag that emptied at 125 ml per hour it would take 8 hours to empty the bag, therefore you would need 3 bags for the day ie 3000 ml for the day.
33
Example of a 90 Kg man and the 100-50-20 maintenance requirements?
(10x100) + (10x50) + (70x20) = 2,900 ml/day
34
Maintenance electrolytes
Daily Na Needed:
Daily K Needed:
Daily Na Needed: Maintaining Na+ is 2-3mmol/kg/day
Daily K Needed: 0.5-1 mmole/kg/day
35
Resuscitation (losses that already occurred)
NPO
Bowel Prep
Measurable fluid loss
what is a fleet enema?
oNPO deficit: Number of hours NPO x maintenance fluid requirement
oBowel prep: May result in up to 1L fluid loss
oMeasurable fluid losses: NG suctioning, vomiting, ostomy output
•Fleet enema: 1x enema that clears out the rectum, not the entire bowel. May also be given to stimulate a BM.
36
Replacement (during sx)
Third space loss depeneds on:
Superficial surgical trauma:
Ex:
Minimal surgical trauma:
ex:
Moderate Surgical trauma:
Ex:
Severe surgical trauma:
Ex:
Depends on location of sx, duration of procedure, amount of tissue trauma, temperature, ventilation
Superficial surgical trauma: 1-2ml/kg/hr
Ex:Knee arthoscopic sx, third spacing localized. Quicker, less fluid loss
Minimal surgical trauma: 2-3 ml/kg/hr
ex:Head and neck, hernia, knee sx. Trauma is present
Moderate Surgical trauma: 5-6ml/kg/hr
Ex:Hysterectomy, chest surgery
Severe surgical trauma: 8-10ml/kg/hr
Ex:AAA repair, nephrectomy. Requires extensive manipulation of lungs/heart/etc.
37
Replacement (during sx)
Blood losses
If you are using crystalloid you must replace:
explain:
•If using blood products or colloids, replace blood loss:
•Replace 3ml of crystalloid solution per ml of blood loss
Crystalloid solutions leave intravascular space. You give is intravascular but it redistributes. Give 3x as much!
-volume per volume. Does not go out of intravascular space. Keeps fluid in.
38
IV Fluids:Crystalloids: what are Crystalloids?
•Balanced salt solutions:
-Saline:
•LR: contains:
oHealthy liver:
oLiver disease:
* Plasmalyte: Contains:
* Normosol: Contains:
all crystalloids contain what?
oCrystalloids: Water and electrolytes
•Balanced salt solutions: Electrolyte composition and osmolality similar to plasma
0.9% NaCl is a Crystalloid
•LR: Na(130), Cl(109), Lactate (28mmol/L), K(4), Ca(1.5)
oHealthy liver: Lactate is metabolized to bicarb by the liver
oLiver disease: Cannot metabolize lactate, do not give! Will become acidic
* Plasmalyte: No lactate, contains Mg and K+….$$$!
* Normosol: No lactate, contains Mg and K+
all contain: Calcium, too much is not good! Must monitor!
39
Normal saline or LR?
Studies differ, LR may protect kidneys with electrolyte comp
40
Crystallods cont:
•Hypotonic Salt Solution: what is this?
D5W: why is this considered hypotonic?
o D5W is Used in IV just to keep vein open what does this mean?
Electrolyte composition lower than plasma
Can be considered isosmotic solution because 5% dextrose osmolarity is similar to plasma but is actually hypoosmotic because glucose goes into cells and you are left with just water
, run it as slow as possible. The pt does not get much fluid. Can switch to other fluid if you decide you need to.
41
```
•Hypertonic solutions:
•.9% NaCl has
•types:
oMust give
oToo much =
```
Electrolyte composition higher than normal saline
.9% NaCl has same osmolarity as plasma
•1.8% (2x as much), 3%, 5%, 7.5%, 10%
oMust give slowly! Have on pump to regulate how much is given
oToo much = death!
42
.9% NS
Na:
Cl:
Osmolarity:
Na+ 154,
Cl- 154
308
43
.45% NS
Na:
Cl:
Osmolarity:
Na+ 77, Cl- 77
| 154
44
Glucose 4%, Saline .18%
Na:
Cl:
Osmolarity:
Na+ 31,
Cl- 31
284
45
Glucose 5%
Na:
Cl:
Osmolarity:
Na+ 0,
Cl- 0
278
Originially the osmolarity of D5W is the same as the plasma but it becomes hypotonic as Glucose eventually goes into cell and you are just left with water. This can shift in or out of cell.
