Unit 9: Fluids & Blood Flashcards
What is the distribution of body water?
Water represents 60% of the total body weight (42L in 70kg male)
Intracellular Volume = 40% of total body weight (28L)
Extracellular Volume = 20% of total body weight (14L)
-interstitial fluid = 16% (11L)
-plasma fluid = 4% (2L)
Which populations tend to have a greater percentage of TBW% by weight? Which have less?
- Higher TBW% = Neonates
- Lower TBW% = Females, Obese, and Elderly
What are the 2 most important determinants of fluid transfer between the capillaries and interstitial space?
Movement of fluid between intravascular space and the interstitial space is determined by:
-Starling Forces
-The Glycocalyx
What are the Starling forces in the context of capillary fluid transfer?
Forces that move fluid from the capillary to the interstitium:
- Pc = capillary hydrostatic pressure (pushes fluid out of capillary)
- πif = interstitial oncotic pressure (pulls fluid out of capillary)
Forces that move fluid from interstitium into the capillary:
- Pif = interstitial hydrostatic pressure (pushes fluid into capillary)
- πc = capillary oncotic pressure (pulls fluid into capillary)
*net filtration pressure > 0 = filtration (fluid exits capillary)
*net filtration pressure < 0 = reabsorption (fluid is pulled into capillary
What is the glycocalyx? What factors disrupt it?
Endothelial glycocalyx = protective layer on the interior wall of blood vessels
-determines what can pass from the vessel into the interstitial space
Disruption = Capillary Leak – accumulation of fluid and debris in the interstitial space reduces tissue oxygenation
-Conditions that impair the integrity = sepsis, ischemia, DM, major vascular surgery
What is lymph, and how does the lymphatic system work?
Lymphatic system removes fluid, protein, bacteria, and debris that has entered the interstitium
Accomplishes this with a pumping mechanism that propels lymph through a vessel network lined with one-way valves
-creates a net negative pressure in the interstitial space
*edema occurs when lymphatic system is unable to do its job
How is lymph returned to the systemic circulation?
Returned to the venous circulation by way of the thoracic duct at the juncture of the IJ and subclavian vein
*thoracic duct can be injured during venous cannulation – greater risk of chylothorax during left sided IJ insertion
What is the difference between osmosis and diffusion?
Osmosis = net movement of WATER across a semipermeable membrane (direction of water movement is driven by the difference in solute concentration on either side of the membrane)
Diffusion = net movement of MOLECULES from a region of high concentration to a region of low concentration (solvent and solute move)
What is osmotic pressure, and what is its primary determinant?
The pressure of a solution against a semipermeable membrane that prevents water from diffusing across that membrane
-osmotic pressure is a function of the number of osmotically active particles in a solution
-it is NOT a function of their molecular weights
What is the difference between osmolarity and osmolality?
Both are measures of concentration – the amount of solvent within a defined space
Osmolarity: measures the number of osmoles per liter of solution
Osmolality: measures the number of osmoles per kilogram of solvent
What is the normal plasma osmolarity? What are the 3 most important contributors?
What is the equation to determine plasma osmolarity?
Plasma Osmolarity = 280 - 290 mOsm/L
Important Determinants:
-Sodium, Glucose, BUN
= 2 [Na] + Glucose/18 + BUN/2.8
What is the difference between a hypotonic and hypertonic solution relative to plasma osmolarity?
Hypotonic (255 mOsm/L) = solution osmolarity is less than plasma osmolarity – water enters and cell swells
Hypertonic (315 mOsm/L) = solution osmolarity is more than plasma osmolarity – water exits and cell shrinks
What IV fluids are hypotonic, isotonic, and hypertonic?
Hypotonic:
-NaCl 0.45% (154 mOsm/L)
-D5W (253 mOsm/L)
Isotonic:
-LR (273 mOsm/L)
-Plasmalyte A (294 mOsm/L)
-Albumin 5% (300 mOsm/L)
-NaCl 0.9% (308 mOsm/L)
Hypertonic:
-D5 NaCl 0.45% (405 mOsm/L)
-D5 LR (525 mOsm/L)
-D5 NaCl 0.9% (560 mOsm/L)
-NaCl 3% (1026 mOsm/L)
How does dextrose affect the tonicity of IV fluids?
Glucose contributes osmotically active molecules to the plasma
Glucose is metabolized to CO2 and water –> water = hypotonic
How do isotonic IV fluids distribute in the patient?
