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Spring '20/ L. BASICS- Immune, OR Hazards, OP > Week 4- Fluid and Blood Transfusion > Flashcards

Week 4- Fluid and Blood Transfusion Flashcards

1
Q

Importance of thorough preoperative evaluation of fluid balance status

A 
Patient History
Systemic B/P
Heart Rate
Urine Output
Hematocrit
BUN
Electrolytes
CVP
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2
Q 
Importance of thorough preoperative evaluation of fluid balance status
Grandma?(class discussion)
A

we know grandma and grandpa area already dry. now they are super dry.

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3
Q

Perioperative Assessment of Intravascular Fluid Status

causes of intravascular volume depletion

A 
Causes of Intravascular Volume Depletion
Prolonged GI losses
Chronic Hypertension
Chronic Diuretic Use
Sepsis
Trauma
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4
Q

chronic hypertension

A

blood pressure maintain within 20% of baseline

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5
Q

Physical signs and symptoms of Hypovolemia

A

Supine Hypotension
(implies blood volume deficit greater than 30%)
Orthostasis or Positive tilt test
( increases in HR greater than 20 beats/min and decreases in systolic BP greater than 20 mmHg when the patient assumes the standing position)
Oliguria

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6
Q

Is Hematocrit a useful tool in determining hypovolemia?

A

Hematocrit a useful tool ?? Yes they will be concentration to a crit of 40%

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7
Q

What are some of the initial (early) signs and symptoms of hypovolemic shock

A

Hypovolemia shock- tachycardia- decreased urine out

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8
Q

Hemoconcentration

A

(hct is a poor indicator of blood volume). High Hct means the patient is dry

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9
Q

Azotemia

A

(nitrogenous products in blood)

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10
Q

Low urine sodium concentration

A

(less than 20 meq for every 1000 ml of urine)

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11
Q

Metabolic acidosis

A

(reflects hypoperfusion). Due to Na++ reabsorption

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12
Q

Body Fluid Compartments

A

Total body water is divided into:
ICF
ECF (PV + ISF)

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13
Q

TBW content varies with:

A

Age
Gender
Body Habitus

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14
Q

Hypervolemia

A

increases the risk of pulmonary edema

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15
Q

Hypovolemia

A

increases the risk of organ hypoperfusion

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16
Q

Intra-Operative fluid loss

A 
Most fluid looses occurring intraoperatively are replaced with isotonic type solutions:
Lactated ringers (LR)
Plasmalyte (Normosol)
Normal saline (NS)-used to dilute blood as well
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17
Q

colloids

A

They are high molecular weight solutions which tend to stay intravascularly. The half – life is approximately 3 – 6 hours

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18
Q

Indications for Colloid Solutions

A 
Fluid resuscitation (hemorrhage) prior to transfusion Ex. Trauma
Fluid resuscitation (hypoalbuminemia or protein loss) Ex. Burns
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19
Q

Blood Derived Colloids, name them

A

5 % albumin
25 % albumin
5 % plasma protein fraction
Heated to 60º C for 10 hours to decrease the risk of hepatitis or viral diseases

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20
Q

Synthetic Colloids

A

Dextrose starches
Dextran 70 (macrodex) MW 70,000
Dextran 40 (rheomacrodex) MW 40,000
Dextran 40 improves microcirculation blood flow because it decreases blood viscosity. It also has anti-platelet effects. (Vascular surgery)
Referred to as LMD (Low molecular Dextran)

21
Q

More on Dextran…

A

Doses greater than 20 ml/kg/day can:
Interfere with blood typing
Prolong bleeding time
Cause renal failure
Cause anaphylactoid/anaphylactic reactions
Dextran 1 (promit) may be given prior to dextran to prevent severe anaphylaxis

22
Q

Hetastarch (hespan)

A

6 % solution MW 450,000. Plasma expander less expensive than albumin

Anaphylactoid reactions are rare

Coagulation and bleeding times are not affected when infusions are not greater than 1 literMax. dose 20 ml/kg/day

Hespan 6% in saline and Hextend 6% in balanced electrolytes (Ca)

Half-life for 90% of hydroxyethyl starch particles is 17 days.- reaction will be down the road if it happens.

Do not use hydroxyethyl starch (HES) products, including Hespan®, in critically ill adult patients, including patients with sepsis, due to increased risk of mortality and renal replacement therapy (RRT).

