Week 5: Fluid Management, Hematology, Blood Product Management Flashcards
Regulatory Mechanisms
The _______ and ________ of solute are regulated to maintain the volumes of the intracellular and extracellular compartments.
amount & concentration
- The primary extracellular solute.
- The primary intracellular solute.
- Sodium
- Potassium
- Albumin is the primary soluble protein that creates _________ _________ pressure.
- Serum osmolality is maintained between ____ -_____mOsm/L.
- colloid oncotic
- 280-300
Regulatory Mechanisms
- Sodium continuously leaks into cells along a concentration gradient and is exchanged for ________.
- Increases in intravascular volume result from increases in _______ and _______ retention.
- potassium
- sodium and water
Serum osmolality is regulated by:
Also influenced by:
- Renal concentrating ability.
- Arginine vasopressin,
- Thirst
Blood pressure
Cardiac output
Vascular capacitance.
Serum osmolality
________, __________ and the ___________ maintain the BP and volume status within range.
AVP, pressure diuresis, renin angiotensin system
EBV: Estimated Blood Vol (mL/kg)
Age:
1. Preterm infant
2. Full-term neonate
3. Infant
4. School age (5yr)
5. Adult
Estimate of Circulating Blood Volume
- 100
- 90
- 80
- 70
- 70
Maturation of Homeostatic Mechanisms
At 38 weeks gestation:
Renal blood flow is ______ of normal.
Renal blood flow increases as ____________ in the kidney decreases after birth.
1/3;
vascular resistance
Neonates have a limited ability to __________ urine.
So, they need to make _____ volumes of urine in order to excrete solutes.
concentrate;
larger
Neonates and infants have limited ability to handle fluid and solute loads.
Fluid requirements are ______, dehydration is common and errors in therapy are poorly tolerated.
high
When calculating maintenance fluid requirements, multiple factors are considered and titrated to effect for the individual child. It is important to understand the exceptions to the system and use clinical judgement to modify as necessary.
The 4-2-1 rule is a general guideline:
4ml/kg/hr for the first 10kg of weight
2ml/kg/hr for the next 10 kg
1ml/kg/hr for each kg thereafter
Dysregulation of ________ secretion is a hallmark of critical illness.
Therefore, the choice of IV fluid to utilize and rate of replacement are approached carefully.
Monitor serial electrolytes regularly.
ADH
Perioperative causes of increased ADH release.
Pain
Inflammation
Stress, catecholamines
Surgery; Laparoscopic sx.
Vomiting
Hypoxia
Hypercapnia
Medications (Opioids, Amiodarone, Vincristine)
Resp. diseases (asthma, penumonia, atelectasis)
CNS disorders (head injury, tumors)
Osmotic
Fasting
Hypovolemia
Hypertonicity
Hypotension
Renal/ Hepatic insufficiency
Table 9.5
Intraoperative Fluid Management
In healthy children, induce anesthesia with a mask and then obtain IV access.
In the pediatrics world, a _______-gauge catheter is considered a large bore IV.
22;
Children may have preexisting PICC lines which are less than desirable.
Limitations:
- Portals for infection,
- Flow resistance is high,
- Already may have pre-existing infusions running.
Intraoperative Fluid Management
Intraosseous devices cons:
- Flow rates are variable
- Drug effects are variable.
- Consider possibility of compartment syndrome and
- Injury to growth plates as complications.
Choice of Intravenous Fluids
_________ fluids are preferred (Ex:)
Isotonoic;
Plasmalyte,
Normal saline, or
Lactated ringers
Choice of Intravenous Fluids
- ________ containing fluid shouldn’t be used to replace fluid deficits.
- Debilitated infants, malnourished, neonates and infants younger than _____ months of age are at risk for intraoperative hypoglycemia and may benefit from _____ infusions.
- Monitor blood glucose intraoperatively.
- DO NOT discontinue D10 or D20 abruptly.
- Glucose
- 6; dextrose
Hypoglycemia
- Glucose < _____mg/dL require treatment.
- Symptoms:
- 40
- Jitteriness, lethargy, hypotonia, seizures, and apnea.
“Hypoglycemia” in full term infants is generally described as less than _____ mg/100 ml during the first day of life and less than ______mg/100 ml during the second day of life.