Isotonic solutions are very close to plasma –> these solutions expand the plasma volume and the ECV
-crystalloids tend to remain in the intravascular space for ~30 min before moving to the ECF
What complication can result when hypertonic saline is administered too quickly?
Central Pontine Myelinolysis
What are the advantages and disadvantages of colloids?
Advantages:
- Replacement ratio = 1:1
- Increases plasma volume (3-6 hrs)
- Smaller volume needed
- Less peripheral edema
- Albumin has anti-inflammatory properties
- Dextran 40 reduces blood viscosity (improves microcirculatory flow in vascular surgery)
Disadvantages:
- Albumin – binds Ca (hypocalcemia)
- FDA black box warning on synthetic colloids (risk of renal injury)
- Coagulopathy (Dextran > Hetastarch > Hextend)
What are the advantages and disadvantages of crystalloids?
Advantages:
-Replacement ratio = 3:1
-Expands the ECF
-Restores 3rd space loss
Disadvantages:
-limited ability to expand plasma volume – increases plasma volume 20-30 min (higher potential for peripheral edema)
-large volume of NaCl –> hyperchloremic metabolic acidosis
-dilutional effect on albumin (reduces capillary oncotic pressure)
-dilutional effect on coagulation factors
How does hyperkalemia affect the EKG? (list in order of appearance)
K+ 5.5 - 6.5 = Peaked T waves
K+ 6.5 - 7.5 = P wave flattening / PR prolongation
K+ 7.5 - 8.0 = QRS prolongation
K+ >8.5 = QRS –> sine wave –> VF
How do you treat hyperkalemia?
Cardiac membrane stabilization –> Calcium
Redistribution (shift K+ intracellularly –> Insulin/D50, Hyperventilation, Bicarbonate, Albuterol
Elimination –> Potassium wasting diuretics, Kayexalate, Dialysis
What are the signs/symptoms of hypocalcemia?
-Skeletal muscle cramps
-Neve irritability –> paresthesia and tetany
-Chvostek sign
-Trousseau sign
-Laryngospasm
-Mental status changes –> seizures
-Long QT interval
What are the signs/symptoms of hypercalcemia?
-Nausea
-Abdominal pain
-Hypertension
-Psychosis
-Mental status change –> seizures
-Short QT interval
How do you treat hypercalcemia?
0.9% NaCl
Loop Diuretic (Furosemide)
What are the signs/symptoms of hypermagnesemia?
5.8 - 10 mEq/L or 7 - 12 mg/dL = Loss deep tendon reflex
> 10 mEq/L or >12 mg/dL = Respiratory depression and Cardiac arrest
What is the treatment for hypermagnesemia?
Calcium chloride or Calcium gluconate
How does hypermagnesemia affect neuromuscular blockade?
Potentiates neuromuscular blockade
What are the cardiac, CNS, pulmonary, and electrolyte effects of acidosis?
Cardiac:
- increases P50 (right = release)
- increases SNS tone
- increases risk of dysrhythmias
- decrease contractility
CNS:
- increases cerebral blood flow and ICP
Pulmonary:
- increases pulmonary vascular resistance
Electrolyte:
- hyperkalemia
What are the cardiac, CNS, pulmonary, and electrolyte effects of alkalosis?
Cardiac:
- decreases P50 (left = love)
- decreases coronary blood flow
- increases risk of dysrhythmias
CNS:
- decreases cerebral blood flow and ICP
Pulmonary:
- decreases pulmonary vascular resistance
Electrolyte:
- hypokalemia
- decreased ionized calcium
What is the anion gap? What does it tell you?
Anion gap helps determine the cause of acidosis
Anion Gap = [Na+] - ([Cl-] + [HCO3-])
-normal = 8-12 mEq/L
-Accumulation of acid (AG >12) = gap acidosis
-Loss of bicarb or ECF dilution = non-gap acidosis
What are the possible causes of an anion gap acidosis?
(MUDPILES)
-Methanol
-Uremia
-Diabetic Ketoacidosis
-Paraldehyde
-Isoniazid
-Lactate (decreased DO2, sepsis, cyanide poisoning)
-Ethanol, ethylene glycol
-Salicylates (inhibits Krebs cycle)
What are the possible causes of a non-gap acidosis?
(HARDUP)
-Hypoaldosteronism
-Acetazolamide
-Renal Tubular Acidosis
-Diarrhea
-Ureterosigmoid Fistula
-Pancreatic Fistula
What is the etiology of metabolic alkalosis?
