Principles Test 2-Fluid

Front 1

TBW: total adult (men and women) body water 50-60%= approximately ... L

Back 1

48L
-dependent on sex, age and weight

Front 2

TBW is distributed into the into extracellular (ECF) and intracellular (ICF)
Intracellular 2/3 of TBW = ...L
Extracellular 1/3 of TBW = ...L

Back 2

Intracellular 2/3 of TBW= 32 L
Extracellular 1/3 of TBW= 16L

Front 3

Extracellular Fluid includes ... fluid & ... fluid, each composed of ...L & ...L respectively.

Back 3

Intravascular fluid 1/4 of ECF= 4L
Interstitial fluid 3/4 of ECF= 12L

Front 4

Extracellular composition (3)

Back 4

Sodium (+), Chloride(-) and Bicarbonate(-)

Front 5

Intracellular composition (4)

Back 5

Potassium(+), Magnesium(+), Phosphate and Proteins (-)

Front 6

Fluid movement between the intravascular and interstitial spaces occurs across capillary walls by either filtration or diffusion and is determined by ...

Back 6

Starling Forces

Front 7

Starling Forces is the ...

Back 7

oncotic and hydrostatic pressures involved in the movement of fluids across the capillary membrane.

Front 8

Capillary ... pressure - the pressure that will force fluid out from the capillary (pushing pressure)

Back 8

hydrostatic

Front 9

Capillary ...pressure the osmotic pressure that will force the fluids to enter the capillary from the interstitial space (pulling force)

Back 9

oncotic

Front 10

Hydrostatic pressure is the ... pressure

Back 10

pushing

Front 11

Oncotic pressure is the ... force

Back 11

pulling

Front 12

Evaluation of fluid volume
give examples ...

Back 12

Patient’s history
Systemic BP (supine & standing)
Heart Rate
Urine output
Hematocrit
BUN
Electrolytes
ABG
CVP
NPO status/ length of time
persistent vomiting/ diarrhea
inpatient gastric secretion
hemodialysis
bowel prep
significant blood loss
wound drainage

Front 13

Pre-op patients can become volume depleted & experience alterations of electrolyte balance due to several processes ... (5)

Back 13

burns
vomiting
diarrhea
fever
gastric secretions
-All could lead to hypovolemia before surgery

Front 14

During Intra-op the effects of surgery & anesthesia combine to challenge fluid and electrolyte homeostasis. Surgery losses include but not limited to ... (3)

Back 14

-evaporative loss
-viscera exposure
-manipulation of tissue leading to 3rd spacing (3rd space redistribution of fluid from the intravascular space to the interstitial space)

Front 15

... can result from absolute loss of fluid from the body or a relative loss of bodily fluids in which water is ... within the body, leading to a reduced circulating volume.

Back 15

-HYPOvolemia
-redistributed

Front 16

Because most causes of hypovolemia are caused by the loss of ...; replacement with ... crystalloids (same composition similar to ... is appropriate

Back 16

ECF
isotonic
ECF

Front 17

Hypovolemia Physical exam
Pre-op s/s ...

Back 17

-abnormal skin turgor
-dehydration of mucous membrane
-thready peripheral pulses
-increase resting HR
-decrease BP (positional)
-decrease u/o

Front 18

Hypovolemia Physical exam
Intra-op s/s ...

Back 18

-decrease BP may be extra secondary to positive pressure ventilation,
-vasodilating and/or negative inotropic effects of anesthetic

Front 19

Hypervolemia is an excess of fluid volume in an ... concentration

Back 19

isotonic

Front 20

Hypervolemia is not usually encountered in surgical patients but can be seen if diseases such as ..., ..., or ... are present.

