Required Reading-Fluids/Intraop Complications Flashcards
Total body water is _____ of body weight. Intracellular is ___ and extracellular (interstitial fluid and plasma) is ____.
60%; 40%; 20%
Extracellular to intracellular shift of fluids cause dramatic illnesses, such as ____ of cells, swelling of ______ and ____.
lysis; brain/SC; renal failure
If 70kg man, TBW is ____, intracellular water is ____ and extracellular water is ____.
42L; 28L; 14L
Extracellular fluid consists of ____ (16% TBWt) and ____ (4% TBWt)
interstitial fluid (~11.2L); plasma (~2.8L)
RBCV + plasma volume is ___ liters, or the total blood volume
2L + ~3L = 5L
CO is about ____ per minute
5L
Transfusing blood products adds volume to BOTH ____ and ___ space.
extracellular; intracellular (RBCV)
Fluids are to support ___ of heart, avoid excessive expansion of ____ space, allow some ____ fluid to be transported back into intravascular space, and avoid changing ____ space (specifically in neurons)
preload; interstitial; interstitial; intracellular
Clinical var to assess intravascular volume status include:
skin turgor, neck veins, SBP, var of BP w/ respiration, CVP, HR, UO, hypoTN w/ anesthesia, orthostasis, base excess or HCO3
An increase in variability of BP w/ respiration indicates ___ intravascular volume status.
hypovolemic
A CVP between ____ indicates normal intravascular volume status.
8-12mmHg
Base excess less than -2 or HCO3 mEq/L less than 22 indicates ___ intravascular volume status.
hypovolemic
Pts kept deliberately hypovolemic are those with elevated ____ pressures, ____ pts, or after ____ surgeries.
pulmonary artery; COPD; thoracic
Crystalloids, like NS, LR (contains Ca+, K+, lactate), normosol-R mostly diffuse into ____ space and is for mostly minor procedures.
intracellular
Colloids are derived from human serum protein macromolecules like ____, or carb macromol like ___.
albumin/Plasmanate; Hetastarch
B/c oncotic pressure, macromol in colloids allows them to remain in ____ longer (hrs-days) than crystalloids (min-hrs)
intravascular space [minimize wt gain/edema]
Albumin 5% used for ____ replacement. If not diluted with NS (as opposed to 1/2NS), can cause fatal ____.
volume; hemolysis
Plasmanate contains 88% albumin and also alpha/beta/gamma ____; considered to be ______ therefore not given to Jehovah’s Witnesses. Diluted w/ NS.
globulins; blood product
Hetastarch derived from ____ and not a blood product; also less expensive than protein-derivatives
vegetable matter [complex carbs]
Calculating periop fluids: (1) Maintenance fluids (2) NPO (3) EBL (4) “third-space” loss
(1) 4 + 2 + 1 rule = 100ml/hr for first 60kg + 1ml/hr*remaining kg
(2) 8h x (maint. fluids) [give in first 2hrs] (3) 3 x EBL (4) minor 1-3ml/kg/h, laparoscopy 3-6ml/kg/h, exlap 6-10ml/kg/h
Estimate periop fluids for 100kg man who hasn’t eaten for 8 hrs, EBL about 100ml for 2h lap chole.
