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Principles > Perioperative Fluid therapy > Flashcards

Perioperative Fluid therapy Flashcards

1
Q

% tbw in the average adult

A

60% water

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2
Q

Low % of water in _______ tissue

A

adipose

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3
Q

intracellular fluid compartment %

A

55%

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4
Q

Extracellular fluid compartment %

A

25%

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5
Q

Extraceulllar componenets

A

Interstitial: lymphatics and protein-poor fluid around cells
Intravascular: plasma volume
Transcellular: GI tract, urine, csf, joint fluid, aqueous humor

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6
Q

Describe diffusion (5)

A

-Solute particles fill solvent volume
-High to low concentration
-Speed is proportional to distance squared
-Can occur across permeable membranes
-Can relate to electrical gradients

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7
Q

types of solutes

A

Glucose, proteins, electrolytes

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8
Q

Primary extracellular cation

A

Sodium

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9
Q

Primary intracellular cation

A

Potassium

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10
Q

Describe osmosis

A

A semipermeable membrane separates pure water from water with solute
Diffuses from low to high concentration

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11
Q

Osmotic pressure formula

A

P = nRT/ V

N = number of molecules
R= constant
T= Temperature
V= Volume

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12
Q

Osmotic pressure definition

A

Pressure that resists the movement of water through osmosis

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13
Q

number of osmotically active particles/L of solvent

A

Osmolarity

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14
Q

_____osmolarity…_____“pulling power”

A

Higher osmolarity…higher “pulling power”

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15
Q

Number of osmotically active particles per kg of solvent

A

Osmolality

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16
Q

normal osmolality

A

Normal: 280-290 mOsm

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17
Q

The component of total osmotic pressure due to colloids

A

Oncotic pressure

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18
Q

Colloids types

A

Albumin (most), globulins, fibrinogen

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19
Q

Albumin % responsible for oncotic pressure

A

65-75% from albumin

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20
Q

Average intake (3)

A

750 ml of solids
350 ml from metabolism
1400 ml liquid intake

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21
Q

Average ouptuts (3)

A

1000 ml insensible loss (tears/vapor)
100 ml GI loss
0.5-1 ml/kg/hr urine output (60%)

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22
Q

ADH response

A

Antidiuretic Hormone (ADH) – renal H2O excretion in response to plasma tonicity.

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23
Q

ANP response

A

Atrial Natriuretic Peptide (ANP) – activated with ↑ fluid volume
↑ atrial stretch = ↑ renal excretion.

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24
Q

Aldosterone response

A

Aldosterone – regulates Na+ and K+ levels
If Na+ and fluid volume ↓ aldosterone is released causing Na+ and H2O conservation.

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25
Q

Urine output is regulated by

A

adh
ANp
aldosterone

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26
Q

Urine section = ____ of dailty water loss

A

60%

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27
Q

Sensory for fluid balance (3)

A

Hypothalamic osmoreceptors
Low pressure baroreceptors; large veins and RA
High pressure baroreceptors; carotid sinus and aortic arch

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28
Q

Triggers for fluid balance

A

Increased thirst or adh release

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29
Q

The compensatory mechanism for disturbances in circulating volume (5)

A

Venoconstriction
Mobilization of venous reservoir
Autotransfusion from ISF to plasma
Reduced urine production
Maintenance of CO…tachycardia, increased inotropy

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30
Q

Sensors for disturbances in circulating volume

A

low and high pressure baroreceptors
RAA axis

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31
Q

RAA axis

A

Renin
ang 1 becomes 2
aldosterone released from adrenal cortex

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32
Q

Renin facts

A

Released from juxtaglomerular cells
Cleaves angiotensinogen to make angiotensin I

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33
Q

Angiotensin I becomes II causes

A

vasoconstriction and aldosterone release

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34
Q

Aldosterone released from adrenal cortex causes_____

A

salt and water retention

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35
Q

IN the absence of ongoing loss RAA axis and compensatory mechanisms restores ______

A

Restores volume in 12-72 hours
Restores RBC numbers through erythropoiesis in 4-8 weeks