Back 20

CHF, renal failure, or cirrhosis of the liver

Front 21

Iatrogenic causes of fluid overload includes administration of ... & excessive IV administration of ... fluids

Back 21

steroids
isotonic

Front 22

Excessive consumption of ... in the diet or in medication can lead to retention of water and hypervolemia

Back 22

sodium

Front 23

Hypervolemia Treatment ... (3)

Back 23

sodium restriction, diuretics, hemodialysis (renal failure)

Front 24

Hypervolemia Physical exam
Pre-Op ... (3)

Back 24

-pitting edema seen more with bedridden patient
-pretibial edema seen more with ambulatory patient
-increase u/o

Front 25

Hypervolemia Physical exam
Late signs ... (6)

Back 25

-increase HR
-increase jugular pulse pressure
-pulmonary crackles & rales
-wheezing
-cyanosis
-pink frothy secretions

Front 26

Intravascular volume Measurement
Laboratory Evaluation ... (5)

Back 26

-Hemoglobin/Hematocrit
-Arterial blood pH
-Urine specific gravity & osmolality
-Serum and urine Na+
-BUN to creatinine ratio

Front 27

Intravascular volume Measurement
Hemodynamic Measurements:
a Low CVP: < ... mmHg
a High CVP: > ... mmHg

Back 27

<5
>12

Front 28

Low CVP: <5 mmHg may be normal unless associated with other signs of ...

Back 28

hypovolemia

Front 29

CVP greater than 12 mmHg is considered elevated and may imply hypervolemia in the absence of ... ventricular dysfunction, increased ... pressure, or restrictive ... disease

Back 29

-right ventricular dysfunction
-intrathoracic pressure
-pericardial disease

Front 30

PAOP <8mmHg may indicate ... and PAOP >15mmHG may indicate ...

Back 30

HYPOvolemia
HYPERvolemia

Front 31

... fluids:
-Provision of maintenance fluids
-Replacement of fluids loss as a result of surgery and anesthesia
-Correction of electrolyte disturbances

Back 31

Parenteral Fluids

Front 32

Parental Fluid Therapy includes
... & ... or a combination of both

Back 32

crystalloids (iso/hypo/hypertonic)
colloids

Front 33

Crystalloids are fluids with a (low/high) volume of distribution

Back 33

High

Front 34

Components of crystalloids are ...

Back 34

water, electrolytes and/or dextrose.

Front 35

Crystalloids cross ... easily and may dilute plasma proteins, resulting in a reduction of the plasma ... pressure

Back 35

-plasma membranes
-oncotic

Front 36

LR/NS distribute within the ... spaces

Back 36

extracellular

Front 37

D5W provides ... & distributes to both the intracellular and extracellular

Back 37

free water

Front 38

LR and NS are the two ... crystalloids generally used to correct the hypovolemia resulting from surgery and anesthesia.

Back 38

isotonic

Front 39

... is the preferred isotonic solution

Back 39

LR

Front 40

Crystalloid solutions intravascular half-life is ...-... minutes

Back 40

20-30 min

Front 41

Hypotonic crystalloid solution shifts fluid out of ... into ...
-It ... cells
-examples ...

Back 41

out of vessels into cells.
-Hydrates cells
-0.25% NS, 0.45% NS, D5W

Front 42

Hypotonic crystalloid solution nursing considerations ... (3)

Back 42

May worsen hypotension
Can increase edema
May cause hyponatremia
D5W may also irritate veins

Front 43

D5W spares protein, provides calories and free water, treats ..., is a diluent for IV drugs

Back 43

hyperkalemia

Front 44

Isotonic crystalloid solution has no ... It's action is ... and ...
-examples ...

Back 44

No fluid shift
Vascular expansion and electrolyte replacement
-0.9% NS
Lactated Ringer's (LR)

Front 45

Isotonic crystalloid solution nursing considerations ... (6)

Back 45

-May cause fluid overload
-Generalized edema
-Dilutes Hemoglobin
-May cause hyperchloremic acidosis
-May cause electrolyte imbalance
-Proinflammataory in large doses

Front 46

Isotonic solutions may cause ... acidosis

Back 46

hyperchloremic acidosis

Front 47

Hypertonic crystalloid solutions shift fluid back into ... Is is a ... and replaces ...
-examples ...