30;
40
To create D5LR for use in the OR: add _______ ml of D50 to _____ ml of LR (in a buretrol or a burette)
10; 90
Intravascular Volume Assessment
- CVP is not a great predictor of volume or preload (influenced by ________, _______ , _______
- Volume had been administered in _______ml/kg test challenges to determine volume responsiveness.
- PEEP,
Intrabdominal pressure, RV compliance - 5-10
Ongoing Fluid Loss
- Causes:
- Replace 1ml EBL with ________ml colloid or _____ml crystalloid.
- bleeding, third spacing, vasodilation, evaporation.
- 1; 1.5
- Third space losses range from ________ml/kg/hr depending on extent of surgery.
- Fluid overload may result in:
- 3-10
- Anasarca, pulmonary edema, bowel swelling, laryngotracheal edema.
Edema is essentially a ________ problem.
Sodium and water overload reside in the ______ space.
Plasma volume is generally _______.
sodium;
extracellular
increased
Therapy for fluid overload/edema
Salt restriction,
Diuresis,
dialysis,
Salt poor albumin
In the extracellular fluid (ECF)
- Major cations (+):
- Major anions (-):
- Sodium, Potassium and Calcium
- Chloride, Bicarbonate and Proteins
In the intracellular fluid (ICF)
Major cations (+):
Major anions (-):
- Potassium, Magnesium and Sodium
- Chloride, Bicarbonate and Proteins
- Most important electrolytes with regard to the excitability of nerve & muscle
- ______ effects resting membrane potential
- _______determines threshold potential
- Potassium and Calcium
- K+
- Ca++
Hypernatremia
- Symptom severity of hypo and hyper natremia are determined by the ______ and the ___________ of serum sodium.
- Acute hypernatremia is _______ in children with a mortality greater than 40% for the acute disorder.
- Children with acute conditions are usually symptomatic while chronic conditions are asymptomatic.
- Symptoms include:
- degree; rate of change
- common
- Irritability, Seizures, Coma, Circulatory collapse.
Hypernatremia
- In the case of circulatory collapse, administer ____ or ______.
- Once stable, restore fluid deficit over ____-____ hours.
- Correct Na no more than ____- _____ mOsm/L/hr. Rapid correction can result in cerebral edema, seizures, death.
- colloid or NS bolus
- 48-72
- 1-2
Hyponatremia
- Common in infants and children. Seen when?
- After surgery, acutely hyponatremic children present with _______ symptoms.
- Early CNS symptoms include:
- Late CNS symptoms include:
- Formula has been diluted
- nonspecific
- Headache, Nausea, Weakness, Anorexia.
- Mental status changes, Confusion, Irritability, Progressive obtundation, Seizures, Respiratory arrest.
Hyponatremia Treatment
- Asymptomatic hyponatremia is not a medical emergency.
- Correct at no more than ______mEq/L/hr to avoid central pontine myelinolysis.
- Symptomatic hyponatremia is a medical emergency. Therapy is aimed at stopping ________ _______.
- A dose of _______ml/kg of 3% saline over 20-30 minutes.
- Subsequent correction occurs over the next _____-______ hours with frequent electrolyte sampling.
- 0.5
- stopping seizure activity
- 2-3
- 24-48
Hyperkalemia
- Potassium (____ -____ mEq)
- Increase in total K content
- Altered distribution of K between intra- & extracellular sites.
- Adverse effects are 2◦ to acute ↑ in serum concentration.
- Most detrimental effect occurs in ____________ system
- 3.0 – 5.5
- cardiac conduction
EKG changes w/ Hyperkalemia
- Peaked T wave
- Prolonged PR interval
- Widening QRS complex
- P waves are lost
- Sinusoidal pattern
Hyperkalemia
In children, may be seen in the setting of?
Massive tissue injury
Adrenal hyperplasia
Massive blood transfusions.
Acidosis
Rhabdomyolysis
Iatrogrenis mishaps
Sux administation in children with myopathies.
Acute renal insufficiency
MAMA RISA
Treatment of Hyperkalemia
- Administration of _______ will protect the heart from hyperkalemia
- It will decrease ________.
- Depresses membrane ___________ and prevents spontaneous _________.
- Calcium chloride _______mg/kg or calcium gluconate ______mg/kg over 3-5 minutes
- Ca++
- excitability
- threshold potential; depolarization.