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36
Q

NS na, cl, osmolarity

A

na; 154
cl; 154
osmolarity; 308

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37
Q

LR; na, k , cl , lactate, osmolarity

A

na; 130
k; 4
cl; 109
lactate; 28
osmolarity; 274

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38
Q

Isolyte P; na, k, cl, mg, acetate, glucose, posphate

A

na; 26
k; 21
cl; 21
mg; 3
acetate; 24
glucose; 5
phosphate; 3

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39
Q

Plasmalyte A; na, k, cl, acetate, osmolarity

A

na; 140
k; 5
cl; 98
acetate; 27
osmolarity 295

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40
Q

D5 glucose and osmolarity

A

gluose; 5
osmolarity; 252

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41
Q

Albumin 5% na; k, cl, osmolairty

A

na; 145 + 15
k; <2.5
cl; 100
osmolarity 330

42
Q

Hetastarch 6% na, cl , osmolairty

A

na 154
cl; 154
osmolarity; 310

43
Q

Solutions of electrolytes in water

A

Crystalloids

44
Q

Called balanced solutions

A

Crystalloids

45
Q

Most balanced crystalloid

A

LR

46
Q

indications for crystalloids

A

Replacement of free water and electrolytes
Volume expansion

47
Q

Distribution of crystalloids volume through entire ecf

A

70% intravascular after 20 minutes
50% after 30 minutes

48
Q

Too much crystalloids can cause____ and where?

A

Tissue edema
Lung, gut, soft tissues

49
Q

Cyrtalloids side effect

A

Hypercoagulable…anticoagulant factors diluted (at low dilution)

50
Q

effects of ns (0.9%) (3)

A

-Dilutes hct and albumin
-Increases cl- and K+ concentrations
-Late onset of diuresis

51
Q

Side effect of NS (2)

A

Causes hyperchloremic metabolic acidosis
Increased AKI and RRT in critical care patients

52
Q

Pulls water out of ICF to ECF including plasma

A

Hypertonic saline (3%)

53
Q

Hypertonic saline used for _____

A

Treats hypoosmolar hyponatremia
Treats increased ICP

54
Q

Much lower osmolarity than NS

A

LR; Lower Na+ and Cl- concentrations (close to plasma)

55
Q

Lr has ___ added as a buffer

A

Lactate added as buffer

56
Q

What relies on hepatic metabolism?

A

Lactate (dont use LR for liver insufficiency)

57
Q

Lr Excretes excess water faster than ns
by____

A

Suppresses adh secretion/allows diuresis

58
Q

Indications for Dextrose solutions

A

A source of free water (5%)
Could be used for caloric intake in diabetics (10%)

59
Q

Dextrose is not suitable for _____

A

Not suitable for volume expansion; water moves freely between all compartments

60
Q

Large molecules of a homogeneous, non-crystalline substance that cant be separated

A

Colloids

61
Q

Types of colloids

A

Semisynthetic colloids; hetastarch, hespan
Human plasma derivatives; FFP

62
Q

Colloids dispersion facts

A

Large molecules of a homogeneous, non-crystalline substance (in a balanced solutions (crystalloid).
Cant be separated. Disolved in crystalloid
dispersed in a second substance (typically a balanced crystalloid)
Particles cannot be separated (through filtration or centrifuge

63
Q

effects of colloids

A

Increased cop = increased potential plasma volume expansion
Cause hemodilution
Uncertain effect on immune, coag, renal systems

64
Q

What are the effects of colloids causing hemodilution (2)

A

Decrease plasma viscosity
Inhibit rbc aggregation

65
Q

when are Uncertain effect on immune, coag, renal systems of colloids seen?

A

Maximum recommended dosages

66
Q

Hydroxyethly starch is Modified natural polymers of ____

A

Modified natural polymers of amylopectin

67
Q

where is hydroxethyl starch deterived from

A

Modified natural polymers of amylopectin
Derived from potato or maize
Substitution onto glucose

68
Q

Hydroxyethyl starch metabolism is dependent on_____

A

Metabolism dependent on molecular weight of molecules

69
Q

Hydroxyethyl starch effects

A

Plasma volume effects last longer
70-80% larger at 90 minutes

70
Q

side effects of Hydroxyethyl starch

A

Side effects r/t MW
Coagulopathy…vwf, factor VIII and clot strength (at high dilution)
Renal dysfunction

71
Q

Highly branched polysaccharides

A

Dextrans

72
Q

Dextrans highly branched polysaccharides are procduced by _____

A

Produced by leuconostoc mesenteroides

73
Q

Dextrans plasma volume is similar to______

A

Plasma volume similar to the starches (6-12 hours)

74
Q

When is dextrans used and what are the effects

A

Dextran-40 used for microvascular surgery
Inhibits factor VIII, vWf factor, platelet aggregation
Coats rbc…may interfere with cross-matching

