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73 Cards in this Set
- Front
- Back
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What's the 4-2-1 Rule?
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If you take a person’s weight in kg:
For each kg of the first 10 kg they get 4 cc/hr. For the next 10 kgs after the first 10, you add 2 cc/kg/hr. After the first 20 kg, you get 1 cc/kg/hr. |
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Principal component of crystalloids is what ?
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the inorganic salt, sodium chloride (NaCl).
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75-80% of the volume of sodium-based IV fluids are distributed in the ________ space.
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75-80% of the volume of sodium-based IV fluids are distributed in the interstitial space.
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the predominant effect of volume resuscitation with crystalloids is to expand the __________ volume rather than the _______ volume
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the predominant effect of volume resuscitation with crystalloids is to expand the interstitial volume rather than the plasma volume
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80% of the ECF is __________ fluid
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80% of the ECF is interstitial fluid
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resuscitating a pt with normal saline can give
a) respiratory acidosis b) resp alkalosis c) metab acidosis d) metab alkalosis |
metabolic acidosis
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What's unique about Normosol?
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It has Mg
It has 7.4 pH |
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What's unique about lactated ringers?
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It has Ca
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Is there evidence that LR provides any benefit over isotonic saline?
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No
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Risk with giving lactated ringers
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The calcium in LR can bind to certain drugs and reduce their bioavailability and efficacy
In patients with liver failure, often they cannot convert the lactate to bicarbonate. This allows for a build-up of lactate and creation of a metabolic acidosis (the exact thing we are trying to avoid by giving LR). administered blood to clot B/c Calcium binds to citrate (anticoagulant) in blood products According to one text, LR is contraindicated as a diluent for blood transfusions |
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Buffer of Normolyte
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Acetate [Normosol] or gluconate [Plasma-lyte] is added for buffering
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Are Dextrose Containing Solutions
effective volume expanders? |
No
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Dextrose Containing Solutions
were originally intended to supply nonprotein calories and thus provide a protein _______ effect. Now we use enteral and parenteral nutrition (standard of care). So it would seem this would be obsolete |
Dextrose Containing Solutions
were originally intended to supply nonprotein calories and thus provide a protein sparing effect. Now we use enteral and parenteral nutrition (standard of care). So it would seem this would be obsolete |
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Some adults and children are not that sick and don’t need tube feeds or parenteral nutrition. They just need a temporizing solution (no pun intended). This is where ________ comes in.
Example: Patient waiting for surgery, newborns that are relatively healthy, some metabolic diseases need infusions. |
Some adults and children are not that sick and don’t need tube feeds or parenteral nutrition. They just need a temporizing solution (no pun intended). This is where dextrose comes in.
Example: Patient waiting for surgery, newborns that are relatively healthy, some metabolic diseases need infusions. |
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Dextrose Containing Solutions
Disadvantages |
The addition of dextrose to IV fluids increases osmolarity and creates a hypertonic solution when added to LR or NaCl.
If glucose use is impaired (in the critically ill) accumulation of glucose and increase in osmotic forces may cause cell dehydration. Glucose increases CO2 production can be a problem in ventilated patients Increases lactate production in the critically ill Can aggravate ischemic brain injury Causes problems for diabetics |
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The proportion of a glucose load that contributes to lactate formation can increase from 5% in health subjects to __% in critically ill patients.
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The proportion of a glucose load that contributes to lactate formation can increase from 5% in health subjects to 85% in critically ill patients.
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When to use Dextrose-containing solutions
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Infants
People that have been receiving some sort of sugar or nutrition continuously People on insulin infusions coming for surgery When patients are NPO for surgery unless contraindicated (i.e. diabetes) |
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________ are large molecules that do not pass across diffusional barriers as readily as crystalloids.
_______ fluids infused into the vascular space have a greater tendency to stay in the plasma. This will enhance plasma volume to a greater degree. |
Colloids are large molecules that do not pass across diffusional barriers as readily as crystalloids.