- 20; 60
Treatment of Hyperkalemia
- NaHCO3 promotes cellular uptake of K+ (___-___mEq/kg)
- ______ agonists
- Glucose (___-____gm/kg) + Insulin (______U/kg); over 30-60 min
- ________ - mild to moderate
- Kayexalate, furosemide, dialysis and correction of underlying cause
- 1-2
- Beta
- 0.5-1; 0.1
- Hyperventilation
Hypokalemia
- Most common complication of ______ and ______ seen in children.
- Also seen with:
- Diarrhea and vomiting
- Pyloric stenosis,
- Starvation,
- Chronic steroid use
- Beta agonist therapy.
Hypokalemia
- Generally serum K of ___-____ are corrected preoperatively.
- EKG:
- Correction should not exceed _____mEq/kg/hr
- In the setting of ________ and hypokalemia, _______ deficit must be replaced first.
- 2.0-2.5
- QT prolongation; Flattened T waves and presence of U wave
- 1
- hypochloremia; chloride
SIADH
- SIADH is common in children yet it is often overlooked.
- ___,____,_____,____,_____,_____,____, and a variety of other factors may all stimulate ADH release above and beyond that necessary to maintain osmolar balance.
Pain,
Surgical stress,
Critical illness,
Sepsis,
Pulmonary disease,
Central nervous system injury, Drugs
SIADH diagnosis
- Hyponatremia (Na+ <_______mEq/L),
- serum osmolality less than ______mOsm/L, and
- urine osmolality greater than ______ mOsm/L in the absence of volume depletion, cardiac failure, nephropathy, adrenal insufficiency, or cirrhosis are generally considered sufficient for diagnosis.
- 135
- 280
- 100
SIADH treatment includes:
- Restriction of free water
- Repletion of sodium deficits (if present)
- Administration of diuretics to offset the effects of vasopressin
Diabetes Insipidus
- results from decreased secretion of, or renal insensitivity to, _______.
- s/s include:
- Tx:
- Central DI responds to treatment with ________ by concentrating urine when water deprivation does not.
- vasopressin
- massive polyuria, volume contraction, dehydration, and plasma hyperosmolality.
- Maximal antidiuresis and fluid restriction
- desmopressin
Dilute polyuria (<______ mOsm, >___ mL/kg per hour)
in the presence of hypernatremia (Na+ >____mEq/L) with
hyperosmolality (>_____ mOsm/L) is the hallmark of DI
- 250; 2
- 145
- 300
Hyperchloremic Acidosis
May occur as a result of administration of large amounts of _________.
Clinical significance is still being reviewed.
- NS
Hypochloremic Metabolic Alkalosis
- Chronic vomiting as seen in infants with pyloric stenosis results in a ______, ________ state.
- Children with chronic, hypokalemic, hypochloremic, metabolic alkalosis: correction is achieved with:
____________ at ____- ____ ml/kg/hr until K+ is>3mEq/L and Cl >95mEq/L
- dehydrated; alkalotic
- NS with 20mEq/L K+ at 10-20
Hematology
A term neonate has relative ______, ________ and ________ compared with an older child.
Neonatal ________ counts are similar to those of an adult.
- polycythemia, reticulocytosis, leukocytosis
- platelet
Table 10.1
Hemoglobin , Hematocrit , WBC
Preterm 28-32
Preterm 32 - 36
Term neonate
1-yr old
Child
Adult
Preterm 28-32 : 12.9 / 40% / 5000
Preterm 32 - 36: 13.6 / 43% / 7700
Term neonate: 17 / 55% / 18,000
1-yr old: 12 / 36% / 10,000
Child: 13 / 38% / 8000
Adult: 15 / 45% /7500
Hematology
“Physiologic anemia of infancy” or “physiologic anemia of the newborn”
- In healthy, term infants, the hemoglobin levels begin to decline around the ________ week of life.
- They reach a nadir (i.e., the lowest point)
of _____ g/dL around ___-____ weeks of life.
- third
- 11; 8 - 12
Hematology
Premature infants have slightly lower hemoglobin levels.
- The nadir is lower and is reached sooner.
- Average nadir is __-___ g/dL and is reached at __-__ weeks of age.