75
Q

Types of human plasma derivatives

A

Albumin 5%, FFP, immunoglobulin solution

76
Q

Physiologic COP with plasma derivatives indications_____ (4)

A

Volume replacement
Trauma, sepsis, replacement following paracentesis

77
Q

indications for preop fluids (9)

A

Disordered Na+ distribution
Requirement for dialysis
Chronic use of diuretics
Diagnosis of hypertension
Preop fasting
Bowel prep
Acute hemorrhage
N,V,D and/or suction
3rd space redistribution

78
Q

indications for intraop fluids (6)

A

Vasodilation from anesthetics
Sympathetic blockade
Autoregulatory responses
Acute hemorrhage
Insensible losses
Inflammation related redistribution

79
Q

Assessments of low intravascular volume (5)

A

-Signs of hypovolemia; Tachycardia, ↓ pulse pressure, hypotension, ↓ capillary refill
-urine output; Inadequate as end-organ due to raa
-CVP; Measures central venous volume but distensible
-Tissue perfusion; lactate, mixed venous O2

80
Q

Assessments of high intravascular volume (5)

A

Excessive crystalloids/colloids;
-↑ capillary hydrostatic pressure
-Excessive fluid development in lungs, bowel, muscle
-Reduced tissue oxygenation
-Poor wound healing
-Hypo/hyper coagulation

81
Q

Uses for classic fluid therapy

A

NPO deficit
ongoing maintenance
anticipated surgical loss

82
Q

Npo status

A

Clear liquids: 2 hours
Breast milk: 4 hours
Infant formula: 6 hours
Light meal: 6 hours
Meat/fatty, fried: 8 hours

83
Q

classic approach for NPO/ maintainance formula (4-2-1)

A

1st 10 kg = 4ml/kg/hr
2nd 10kg = 2 ml/kg/hr
Each 1kg > 20kg = 1 ml/kg/ hr

calculate total deficit
(multiply by number of hours of NPO)

84
Q

How to replace a NPO deficit

A

½ in the 1st hour of surgery.
¼ in the 2nd hour.
¼ in the 3rd hour.

85
Q

Estimating Blood loss possiblities

A

Suction

Lap sponges 100ml

Raytech’s 20ml

4x4’s 10ml

86
Q

Lap sponges thats saturated holds

A

100 ml
come in packs of 5

87
Q

Raytechs comes in packages of ____

A

10

88
Q

why do sponges have markings?

A

x ray able

89
Q

Hypovolemic replacement

A

Preoperative bleeding
Crystalloid traditionally 3:1
May replace prbc’s, ffp, cryo using TEG/ROTEM

90
Q

Average fluid with bowel prep

A

2000ml average

91
Q

Everage fluid loss with fever

A

10% deficit q1degree Celsius

92
Q

evaporative/redistribution losses

A

Minimal= 0-2 ml/kg/hr

Moderate = 2-4 ml/kg/hr

Severe = 4-8 ml/kg/hr

93
Q

Parkland Burn resuscitation formula; what to use, when to use, and how much to give

A

Based on “rule of 9’s”
Adjusted due to obesity
Lactated ringers

use formula if; 20% TBSA of 2nd/3rd degree burns

4ml/kg/%BSA burn
½ over 1st 8 hours
½ over next 16 hours

94
Q

Rule of 9s

A

Head; 9
chest ; 9
abdomen; 9
upper back; 9
lower back; 9
legs; 9 and 9
arms together; 4.5 and 4.5
perineum; 1%

95
Q

Goal directed therapy fluid administration is based on_____

A

Cvp
Co
sv
Svv

96
Q

What do the studies show about goal directed therapy

A

Studies: less aki, respiratory failure, wound infection, mortality

97
Q

Goal-directed therapy allows decisions to use:

A

More fluid
Vasopressors
Inotropes
Blood products

98
Q

Goal-directed therapy principles (3)

A

-Maintenance of 1-3 ml/kg/hr of crystalloid
-Fluid challenges of 250cc to increase sv
-Colloids 1:1 with blood loss or blood products

99
Q

Normal svv

A

10-15%

100
Q

Shows difference in arterial pulse pressure during inspiration/expiration

A

(SPV, PPV, SVV)

101
Q

Limits to arterial waveform pressure monitoring

A

SVV >15% = fluid responsive
Low hr/rr
Irregular heartbeats
Mechanical ventilation (with low tidal volume)
Increased abdominal pressure
Thorax open
Spontaneous breathing

Principles (34 decks)

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