Colloid fluids infused into the vascular space have a greater tendency to stay in the plasma. This will enhance plasma volume to a greater degree. |
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Common colloids
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5% Albumin
25% Albumin (SPA = salt poor albumin) 6% Hetastarch |
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Albumin is a transport protein that is responsible for __% of the oncotic pressure of the plasma
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Albumin is a transport protein that is responsible for 75% of the oncotic pressure of the plasma
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One potential problem from giving albumin
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allergic reaction
prion exposure |
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A 5% albumin solution has a COP of __ mm Hg which is similar to the 25 mm Hg of plasma
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A 5% albumin solution has a COP of 20 mm Hg which is similar to the 25 mm Hg of plasma
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The 25% albumin solution has a COP of __ mm Hg and expands the plasma volume by 4-5 times the volume infused.
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The 25% albumin solution has a COP of 70 mm Hg and expands the plasma volume by 4-5 times the volume infused.
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SPA mediated expansion occurs at the expense of the interstitial fluid, therefore SPA should never be used for volume resuscitation in a ________________ patient.
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SPA mediated expansion occurs at the expense of the interstitial fluid, therefore SPA should never be used for volume resuscitation in a hypovolemic patient.
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SPA is intended for shifting fluid from the interstitium to the vascular space in hypo______emic patients wisdom of this has been questioned.
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SPA is intended for shifting fluid from the interstitium to the vascular space in hypoproteinemic patients wisdom of this has been questioned.
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Albumin Disadvantages
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Because it is heat-treated, there is no risk of viral transmission (including HIV).
Allergic reactions are rare Dilutional coagulopathies can occur not accompanied with bleeding. VERY EXPENSIVE |
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Synthetic colloid
Available as 6% solution in isotonic saline It contains amylopectin molecules that vary in size from a few hundred to over a million daltons. Average weight is equivalent to albumin. The colloid effects are equivalent to 5% albumin It is slightly more potent than 5% albumin. Its COP is 30 mm Hg vs 20 mm Hg. Longer elimination half-life (misleading because the effects oncotically disappear in 24 hours). |
Hetastarch (or Hespan
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Hetastarch Disadvantages
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Hetastarch molecules are constantly cleaved by amylase enzymes in the bloodstream before their clearance by the kidneys. Serum amylase levels are often elevated for the first few days after a hetastarch infusion.
What could this mimic? How would you differentiate the infusion from the other? Anaphylaxis, although rare, has been reported Prolongation of PTT has been seen no clinical bleeding. This is the side-effect most asked about. |
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Crystalloid versus Colloid Debate
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For years, people have debated the advantages and disadvantages of the two.
It is hard to do a clear-cut, double-blinded randomized study to determine which is better. There are studies on both sides of the fence. People are very passionate one way or the other when it comes to colloids. There is no study outlining a clear winner, but there are a few studies from the ICU that show worse outcomes with colloids. |
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the best resuscitation fluid in trauma.
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No good study to determine what is the best resuscitation fluid in trauma. But several point to normal saline and it is the standard of care for volume resuscitation in trauma.
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For adults that are NPO, most places use D5/½NSFor adults that are NPO, most places use _______
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For adults that are NPO, most places use D5/½NS
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For children who are NPO, most places use:
Less than 3-6 months _____________ |
For children who are NPO, most places use:
Less than 3-6 months D10/ ¼ NS or D5/ ¼ NS |
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Why give baby D10/ ¼ NS or D5/ ¼ NS
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Babies have no glucose stores up to 3 months and can become hypoglycemic
Babies kidneys cannot handle large sodium loads initially. When I have an infant come to the OR on a sugar containing infusion, I keep it running, but usually cut back the rate. |
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To determine how much fluid to give in the OR:
First calculate the patient’s fluid deficit. This is equal to the number of hours NPO X hourly maintenance. Ex. A 70-kg patient is NPO since midnight and is in the OR at 10 am. 10 hours x ___ cc/hour = ____ cc Half of this should be given in the first hour, ¼ in the second hour, and ¼ in the third hour Next calculate maintenance which we did above 110 cc/hr for our patient. So in the first hour he/she should get 550 cc (1/2 of 1100) + ___ = 660 cc |
To determine how much fluid to give in the OR:
First calculate the patient’s fluid deficit. This is equal to the number of hours NPO X hourly maintenance. Ex. A 70-kg patient is NPO since midnight and is in the OR at 10 am. 10 hours x 110 cc/hour = 1100 cc Half of this should be given in the first hour, ¼ in the second hour, and ¼ in the third hour Next calculate maintenance which we did above 110 cc/hr for our patient. So in the first hour he/she should get 550 cc (1/2 of 1100) + 110 = 660 cc |
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Third-spacing is when fluid leaves the vasculature for the interstitium, environment, etc. for a variety of reasons ______________ is a big reason.