23
Q

Advantages of crystalloids

A

Inexpensive
Greater urine output
Replaces interstitial fluid

24
Q

Disadvantages of crystalloids:

A

Short lived hemodynamic improvement
Peripheral edema
Pulmonary edema

25
Q

Advantages of colloids:

A

Smaller infused volume
Prolonged increase in plasma volume (half life is 3 – 6 hours)
Minimal peripheral edema
Lower ICP (controversial)

26
Q

Disadvantages of colloids:

A

Expensive
Coagulopathy (dextran more than hetastarch)
Pulmonary edema (capillary leaky states)

27
Q

Colloids and Crystalloids

A

There is no evidence to support the superiority of either colloids or crystalloid containing solutions

28
Q

Urine Output/Goal During Surgery

A

Adequate is 0.5 - 1 ml/kg/hour

29
Q

Intraoperative Fluid Replacement

A 
In healthy adults undergoing elective surgery, the following must be taken into consideration:
NPO loss
Insensible loss (third space)
EBL Replacement
Maintenance
30
Q

Intraoperative Fluid Replacement

A 
The predicted daily maintenance fluid requirements for healthy adults may exceed 2500ml/day.
Insensible loss (diaphoresis, respiration, etc.) may exceed 1000ml/day
Urinary losses to maintain renal function average 1000ml/day, GI losses 200ml/day
31
Q

Intraoperative Fluid Replacement

A

Surgical Patients require additional fluids and electrolytes to replace losses from the ECF to nonfunctional “third space”
We base our fluid replacement on the anticipated need categorized by the amount and duration of tissue trauma caused

32
Q

Insensible losses

A

500-1000mL/day (respiratory/cutaneous)

33
Q

Evaporation

A

(most common from larger wounds)

34
Q

Fluid shifts/internal redistribution (third spacing)

A

Ex. Burns, trauma, extensive injuries

35
Q

The following is an accepted example of “third space” replacement

A

Minor trauma 2 ml/kg/hr *Values vary
Moderate trauma 4 ml/kg/hr between sources
Extensive trauma 8 ml/kg/hr

Keep in mind that colloids may be required if EBL is extensive

36
Q

Calculation of Third Space Losses

Mild

A

(lower abdominal) 0 – 2 ml/kg/hr (hysterectomy, herniorrhaphy)

37
Q

Calculation of Third Space Losses

Moderate

A

(upper abdominal) 2 – 4ml/kg/hr (colectomy, gastrectomy)

38
Q

Calculation of Third Space Losses

Extreme

A

(combined upper/lower) 4 – 8 ml/kg/hr (thoracotomy, AAA repair)

39
Q

Mobilization of third space fluids occurs in about 72 hours post-op

A

Mobilization of third space fluids occurs in about 72 hours post-op

40
Q

Maintenance fluid

calculation

A

Maintained with isotonic solution
4cc/kg for the 1st 10kg of body weight (Up to 10 kg)
2cc/kg for the next 10kg of body weight (11- 20 kg)
1cc/kg for the rest of the body weight (21 kg and above)

41
Q

hourly maintenance

A

Another option for hourly maintenance (approximation) in the adult patient is to use 1.5 cc/Kg/hr

Mostly done in emergency cases when calculations are not feasible

42
Q

NPO Deficit

A

Deficit is described as the maintenance rate x the hours of NPO

43
Q

Fluid maintenance administration per hour

A

Give ½ in the first hour, ¼ in the second hour, and ¼ in the third hour.

44
Q

Formula to Calculate Adjusted Body Weight

A

actual patient weight + ideal patient weight /2

45
Q

Ideal Body Weight

A

First 5 feet = 100 pounds then
For females add 5 pounds for every inch above 5 feet
For males add 7 pounds for every inch above 5 feet

46
Q

Ideal Body Weight Obesity

A

Obesity is 20 % above the ideal body weight

Morbid obesity is twice the IDEAL BODY WEIGHT

47
Q

Ideal Body Weight

morbid obesity

A

Morbid obesity is twice the IDEAL BODY WEIGHT

48
Q

obese patient calculate fluid and drugs

A

For obese patients calculate fluid and drugs required according to the adjusted body weight

Spring '20/ L. BASICS- Immune, OR Hazards, OP (18 decks)

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