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88 Cards in this Set
- Front
- Back
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INTRA-OP GOAL URINE OUTPUT
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0.5 - 1 cc/kg/hr
change in urine output does not occur until 20% of blood is lost |
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ICF
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2/3 of body water
40% of weight primarily K+ organic anions and proteins |
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EQUATION FOR TOTAL BODY WATER DEFICIT
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TBW (L) = (WT in kg X % water)
TBW males = 60% TBW females = 50% TBW infants = 80% |
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HYPONATREMIA
Na+ req. (mmol) = |
Na+ req. (mmol) = TBW x (desired Na+ - serum Na+)
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RATE OF INFUSION FOR SODIUM REPLACEMENT
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Rate of Infusion (Na+) cc/hr = Na+ req. (mmol) x 1000 / infusate Na+ (mmol/L) x time (hrs)
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EFFECTS OF K+ AND CA++
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K+ effects resting membrane potential
Ca++ determines threshold potential |
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HYPERNATREMIA
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-secondary to lack of water (not too much salt)
-Hallmark sign - peripheral edema -Tx crystalloids |
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HYPONATREMIA
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Neurologic systems occur below 120 mEQ/L
- associated with alcoholism, liver failure, severe burns, hemodialysis, and sepsis (COMA SEIZURES, H/A, CEREBRAL EDEMA, N/V, CRAMPS, AND WEAKNESS) |
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TYPE OF HYPOTONIC HYPONATREMIA
(SERUM OSMO < 280) HYPOVOLEMIC HYPONATREMIA |
causes - diuretics, ketonuria, 3rd spacing, adrenal insufficiency, and N/V.
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HYPOTONIC HYPONATREMIA
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^ water in serum (hypotonic) --> decrease in osmolarity < 280 --> decrease in solutes in serum (decrease in osmo b/c of dilution) -->
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PSEUDOHYPONATREMIA
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A.K.A. isotonic hyponatremia
osmo 280-285 causes- hyperlipidemia, hyperproteinemia, infusion of ISOTONIC non electrolytes ex- glucose, mannitol, and glycine |
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HYPOVOLEMIC HYPONATREMIA
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-decrease in TBW and Na+ with a relatively greater decrease in Na+
-causes- diuretics, ketonuria, 3rd spacing, adrenal insufficiency, and N/V TX- 0.9%NS regardless whether Urine Na+ >20 or < 10 |
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ISOTONIC HYPONATREMIA
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Increase in TBW with a near normal total body Na+
-causes- diuretics, barbs, adrenal insufficiency, hypothyroid, SIADH, increase in uptake of fluids, ESRD, and ARF TX Urine Na+ >20 treat with water restriction Urine Na+ <10 tx with hypertonic saline, fluid restriction, -/+ loop diuretic |
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HYPERVOLEMIC HYPONATREMIA
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Increase in Na+ with a relatively greater increase in TBW
-causes- nephrotic syndrome, CHF, and cirrhosis treatment with Sodium and Water restriction, diuretics |
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HYPONATREMIA CORRECTION
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-rapid causes demyelinating lesions in brain (pontine myelonitis)
-mild sx 0.5mEQ/L/Hr -mod sx 1 mEQ/L/Hr -severe sx 1.5 mEQ/L/Hr |
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SEVERE HYPONATREMIA WITH SX AND SEIZURES
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3% hypertonic saline
-fluid restriction -furosemide correction to Na+ > 130 safe for GA |
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HYPERKALEMIA EFFECTS
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-prolonged PR interval
-widening QRS complex -peaked T wave |
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ACUTE HYPERKALEMIA... WHAT HAPPENS AND HOW DO YOU TREAT?
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-resting membrane potential is less neg
-cell depolarizes and resting potential moves TOWARD threshold -paralysis, and EKG changes -TX sodium bicarb (~50mEQ promotes cellular uptake of K w/in 15 min, beta agonists, glucose 30-50 gm + 10 units of insulin --> can take up to an hour, hyperventilation, hemodialysis |
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ACUTE HYPOKALEMIA... WHAT HAPPENS AND HOW DO YOU TREAT?