46
Be careful using glucose solutions because hyperglycemia is associated with worse outcomes:
why would a surgical patient be hyperglycemia
what else occurs with hyperglycemia:
oEpinephrine and cortisol are released and cause insulin resistance, glucose levels will go up.
Urine output increases when glucose is hight, so you become volumem depleted and have a volume problem.
47
Explain the 2001 NEJM (VanDenBerghe) Study
* Prior to this study, nothing was done with glucose levels until 180ish, then insulin
* Intensive insulin therapy lowered mortality among hyperglycemic surgical ICU patients (most were CV surgery patients)
* Glucose checked every couple hours and given insulin based on this
* Kept glucose within narrow range
•Institution of intensive insulin therapy → monitor every pt’s glucose. If > 140, INSULIN!
No matter what, even if they are eating!
48
Explain the follow up 5 year study in Arizona
```
•They kept glucose levels <150mg/dL
Of the participants
•65% normal glucose levels
•24% required insulin but no hx of DM
•15% known DM
```
•Nondiabetic hyperglycemic patients were sicker than DM patients and had higher mortality rates
o24% really needed glucose monitored and brought down
49
Explain Maryland ICU study
In nondiabetic patients, hyperglycemia on admission independently predicted mortality (in CV and Neuro cases, not general med surgical ICU’s)
50
Explain the contradictory 2009 NICE-SUGAR NEJM Study
2 groups:
1:
2:
```
4 findings:
1:
2:
3:
4:
```
why is hypoglycemia bad?
Overall findings:
* 3,054 patients to intensive control group (keep glucose in normal range) 180)
* 27.5% died in intensive control group and 24.9% died in conventional group
•Severe hypoglycemia occurred in 6.8% of intensive group & 0.5% in conventional group
oNo difference in medial length of ICU stay or hospital stay
oNo difference between number of days mechanically ventilated, blood cultures, or RBC transfusions.
•Hypoglycemia is bad, if brain not getting glucose, brain cells die.
* This study used any patient that came into ICU, not just cardiovascular/neuro. Could have been major abdominal surgery, cancer, prostatectomy.
* This has physicians rethinking what to do with glucose levels when they increase.
* Still hanging onto intensive therapy model….may begin to shift soon.
51
Do you begin insulin in the OR?
No, start in recovery after closed up.
| Give in OR if previous DM diagnosis.
52
What is practical crystalloid therapy
•If you infuse NaCl 0.9% 1,000ml, where will the Na+ and volume go?
If you bleed out 1L, how much 9% Nacl do you need to give to replace the fluid:
If you influse 0.45%
•Initially, 333mL intervascular and 667mL interstitisal. No shift of water since cells are 300mOsm too. No osmolarity change. Water stays put. all stays extravascular
If you bleed out 1L, give 3L NaCl .9% because 1L goes intravascular and 2L goes interstitial. Best if bleeding!
•If it was .45% you would have same distribution however lower the osmolarity causing water to go into the cell (trying to dilute its osmolarity to match). Less in vascular.
oRemember: Colloids are large particles that remain intravascular and keeps water with it. If bleed out 2 L and have no blood, can give colloid because it stays in!
53
If you infuse 1,000mL glucose 5%, where will the volume go?
* Dextrose diffuses out and goes into the cell.
* Water distributes equally in all three places: 666mL to cells, 333mL into extracellular space (100 intravascular, 200 interstitial).
* Not a good solution if hemorrhage, most goes into the cells and not vascular!
54
```
Colloids:
-
-
Types:
1:
-
-
2:
-
3:
-
```
Molecules large and dont cross capillary membranes
they stay into which they are infused (vascular space)
Types:
Hetastarch: Given while waiting for blood, $$$
oCannot use in patients with renal disease: Nephrotoxic
oCan cause anaphylaxis
Albumin: Allows fluid to stay in vasculature
oBetter one to give if need volume expansion
Dextran: stays in the vascular space and draws fluid from the interstitial space
Used for thromboembolic prophylaxis in vascular procedures (dilutes out clotting factors).
-Increases volume of 100-200%, will keep fluid in and draw more in too from interstitial space.
-Dilutional effect on coag factors and platelets
55
What is a good indicator for good prognosis before having thoracic surgery?
* Albumin levels – If protein levels high, good outcome!
* If protein high before surgery, have oncotic pressure to keep fluid in blood vessels. Able to profuse organs better now.
* If open heart surgery, educate pt to be on high lean protein diet 6 weeks prior to surgery. High albumin = better outcome!