Addition of HCO3:
-sodium bicarb administration
-massive transfusion (liver converts preservatives to HCO3)
Loss of Nonvolatile Acid:
-loss of gastric fluid (most common)
-loss of acid in urine
-diuretics
-ECF depletion (increased Na reabsorption –> H and K excretion)
Increased Mineralocorticoid Activity:
-Cushing’s syndrome
-hyperaldosteronism
What are the 4 steps of hemostasis?
- Vascular Spasm
- Formation of the platelet plug (primary hemostasis)
- Coagulation and Formation of Fibrin (secondary hemostasis)
- Fibrinolysis when the clot is no longer needed
Where are platelets formed? Where are they metabolized?
Formed by megakaryocytes in the bone marrow
Cleared by macrophages in the reticuloendothelial system and the spleen
What is the normal value for platelets? What are the critical values?
Normal = 150,000 - 300,000
<50,000 = increases surgical bleeding risk
<20,000 = increases spontaneous bleeding risk
*monitors number of platelets, not the function
What are the 3 steps of platelet plug formation (Primary Hemostasis)?
- Adhesion
- Activation
- Aggregation
*platelet plug is formed in ~5 minutes
What are the 12 coagulation factors?
1 - Fibrinogen
2 - Prothrombin
3 - Tissue Factor
4 - Calcium Ions
5 - Labile Factor
7 - Stable Factor
8 - Antihemophilic Factor
9 - Christmas Factor
10 - Stuart-Power Factor
11 - Plasma Thromboplastin
12 - Hageman Factor
13 - Fibrin Stabilizing Factor
*all except factor 3 and 4 are synthesized in the liver
What activates the extrinsic coagulation pathway? What lab test measures it? What drug inhibits it?
Activated by vascular injury (tissue trauma liberates tissue factor from the subendothelium)
-measured by the PT and INR
-inhibited by warfarin
What activates the intrinsic coagulation pathway? What lab test measures it? What drug inhibits it?
Activated by blood injury or exposure to collagen
-measured by the PTT and ACT
-inhibited by heparin
What factors are in the extrinsic pathway, intrinsic pathway, and final common pathway of the coagulation cascade?
Extrinsic Pathway: Factors 3 and 7
-“…can be purchased for 3 cents”
Intrinsic Pathway: Factors 8, 9, 11, and 12
-“if you can’t buy the intrinsic pathway for $12, you can buy it for $11.98”
Final Common Pathway: Factors 1, 2, 5, 10, and 13
-“…can be purchased at the5 and dime (10) for 1 or 2 dollars on the 13th of the month
What is fibrinolysis? What enzyme causes it?
The breakdown of a clot once it is no longer needed
-Plasminogen is a proenzyme that is synthesized in the liver –> it is incorporated into the clot as it is being formed, but lays dormant until it is activated
-Plasmin is a proteolytic enzyme that degrades fibrin into fibrin degradation products
What are the 3 phases of the contemporary cell-based coagulation cascade?
Contemporary cell-based coagulation cascade attempts to explain how platelets, the extrinsic pathway, and the intrinsic pathway function in an interdependent manner
-the idea is that coagulation takes place on the surface of a cell that expresses tissue factor
Three Phases:
1. Initiation
2. Amplification
3. Propagation
What are the components of the TEG? What products are used to treat each component?
R Time: time to begin forming clot – 6-8 min – issue w/ coagulation factors – treat w/ FFP
K Time: time until clot has achieved fixed strength – 3-7 min – issue w/ fibrinogen – treat w/ Cryo
Alpha Angle: speed of fibrin accumulation – 50-60 degrees – issue w/ fibrinogen – treat w/ Cryo
Max Amplitude: highest vertical amplitude on the TEG (measures clot strength) – 50-60 mm – issue w/ platelets – treat w/ platelets +/- DDAVP
Amplitude at min after max amplitude (A60): height of vertical amplitude 60 min after the max amplitude – MA-5 – issue w/ excess fibrinolysis – treat w/ TXA, Aminocaproic acid
Identify the cause of the following TEGs
What is the mechanism of action of heparin?
Inhibits the intrinsic and final common pathways
-antithrombin III is a naturally occurring anticoagulant that circulates in the plasma – heparin binds to antithrombin and greatly accelerates its anticoagulant ability 1000-fold
-Heparin-AT complex neutralized thrombin and activated factors 9, 10, 11, and 12
How do you treat a patient with ATIII deficiency?
Treat with AT concentrate of FFP
-antithrombin deficiency is a common cause for failure to achieve anticoagulation despite an adequate heparin dose prior to cardiopulmonary bypass