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Third-spacing is when fluid leaves the vasculature for the interstitium, environment, etc. for a variety of reasons inflammation is a big reason.
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*********BLOOD LOSS: For every 1 cc of blood lost we must replace it with _ cc of crystalloid. Remember most leaves the vasculature. Colloid is 1 cc for 1 cc.
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*********BLOOD LOSS: For every 1 cc of blood lost we must replace it with 3 cc of crystalloid. Remember most leaves the vasculature. Colloid is 1 cc for 1 cc.
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OK, now to third spacing: For minimal trauma, procedures _ cc/kg/hour For moderate trauma, _ cc/kg/hour For extreme trauma, _ cc/kg/hour |
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OK, now to third spacing: For minimal trauma, procedures 4 cc/kg/hour For moderate trauma, 6 cc/kg/hour For extreme trauma, 8 cc/kg/hour |
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Memorize the "communicating lab values" slide
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Serum Na+ concentration is a laboratory index representing _____ ____ _____ (TBW) rather than total body sodium. This means that disorders of TBW are reflected by an abnormal serum Na+ concentration.
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Serum Na+ concentration is a laboratory index representing total body water (TBW) rather than total body sodium. This means that disorders of TBW are reflected by an abnormal serum Na+ concentration.
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________ exam is the only index of total body sodium stores.
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Physical exam is the only index of total body sodium stores.
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Signs of RV failure
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Elevated JVD
Hepatomegaly |
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Signs of LV failure
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Pulmonary rales
S3 or S4 on auscultation |
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Physical exam signs showing dehydration
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Baby is somnolent, but responds to painful stimuli.
Tenting Poor capillary refill Dry mucous membranes Dry diaper Sunken fontanelles Sunken eyes |
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Defined as Na+ > 145 meq/L [Remember this is a deficiency in total body water]
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Hypernatremia
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General Signs and Symptoms of Hypernatremia
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Mental status changes
Irritability Hyperreflexia Ataxia Seizures |
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Signs and symps of Hypovolemic Hypernatremia
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Hypotension
Tachycardia Dry mucous membranes Loss of skin turgor |
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Signs and symps of Hypervolemic Hypernatremia
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Peripheral edema
Signs of RV or LV failure |
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H20 deficit (in liters) =
[0.6 x wt in kg] x [(serum sodium-140)/140] This gives you the liters you need to replace. |
H20 deficit (in liters) =
[0.6 x wt in kg] x [(serum sodium-140)/140] This gives you the liters you need to replace. |
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If our patient weighs 4 kg, how much free water do we need to replace? Na+ = 160
A – 3 L B – 1 L C – 500 mls D – 340 mls E – 30 L |
D – 340 mls
To give you an idea of how much this is…The baby’s total blood volume is about 320 mls normally |
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In cases of hypovolemic hypernatremia (our patient):
____ should be used first to reestablish the patient’s volume status. This will be done in 10-20cc/kg boluses until vital signs stabilize. In adults, you may just give liters at a time. After vitals stabilize, recalculate the water deficit |
In cases of hypovolemic hypernatremia (our patient):
NaCl should be used first to reestablish the patient’s volume status. This will be done in 10-20cc/kg boluses until vital signs stabilize. In adults, you may just give liters at a time. After vitals stabilize, recalculate the water deficit |
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Half of the free water deficit calculated should be replaced within the first __ hours. The rest can be replaced over the next 1-2 days. REMEMBER to give maintenance as well
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Half of the free water deficit calculated should be replaced within the first 24 hours. The rest can be replaced over the next 1-2 days. REMEMBER to give maintenance as well
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Example: If deficit is 4 liters 2 liters in first 24 hours (__ cc/hour plus maintenance) and then 2 liters over the next 1-2 days plus maintenance.
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Example: If deficit is 4 liters 2 liters in first 24 hours (80 cc/hour plus maintenance) and then 2 liters over the next 1-2 days plus maintenance.
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Treatment for Hypervolemic Hypernatremia
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Diuretics
Hemodialysis |
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Defined as serum Na+ < 135 meq/L.