Back 47

-circulation
-vascular expansion
-replaces electrolytes
-D50.45%NS
-D50.9%NS
-Hypertonic saline (HS) 3% or 5%

Front 48

Hypertonic crystalloid nursing considerations ... (5)

Back 48

-irritating to veins
-may cause fluid overload
-may cause hypernatremia
-may cause hyperchloremia
-HS slows inflammation and increases capillary permeability

Front 49

Hypertonic saline (HS) slows/speeds up inflammation and decreases/increases capillary permeability

Back 49

slows
increases

Front 50

Colloid Solutions contain osmotically active substances of (low/high) molecular weight that (do/do not) easily cross the capillary membrane, therefore they draw fluid into the ... space and expand ... volume

Back 50

-high molecular weight
-do not cross easily
-intravascular space
-circulating volume

Front 51

Colloid solutions intravenous half life is between ... & ... hours

Back 51

3-6 hours

Front 52

Many anesthetists use colloids in conjunction with crystalloids when fluid replacement needs exceed ...-... liters

Back 52

3-4L

Front 53

Colloids particles are much larger than the electrolyte components in crystalloid solution, so they will provide (less/more) free water & stay primarily in the ... space.

Back 53

less free water
intravascular space

Front 54

Colloids contain large molecules such as proteins and/or starches to increase ... pressure in the intravascular space

Back 54

oncotic

Front 55

Colloid:
Blood derived example ...

Back 55

albumin

Front 56

Colloid:
Synthetic derived examples (3)

Back 56

Dextran, Hetastarch, Mannitol

(Dextran prevents clots during surgery but now there is a correlation w/ leaking so it's not used often)
(Mannitol is used with eye cases & cranies)

Front 57

Albumin (plasma protien) keeps fluid in/out vessels. It maintains volume and is used to replace ... and treat ... and erythroblastosis fetalis

Back 57

fluid IN vessels
-protein and treat shock

Front 58

Albumin comes in ..% and ...%

Back 58

5% and 25%

Front 59

Albumin nursing considerations ... (2)

Back 59

-May cause anaphylaxis (watch for hives, fever, chills, headache)
-May cause fluid overload and pulmonary edema

Front 60

Dextran (polysaccharide) shifts fluid into ... It causes vascular ... and prolongs hemodynamic response when given with HS.

Back 60

into vessels
vascular expansion

Front 61

Dextran (40 kDa or 70 kDa) nursing considerations ... (3)

Back 61

-May cause fluid overload and hypersensitivity
-Increased risk of bleeding
-Contraindicated in bleeding disorders, CHF and renal failure

Front 62

Hetastarch (HES) (synthetic starch in 6% or 10%) shifts fluid into ... It causes vascular ...

Back 62

into vessels
vascular expansion

Front 63

Hetastarch nursing considerations ... (3)

Back 63

-May cause hypersensitivity and fluid overload
-Increased risk of bleeding
-Contraindicated in bleeding disorders, CHF, and renal failure

Front 64

Mannitol (alcohol sugar) (5% or 25%) causes ... It also reduces ... edema and eliminates toxins.

Back 64

oliguric diuresis and reduces cerebral edema

Front 65

Mannitol nursing considerations ... (4)

Back 65

-May cause fluid overload.
-May cause electrolyte imbalances
-Cellular dehydration
-Extravassation can cause tissue necrosis

Front 66

Estimation of intra-op fluid requirements is based on an understanding of your patient’s fluid needs as well as the dynamic of fluid compartments
3 types of fluid therapy ...

