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166 Cards in this Set

  • Front
  • Back
Pressure =
flow x resistance
Flow =
(Pa - Pv) / resistance
Resistance =
nxl/ r^4
This equation determines flow
Poiseuilles equation
Autoregulation
ability of an organ to maintain constant blood flow despite changes in pressure
______ vessels get less flow than ____ vessels at the same pressure.
constricted, dilated
As blood vessels dilate, flow ______.
increases
4 chief goals of fluid management
1. adequate O2 delivery (Hgb)
2. maintain electrolyte balance, normoglycemia
3. optimizing circulating volume
4. optimizing perfusion pressure
hypovolemia leads to ______ causing eventual _____.
ischemia, organ dysfunction
Effective intra-vascular flow is necessary to achieve (2):
perfusion and oxygenation
This site stores the greatest amount of H20 in the body, 28 liters, and composes 40% of body weight.
intracellular water
Total body water composes _____ percent of body weight.
60%
Extracellular water composes ____ % of body weight and includes these 3 compartments:
20%,
interstitial, plasma, transcellular
Intracellular fluid (ICF) is found largely in ______ and contains these cations and anions:
skeletal muscle mass
cations: K, Mag
anions: proteins and phosphates
The purpose of extracellular fluid is to:
provide nutrients and remove waste
____ % of ECF is interstitial and includes lymph, CSF, intraocular, synovial, pericardial, and peritoneal fluid.
70%
____ % of ECF ia intravascular and includes Na+ and Cl- ions.
30%
The other name for antidiuretic hormone (ADH) is
vasopressin
Describe the process of the renin-angiotensin-aldosterone system: (RAAS)
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
The baroreceptors are located at these 2 sites and stimulated by these 2 cranial nerves, releasing vasopressin when activated.
carotid - glossopharyngeal CN9
aortic - vagus CN 10
Stretch receptors that regulate fluid/electrolyte balance are located at these 2 sites
atrium, juxtaglomerular apparatus
______ is released from renal cortex, enhancing vasomotor tone and renal absorption.
Cortisol
Plasma osmolality is regulated by
ADH,
central and peripheral osmoreceptors (portal veins)
Sodium concentration is regulated by:
RAAS,
macula densa of JG apparatus
A decr. in renal perfusion detected in the JG apparatus stimulates kidney to release _____, which is converted by angiotensinogen from liver into ______.
renin, angiotensin I
Pulmonary and renal endothelium release ______, which coverts Angiotensin I to _______.
ACE,
Angiotensin II
Angiotensin II acts by these 5 effects:
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
The water and salt retention that results from RAAS activation improves volume status by:
improved circulating volume will lead to greater perfusion of JG apparatus.
Water moves freely through ___ and ____ walls and is distributed throughout multiple compartments (cell membrane, endothelium, capillaries, arteries/veins, intra/extracellular)
cell and vessel walls
Slow continuous flow from capillaries to interstitium occurs because net intra-capillary pressure is greater than _____.
interstitial pressure
In normal vasculature, there is small net flow out into the lymph, which travels to the _____ duct to return to the venous system.
thoracic duct
In pts experiencing hypovolemia pre-operatively, the provider should give reduced induction dose to prevent
cardiovascular collapse!
What are the contributors to activating vascular inflammation?
tissue trauma/hypoperfusion, ischemia, reperfusion injury, sepsis, extracorporeal circulation (cardiopulm bypass)
Low intravascular albumin results in a _____ drug response.
exaggerated
This solution is composed of inorganic ions and small organic molecules dissolved in h20
crystalloid solution
In crystalloid solutions, osmotically active particles attract water across semipermeable membranes until....
equilibrium is obtained
Isotonic solutions remain in this space
intravascular
Hypotonic solutions result in a fluid shift into:
interstitium
Hypertonic fluids have this effect:
pull fluid into vasculature from interstitium
LR contains calcium, and therefore should never be hung to co-admin with ____
blood
D5W is this type of solution
hypotonic
This is a homogenous non-crystalline substance consisting of LARGE molecules or ultramicroscopic particles of one substance dispersed through a second substance
colloid
Colloids can be either _____ or _____.
semi-synthetic, naturally occurring
How do colloids affect plasma volume expansion (PVE)?
large molecules incr. oncotic pressure to pull fluid into intravasc. space
How do colloids affect hemostasis?
could make pt bleed more bc clotting factors are diluted - dilutional coagulopathy
could make plts more slippery/less likely to bind together
How do colloids affect viscosity?
increase viscosity
Administration of colloids poses the risk of:
anaphylaxis or anaphylactoid events
Semi-synthetic colloids contain gelatins derived from the hydrolysis of ______ collagen.
bovine