This is related to a combination of:
- decreased _____ mass at birth,
- increased ______ losses from multiple lab draws,
- shorter RBC ______,
- inadequate _______ production, and
- rapid body _______
- 7-9; 3-6
- RBC;
- iatrogenic,
- life span;
- erythropoietin
- growth.
Guidelines for Transfusion
As a general guideline, transfusion is not indicated for hemoglobin concentrations greater than ________ g/dL but is indicated for concentrations less than ______g/dL.
10; 6
Packed red blood cells (PRBCs) should be transfused based on the child’s:
vital signs
- adequacy of oxygenation and perfusion,
- acuity and degree of blood loss, and
- other physiologic and surgical factors
Guidelines for Transfusion
- Transfusion thresholds may vary however.
- A neonate with a hemoglobin of 12g/dL for example, may require transfusion in the setting of _______, ______ or ______,
- A premature infant has increased risks of complications from hypovolemia, hypotension, acidosis, postoperative apnea in the setting of anemia and blood loss.
- congenital heart disease, lung disease or heart failure.
Guidelines for Transfusion
Transfusion guidelines for other blood products, including fresh frozen plasma (FFP) and cryoprecipitate, have been establishedand in the context of coagulation disorders. Indications for transfusing FFP are usually limited to the following:
- Replacement of documented congenital or acquired coagulation factor deficiency when a specific sterilized or combined factor concentrate is unavailable, especially in the setting of anticipated or active bleeding.
- Acquired coagulopathy resulting from massive transfusion
- Immediate reversal of warfarin’s effect when prothrombin complex concentrate (PCC) is unavailable
- Coagulation support in disease processes such as disseminated intravascular coagulation (DIC) and thrombotic thrombocytopenic purpura
- A source of antithrombin III for children deficient of this inhibitor who require heparin
Guidelines for Transfusion
- When ordering products for transfusion, guidelines recommend _________ and ______ blood components.
- For patients who will require multiple transfusions, an _____ _______ crossmatch will minimize the risk of developing alloantibodies and transfusion reactions.
- To reduce (but not eliminate) the risk of CMV transmission, ________ blood can be used in susceptible patients.
- leukocyte reduced; irradiated
- extended phenotypic
- CMV negative
Table 10.5
Indications for CMV-seronegative or Leukocyte-reduced RBCs to prevent virus transmission:
Well defined indications:
- Low birth weight <1200g
- HIV patient
- Recipient of seronegative allogeneic organ or hematopoietic stem cell transplant or prospective recipient.
- Pregnant woman
- Intrauterine transfusion
Table 10.5
Indications for CMV-seronegative or Leukocyte-reduced RBCs to prevent virus transmission:
Possible indications:
Probable absence of indications:
- Hodgkin disease or non-hodgkin lymphoma
- Recepient of immunosupressive therapy
- Candidate for aautologous hemotopoietic stem cell transplantation
- Hereditary or acquired cellular immunodeficiency
- seronegative term infant
- seropositive pregnant woman
Table 10.4
Well defined indications for irradiation of celullar blood components:
- Hematopoetic stem cell transplantation
- Actual or anticipated congenital cell-mediated immunodeficiency
- Intrauterine transfusion or after it
- Directed donation from relative or HLA-matched donor
- Hodking disease
- ALL
- Immunocompromised organ transplant recipient
Sickle Cell Disease (SCD)
- Chronic _______ ______ is a hallmark of HbSS disease.
- It is characterized by a baseline hemoglobin value of ____ to ______ g/dL
- __________ is used to prevent vasoocclusive episodes and end-organ damage
- Perioperative complications for children with sickle cell trait are rare.
- hemolytic anemia
- 5-9
- Hydroxyurea
Sickle Cell Disease (SCD)
- There are large _______ variations in severity of this disease.
- Hemoglobin S results from a single base-pair mutation in the _________ gene on chromosome ____,
- which results in the replacement of a negatively charged, hydrophilic _______ residue with a noncharged, hydrophobic ______ residue.
- This results in polymerization of HbS, precipitation and hemolysis.
- phenotypic
- β-globin; 11
- glutamate; valine
Thalassemia disorders are among most common genetic disorders worldwide
- Anemia in thalassemia is the result of _______ and ineffective _________.
- ________ expansion results and ___________ develops in the liver and spleen.