* Can have older patients to drink ensures (high protein)
56
• How do you evaluate fluid replacement?
Urine output: 1.0ml/kg/hr → want this, means professing kidneys good!
Vital signs: BP, HR
oPhysical Assessment:
•Plasma volume deficit – reduced tissue perfusion because high HR (< time in diastole)
•See with color and capillary refill
•Interstitial fluid deficits – decrease turgor, dry skin, fissuring tongue, sunken eyes
o Invasive monitoring: CVP, PAP, PWP
o Laboratory Tests: HgB, Hct
oDaily weights
57
•If pt was dehydrated and you gave fluid,what happeneds to HR and BP
You dont want the HR to be high why?
HR will go down and BP will go up
Dont perfuse the myocardium durring diastole, shorter time in diastole
58
o Laboratory Tests: HgB, Hct
•Rule of thumb: 1
•If throwing up or diarrhea, dehydrated. Hct will
o Laboratory Tests: HgB, Hct
•Rule of thumb: 1% hct rise for each 500mL ECF deficit if RBC loss is nil
•If throwing up or diarrhea, dehydrated. Hct will rise bc not losing RBC’s.
59
•Daily weight gain or loss greater than 0.5 lbs represent:
•Daily weight gain or loss greater than 0.5 lbs represent changes in body fluid content.
i lost 10 lbs in 5 days, this means you lost water
60
```
Daily weights
•During replacement of 3rd space losses:
-
-
-
o In surgical patients, diuresis and associated weight loss is expected:
•This fluid needs to be:
•High protein diet will:
```
•During replacement of 3rd space losses, weight gains do not represent intravascular volume overload - fluid is kept in extravascular space
•Caused by replacement of ECF volume to compensate for volume that was lost or sequestered into that third space.
•When cardiac patients come out after surgery and have so much vessel leakage, depending on surgery will have different fluid loss into this interstitial space (third spacing).
oIf you give fluid to replace shifting, the fluid you give does not represent vascular space. It represents fluid shifting. Will lose this extra weight after surgery in about six weeks.
o In surgical patients, diuresis and associated weight loss is expected 3 or more days postop when 3rd space fluid accumulations are mobilized (moved into intracellular or intravascular compartments).
•This fluid needs to be excreted, not replaced as you already corrected for it during preop with replacement of this fluid.
•High protein diet will keep fluid in vessels so you can excrete sooner.
61
Summary of Fluid Replacement
Key is to:
Look for signs in your clinical observations:
-
-
-
oKey is to protect vital organs from hypoperfusion
Look for signs in your clinical observation:
•Hemodynamic changes (tachy, narrowed pulse pressure, hypotension)
•Urine Output ( 20:1, Urine Na+ <20mEg/L)
If less than 20 body is trying to compensate to keep H2o up.
62
```
What are indications for blood transfusion?
Rare:
Usual:
Heathy Pt:
Compromised pts:
```
•If elderly pt 85y.o. with afib has hemoglobin of 9-10,
Varies with patient and procedures
•Rare if Hb >10 gm/dL
•Usual if Hb <7gm/dL
•Healthy patients: Can tolerate Hb levels of 7gm/dL
•Compromised patients: May require Hb levels above 10mg/dL
•If elderly pt 85y.o. with afib has hemoglobin of 9-10, this is good. Don’t want hemoglobin of 12-14 because you want blood thin, less likely to clot.
63
What are packed RBC’s?
1 Unit:
Hct:
1 unit pRBC's=
Hemoglobin:
Hematocrit:
Infuse with normal saline, why?
o When someone donates blood it’s between 400-500mL thats donated-This is separated out for storage and things are given back as needed
o Packed RBC’s come in unit of 250mL with hematocrit of 70-80%- removed plasma
o 1 unit pRBC’s raises Hb 1gm/dL
* Hemoglobin: Tests how much hemoglobin (oxygen binding compound) is present
* Hematocrit: Determines how much of total blood volume contains RBC’s
o Infuse pRBC’s with normal saline so you won’t have RBC crenating and shriveling up.
64
1 unit pRBC’s raises Hb:
1 unit pRBC’s raises Hb 1gm/dL
65
• Military found it is better to give:
-
-
• Military found it is better to give whole blood instead of separate parts. If pt needs RBC’s, platelet rich plasma, etc….could be getting from multiple people. Now chance to have complications from transfusion.
Now military uses whole blood. Also can cryoprecipate RBC’s → reconstitute → regive them. Not every RBC lives through drying process (only 60% do) but instead of living 45 days, they can now live 90 days if dryed.
