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166 Cards in this Set
- Front
- Back
Pressure =
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flow x resistance
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Flow =
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(Pa - Pv) / resistance
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Resistance =
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nxl/ r^4
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This equation determines flow
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Poiseuilles equation
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Autoregulation
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ability of an organ to maintain constant blood flow despite changes in pressure
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______ vessels get less flow than ____ vessels at the same pressure.
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constricted, dilated
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As blood vessels dilate, flow ______.
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increases
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4 chief goals of fluid management
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1. adequate O2 delivery (Hgb)
2. maintain electrolyte balance, normoglycemia 3. optimizing circulating volume 4. optimizing perfusion pressure |
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hypovolemia leads to ______ causing eventual _____.
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ischemia, organ dysfunction
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Effective intra-vascular flow is necessary to achieve (2):
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perfusion and oxygenation
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This site stores the greatest amount of H20 in the body, 28 liters, and composes 40% of body weight.
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intracellular water
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Total body water composes _____ percent of body weight.
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60%
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Extracellular water composes ____ % of body weight and includes these 3 compartments:
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20%,
interstitial, plasma, transcellular |
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Intracellular fluid (ICF) is found largely in ______ and contains these cations and anions:
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skeletal muscle mass
cations: K, Mag anions: proteins and phosphates |
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The purpose of extracellular fluid is to:
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provide nutrients and remove waste
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____ % of ECF is interstitial and includes lymph, CSF, intraocular, synovial, pericardial, and peritoneal fluid.
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70%
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____ % of ECF ia intravascular and includes Na+ and Cl- ions.
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30%
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The other name for antidiuretic hormone (ADH) is
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vasopressin
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Describe the process of the renin-angiotensin-aldosterone system: (RAAS)
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decr. GFR causes decr. Na+ delivery to the distal tubule --> activation of SNS --> renal HTN releases renin --> converts to aldosterone --> causes kidneys to conserve H20 and reabsorb
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The baroreceptors are located at these 2 sites and stimulated by these 2 cranial nerves, releasing vasopressin when activated.
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carotid - glossopharyngeal CN9
aortic - vagus CN 10 |
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Stretch receptors that regulate fluid/electrolyte balance are located at these 2 sites
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atrium, juxtaglomerular apparatus
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______ is released from renal cortex, enhancing vasomotor tone and renal absorption.
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Cortisol
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Plasma osmolality is regulated by
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ADH,
central and peripheral osmoreceptors (portal veins) |
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Sodium concentration is regulated by:
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RAAS,
macula densa of JG apparatus |
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A decr. in renal perfusion detected in the JG apparatus stimulates kidney to release _____, which is converted by angiotensinogen from liver into ______.
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renin, angiotensin I
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Pulmonary and renal endothelium release ______, which coverts Angiotensin I to _______.
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ACE,
Angiotensin II |
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Angiotensin II acts by these 5 effects:
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1. incr. sympathetic activity
2. Tubular Na,Cl reabsorption and K excretion --> water retention 3. adrenal cortex is stimulated to release aldosterone 4. arterial vasoconstriction to incr BP 5. posterior pituitary gland secretes ADH to promote water absorption in collecting duct |
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The water and salt retention that results from RAAS activation improves volume status by:
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improved circulating volume will lead to greater perfusion of JG apparatus.
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Water moves freely through ___ and ____ walls and is distributed throughout multiple compartments (cell membrane, endothelium, capillaries, arteries/veins, intra/extracellular)
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cell and vessel walls
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Slow continuous flow from capillaries to interstitium occurs because net intra-capillary pressure is greater than _____.
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interstitial pressure
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In normal vasculature, there is small net flow out into the lymph, which travels to the _____ duct to return to the venous system.
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thoracic duct
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In pts experiencing hypovolemia pre-operatively, the provider should give reduced induction dose to prevent
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cardiovascular collapse!
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What are the contributors to activating vascular inflammation?
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tissue trauma/hypoperfusion, ischemia, reperfusion injury, sepsis, extracorporeal circulation (cardiopulm bypass)
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Low intravascular albumin results in a _____ drug response.
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exaggerated
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This solution is composed of inorganic ions and small organic molecules dissolved in h20
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crystalloid solution
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In crystalloid solutions, osmotically active particles attract water across semipermeable membranes until....
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equilibrium is obtained
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Isotonic solutions remain in this space
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intravascular
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Hypotonic solutions result in a fluid shift into:
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interstitium
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Hypertonic fluids have this effect:
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pull fluid into vasculature from interstitium
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LR contains calcium, and therefore should never be hung to co-admin with ____
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blood
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D5W is this type of solution
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hypotonic
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This is a homogenous non-crystalline substance consisting of LARGE molecules or ultramicroscopic particles of one substance dispersed through a second substance
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colloid
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Colloids can be either _____ or _____.
