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73 Cards in this Set

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What's the 4-2-1 Rule?
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.
Principal component of crystalloids is what ?
the inorganic salt, sodium chloride (NaCl).
75-80% of the volume of sodium-based IV fluids are distributed in the ________ space.
75-80% of the volume of sodium-based IV fluids are distributed in the interstitial space.
the predominant effect of volume resuscitation with crystalloids is to expand the __________ volume rather than the _______ volume
the predominant effect of volume resuscitation with crystalloids is to expand the interstitial volume rather than the plasma volume
80% of the ECF is __________ fluid
80% of the ECF is interstitial fluid
resuscitating a pt with normal saline can give
a) respiratory acidosis
b) resp alkalosis
c) metab acidosis
d) metab alkalosis
metabolic acidosis
What's unique about Normosol?
It has Mg
It has 7.4 pH
What's unique about lactated ringers?
It has Ca
Is there evidence that LR provides any benefit over isotonic saline?
No
Risk with giving lactated ringers
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
Buffer of Normolyte
Acetate [Normosol] or gluconate [Plasma-lyte] is added for buffering
Are Dextrose Containing Solutions
effective volume expanders?
No
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
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.
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
The proportion of a glucose load that contributes to lactate formation can increase from 5% in health subjects to __% in critically ill patients.
The proportion of a glucose load that contributes to lactate formation can increase from 5% in health subjects to 85% in critically ill patients.
When to use Dextrose-containing solutions
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)
________ 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.
Common colloids
5% Albumin
25% Albumin (SPA = salt poor albumin)
6% Hetastarch
Albumin is a transport protein that is responsible for __% of the oncotic pressure of the plasma
Albumin is a transport protein that is responsible for 75% of the oncotic pressure of the plasma
One potential problem from giving albumin
allergic reaction
prion exposure
A 5% albumin solution has a COP of __ mm Hg which is similar to the 25 mm Hg of plasma
A 5% albumin solution has a COP of 20 mm Hg which is similar to the 25 mm Hg of plasma
The 25% albumin solution has a COP of __ mm Hg and expands the plasma volume by 4-5 times the volume infused.
The 25% albumin solution has a COP of 70 mm Hg and expands the plasma volume by 4-5 times the volume infused.
SPA mediated expansion occurs at the expense of the interstitial fluid, therefore SPA should never be used for volume resuscitation in a ________________ patient.
SPA mediated expansion occurs at the expense of the interstitial fluid, therefore SPA should never be used for volume resuscitation in a hypovolemic patient.
SPA is intended for shifting fluid from the interstitium to the vascular space in hypo______emic patients  wisdom of this has been questioned.
SPA is intended for shifting fluid from the interstitium to the vascular space in hypoproteinemic patients  wisdom of this has been questioned.
Albumin Disadvantages
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
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
Hetastarch Disadvantages
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.
Crystalloid versus Colloid Debate
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.
the best resuscitation fluid in trauma.
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.
For adults that are NPO, most places use D5/½NSFor adults that are NPO, most places use _______
For adults that are NPO, most places use D5/½NS
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
Why give baby D10/ ¼ NS or D5/ ¼ NS
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.
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
Third-spacing is when fluid leaves the vasculature for the interstitium, environment, etc. for a variety of reasons  ______________ is a big reason.
Third-spacing is when fluid leaves the vasculature for the interstitium, environment, etc. for a variety of reasons  inflammation is a big reason.
*********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.
*********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.
**********
OK, now to third spacing:
For minimal trauma, procedures _ cc/kg/hour
For moderate trauma, _ cc/kg/hour
For extreme trauma, _ cc/kg/hour
**********
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
Memorize the "communicating lab values" slide
-
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.
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.
________ exam is the only index of total body sodium stores.
Physical exam is the only index of total body sodium stores.
Signs of RV failure
Elevated JVD
Hepatomegaly
Signs of LV failure
Pulmonary rales
S3 or S4 on auscultation
Physical exam signs showing dehydration
Baby is somnolent, but responds to painful stimuli.
Tenting
Poor capillary refill
Dry mucous membranes
Dry diaper
Sunken fontanelles
Sunken eyes
Defined as Na+ > 145 meq/L [Remember this is a deficiency in total body water]
Hypernatremia
General Signs and Symptoms of Hypernatremia
Mental status changes
Irritability
Hyperreflexia
Ataxia
Seizures
Signs and symps of Hypovolemic Hypernatremia
Hypotension
Tachycardia
Dry mucous membranes
Loss of skin turgor
Signs and symps of Hypervolemic Hypernatremia
Peripheral edema
Signs of RV or LV failure
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.
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
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
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
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
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.
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.
Treatment for Hypervolemic Hypernatremia
Diuretics
Hemodialysis
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
Hyponatremia Signs and Symptoms
Mental status changes
Lethargy
Cramps
Decreased deep tendon reflexes
Seizures

Physical exam is similar to hypernatremia.
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
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
An elevated osmolal gap indicates the presence of ______.
An elevated osmolal gap indicates the presence of toxins.
Treatment of Hypovolemic/Euvolemic Hyponatremia
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.
If the correction of hyponatremia occurs too rapidly, a demyelinating brain lesion may occur called
central pontine myelinosis
sequellae of CPM
mutism, dysphasia, spastic quadriparesis, pseudobulbar palsy, delirium, coma, and even death
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.
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.
drugs that can cause Hyperkalemia
ACEI
B-blockers
sux
review this lecture... couldn't keep up
-
what do you give for hyperkalemia
diuretics
calcium
insulin
Kayexalate
Treatment of Hyperkalemia
Calcium Chloride
Sodium bicarbonate
Glucose and insulin
Albuterol (increases plasma insulin)
Diuretics
Kayexalate
Dialysis
Hyperventilation (if on mechanical ventilation)
Hypokalemia
Defined as a K+ < ___ meq/L
Hypokalemia
Defined as a K+ < 3.5 meq/L
EKG finding with hypokalemia
U wave
Common Causes of Hypercalcemia
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
Signs and Symptoms of Hypercalcemia
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.
Signs and Symptoms of Hypocalcemia
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
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
Signs and Symptoms of Hypermagnesemia
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