- _________ overload from transfusions and paradoxical increased __________ absorption
- hemolysis; erythropoiesis
- Bone marrow, extramedullary hematopoesis
- Iron; iron
Thalassemias
Clinical problems include (9):
Thalassemia patients also may be ______________ due to formation of reactive oxygen species that alter red cell membranes.
- Transfusion-associated alloimmunization and infection.
- Splenomegaly,
- Bone abnormalities,
- Endocrine dysfunction (including hypogonadism, hypopituitarism, and diabetes mellitus),
- Short stature,
- Pulmonary hypertension,
- Venous thrombosis
- Thromboembolism,
- Cardiomyopathy (primarily due to iron overload).
hypercoagulable
Idiopathic Thrombocytopenic purpur (ITP)
ITP is the most common cause of _____________ ____________ in the otherwise healthy child, and it commonly manifests in the ________ __________.
Incidence is 4 per 100,000 children and is usually self limiting between the ages of _____ and ______ yrs.
- acute-onset thrombocytopenia
- operative setting
- 2 and 10 years.
ITP is characterized by antibody-mediated clearance by tissue macrophages, resulting in thrombocytopenia (platelet count <___________/mm3) and shortened _____________ .
Treatment is usually only initiated when platelet counts are less than _____-______/mm3
- 100,000; platelet survival.
- 10,000-20,000
Von Willebrand Disease
- is one of the most common bleeding disorders, although studies suggest that the prevalence may be as low as ___ case per _______ people.
- The glycoprotein vWF serves two main roles in the coagulation cascade:
- Classified as mild, moderate and severe based on bleeding history and factor concentration and activity as measured by labs.
- 1; 1000
- Adhering platelets to damaged subendothelium and
- Carrying factor VIII in plasma.
Hemophilia
- Hemophilia is a group of congenital bleeding disorders caused by deficiency in factors:
- factor VIII (i.e., hemophilia A, or classic hemophilia),
- factor IX (i.e., hemophilia B, or Christmas disease), or
- factor XI (i.e., hemophilia C).
allowable blood loss formula:
Dose and effect of:
- PRBCs
- Platelets
- FFP
- Cryoprecipitate
- Fibrinogen concentrate
Platelets are essential to hemostasis associated with the vascular injury of surgery and are necessary for the control of surgical bleeding
For children who are thrombocytopenic before surgery, platelets should be infused just before the surgical procedure to ensure the greatest concentrations during the time of peak demand. The start of the procedure should________be delayed to obtain the results of a posttransfusion platelet count.
- not
Platelets should be filtered only by large-pore filters (≥________ µm) or ________ filters (if indicated).
__________ filters may adsorb large numbers of platelets, thereby diminishing the effectiveness of the platelet transfusion.
- 150; leukocyte-reduction
- Micropore
Platelets are suspended in ______, which may help to replenish coagulation factors other than
factors ____ and _____, which are labile, and
factor ________, which has an especially brief half-life.
Platelets should not be refrigerated or placed in a cooler with ice before administration, because cold-exposed platelets are rapidly cleared from the circulation.
- plasma,
- V and Vlll, which are labile.
- VII
Fresh Frozen Plasma (FFP)
- Contains all of the _____ and ______ at approximately the native concentration, but after 6 hours at 1°C to 6°C, the concentrations of the labile factors _______ and _________ begin to diminish.
- A major surgical indication for FFP is to correct coagulopathy associated with __________ or to correct _____________.
- clotting factors and regulatory proteins
- V; VIII
- massive blood transfusion;
- acquired coagulation factor deficiencies
______________ is present in FFP.
Rapid administration of FFP especially via a central line, is more likely to be associated with __________ toxicity than the transfusion of components with smaller volumes of plasma
Citrate anticoagulant; citrate
Cryoprecipitate
is prepared by thawing ______ at 4°C to 10°C and removing most of the _________, leaving behind precipitated protein that is then resuspended in a small volume of residual plasma (____-_____ mL) and refrozen.
FFP; plasma
15–25
Cryoprecipitate
component contains 20% to 50% of the factor ______ from the original unit of plasma,
____________, _________ (approximately _______ mg), and factor ________.
VIII;
von Willebrand factor (vWF)
fibrinogen: 250
XIII
Cryoprecipitate is indicated for the treatment of
- Factor XIII deficiency,
- Dysfibrinogenemia, and
- Hypofibrinogenemia
Desmopressin-DDAVP
DDAVP, a synthetic analog of vasopressin, can increase the levels of factor __________ (i.e., coagulant activity) and factor __________ in children with ________ or _________.