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semi-synthetic, naturally occurring
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How do colloids affect plasma volume expansion (PVE)?
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large molecules incr. oncotic pressure to pull fluid into intravasc. space
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How do colloids affect hemostasis?
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could make pt bleed more bc clotting factors are diluted - dilutional coagulopathy
could make plts more slippery/less likely to bind together |
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How do colloids affect viscosity?
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increase viscosity
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Administration of colloids poses the risk of:
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anaphylaxis or anaphylactoid events
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Semi-synthetic colloids contain gelatins derived from the hydrolysis of ______ collagen.
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bovine
this may cause diseases due to derivation from bovine animals |
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Gelofusin/haemaccel is an example of a
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semi-synthetic colloids
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Creutzfeldt Jakob disease, bovine spongiform encephalitis, von willenbrand, and decreased clot strength are all adverse effects possible from administration of:
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semi-synthetic colloids
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These semi-synthetic colloids are biosynthesized from sucrose by leuconostoc bacteria with the enzyme dextran sucrase
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Dextrans
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Between Gentran 40 and Gentran 70, which is a larger molecule that is metabolized more slowly and lasts longer?
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Gentran 70
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These are the effects of administration of dextrans:
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coagulopathy, anti-thrombotic, incr. microvasc. flow, anti-inflammatory effects, anaphylaxis
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Hetastarch/hespan is a semi-synthetic colloid generated from _____ from maize or sorghum.
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amylopectin
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Dose allowed of hespan in 24 hrs (to avoid side effects)
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20 mL/kg
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Hespan may cause:
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coagulopathy, anti-inflammatory effects, anaphylaxis
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Giving isotonic crystalloid to incr. intravascular volume is only temporary, as only _____ % will remain in intravasculature after 20-30 min. The sicker the patient, the more it leaks into interstitium.
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20-30%
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Administration of 1 L hypertonic saline will bring in ___ L of fluid into intravasculature from interstitium.
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2.5L
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Albumin has a shelf life of ___ and is (cheap/expensive). There is a risk of ____ with administration.
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3 years, expensive, virus transmission
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5% albumin is an ____ fluid, where as 25% albumin will increased osmotic pressure by ___ times.
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isotonic, 5 times
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The half life of albumin is ____ hrs, and it is/is not a volume expander.
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16 hrs, not a volume expander
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Albumin is indicated in patients with:
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low albumin
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FFP is derived from ____, can be stored for ____ years, and contains ____ mL/unit.
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whole blood, 1 year, 200-250 mL
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FFP is given to replace _____ and can be used as a volume expander during ____.
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coagulation factors, massive transfusion
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The INR of FFP is _____, and carries risk of ______.
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1.3, disease and allergic reactions
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Total body water is ___ L, and the 14 L of ECF is composed of these 3 compartments:
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42 L,
RBC 2 L, plasma 3L, ICF 9L |
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What are the consequences of inadequate fluid administration? (5)
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1. decr. circulating volume
2. shunting blood toward vital organs 3. inadequate tissue perfusion/O2 delivery --> anaerobic cellular metabolism 4. inflammatory cascade activation 5. SHOCK |
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What are the consequences of excessive fluid administration?
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pulm edema
cardiac failure interstitial edema abd compartment syndrome impaired GI fcn coagulopathies incr. wound infection |
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Is BP a good indicator of volume status?
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no because we shunt blood flow to maintain BP, can be hypovolemic w norman BP, esp in young healthy ppl,
BP does not = flow |
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Is HR a good indicator of volume status?
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not specific enough for reliability, can be altered for so many other causes
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Volume status indicators on surface of pt include (2)
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mucous membrane moisture, skin turgor
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Urine output may not be a good indicator of volume status because it can be influenced by
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medications
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A TEE may not be a good fluid status indicator because
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shunting can cause adequate TEE values even if volume status is altered
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CVP is not always a good indicator of fluid status because
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any change in vent settings, SVR, or positioning will affect CVP
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Labs to indicate fluid/electrolyte status:
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serum sodium (hypovolemic = high, hypervolemic = low), serum osmolarity (280-85 normal), BUN:Creatinine (10:1 normal), H/H (not as reliable, may be anemic), pH (not direct indicator), Lactate/base deficit (may be altered for other reasons)
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In elderly pop, water composes __% of body weight.