Back 66

-Fluid therapy is administered to compensate for pre-op fluid deficit
-Maintenance fluids are administered to compensate for evaporative losses & to provide solute for excretion of waste
-Replacement fluids are administered to compensate for surgical fluid losses (3rd spacing and blood loss)

Front 67

Fluid Losses
-GI ...-... ml/day
-Insensible losses ...-... ml/day
-urinary losses ...-... ml/day

Back 67

-GI 100-200 ml/day
-Insensible losses 500-1000 ml/day
-urinary losses 1000 ml/day

Front 68

Fluid loss increases with ... (6)

Back 68

Fever
Wound drainage
GI losses
Perspiration
Blood loss
Drugs

Front 69

Intra-Op Fluid Loss types (4)

Back 69

Surgical
Suction Canister
Surgical sponges
Evaporation (3rd space)

Front 70

4x4 sponges holds approximately ... mL of blood
lap sponges holds approximately ...-... mL of blood
Raytec up to ... ml

Back 70

10ml
100-150ml
25ml

Front 71

Maintenance Fluid Calculation is the ... rule

Back 71

4-2-1

Front 72

Maintenance fluid calculation
>21 kg just add ... to the kg = hourly maintenance

Back 72

40

Front 73

Example: Calculate maintenance fluid for a 82 kg male.
1 – 10 kg 4ml/kg/hr x 10 kg = ... ml/hr
11 – 20 kg 2ml/kg/hr x 10 kg = ... ml/hr
21 – 82 kg 1ml/kg/hr x 62 kg = ... ml/hr

Hourly fluid requirement of: ... ml

Back 73

40, 20, 62 = 122 ml
or
Patient > 21 kg rule: 82 + 40 = 122 ml

Front 74

Replace Fluid Deficit Calculation:
Maintenance Fluid multiply by number of hours ....
1st hr. replace ... half, second and third hrs. replace ... of the other ½ half

Back 74

NPO
½
¼

Front 75

Example: 82 kg Male Patient NPO X 7 hours.
His maintenance fluid was ... ml x 7 hrs.= 854 ml
Replace deficit:
½ of (...ml) in the first hour = 427 ml.
¼ of (...ml) in the second hour = 214 ml.
¼ of (...ml) in the third hour = 214 ml.

Back 75

122 ml
854ml
427ml
427ml

Front 76

Third space losses of body fluids refers to the transfer of fluids from the ... space to the ... space or other non-intravascular spaces

Back 76

extracellular space to the interstitial space

Front 77

In third space loss, the volume of fluid that is transferred corresponds to the degree of manipulation of ... intra-op

Back 77

tissues

Front 78

The replacement of third space losses of fluids intra-op is therefore (in/dependent) on the type of surgical procedure the patient is undergoing

Back 78

dependent

Front 79

3rd space fluid losses becomes mobilized on about the ... day post-op and may manifest as an (increase/decrease) in the intravascular fluid volume.

Back 79

3rd
increase

Front 80

3rd Space fluid loss depends on ... (3) of procedure

Back 80

Type, length and extent of procedure

Front 81

3rd space Fluid Loss (ml/kg/hr)
Generic ...
Minimal ...
Moderate ...
Severe ...

Back 81

Generic 2 ml/kg/hr
Minimal 3 – 4 ml/kg/hr
Moderate 5– 6 ml/kg/hr
Severe 7 – 8 ml/kg/hr

Front 82

Current time = 1300 hrs
82 kg 55 yrs. old male
NPO since midnight
Surgery began at 7 am
Case = bladder repair (5 ml/kg/hr)
No blood loss
How much fluid should he have on board at 1300?

Back 82

4047ml

Front 83

Volume Replacement from Blood Loss
Crystalloid Ratio ...
Colloid Ratio ...

Back 83

Crystalloid (3:1 Ratio)
-3 ml of isotonic fluid per 1 mL blood loss
Colloid (1:1 Ratio)
-1 mL of colloid per 1 mL blood loss

Front 84

Goals of Fluid Management (6)

Back 84

Optimizing blood oxygenation
Circulating volume
Perfusion pressure
Electrolyte balance
Normoglycemia
Intra-op fluid Replacement Goal

Front 85

Intra-op fluid replacement Goals: (4)

Back 85

replace pre-op/ intra-op deficits
blood loss
fluid redistribution
evaporation

Front 86

Calculate This!
Current time = 1100
70kg 38 yrs. old female
NPO since midnight
Surgery began at 0800
Case: total abdominal hysterectomy (8 ml/kg/hr)
150 mL blood loss
How much fluid should she have on board at 1100?