this may cause diseases due to derivation from bovine animals
Gelofusin/haemaccel is an example of a
semi-synthetic colloids
Creutzfeldt Jakob disease, bovine spongiform encephalitis, von willenbrand, and decreased clot strength are all adverse effects possible from administration of:
semi-synthetic colloids
These semi-synthetic colloids are biosynthesized from sucrose by leuconostoc bacteria with the enzyme dextran sucrase
Dextrans
Between Gentran 40 and Gentran 70, which is a larger molecule that is metabolized more slowly and lasts longer?
Gentran 70
These are the effects of administration of dextrans:
coagulopathy, anti-thrombotic, incr. microvasc. flow, anti-inflammatory effects, anaphylaxis
Hetastarch/hespan is a semi-synthetic colloid generated from _____ from maize or sorghum.
amylopectin
Dose allowed of hespan in 24 hrs (to avoid side effects)
20 mL/kg
Hespan may cause:
coagulopathy, anti-inflammatory effects, anaphylaxis
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.
20-30%
Administration of 1 L hypertonic saline will bring in ___ L of fluid into intravasculature from interstitium.
2.5L
Albumin has a shelf life of ___ and is (cheap/expensive). There is a risk of ____ with administration.
3 years, expensive, virus transmission
5% albumin is an ____ fluid, where as 25% albumin will increased osmotic pressure by ___ times.
isotonic, 5 times
The half life of albumin is ____ hrs, and it is/is not a volume expander.
16 hrs, not a volume expander
Albumin is indicated in patients with:
low albumin
FFP is derived from ____, can be stored for ____ years, and contains ____ mL/unit.
whole blood, 1 year, 200-250 mL
FFP is given to replace _____ and can be used as a volume expander during ____.
coagulation factors, massive transfusion
The INR of FFP is _____, and carries risk of ______.
1.3, disease and allergic reactions
Total body water is ___ L, and the 14 L of ECF is composed of these 3 compartments:
42 L,
RBC 2 L, plasma 3L, ICF 9L
What are the consequences of inadequate fluid administration? (5)
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
What are the consequences of excessive fluid administration?
pulm edema
cardiac failure
interstitial edema
abd compartment syndrome
impaired GI fcn
coagulopathies
incr. wound infection
Is BP a good indicator of volume status?
no because we shunt blood flow to maintain BP, can be hypovolemic w norman BP, esp in young healthy ppl,
BP does not = flow
Is HR a good indicator of volume status?
not specific enough for reliability, can be altered for so many other causes
Volume status indicators on surface of pt include (2)
mucous membrane moisture, skin turgor
Urine output may not be a good indicator of volume status because it can be influenced by
medications
A TEE may not be a good fluid status indicator because
shunting can cause adequate TEE values even if volume status is altered
CVP is not always a good indicator of fluid status because
any change in vent settings, SVR, or positioning will affect CVP
Labs to indicate fluid/electrolyte status:
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)
In elderly pop, water composes __% of body weight.
50%
Stroke volume variation
when mech vent is affecting BP to cause ebb and flow in pressure (>13% is significant), does not occur in euvolemia
What is shock index?
if HR/SBP > 0.7, then pt is hypervolemic
In the "Recipe book" approach, these considerations should be addressed in calculating fluid deficit
pre-op deficit (did pt have anything after midnight),
intra-op losses (blood, insensible, 3rd space)
Expected GI fluid loss in 24 hrs
100-200 mL
Expected insensible loss in 24 hrs
500-1000 mL
Expected urinary loss in 24 hrs
1 L
Factors that increase fluid losses (there's a bunch)
fever (incr 500 mL/day)
wound drainage
incr GI loss
perspiration
blood loss
drugs (etoh, diuretics)
low humidity
What are some places pt can lose fluid to intra-operatively? (there's a bunch)
lap sponge (100 mL/ea)
raytec (25 mL/ea)
drapes
floor
OR table
sxn cannister
irrigation
crani-bag
Who is the most accurate estimator of intra-op blood loss?
anesthesia!
second is circulating RN
What is the estimated fluid requirement for a 70 kg pt in a day?
2500 mL
Metabolic Rate in relation to fluid requirement
80-100 mLs/100 kcals
Body surface area in relation to fluid requirement
1.5 mL/m^2/day
Weight in relation to fluid requirement
30-40 mL/kg/day
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
What is the estimated blood volume of a 70 kg adult?
70 kg x 70 mL = 4900 mL blood volume
Describe the 4-2-1 Rule
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
Parkland Burn Fluid Replacement Formula
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
What is the fluid resuscitation formula for an 80 kg pt with 50% TBSA burn?
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
How much crystalloid should be administered for volume replacement for blood loss?
3 mL isotonic per 1 mL blood loss
How much colloid should be administered for volume replacement for blood loss?
1 mL colloid per 1 mL blood loss
Only __ % of crystalloid remains intravascular.
20%
Fluid loss in the OR is influenced by these 3 factors:
1. type of procedure
2. length of procedure
3. extent of procedure
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
Third space fluid loss
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
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
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?
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)
What are the intra-op methods to determine if pt requires additional fluids? (there's a bunch)
CVP/PA cath
A-line (poor mans cvp)
Urine output
VS
labs
extent of surgery
outcome of fluid challenge
When giving a fluid challenge of 200-400 mL rapidly, no change in pt indicates that provider should...
give more fluid
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
blood component therapy

