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Fluid Management
Fluid Management and Blood Administration - Basics Exam 4
87
Other
Graduate
02/18/2012

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Cards

Term
Name 5 goals for fluid management
Definition

To maintain adequate:

Intravascular fluid volume

Left ventricular filling pressure

Cardiac output

Systemic blood pressure

Oxygen delivery to the tissues

Term
Name components of a physical assessment that relate to fluid status
Definition

Skin turgor

Mucous membranes

Peripheral pulses

Resting HR and BP (orthostatics)

Urine output

NPO status

Term

Name effects of hypovolemia seen

on blood lab results

Definition

Increased Hct

Metabolic acidosis

Hypernatremia

BUN/creatinine ratio > 10:1

Term

Name effects of hypovolemia on

urine lab results

Definition

Specific gravity > 1.010

Urine sodium < 10 mEq/L

Urine Osmolality > 450 mOsm/kg

Term
T/F A patient on beta-blockers will be less likely to show tachycardia from hypovolemia.
Definition
True
Term
A drop in BP does not occur in a patient that is already in supine position until ____ % of the blood volume is lost.
Definition
30
Term
What is the intraoperative goal for urine output?
Definition
0.5-1 ml/kg/hr
Term
Change in urine output does not occur until ____% of blood volume is lost.
Definition
20
Term
Name signs of hypervolemia that may be seen on physical assessment
Definition

Pitting edema

Presacral edema

Later signs:  Tachycardia

Crackles

Wheezing

Pulmonary edema

Term

What are some manifestations of hypervolemia that may be seen

on x-ray?

Definition
  • Kerley B lines (increased pulmonary and interstitial markings)
  • Diffuse alveolar infiltrates

 

Term

Intracellular fluid is approximately ___ of

the body's water and ___% of body weight

Definition
2/3 ; 40%
Term
What are the major cations of intracellular fluid?
Definition

potassium (140 mEq)

 

magnesium (26 mEq)

 

sodium (10 mEq)

 

 

Term
What is the major cations of extracellular fluid?
Definition

sodium (140 mEq)


potassium (3.5-5.5 mEq)

 

calcium (8.4-10.5 mEq)

Term
Extracellular fluid is approximately ___ of body water and ___% of body weight
Definition
1/3 ; 20
Term

What fluid surrounds the cells and does not circulate?

 

It comprises ___ of the ECF.

Definition

Interstitial fluid

 

3/4

Term

The extracellular component of blood.

 

It comprises ___ of the ECF

Definition

Plasma

 

1/4

Term
What fluid is outside of normal compartments?
Definition
Transcellular fluid
Term

The typical male will be ___% water

 

Female?  ___%

 

Infant?  ___%

Definition

60

 

50

 

80

Term

Obese adults will have ___ (more/less) water per kg of body weight.

 

A patient with DM will have ___ (more/less) water per kg of body weight

Definition

less

 

less

Term

Name the formula for Free Water Deficit

 

Definition
[image]
Term

This cation affects resting

membrane potential

Definition
potassium
Term

What are the major anions of

extracellular fluid?

Definition

chloride (108 mEq)

 

bicarbonate (24 mEq)

 

proteins (16 mEq)

 

 

Term

What are the major anions of

intracellular fluid?

Definition

chloride (4 mEq)

 

bicarbonate (12 mEq)

 

phosphate (40-95 mEq)

 

proteins (54 mEq)

Term

What is the hallmark sign for

hypernatremia?

Definition
peripheral edema
Term

Name and describe three types

of hyponatremia

Definition
  1. hypovolemic:  ↓ total Na+
  2. isotonic/pseudohyponatremia:  normal total Na+
  3. hypervolemic:  ↑ total Na+ 
Term

Name some clinical manifestations of

hypernatremia

Definition

Neuro:  thirst, weakness, ICB, disorientation, hallucination, irritability

CV:  hypovolemia

Renal:  polyuria, oliguria, renal insufficiency

Term
How should water deficits associated with hypernatremia be corrected?
Definition
With a hypotonic solution such as D5W over 48 hours
Term

How should hypernatremia with increased total body sodium be corrected?