VIII:C;
VIII:vWF
mild hemophilia A or von Willebrand disease
Desmopressin-DDAVP
An IV dose of _______ (maximum _______) increases the levels of both factors _____ to ______ within 30 to 60 minutes, with a half-life of 3 to 6 hours
0.3 µg/kg; 20 µg
twofold to threefold
Desmopressin-DDAVP
Has been used to treat the coagulopathy associated with: (3)
Avoid in children less than ____yrs old, and those with _________ due to the potential for hyponatremia from water retention.
- Platelet dysfunction,
- Uremia, and
- Cirrhosis
- 2; CNS lesions
Massive Blood Transfusion
- Defined as replacement of a patient’s entire blood volume one or more times or as more than _______ml/kg PRBC transfused in less than ______ hours with ongoing uncontrolled bleeding.
- In children, think in terms of _______ of blood or blood volumes lost rather than _______ of blood transfused.
- 30; 4
- percent; units
Complications of Transfusion of components
- ___-____mEq of K+ are present in the extracellular fluid on a unit of RBCs by the time the unit reaches it’s shelf life. (Because RBCs leak K+ into the extracellular fluid during storage.)
- This leak is doubled and more rapid in a unit of _______ cells.
- A rapid transfusion rate of _________ in a 70kg adult is equivalent to _____-______ per minute of blood, which is a more accurate way to interpret this data in a pediatric patient.
- Warm blood and administer through a peripheral IV rather than a CVL to minimize risk of hyperkalemia.
- Monitor the ECG.
- 5-7
- irradiated
- 120ml/min; 1.5-2ml/kg
Hypocalcemia and citrate toxicity
- During massive transfusion, the citrate present in FFP and whole blood may overwhelm the capacity of the recipient to clear it which results in a decrease in __________.
- Treat with:
- Large decreases in ionized calcium can be avoided if exogenous calcium is administered during rapid FFP transfusion.
- ionized calcium
- calcium chloride or calcium gluconate.
Complications of Massive Transfusion
- Acid-base balance: after massive transfusion, moderate to severe _______ ________ is caused by large volumes of citrate transfused and conversion to ________ is common.
- Severe __________ is caused by low cardiac output and diminished oxygen delivery.
- Hypothermia: infuse blood products through a proper blood warmer
- metabolic alkalosis; bicarbonate
- acidosis
Acceptable component ABO groups (Second Choice)
Recipient ABO Group O
Whole blood
PRBC
FFP/ Cryo
Platelets
Whole blood: O
PRBC: O
FFP/ Cryo: O (A,B,AB, Plasma)
Platelets: O (A,B,AB)
Acceptable component ABO groups (Second Choice)
Recipient ABO Group A
Whole blood
PRBC
FFP/ Cryo
Platelets
Whole blood: A
PRBC: A (O)
FFP/ Cryo: A (AB)
Platelets: A (AB)
Acceptable component ABO groups (Second Choice)
Recipient ABO Group B
Whole blood
PRBC
FFP/ Cryo
Platelets
Whole blood: B
PRBC: B (O)
FFP/ Cryo: B (AB)
Platelets: B (AB)
Acceptable component ABO groups (Second Choice)
Recipient ABO Group AB
Whole blood
PRBC
FFP/ Cryo
Platelets
Whole blood: AB
PRBC: AB ( A, B, O)
FFP/ Cryo: AB
Platelets: AB
Packed RBC
Dose
Effect
Dose: 10-15 ml/kg
Effect: Increase Hgb by 2-3 g/dl
Platelets
Dose
Effect
Dose: 5-10ml/kg
Effect: increase platelet count by 50,000 - 100,000
FFP
Dose
Effect
Dose: 10-15ml/kg
- Factor level increase by 15-20%
Cryoprecipitate
Dose
Effect
1-2 units/kg
Increase fibrinogen by 60-100mg/dl
Fibrinogen concentrate
Dose
Effect
70 mg/kg
Increase in fibrinogen level of 120mg/dl