more than 60% of RBC are admin in OR
DO2
oxygen delivery to cells

DO2 = CO x CaO2 (O2 content)
CO =
HR X SV
CaO2 =
(hgb x 1.34)02 sat + PaO2 (0.003)
This is the main determinant of O2 content in blood
Hgb
Proteins in the blood include:
albumins, globulins, fibrins
Metabolites in the blood include:
lipids, glucose, amino acids, nitrogen wastes
White blood cells in the blood include:
neutrophils, lymphocytes, monocytes, eosinophils, basophils
How do anemia and hemodilution affect CO, HR, SV, contractility, O2 release, and O2 consumption/demand?
increase!
How do anemia and hemodilution affect peripheral vascular resistance and blood viscosity?
DECREASE!
Each blood group (A, B, AB, O), represent an ____ that modifies cell surface.
enzyme/antigen
Rh represents the presence or absence of _____ in RBC membranes.
C, D* or E antigens
Antibodies occur in _____ and antigens occur _____.
plasma, on surface of RBC
Group A blood has ____ antibodies and ____ antigens.
anti-b antibodies, a antigen
Group B blood has _____ antibodies and _____ antigens present.
anti-A antibodies, B antigens
Group AB blood has ____ antibodies and ____ antigens present.
NO ANTIBODIES, A and B antigens
Group O blood has _____ antibodies and _____ antigens present.
anti-A and anti-B antibodies, NO ANTIGENS
What does Rh +/- indicate?
rhesus D antigen
Rh+ = presence of D antigen
Rh- = absence of D antigen

anti-D antibodies
Providers must give ____ blood to women of childbearing age!
O negative
Providers should give ____ blood to women not of childbearing age and men if type cannot be verified in an emergency.
O positive!
Blood band crossmatch is good for ___ hours, because after this time, blood antibodies change and pt must be re-crossmatched.
72 hrs
What is the risk of transfusion rxn if giving O positive blood to an uncrossed/no prior transfusion pt?
0.1%
What is the risk of transfusion rxn if giving O positive blood to an uncrossed pt who has received prior transfusion?
1%
What is the risk of transfusion reaction if blood has been typed but not crossed? typed and crossed?
type specific - 0.1-0.01%
crossmatched - 0.001%
These are components of whole blood that can be administered to achieve certain patient-specific goals: (There's a ton)
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
Decribe the HCT, volume, shelf life, and indications for RBC administration.
HCT 70-80%, volume 300-350 mL, shelf life 21-42 days at 1-6 C, indicated for increasing O2 carrying capacity
Anesthesia _____ metabolism and O2 requirements in tissues.
decreases
Trasfusion Hgb triggers:
ASA- 6 g/dl
NIH - 7 g/dl

to maintain aerobic metabolism
RBC that are washed (with sterile saline): describe HCT, volume, shelf life, and indications for use...
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
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)
5000-10000 plts/mm^3, 50-70 mL/unit, stored 5 days, indicated for thrombocytopenia and abnormal plt functioning
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.
freeze within 8 hrs, contain 200-250 mL, use within 24 hrs of thawing
FFP universal donor and recipient:
donor- AB
recipient- O
FFP is indicated for patients with:
coagulation factor deficiencies, volume expander during massive transfusion (not other types of hypovolemia)
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 _______.
oncotic,
5% - raise albumin level
25% - incr. intravasc volume
The plasma half life of albumin is __ hrs and can be stored for __ yrs at 2-10 C.
16 hrs, 5 yrs
Albumin is indicated when
you want to promote oncotic pressure during hypovolemia or hypoproteinemia.
controversial
Cryoprecipitate is formed from thawing ____. It must be used within ___ hrs of thawing.
FFP, 4 hrs
Cryoprecipitate indications/effect on fibrinogen level:
contains factors 1, 8, 13, fibronectin, von willebrands factor
will raise fibrinogen 50 mg/dl
List some techniques for blood conservation during OR:
- 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
This is the collection, storage, and reinfusion of the pt's own blood, and is the safest type of blood transfusion:
autologous blood
Autologous blood can be stored for ___ days at 1-6 C, and pt may donate ___ units/wk.
storage for 42 days, donate 1 unit/wk
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.
perioperative blood collection of autologous blood "cell saver"
Cell saver peri-op blood collection is contraindicated in patients with
tumor cells, bacterial invasion
The primary reason for PRBC transfusion is
to increase O2 carrying capacity
Intra-op hemodilution of autologous blood
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
Risks for transfusion include (There's a bunch)
infection transmission, immunosuppression (the more you give the more immunosupr. the pt becomes),
TRALI,
graft vs host dx.,
anaphylaxis,
hypothermia,
metabolic issues,
circulatory overload
The most common and second most common transfusion reactions are
first- fever
second- allergic rxn w wheezing, hives, rash, anaphylaxis
Blood is cold, and should be...
warmed prior to pt admin
What are the metabolic complications of blood therapy?
acidosis, incr K+, decr. 2,3 DPG
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