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-resting membrane potential becomes MORE neg
-cell hyperpolarizes, RMP moves away from threshold -cell becomes more excitable, harder to reach threshold -palpitations, cramping, parasthesias, hallucinations - |
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NMBD AND HYPOKALEMIA?
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NMBD should be reduced 25-50% since hypokalemia causes increased sensitivity
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HYPOCALCEMIA
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-skeletal muscle spasm including laryngospasm
-decreased myocardial contractility -***avoid hyperventilation 0.1 decrease in arterial pH can increase ionized Ca <> by 0.16 mg/dL |
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ACUTE HYPOCALCEMIA
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-increase in nerve and muscle excitability
-tingling in lips and hands due to increasing of firing -twitches and tetany -parathyroidectomy- tetany laryngospasm -hyperventilation -prolonged QT interval and t wave inversion -trousseaus's and chvosteks sign |
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TX OF ACUTE HYPOCALCEMIA
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-symptomatic hypoCa is a true medical emergency
-CaCl2 300-500 mg or cal gluconate 100 - 200 mg -check a Mg and consider giving 1 gm |
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HYPERCALCEMIA
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-causes- hyperparathyroidism, malignancy (bone), renal failure, thiazide diuretics, excess Ca
- signs- HTN, dysrhythmias, shortened QT, sedation, polyuria, anorexia, pancreatitis |
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ACUTE HYPERCALCEMIA
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-threshold potential shift away from resting potential
-threshold becomes less neg -cells become less excitable -excessive urination, constipation, renal failure, death TX - rehydration with NS followed by brisk diuresis with LOOP diuretic to accelerate Ca excretion |
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HYPOMAG
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causes- starvation, chronic alcohol, diarrhea, insulin
-chosvteks, trouseaus, cardiac changes simlar to hypo Ca. |
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TREATMENT FOR HYPER MG
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-rehydration with D5 1/2 NS and loop diuretic
-monitor for vasodilation and negative inotropic effects -decrease NMBD by 25-50% |
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PROLONGED FASTING CAN CONTRIBUTE TO ...?
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hypoglycemia, hypovolemia, and anxiety
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PEDIATRIC NPO GUIDELINES
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-up to 2 hours pre-op can have clear liquids
-breast milk up to 4 hours pre op -formula, nonhuman milk, light meal up to 6 hours pre op -full meal carbonated bev up to 8 hours pre op - |
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NPO DEFECIT
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# hours NPO x Hourly maintenance
give 50% first hour give 25% second hour give 25% third hour |
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TYPICAL DAILY OUTPUT
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Urine 1500 ml
insensible/ evaporation 800ml (resp 400ml, skin 400ml) sweat glands 100ml stool 100ml |
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INTRA-OP FLUID SHIFTS
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fluid shift into 3rd space
-small incision/ minimal trauma 2-4 cc/kg/hr -mod incision/ mod trauma 4-6 -large incision/ large trauma 6-8 -major vascular case 8-10 |
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CRYSTALLOIDS
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-contain electrolytes dissolved in water or dextrose in water
-isotonic- 0.9% NS, LR -NS contains more Cl than ECF |
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COLLOIDS
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-natural or synthetic molecules, impermeable to vascular membrane
-determine the colloid osmotic pressure that balances the distribution of water b/t intravascular and interstitial spaces -albumin, 6% hydroxyethyl starch (hespan, hextend) |
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IV FLUIDS
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-NaCl 0.9%- renal patients, blood admin