Back 86

3340 ml

Front 87

A, B, AB, O : Each represents an enzyme (antigen) that modifies the ...

Back 87

cell surface

Front 88

AB blood: universal ...
O blood: universal ...

Back 88

AB blood: universal recipients
0 blood: universal donors

Front 89

Rh: represent presence/absence of ... antigens in RBC membranes

Back 89

D
80-85% have D antigen= Rh +
15-20% don’t have D antigen= Rh -

Front 90

The primary indication for the transfusion of blood is to increase the ... of the blood.

Back 90

oxygen-carrying capacity

Front 91

Blood has the advantages of ... volume expansion.

Back 91

intravascular

Front 92

... refers to the transfusion of the specific part of blood that the patient needs as opposed to the routine transfusion of Whole Blood

Back 92

Blood component therapy

Front 93

More than ...% of all RBC units are administered in the operating room.

Back 93

60%

Front 94

Average blood volume for adult is approximately ...- ... liter; women may be slightly lower.

Back 94

4.7-5L

Front 95

From ... Blood we can get RBC, Granulocytes, Platelets, FFP, Cryoprecipitate, Factor VIII, Factor IX, Alpha 1 Proteinase Inhibitor, Anti-Inhibitor Coagulation Complex, Albumin, Plasma Protein Fraction, Immune Globulin, Rh Immune Globulin, Anti-thrombin I

Back 95

Whole Blood

Front 96

RBCs
-From 450 mL (donor)
-... needed during administration to trap any clots or debris
-Blood for intra-op transfusion should be warmed to ... degrees centigrade during infusion

Back 96

Filter
37 degrees

Front 97

A single unit of PRBCs will increase adult hemoglobin concentrations about ...g/dL & Hct ...-...%

Back 97

1g/dL & Hct 2-3%

Front 98

RBC Shelf life ..., ... or ... days (1-6 degrees C)

Back 98

21, 35, or 42 days

Front 99

RBC indication for use:

Back 99

increase O2 carrying capacitiy

Front 100

... concentration is the basis on which the decision to transfuse is made

Back 100

Hemoglobin

Front 101

Blood transfusion is almost always justified when the hemoglobin valve is less than ...g/dL and some state it is rarely justified when the hemoglobin valve is greater than ...g/dL. Oxygen transport is said to be maximized when the hemoglobin level is ...g/dL.

Back 101

6g/dL
10g/dL
10g/dL

Front 102

Standard for transfusing blood
ASA – Hemoglobin ... g/dL
NIH – Hemoglobin ... g/dL

Back 102

ASA- 6
NIH- 7

Front 103

**Most important transfusion predictor pre-op is ... **

Back 103

hgb/hct

Front 104

What factor (#) helps determine the Hgb if you have the Hct and vice versa?

Back 104

3
i.e., Hgb 6, what is Hct
6 x 3 = 18

Front 105

Platelets are collected from (single/multiple) donor(s).
Plts are store ... days with gentle agitation

Back 105

multiple
5
-highest transfusion rx d/t multiple donors, may pretreat w/ benedryl or steroids

Front 106

Platelets indication for use (3)

Back 106

-Thrombocytopenia
-Abnormal functioning in the presence of bleeding
-Plt. Count < 50,000 pre-op or intra-op

Front 107

Giving platelets increases the count by ...-...

Back 107

5,000-10,000

Front 108

Fresh frozen plasma comes from whole blood and includes all ...