66
When is platelet concentrate used?
```
•1 Unit increases platelet count by
•1 unit RDP(random donor platelet) for every 10kg increases platelet count by:
•The larger the patient:
1 Unit of SDP =
why?
```
Do platelets need to be typed and crossed?
•Platelets get consumed in surgery –
-Thrombocytopenia (90,000
67
FFP
whats in FFP?
```
Indications: amount and when
-
-
-
-
```
Does FFP need to be cross matched?
Coag factors
No platelets
Indications: 15ml/kg if:
-Factor deficiencies
-Reversal of coumadin effects
(80 yo that falls and hits the head INR comes back at 7, need to give FFP to get facors up)
-TTP
-Interoperativley when PT and PTT are >1.5 normal
oMust be ABO compatible but does not require cross matching or Rh typing-If you have someone getting ffp that is a cancer patient that may need a ton of it, they recommend that you do cross matching now. If 80 year old on Coumadin and bleeding only needing 1-2x a year when INR is high, no need to crossmatch.
68
From being thawed when do you need to use FFP?
Must be used with in 24 hours, or factor 5 and 8 will break down
69
• If 80 years old and falls, hitting her head with INR of 7 what do you do?
o Vitamin K will probably not work right away, need FFP!
o Give FFP to increase clotting factors….higher INR means thinner the blood!
o 1 is normal blood without blood thinners, if INR 2, blood takes twice as long to clot.
70
What is cryoprecipitate?
what makes cryo diff from FPP
what else is in there?
o It is loaded with fibrinogen!! • 200mg fibrinogen/bag
o When fresh frozen plasma is centrifuged and its components are taken and given separately. You just have a powder. It holds a lot longer now.
Alot less fluid required to give the facrors
o Fibrinogen, vWF, Factor VIII, factor XIII
71
what happeneds with transfusion reactions:
1: Febrile:
72
• What are benefits of cryopreciptate?
o There is a lot less fluid required to give a high concentration of factors.
o Perfect to give if CHF and cannot handle excess fluid.
73
• What are complications of using blood components/transfusion reactions?
Febrile – most common transfusion reaction in nonhemolytic reaction
Allergies –
Hemolytc Anemia –
Viral Transmission
oOther (40:07)
•Citrate: Calcium binding –kelates calcium. When you give PRBC’s with citrate to new patient, it can bind up calcium leading to
1:arrhythmias because it is more excitable → twitch/seizure/bleed.
2: Bleeding: No calcium as a cofactor to platelets and cofactors
* Hypothermia: Use warmers
* Coagulation disorders: Massive transfusion (>10 units pRBCs) may dilute platelets and factor V and VIIII
74
why do you get a Febrile reaction with transfusion
FNHTR (febrile non-hemolytic transfusion reaction) are benign causing little to no lasting sequelae.
Must take temperature q 10-15 minutes after transfusion to look for reaction.
Due to cytokines in bag of RBC that accumulate during storage (IL-2, 6, 8, TNF) generating and accumulating during storage of blood components.
75
Allergic reaction:
Not really an allergy (IgE response), it’s an ABO incompatibility, usually IgM or IgG against protein on the transfused RBC
•If A+ and you give B+, A+ person has antibodies (IgM/IgG) to B+ antigen → binds to blood cells and targets for destruction through macrophages or activates complement.
76
Hemolytic anemia reaction
what happeneds:
signs:
-
-
-
Treatment:
-
Because of the allergy and Hemolytic anemia you must do what?
Acute hemolytic reactions are rapid destruction of RBC’s by preformed antibodies.
this occurs when you: Wrong blood given → Complement activated (intravascular hemolysis)
Signs:
- Fever
- flank pain because intravascular hemolysis (hemoglobin released into blood stream and can get caught into kidneys)
- red/brown urine: Hemoglobin oxidation as it goes through the kidneys – looks brick red
Treatment: Stop the transfusion and give fluids through wide open IV’s to perfuse the kidneys
You do not want hemoglobin trapped in the kidneys
For this reason, you MUST check blood multiple times and obtain signatures with every check to ensure the right blood is given to each patient.
77
Viral Transmission
* Hepatitis C: 1:30,000
* Hepatitis B: 1:200,000
* HIV: 1:450,000-1:600,000/unit
* CMV (cytomegalsovirus) most common organism transferred through blood components.
* Due to poor testing for this.
78
in citrate issues what do you want to order from the lab?
Free and Bound Ca+
If you add citrate the free with be bound up