-Plasmalyte- Mg, acetate, gluconate -LR- Na, Cl, K, Ca -D5W- 5g dextrose/L -dextran, hetastarch- volume expansion - |
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INTRA-OP FLUID SHIFT
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-small incision/minimal trauma 2-4 cc/kg/hr
-moderate incision/mod trauma 4-6 cc/kg/hr -large incision/ severe trauma 6-8 cc/kg/hr -major vascular case/ extreme trauma 8-10 cc/kg/hr |
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LACTATED RINGERS
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-dextrose, K, Ca, Na, lactate
-concerns for patients with renal and hepatic disease -diabetics -blood transfusion |
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CRYSTALLOIDS
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-contains more chloride than the ECF can cause hyperchloremic induced metabolic acidosis
-good choice for renal and diabetic patients -can cause hyponatremia in brain injury patients - |
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DEXTROSE CONTAINING SOLUTIONS
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-prevention of hypoglycemia
-especially for pediatric, insulin infusion -hyperglycemia is associated with increased risk of ischemic neurologic injury |
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CRYSTALLOID ADVANTAGES
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-inexpensive * promotes urinary flow * restores third space loss * used for extracellular repletion * used for initial resuscitation
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CRYSTALLOID DISADVANTAGES
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-dilutes plasma proteins * causes reduction of capillary osmotic pressure * has transient effect * potential for pulmonary edema
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COLLOID ADVANTAGES
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-sustained increase in plasma volume * requires smaller volume for resuscitation * less peripheral edema * tends to remain intravascular * more rapid resuscitation * useful in conditions of altered vascular permeability
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COLLOID DISADVANTAGES
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* expensive * can cause coagulopathy (dextran > hetastarch > hextend) * can cause anaphylactic reaction (dextran) * decreases Ca (albumin) * can cause renal failure (dextran) * can cause osmotic diuresis * can cause impaired immune response (albumin)
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HYPERTONIC SALINE
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-2%/3%
-beneficial in fluid resuscitation from shock/trauma and major surgical losses -INDICATIONS -major surgical procedures, aortic, radical cancer sx -shock -slow correction of hyponatremai -TURP syndrome -reduction in perioperative edema -reduction in ICP |
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HYPERTONIC SALINE EFFECTS
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-hypernatremia, hyperosmolarity, hyperchloremia, hypokalemia, ^CO, decreased SVR/PVR, improved microcirculatory flow, decreased ICP, increased solute to kidneys
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EBV FOR PEOPLE
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-premature- 95ml/kg
-term neonates- 85ml/kg -infants and child- 80ml/kg -adult males- 75ml/kg -adult females- 65ml/kg |
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ESTIMATED BLOOD LOSS FROM OR TOWELS
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4 x 4 soaked = 10ml blood
lap sponge soaked = 100ml blood |
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WHEN TO TRANSFUSE CALCULATION
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MABL = (Body weight in kg x EBV) x (existing Hct - Desired Hct) / existing Hct
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FACTORS THAT AFFECT O2 DELIVERY
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-inability to increase CO
-shifts in the oxyhemoglobin curve -inadequate oxygenation -abnormal Hgb |
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O2 EXTRACTION RATIO (SvO2) mixed venous
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-what fraction of the total O2 delivered is consumed or extracted by the tissues
-ER = O2 consumption / O2 delivery - (VO2 / DO2) = 250 / 1000 = 25% which means a normal mixed venous saturation is 75% |
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PRBC WILL INCREASE Hgb AND Hct BY WHAT?