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50%
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Stroke volume variation
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when mech vent is affecting BP to cause ebb and flow in pressure (>13% is significant), does not occur in euvolemia
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What is shock index?
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if HR/SBP > 0.7, then pt is hypervolemic
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In the "Recipe book" approach, these considerations should be addressed in calculating fluid deficit
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pre-op deficit (did pt have anything after midnight),
intra-op losses (blood, insensible, 3rd space) |
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Expected GI fluid loss in 24 hrs
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100-200 mL
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Expected insensible loss in 24 hrs
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500-1000 mL
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Expected urinary loss in 24 hrs
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1 L
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Factors that increase fluid losses (there's a bunch)
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fever (incr 500 mL/day)
wound drainage incr GI loss perspiration blood loss drugs (etoh, diuretics) low humidity |
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What are some places pt can lose fluid to intra-operatively? (there's a bunch)
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lap sponge (100 mL/ea)
raytec (25 mL/ea) drapes floor OR table sxn cannister irrigation crani-bag |
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Who is the most accurate estimator of intra-op blood loss?
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anesthesia!
second is circulating RN |
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What is the estimated fluid requirement for a 70 kg pt in a day?
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2500 mL
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Metabolic Rate in relation to fluid requirement
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80-100 mLs/100 kcals
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Body surface area in relation to fluid requirement
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1.5 mL/m^2/day
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Weight in relation to fluid requirement
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30-40 mL/kg/day
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What are the estimated blood volumes for the following populations?
premi, newborn, child, adult? |
premi- 95 mL/kg
newborn 85 mL/kg child 75-80 mL/kg Adult 65 f - 70 m mL/kg |
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What is the estimated blood volume of a 70 kg adult?
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70 kg x 70 mL = 4900 mL blood volume
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Describe the 4-2-1 Rule
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maint fluid calculation
1-10 kg, 4 mL/kg/hr or 100 mL/kg/day 11-20 kg, 2 mL/kg/hr or 50 mL/kg/day 21 +, 1 mL/kg/hr, or 20 mL/kg/day if >21 kg (All adults), just add 40 to weight in kg for hourly maint IVF if adult weighs 70 kg, maint is 70+40= 110 mL/hr to maintain euvolemia |
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Parkland Burn Fluid Replacement Formula
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kg x % TBSA (total body surface area burned) x 4 = 24 hr resuscitation
give first half in first 8 hrs, and second half over next 16 hrs |
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What is the fluid resuscitation formula for an 80 kg pt with 50% TBSA burn?
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80 kg x 50 x 4 = 16000
pt should get 8000 in first 8 hrs and 8000 in next 16 hrs = 24 hrs initial rate 1000 mL/hr, then at 9th hr rate should be dropped to 500 mL/hr |
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How much crystalloid should be administered for volume replacement for blood loss?
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3 mL isotonic per 1 mL blood loss
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How much colloid should be administered for volume replacement for blood loss?
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1 mL colloid per 1 mL blood loss
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Only __ % of crystalloid remains intravascular.
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20%
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Fluid loss in the OR is influenced by these 3 factors:
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1. type of procedure
2. length of procedure 3. extent of procedure |
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Decribe the mL/kg/hr for the following types of fluid loss in the OR:
generic, minimal, moderate, severe |
generic 2 mL/kg/hr
minimal 3-4 mL/kg/hr moderate 5-6 mL/kg/hr severe 7-8 mL/kg/hr |
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Third space fluid loss
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fluid lost into transcellular fluid spaces, such as bowel lumen, peritoneal and pleural cavities
losses predominantly from interstitial compartments but must be replaced by other compartments |
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Calculate:
it is currently 13:00, 86 kg male NPO since midnight, OR began at 07:00, bladder repair, no blood loss how much fluid should be on board by 13:00? |
86+40 = 126 maint rate
deficit 13 hrs x 126 = 1638 total deficit 4 mL/kg/hr for minimal intra-op blood loss -- 4 x86 = 344 x 6 hrs OR = 2064 intra-op fluid loss 2064 + 1638 maint = 3702 mL total should be given by 13:00 |
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If an 82 kg male has been NPO x 7 hrs, what is the fluid deficit and how should it be restored over 3 hrs?
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hourly manit 82 + 40 = 122 mL/hr
122 x 7 hrs = 854 mL give half in first hour (427 mL) and next half over next 2 hrs (214/hr) |
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What are the intra-op methods to determine if pt requires additional fluids? (there's a bunch)
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CVP/PA cath
A-line (poor mans cvp) Urine output VS labs extent of surgery outcome of fluid challenge |
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When giving a fluid challenge of 200-400 mL rapidly, no change in pt indicates that provider should...