 

Definition

With a loop diuretic along with

intravenous D5W

Term
Name some clinical manifestations of rapid correction of hypernatremia
Definition

Seizures, cerebral edema, coma, death

 

 

Term
At what rate should plasma sodium concentration be decreased during treatment of hypernatremia?
Definition

No faster than 0.5-1 mEq/L/hr

 

* Be sure to check serum Na+ osmolalities during treatment

Term
What should the plan for elective surgery be in patients with significant hypernatremia (>150 mEq/L)?
Definition
Postpone surgery until the cause is established and fluid deficits are corrected
Term
What are manifestations of hyperkalemia as seen on ECG?
Definition

Prolonged PR interval


Widening QRS complex


Peaked T waves

 

Ventricular Arrhythmias

Term
What are some effects of calcium administration for the treatment of hyperkalemia?
Definition

Ca2+ will decrease excitability

Moves threshold away from threshold

Protects the heart from hyperkalemia

 

*CaCl is 10% solution, thus 1 amp = 1 gm

Term
Name some treatments for hyperkalemia
Definition

1.  Calcium 500-1000 mg IV (effects rapid but short-lived, Ca2+ potentiates digoxin toxicity)

2.  Sodium bicarb when metabolic acidosis present (45 mEq)

3.  Beta agonists

4.  IV infusion of 30-50 gm glucose and 10 units insulin (can take up to 1 hour)

5.  hemodialysis

6.  hyperventilation

7.  Kayexalate

8.  Furosemide

 

Term
What are some manifestations of hypokalemia as seen on ECG?
Definition

1. T wave flattening and inversion

2. Increasingly prominent U wave

3. ST segment depression

4. Widened QRS complexes

5.  Ventricular ectopy

 

Term
What is the relationship between arterial pH and plasma K+ concentration?
Definition
A 0.1 change in arterial pH can change plasma K+ concentration by 0.6 mEq (inversely proportional)
Term
Name some effects of hyperkalemia on membrane potentials
Definition

Resting membrane potential is less negative

 

Cell depolarizes & resting potential moves towards threshold

Term
Name some effects of hypokalemia on membrane potentials
Definition

Resting membrane potential becomes more negative

 

Cell hyperpolarizes, RMP moves away from threshold

 

Cell becomes less excitable - harder to reach threshold

Term
Name some treatments for hypokalemia
Definition

Oral replacement with potassium chloride (60-80 mEq/day)

 

 


Intravenous potassium:  peripheral (no greater than 8 mEq/hr)

central (10-20 mEq/hr)

Term
With a patient that is hypokalemic, what considerations should be taken when dosing NMBDs?
Definition
Dosages should be reduced 25-50% since hypokalemia causes increased sensitivity
Term
Name some causes of hypocalcemia
Definition

Hypoparathyroidism

Pancreatitis

Renal Failure

Decreased serum albumin levels?

Term
Name some clinical manifestations of hypocalcemia
Definition

Carpopedal spasm (Trousseau's sign)

Masseter spasm (Chvostek's sign)

Laryngospasm

Decreased cardiac contractility

Term
What effect does arterial pH have on [Ca2+]?
Definition
They are inversely proportional, a 0.1 decrease in arterial pH can increase [Ca2+] by 0.16 mg/dL
Term

What is the treatment for symptomatic hypocalcemia?

 

Definition

Calcium chloride (3-5 mL of a 10% soln) or calcium gluconate (10-20 mL of a 10% soln)

 

(10 mL of 10% CaCl2 contains 272 mg of Ca2+, whereas 10 mL of 10% cal gluconate contains only 93 mg of Ca2+)

 

**Follow treatment with serial ionized calcium levels

Term
Name some causes of hypercalcemia
Definition

Hyperparathyroidism

Bone malignancy

Renal Failure

Thiazide diuretics

Excess calcium supplements

Term
Name some signs of hypercalcemia as seen on ECG?
Definition

Shortened ST segment

Shortened QT interval

Dysrhythmias - CHB

Term
Name some clinical manifestations of hypercalcemia
Definition

Anorexia

N/V

Polyuria

Weakness

Hypertension

Term
Name some effects of hypercalcemia on membrane potentials
Definition

Threshold potential shifts away from resting potential

 

Threshold becomes less negative

 

Cells become less excitable

Term
Name the treatment for symptomatic hypercalemia
Definition

Rehydration (NS) followed by brisk diuresis (UOP 200-300 mL/hr) with a loop diuretic to accelerate calcium excretion

 

**Follow serial ionized calcium

Term
Name some causes of hypomagnesemia
Definition

Alcoholism

Chronic diarrhea

Hypercalcemia

Hyperaldosteronism

Malabsorption syndromes

Malnutrition

Certain medications

Term
Name some clinical manifestations of hypomagnesemia
Definition

Nystagmus

Seizures

Fatigue

Muscle spasms or cramps

Muscle weakness

Term
Name the treatment for symptomatic hypomagnesemia
Definition

Magnesium sulfate IV 1-2 gm slowly over 15-60 minutes

 

**Monitor labs for concomitant hypokalemia and hypocalcemia

Term
Name the treatment for hypermagnesemia
Definition

Stop all sources of mag (often antacids)


IV calcium 1gm can temporarily antagonize most effects


A loop diuretic with an infusion of D5 1/2NS enhances urinary magnesium excretion



 

Term

With a patient that is hypermagnesemic, what considerations should be taken when

dosing NMBDs?