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-Hgb 1 g/dL
-Hct 2-3 % * 3ml/kg increases Hgb by 1 * 10 ml/kg increases Hct by 10% |
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ALBUMIN
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-pooled plasma in saline
-highly soluble, globular protein, accounting for 70-80% of the colloid osmotic pressure of plasma -5% rapid intravascular volume expansion -25% hypoalbuminemia -has an intravascular 1/2 life of > 24 hours |
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CRYSTALLOIDS WHY DO YOU HAVE TO ADMIN MORE THAN COLLOIDS
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-most perioperative volume deficits are ECF
-crystalloids will eventually equilibrate between plasma and interstitial space therefore more is needed to maintain intravascular volume |
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ALBUMIN AND PLASMA DERIVATIVES
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-no possibility of transfer of diseases because of how heated
-no coag factors -associated with increased mortality in critically ill patients |
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DEXTRAN
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-synthetic plasma expander
-intravascular 1/2 life 6 hours -can cause anaphylaxis, volume overload, pulm edema, cerebral edema, platelet dysfunction, renal failure, and patients with diabetes, renal insufficiency are at an increased risk |
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SYNTHETICS HETASTARCH
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-HETASTARCH, VOLUVEN - non-ionic starch derivatives
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SYNTHETICS HEXTEND AND HESPAN
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HEXTEND (6% in HES and LR)
HESPAN (6% in HES and NS) -synthetic polymers -contains Na, Ca, K, and Mg -intravascular 1/2 life > 24 hours -Infuse no more than 1000 ml -higher volumes can result in bleeding complications due to decreased factor VIII/ vWBf, platelet defects, fibrin clots -anaphylactoid rxns have been reported with both dextran and hetastarch but much less freq with hetastarch |
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WHY IS ROUTINE BLOOD TYPING DONE?
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To identify antigens on the on the erythrocyte membranes (A, B, Rh)
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WHAT ARE ANTIBODIES
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Anti A or Anti B
they are formed whenever membranes lack A and/or B antigens -these antibodies are capable of causing rapid intravascular destruction of erythrocytes that contain the corresponding antigens |
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ABO SYSTEM
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-chromosomal locus produces 3 alleles
A, B, O -each represent an enzyme that modifies a cell surface glycoprotein producing a different antigen |
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EBV FOR PEOPLE
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-premature- 95ml/kg
-term neonates- 85ml/kg -infants and child- 80ml/kg -adult males- 75ml/kg -adult females- 65ml/kg |
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ESTIMATED BLOOD LOSS FROM OR TOWELS
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4 x 4 soaked = 10ml blood
lap sponge soaked = 100ml blood |
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WHEN TO TRANSFUSE CALCULATION
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MABL = (Body weight in kg x EBV) x (existing Hct - Desired Hct) / existing Hct
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FACTORS THAT AFFECT O2 DELIVERY
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-inability to increase CO
-shifts in the oxyhemoglobin curve -inadequate oxygenation -abnormal Hgb |
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PaO2
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-partial pressure of oxygen in the plasma phase of arterial blood
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SaO2
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-percentage of all the available heme binging sites saturated with O2
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CaO2
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(arterial O2 content)
-how much oxygen is in the blood ml O2/dL |
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VO2
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-rate at which oxygen is used by tissues
-product of CO and the difference between arterial and venous content -Normal O2 consumption is 250ml/min |
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DO2
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-quantity of O2 made available to the body in one min is known as the oxygen delivery
- CO x arterial O2 content (CaO2) = 1000 ml O2/min |
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O2 EXTRACTION RATIO (SvO2) mixed venous
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-what fraction of the total O2 delivered is consumed or extracted by the tissues
-ER = O2 consumption / O2 delivery - (VO2 / DO2) = 250 / 1000 = 25% which means a normal mixed venous saturation is 75% |
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ALBUMIN
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-pooled plasma in saline
-5% rapid intravascular volume expansion -25% hypoalbuminemia --highly soluble, globular protein, accounting for 70-80% of the colloid osmotic pressure of plasma -has an intravascular 1/2 of > 24 hours |
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DEXTRAN