Usually corresponds to an excess in TBW. Plasma osmolality can be helpful in determining the cause. Serum Na+ < 120 meq/L has a mortality rate of 50%. (Ex. Marathon runner in DC) |
Hyponatremia
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Hyponatremia Signs and Symptoms
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Mental status changes
Lethargy Cramps Decreased deep tendon reflexes Seizures Physical exam is similar to hypernatremia. |
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Plasma osmolality = 2 [Na+] + glucose/18 + BUN/2.8
Normal = _________ mosm/dl |
Plasma osmolality = 2 [Na+] + glucose/18 + BUN/2.8
Normal = 285-308 mosm/dl |
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Osmolal gap = plasma osmolality (meas.) – plasma osmolality (calc.)
Normal is < __ meq/l |
Osmolal gap = plasma osmolality (meas.) – plasma osmolality (calc.)
Normal is < 10 meq/l |
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An elevated osmolal gap indicates the presence of ______.
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An elevated osmolal gap indicates the presence of toxins.
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Treatment of Hypovolemic/Euvolemic Hyponatremia
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Hypertonic 3% saline may be utilized for treatment in symptomatic patients.
Must calculate Na+ deficit in these patients. Na+ deficit = (0.6 x wt in kg) x (125-measured Na+) 3% saline contains 513 meq of Na+ per 500 ml or approx. 1 meq/ml. Therefore, the volume (in ml) of 3% NaCl needed = the calculated Na+ deficit. |
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If the correction of hyponatremia occurs too rapidly, a demyelinating brain lesion may occur called
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central pontine myelinosis
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sequellae of CPM
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mutism, dysphasia, spastic quadriparesis, pseudobulbar palsy, delirium, coma, and even death
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Raising the serum sodium concentration more than __ mEq/L or to a normal or above-normal level in the first 48 hours increases the likelihood of central pontine myelinolysis.
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Raising the serum sodium concentration more than 25 mEq/L or to a normal or above-normal level in the first 48 hours increases the likelihood of central pontine myelinolysis.
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drugs that can cause Hyperkalemia
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ACEI
B-blockers sux |
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review this lecture... couldn't keep up
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what do you give for hyperkalemia
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diuretics
calcium insulin Kayexalate |
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Treatment of Hyperkalemia
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Calcium Chloride
Sodium bicarbonate Glucose and insulin Albuterol (increases plasma insulin) Diuretics Kayexalate Dialysis Hyperventilation (if on mechanical ventilation) |
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Hypokalemia
Defined as a K+ < ___ meq/L |
Hypokalemia
Defined as a K+ < 3.5 meq/L |
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EKG finding with hypokalemia
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U wave
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Common Causes of Hypercalcemia
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Hyperparathyroidism
Malignancy Breast cancer (25-50% of malignancy-related hypercalcemia) Lung cancer Squamous cell carcinomas of the head, neck, and esophagus Gynecological tumors Renal cell carcinoma Multiple myeloma THESE SECRETE A PTH-like SUBSTANCE stimulate osteoclast activity Sarcoidosis |
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Signs and Symptoms of Hypercalcemia
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ECG Changes
Prolonged P-R intervals Wide QRS complexes Shortened Q-T intervals Nausea / Vomiting Alterations of mental status lethargy, stupor, or even coma Constipation Lethargy Depression Weakness and vague muscle/joint aches Polyuria Headache Proximal muscle weakness that is more prominent in the lower extremities Hyperreflexia and tongue fasciculations may be present. |
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Signs and Symptoms of Hypocalcemia
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Cardiovascular
ECG Prolonged Q-T interval Bradycardia Hypotension Peripheral vasodilation Occasional LV failure Neurologic Numbness around the mouth Paresthesias Muscle cramps Tetany Carpopedal spasm Hyperreflexia Seizures Things that I worry about: Laryngospasm Bronchospasm Apnea |
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Which is more potent?
Calcium chloride (10 ml of 10% solution) Contains 272 mg (13.6 meq) Calcium gluconate (10 ml of 10% solution) Contains 90 mg (4.5 meq) |
Calcium chloride
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Signs and Symptoms of Hypermagnesemia
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Occurs when Mg++ > 5 mg/dL
Primarily neurologic and cardiovascular problems Neurologic: Hyporeflexia Sedation Weakness Cardiovascular: ECG Changes: widened QRS complex and prolonged P-R interval Hypotension related to vasodilation Bradycardia Myocardial depression When severe respiratory arrest is possible |