Definition
The dosages of NMBDs should be reduced by 25-50%
Term
What are the general NPO guidelines for adults?
Definition

No solid food for 8 hours preop

 

May take oral meds with a sip of water day of surgery

 

**No chewing gum or mints after midnight

Term
What are the general NPO guidelines for pediatric patients?
Definition

Clear liquids up to 2 hours preop


Breast milk up to 4 hours preop


Formula, nonhuman milk, light meal at least 6 hours preop


Full meal, carbonated drinks at least 8 hours preop

Term
Name some types of patients that are at an increased risk for aspiration (and should thus adhere to longer fasting times)
Definition

Morbidly obese

Trauma

GI dysfunction, obstruction

Emergency surgery

Diabetes

Term

Describe the 4-2-1 Rule

(hourly maintenance)

Definition
  • 4 mL/kg/hr first 10 kg of body weight
  • 2 mL/kg/hr second 10 kg of body weight
  • 1 mL/kg/hr for the remaining weight in kg

Shortcut:  Patient's weight in kg + 40

Term
Describe how recovery of NPO deficit (fluid) is administered
Definition

Number of hours x hourly maintenance rate

Administer:

50% during the first hour

25% in the second hour

25% in the third hour

 

Term

Describe the guidelines for replacing redistributive and evaporative

surgical fluid losses

 

Definition

small incision/minimal tissue trauma: 2-4 mL/kg/hr

 

 

moderate incision/moderate tissue trauma:  4-6 mL/kg/hr

 

large incision/severe tissue trauma:  6-8 mL/kg/hr

 

major vascular case/extreme tissue trauma: 8-10 mL/kg/hr

Term
Significant variability with ventilation seen on an arterial line waveform is indicative of what?
Definition
hypovolemia
Term

Differentiate between crystalloid and

colloid fluids

Definition

Crystalloids contain electrolytes dissolved in water or dextrose and water (e.g. NS, LR)

 

Colloids are natural or synthetic molecules; impermeable to vascular membrane; determine osmotic pressure that balances distribution of water between intravascular and interstitial spaces (e.g.albumin, Hespan, Hextend)

Term
What potential problem arises when adminstering normal saline in large volumes?
Definition
In large volumes normal saline produces dilutional hyperchloremic acidosis because of its high sodium and chloride content (154 mEq/L):  plasma bicarbonate concentration decreases as chloride concentration increases.
Term
Name some indications for the administration of hypertonic saline
Definition

Major surgical procedures:  aortic, radical cancer surgeries

Shock

Slow correction of hyponatremia

TURP syndrome

Reduction in perioperative edema

Reduction in ICP

Term
Name some effects of hypertonic saline
Definition

Hypernatremia, hyperchloremia, hyperosmolality

Hypokalemia

Increased cardiac output

Decreased SVR/PVR; improved microcirculatory blood flow

Decreased ICP

Increased solute to kidneys

Term

A soaked 4x4 contains ___ of blood

 

A soaked lap sponge contains ___ of blood

Definition

10 mL

 

100 mL

Term

When replacing fluids, what is the ratio of crystalloid replacement : blood lost?

 

colloid replacement : blood lost?

Definition

Crystalloid - 3:1

 

Colloid - 1:1

Term
Explain the difference between a type & screen and a type & cross
Definition

A type & screen matches the patient's blood with compatible ABO and Rh blood for transfusion.