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-composed of polymerized glucose molecules
- intravascular 1/2 6 hours -anaphylaxis, pulm edema, cerebral edema, plt dysfunction, pts with diabetes or renal failure increases the risk |
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ALTERNATIVES TO TRADITIONAL BLOOD THERAPY
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-normovolemic hemodilution
-cell saver - 50-60% Hct (intra op salvage) -oxygen carrying substitutes- bovine petroleum based therapies -autologous donation (pre op) -complete circuit (jehovahs witness) -post op salvage in chest tube (complications are reinfused anticoagulants, dilutional coagulopathy, air embolism) |
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DILUTIONAL COAGULOPATHY
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-seen with massive transfusions (> 1 EBV, > 10 units)
-microvascular bleeding -hematuria -bleeding at IV sites -clinically oozing -increased PT/PTT -decreased platelets TREATMENT -sugically control the bleeding -keep the patient warm -maintain perfusion and euvolemia -don't over hydrate and dilute the patient -consider FFP/ plt -consider vitamin K, DDAVP (enhances plt adhesiveness) |
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SYMPTOMS OF CITRATE INTOXICATION
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-occurs from the addition of CDP as preservative for stored blood, and can occur with rapid tranfusion, >150ml/min
-hypocalcemia -hypotension -increased LVEDP -increased CVP -prolonged QT interval -hypomagnesemia (tacharrythmias, torsades, refractory VF TREATMENT -calcium and mag -citrate will be metabolized quickly in krebs cycle so may be over before it needs to be treated |
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BIOCHEMICAL CHANGES IN STORED BLOOD
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-progressive acidosis
-Increased K, ^CO2, ^lactate, decreased glucose, decreased 2,3 DPG, destroyed plt, decreased factor V (15%) and factor VIII (50%) |
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TRALI
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-transfusion related acute lung injury
-noncardiogenic form of pulm edema associated with blood product admin (RBC, FFP, plt) -appearance similar to ARDS -usually begin within 6 hours of transfusion -pt develops dyspnea, cyanosis, fever, chills, hypotension and noncardiogenic pulm edema -treatment largely supportive - |
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WHAT TO DO IF TRANSFUSION REACTION IS SUSPECTED
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-stop the transfusion
-treat hypotension with fluids and vasopressors, consider steroids -send unused donor blood and sample from patient to blood bank to be recrossmatched -test pt for free Hgb, haptoglobin, Coombs test, and DIC screening -preserve renal with brisk urine output, ivf, lasix, mannitol |
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COMPLICATIONS OF BLOOD TRANSFUSIONS
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-infection, TRALI, hyperkalemia, acidosis, hypothermia
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CRYOPRECIPITATE
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-fraction of plasma that precipitates after FFP thawed
-has high <> of factor VIII for hemophilia -high <> of fibrinogen to treat hypofibrinogemia |
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PLATELETS
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-thrombocytopenia <50,000
- 1 unit replaces 5-10,000 -each unit contains about 50ml of plasma which increases the risk of reaction |
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FFP
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-contains plasma and clotting factors
-no platelets -utilized in coag deficiencies, reversal of warfarin therapy, and microvascular bleeding -1 unit of FFP will increase clotting factors by 3 % -hypernatremia can occur from massive transfusion of FFP |
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WHOLE BLOOD
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-40% Hct
-used primarily in hemorrhagic shock >25 % EBV -contains all factors, increased likelihood of reaction |
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PRBC
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contains rbc, wbc, and plt, reduced plasma
-Hct 70% -cold storage destroys plat - |
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EMERGENCY TRANSFUSIONS
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-O is universal donor
-if > 2 units are given must screen patient blood for antibodies before give their own blood to them -above remains true only for whole blood >10 units give only O blood for 3-4 months (life of RBC) -can give O+ just not to women of child bearing age |
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TYPE AND CROSS
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-always want to use this type compatibility 99.95%
-if in emergency use type specific uncrossmatched blood -last resort O- |
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ABO BLOOD GROUPIN
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A - anti A
B - anti B AB - no antibodies O - anti A and anti B |
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RH SYSTEM
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-involves antigen D
-80-85% of caucasian have the D antigen -people LACKING this are considered Rh NEGATIVE and usually develop antibodies against the D antigen after exposure to previous Rh positive transfusion or pregnancy (Rh negative mother delivering an Rh positive baby) |