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give more fluid
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This type of IV therapy refers to the transfusion of the specific part of blood that the pt needs as opposed to routine transfusion of whole blood
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blood component therapy
more than 60% of RBC are admin in OR |
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DO2
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oxygen delivery to cells
DO2 = CO x CaO2 (O2 content) |
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CO =
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HR X SV
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CaO2 =
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(hgb x 1.34)02 sat + PaO2 (0.003)
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This is the main determinant of O2 content in blood
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Hgb
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Proteins in the blood include:
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albumins, globulins, fibrins
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Metabolites in the blood include:
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lipids, glucose, amino acids, nitrogen wastes
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White blood cells in the blood include:
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neutrophils, lymphocytes, monocytes, eosinophils, basophils
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How do anemia and hemodilution affect CO, HR, SV, contractility, O2 release, and O2 consumption/demand?
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increase!
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How do anemia and hemodilution affect peripheral vascular resistance and blood viscosity?
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DECREASE!
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Each blood group (A, B, AB, O), represent an ____ that modifies cell surface.
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enzyme/antigen
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Rh represents the presence or absence of _____ in RBC membranes.
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C, D* or E antigens
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Antibodies occur in _____ and antigens occur _____.
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plasma, on surface of RBC
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Group A blood has ____ antibodies and ____ antigens.
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anti-b antibodies, a antigen
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Group B blood has _____ antibodies and _____ antigens present.
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anti-A antibodies, B antigens
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Group AB blood has ____ antibodies and ____ antigens present.
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NO ANTIBODIES, A and B antigens
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Group O blood has _____ antibodies and _____ antigens present.
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anti-A and anti-B antibodies, NO ANTIGENS
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What does Rh +/- indicate?
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rhesus D antigen
Rh+ = presence of D antigen Rh- = absence of D antigen anti-D antibodies |
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Providers must give ____ blood to women of childbearing age!
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O negative
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Providers should give ____ blood to women not of childbearing age and men if type cannot be verified in an emergency.
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O positive!
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Blood band crossmatch is good for ___ hours, because after this time, blood antibodies change and pt must be re-crossmatched.
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72 hrs
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What is the risk of transfusion rxn if giving O positive blood to an uncrossed/no prior transfusion pt?
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0.1%
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What is the risk of transfusion rxn if giving O positive blood to an uncrossed pt who has received prior transfusion?
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1%
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What is the risk of transfusion reaction if blood has been typed but not crossed? typed and crossed?
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type specific - 0.1-0.01%
crossmatched - 0.001% |
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These are components of whole blood that can be administered to achieve certain patient-specific goals: (There's a ton)
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RBC, granulocytes, plts, FFP, cryoprecipitate, Factor 8 and 9, alpha 1 proteinase inhibitor, anti-inhibitor coag complex, albumin, plasma protein fraction, immune globulin, Rh immune globulin, anti-thrombin 3
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Decribe the HCT, volume, shelf life, and indications for RBC administration.
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HCT 70-80%, volume 300-350 mL, shelf life 21-42 days at 1-6 C, indicated for increasing O2 carrying capacity
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Anesthesia _____ metabolism and O2 requirements in tissues.
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decreases
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Trasfusion Hgb triggers:
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ASA- 6 g/dl
NIH - 7 g/dl to maintain aerobic metabolism |
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RBC that are washed (with sterile saline): describe HCT, volume, shelf life, and indications for use...
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HCT 70-80%, 180 mL volume, stored 24 hrs at 1-6 C, indicated for recurrent or severe allergic rxns, and in cancer patients, in an effort to remove proteins that could cause a rxn
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Platelets must undergo ______, contain ___ platelets per unit and ____mL, can be stored for ___ days, are contaminated if pool at room temperature, and are indicated for: (2)
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5000-10000 plts/mm^3, 50-70 mL/unit, stored 5 days, indicated for thrombocytopenia and abnormal plt functioning
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FFP is derived from whole blood, must be frozen to -18 C within ____ hrs of collection, volume of ____mL, and must be used within ____ hrs of thawing.
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freeze within 8 hrs, contain 200-250 mL, use within 24 hrs of thawing
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FFP universal donor and recipient:
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donor- AB
recipient- O |
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FFP is indicated for patients with:
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coagulation factor deficiencies, volume expander during massive transfusion (not other types of hypovolemia)
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Albumin is a major source of ____ pressure. It is derived from whole blood and you can give a 5% dose to increase _____ or a 25% dose to increase _______.