 

A type & cross does the same as a T&S but mimics the transfusion but mixing donor cells with recipient serum

Term
What is the formula for allowable blood loss (ABL)?
Definition

ABL = [EBV x (Hi-Hf)]/Hi

 

EBV = weight (kg) x average blood volume

Term

State the average blood volume for:

Preterm neonates

Term neonates

Infants & children

Adult males

Adult females

Definition

Preterm neonates:  95 mL/kg

Term neonates: 85 mL/kg

Infants & Children: 80 mL/kg

Adult males: 75 mL/kg

Adult females: 65 mL/kg

Term
What effect will one unit PRBCs have on Hgb and Hct?
Definition

It will increase Hgb by 1g/dL and Hct by 2-3%

(in adults)

Term

Hct 70%

Reconstitute with NS to decrease viscosity

Use fluid warmer to avoid hypothermia

Use 170 micron filter to trap clots and debris

1 unit should increase Hgb by 1 gm/dL or Hct by 3%

Definition
Packed red blood cells (PRBCs)
Term
Why is it important to infuse PRBCs with NS instead of D5W or LR?
Definition
  • Glucose solutions may cause RBC hemolysis
  • LR contains calcium and may induce clot formation
Term

40% Hct

Used primarily in hemorrhagic shock

Contains all factors (RBCs WBCs, platelets, plasma, clotting factors)

1 unit will raise Hct 3-4% and Hgb 1 gm/dL


 

Definition
Whole blood
Term

Contains plasma proteins and clotting factors

No platelets

Used in coagulation deficiencies, reversal of warfarin therapy

1 unit will increase clotting factors by 3%

Hypernatremia could result in massive transfusion

Definition
Fresh Frozen Plasma (FFP)
Term

Given for thrombocytopenia

Each unit contains about 50 mL of plasma

The presence of plasma poses a risk of transfusion reaction

Definition

Platelets

(1 unit can increase platelet count by 5,000 to 10,000)

Term

Fraction of plasma that precipitates once FFP is thawed

High concentrations of Factor VIII to treat Hemophilia A

High concentrations of fibrinogen to treat hypofibrinogenemia

Definition
Cryoprecipitate
Term
Name two types of nonhemolytic immune reactions (during blood transfusion)
Definition

Febrile reactions - an increase in temperature without evidence of hemolysis (1-3%)

 

Urticarial reactions - pruritis, hives, erythema without fever (1%)

Term
What is the most common cause of acute hemolytic reactions?
Definition
Misidentification of a patient, blood specimen, or transfusion unit
Term
What steps should be taken if a transfusion reaction is suspected?
Definition

1.  Stop transfusion

2. Treat hypotension with fluids and vasopressors. Consider steroids.

3. Send unused donor blood and a fresh patient sample to the blood bank to be recrossmatched

4. Sent patient blood samples for free Hgb, haptoglobin, Coombs test, DIC screen

5. Preserve renal function by maintaining brisk urine output (IVF, lasix, mannitol)

6. Follow hospital protocols

Term
Describe TRALI and its treatment
Definition
  • Transfusion-Related Acute Lung Injury (TRALI)
  • TRALI is a noncardiogenic form of pulmonary edema associated with blood product administration
  • Occurs most frequently with RBCs, FFP and platelets
  • The clinical appearance is similar to ARDS
  • Treatment is largely supportive - the patient should receive oxygen and ventilatory support as necessary, usually with a low tidal volume strategy
Term
Describe how citrate toxicity occurs during massive blood transfusion
Definition

Calcium binding by the citrate preservative can theoretically become significant following transfusion of large volumes of blood.

 

 

Clinically significant hypocalcemia, causing cardiac depression, does not occur in most normal patients unless the transfusion rate exceeds 1 unit every 5 minutes

Term
Name some symptoms of citrate toxicity
Definition

Hypocalcemia

Hypomagnesemia

Hypotension

Increased LVEDP

Increased CVP

Prolonged QT interval

Term
Name the treatment for citrate toxicity
Definition

Calcium (and magnesium)

 

**Citrate will be metabolized quickly in Kreb's Cycle so symptoms may abate before treatment needed.

Term
Name some symptoms of dilutional coagulopathy
Definition

Microvascular bleeding

Hematuria

Bleeding at IV sites

Increased PT/PTT

Decreased platelets

Clinically oozing

**Seen with massive transfusions > 1 EBV (>10 units)

 

 

Term
Describe the treatment for dilutional coagulopathy
Definition

Surgically control the bleeding

Keep patient warm

Maintain perfusion and euvolemia

Do not overhydrate and dilute patient

Consider FFP, platelets

Consider Vitamin K, DDAVP

Term
Name some alternatives to traditional blood transfusion therapy
Definition

Normovolemic hemodilution

Cell saver (intraop salvage)

Autolagous donation (preop)

Complete circuit -> Jehovah's Witness

Postop salvage (chest tube drainage system)

Oxygen-carrying substitutes (bovine blood)

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