Back 108

clotting factors

Front 109

FFP is frozen within ...hrs of collection (-18C), has a volume of 200-250ml and is used within ... hrs of thawing

Back 109

8hrs, 24hrs

Front 110

FFP increases clotting factor levels by ...-...%

Back 110

2-3%

Front 111

FFP indication for use (2)

Back 111

coagulation factor deficiencies
volume expander?

Front 112

Albumin is from whole blood, can be stored for 5 years and has a plasma half life of ... hours

Back 112

6 hours

Front 113

Albumin indication for use (2)

Back 113

generally used for oncotic activity with hypovolemia or hypoproteinemia

Front 114

Cryoprecipitate is from thawed FFP (it precipitates), it is immediately refrozen and must be used within ... hours of thawing.

Back 114

4 hours

Front 115

Cryoprecipitate indication for use (1)

contains which clotting factors ...

Back 115

treating hemophilia A
-Contains factors: I, VIII, XIII, Fibronectin, von Willebrand’s factor.
-Contains ~100u of factor VIII + 250mg fibrinogen

Front 116

Autologous Blood is ...

Back 116

Collection, storage and re-infusion of the patient’s own blood.

Front 117

Autologous Blood is safest but not 100% safe.
Donate ... unit per week
Stored for 42 days

Back 117

one

Front 118

Intra-op Blood Collection- Autologous Blood (cell saver) is ...

Back 118

Blood suctioned from operative field, processed and returned to patient.

Front 119

Cell Saver minimized ... usage.
Sterile collection techinque must be maintained and cell save must be used within ... hours of collection

Back 119

Minimizes “banked blood” usage
6 hours of collection

Front 120

Cell Saver contraindication:

Back 120

contamination – tumor cells, bacteria, etc

Front 121

Potential Risks of Transfusion
examples ...

Back 121

Transfusion Reaction
Infection Transmission
Immunosuppression
TRALI
Graft-vs-Host Disease
Anaphylactic Reaction
Hypothermia
Metabolic issues
Circulatory overload
Hypocalemia

Front 122

Crystalloids advantages (3) & disadvantages (3)

Back 122

Advantages- Inexpensive, Increased Urine output,
Replaces ISF
Disadvantages- Transient hemodynamic effect, Peripheral edema, Pulmonary edema

Front 123

Colloids advantages (3) & disadvantages (3)

Back 123

Advantages- Smaller Volume used, Prolonged increase intravascular volume, Less Peripheral edema
Disadvantages- Expensive, Decreased GFR, Coagulopathy

Front 124

Estimated Blood Volume
Premie
Newborn
Child
Adult Female/Male

Back 124

Premie 95 ml/kg
Newborn 85 ml/kg
Child 75 – 80 ml/kg
Adult
Female 65ml / kg
Male 70ml/kg

Front 125

EBV Example: 70 kg adult male
70 kg X 70 ml = ... ml estimate blood volume (EBV)

Back 125

4900ml

Front 126

Calculating Hct Related to Intra-operative Blood Loss
[EBV x (starting hct – target hct 30)] / starting hct

example: male: 70kg, hct = starting hct 42, target hct 27
How much blood will your patient lose by the time their hct reaches 30?

Back 126

1400ml

Front 127

Calculate This!
70 kg healthy male Hct 42%
Using humidifier on anesthesia circuit
Surgery began at 7am
Time now 10am
NPO since midnight
450 EBL
ORIF distal tibia
Hemodynamically stable
Assume we are only using crystalloid.
What’s the patients volume deficit at 10am?
Volume deficit currently?
What blood loss would put the patient at a HCT of 27%?

Back 127

770ml (NPO status)
2871ml
1750

Front 128

The fundamental requirement of the patient is ..., and sufficient ... delivery is a paramount goal of fluid management

Back 128

oxygen
oxygen

Front 129

Patients pre-procedure volume status may vary greatly.
Correct fluid management influences patient outcome.

Back 129

Patients pre-procedure volume status may vary greatly.
Correct fluid management influences patient outcome.