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oncotic,
5% - raise albumin level 25% - incr. intravasc volume |
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The plasma half life of albumin is __ hrs and can be stored for __ yrs at 2-10 C.
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16 hrs, 5 yrs
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Albumin is indicated when
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you want to promote oncotic pressure during hypovolemia or hypoproteinemia.
controversial |
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Cryoprecipitate is formed from thawing ____. It must be used within ___ hrs of thawing.
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FFP, 4 hrs
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Cryoprecipitate indications/effect on fibrinogen level:
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contains factors 1, 8, 13, fibronectin, von willebrands factor
will raise fibrinogen 50 mg/dl |
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List some techniques for blood conservation during OR:
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- tolerance of lower hgb
- acute normovolemic hemodilution - autologous blood - cell saver (suck blood off OR table, wash and return to pt) - anesthesia tricks (hypothermia, deliberate hypotension, epidural use) - surgical technique - artificial O2 carriers |
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This is the collection, storage, and reinfusion of the pt's own blood, and is the safest type of blood transfusion:
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autologous blood
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Autologous blood can be stored for ___ days at 1-6 C, and pt may donate ___ units/wk.
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storage for 42 days, donate 1 unit/wk
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In this technique, blood is suctioned from operative field, processed, and returned to patient, to minimize bank blood usage. Blood must be used within 6 hrs of collection.
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perioperative blood collection of autologous blood "cell saver"
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Cell saver peri-op blood collection is contraindicated in patients with
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tumor cells, bacterial invasion
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The primary reason for PRBC transfusion is
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to increase O2 carrying capacity
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Intra-op hemodilution of autologous blood
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1-3 units removed and stored, volume replaced w colloid or crystalloid, and blood with a lower hct is lost during surgery. the pt's blood is re-infused when needed, must be done sterilely, and can be stored at room temp x 8 hrs
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Risks for transfusion include (There's a bunch)
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infection transmission, immunosuppression (the more you give the more immunosupr. the pt becomes),
TRALI, graft vs host dx., anaphylaxis, hypothermia, metabolic issues, circulatory overload |
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The most common and second most common transfusion reactions are
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first- fever
second- allergic rxn w wheezing, hives, rash, anaphylaxis |
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Blood is cold, and should be...
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warmed prior to pt admin
|
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What are the metabolic complications of blood therapy?
|
acidosis, incr K+, decr. 2,3 DPG
|
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What are the consequences of the citrate anticoagulant component of blood products?
|
hypocalcemia (Binds of Ca), citrate is metabolized in liver to HCO3 - causes alkalosis
|
|
Coagulation complications of blood therapy are:
|
thrombocytopenia,
factor 5 and 8 affected, dilutes clotting factors |
|
Hypothermia, microaggregates (debris lodged in lungs), and viral disease transmission can all result from:
|
receiving blood products
|
|
Hepatitis and HIV transmission through blood transfusions are very rare, and the most common pathogenic transmission is
|
bacterial contamination
1/40,000 |
|
The decision to use crystalloids vs colloids is controversial, with the current recommendation of:
|
combination fluid therapy
|
|
Advantages of crystalloid
|
inexpensive
incr urine output replaces interstitial fluid |
|
Disadvantages of crystalloid
|
transient hemodynamic effect
peripheral edema pulm edema |
|
Advantages of colloid
|
smaller volume required
prolonged incr. of intravasc volume less peripheral edema |
|
Disadvantages of colloid
|
expensive
decr GFR coagulopathy |
|
Calculate the fluid requirement:
a 70 kg healthy male with a hct 42% is having an ORIF. OR began at 7 am, its now noon, NPO since midnight. EBL 450 |
70+40 = 110 maint rate
deficit = 12 x 110 = 1320 450 EBL require 4 mL/kg/hr replacement 3 x 450 = 1350 (for EBL) 4 mL/kg insensible loss x 5 hrs = 4 x 5 x 70 = 1400 1320+1350+1400= 4070 mL pt needs to be replaced with |
|
The best type of IV to promote rapid flow is:
The limiting factor is the IV tubing, which can help determine rate of flow. |
a short fat IV!
14 g IV allows 330 mL/min 22 g IV allows 35 mL/min 20 cm TLC allows 55 mL/min if using an introducer sheath, flow is IV tubing dependent |
|
Pressure bags, Level 1, fluid management system (FMS), and rapid infusion systems are all used for
|
resuscitation
|
|
The reason that jehovah's witnesses will not take blood products is because
|
they believe if they receive blood the cannot go to heaven. if they die today because they didn't receive blood, they can still go to heaven.
often will accept cell saver but not autologous transfusion |