(1) Maintenance fluids = 140ml/h (2) NPO = 1220ml (3) EBL = 300ml (4) “third-space” loss = 500ml/h; Total = 2700 ml/h LR over 2h periop period
MC use for D5W
withdrawing alcoholic pts from becoming hypoglycemic
MC use D51/2NS + 30mEq KCL/l
classic maintenance fluid for medicine on ward (insensible losses)
MC use NS; MC problem
replacement for initial resuscitation for dehydration and blood loss; may cause metabolic acidosis
MC use LR; MC problems (3)
replacement periop losses; (1) calcium makes incompatible w/ blood products and (2) liver dz pts may not tolerate lactate (impaired gluconeogenesis) (3) hyperkalemia
MC use Normosol
cardiac/renal/hepatic transplant b/c no lactate load
MC fluids where losses exceed 2L
Hetastarch, Albumin/Plasmanate [also if edema and hypoalbuminemia]
MC prob Hetastarch
may induce coaggulopathy if >2L given; inhibits vWF
ABG measures these 4 values
pH, PaCO2, PaO2, HCO3- [base excess is derivative calculation]
In addition to ABG, also know ___ to know quality of O2 delivery and ___ to know if there are compensatory mechanisms working
inspired O2 (FiO2); anion gap = serum Na+ – [Cl- + HCO3-]….nml 12-20mEq/L
Respiratory acidosis MCCs: [remember dec excretion of CO2 and inc prod CO2]
hypoventilation (dec minute ventilation), obstruction sm airways, COPD, asthma, OD EtOH, sedatives, opioids, myasthenia gravis, hyperthermia, overfeeding [overprod CO2]
Metabolic acidosis MCCs w/ anion gap
lactic acidosis/ethanol in blood: MUDPILES–methanol, uremia, DKA, phenytoin/propylene glycol, INH, lactate, ethylene glycol, salicylates
Metabolic acidosis MCCs w/ NO anion gap:
hyperchloremic acidosis–diarrhea, NaCl solns (surgery or s/p blood loss), acetazolamide, renal tubular acidosis
Respiratory alkalosis MCCs:
hyperventilation, hypothermia, muscle relaxation from NONDEPOL NMBs, anxiety from CNS lesion, altitude, pregnancy
Metabolic alkalosis MCCs
vomiting, diuretics (furosemide), antacids, hyperaldosteronism
MC problems metabolic alkalosis; Tx
arrhythmias, cerebral vasoconstriction, coronary vasoconstriction, can also cause retention CO2 in blood; NS +/- KCl, dilue HCl, acetazolamide
Chronic respiratory ACIDOSIS or ALKALOSIS calculation base excess (anion gap)
BE = 0.4 x (PaCO2 - 40)
Allowable Blood Loss [ABL] formula
EBV x (HCTinitial – HCTfinal) / HCTinitial
One gram of Hb is equivalent to _____ HCT percentage points. Each unit of PRBC in an adult is expected to raise HCT by ___ points.
3; 3
Estimated Blood Volume (EBV) formula
wt (kg) x average blood volume [male abv = 75ml/kg; female = 65ml/kg]
If EBL is greater than one liter, must place ____ monitor
CVP (central venous pressure)
Pulmonary artery [PA] monitors are better at measuring ____ than CVPs.
volume status (can sample mixed venous blood and also can assess total O2 delivery)
____ is given for severe coaggulopathy and Factor VIII deficiency
Cryoprecipitate
Factor IX concentrate has factors ___, ___ and nontherapeutic levels of ____
II; X; VII
MC transfusion rxn is Major Acute Hemolytic Reaction, which is from ___ or ___ incompatibility and due to human clerical error.
ABO; Rh
In Acute Hemolytic Rxn, free Hb can damage the ____. Tx is to stop transfusion and use ___ or ____ for diuresis, as well as supportive care.
kidneys; mannitol; furosemide
MC transfusion infection is ____. Least common is ____.
CMV; Malaria
Delayed hemolytic transfusion rxn occurs after admin of multiple RBC transfusions, usually for ____. IgM and complement involved.
SCD
Anaphylactic rxn in transfusion occurs most in pts with cases of _____
selective IgA deficiency
Sxs of TRALI include ______. Supportive care and mech ventilation is needed.
respiratory distress, fever, non-cardio pulmonary edema, hypoTN
TRALI due to antibodies in donor against ____ antigens in recipient [ie crossmatch compatible]. Causes pulmonary capillary leak.
HLA
Use FFP for ____ bleeding, ___ drug therapy needing reversal, massive transfusion, ____ , C1 esterase inhibitor deficiencies
ACTIVE; warfarin; TTP
Minor febrile non-hemolytic transfusion rxn may occur even if ____ is compatible.
crossmatch
Minor febrile non-hemolytic transfusion tx is diphenhydramine, acetaminophen/ibuprofen and monitoring ____ and ___
vital signs; UOP
Transfusion– ____ can be prevented with inline IV fluid warmer
hypothermia
Transfusion–_____ can occur b/c PRBCs tend to lyse and release products the older they are; closer to expiration can cause increase in ion concentrations
hyperkalemia
Transfusion–____ common b/c citrate anticoagulant binds; transiently can cause vaso___ and hypoTN.
hypocalcemia; dilation
Treat hypocalcemia due to transfusion with either 1-2g of ____ or ____
calcium chloride; calcium gluconate [NOT calcium bicarb or it will precipitate]
