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NU 568

Exam 3 - Fluids and Electrolytes

Osmosis is the net movement of _____ across a semi-permeable membrane. water
What are Starling Forces? The four forces that determine motions of fluids across capillary membranes
What are the four Starling Forces? Capillary Pressure (Out), Plasma Colloid Osmotic Pressure (In), Interstitial Fluid Pressure (Out), Interstitial Colloid Osmotic Pressure
What is the exchange ratio of Na for K? 3:2
Define osmolarity. The number of osmoles per liter of solution
What is osmolarity a measure of? Solute concentration
What two variables are capable of changing the osmolarity of a solution? Temperature and pressure
What is osmolality? Number of osmoles per kilogram of solution
One mole = ___________ molecules. 6.02x10 to the 23rd
The effect of a solution on cell volume is referred to as __________. tonicity
Hypertonic solutions (increase/decrease) cell volumes. decrease
Hypotonic solutions (increase/decrease) cell volumes. increase
How much of each of the following ions is present in one liter of RL -> Sodium, Chloride, Lactate, Potassium, Calcium 130, 109, 28, 4, 3
How many grams of NaCl are in a 1L bag of NS? 9 grams
What is the average body percentage of water for males? Females? M=60%, F=50%
What are the receptors responsible for water balance and where are they located? Osmoreceptors in the hypothalamus
What hormone do osmoreceptors influence? ADH
Where is ADH released? Posterior pituitary
How does ADH work to influence water balance? Influences collecting tubules to reabsorb H20 and Na
Osmolality (increases/decreases) as a solute is diluted. decreases
What approach helps accurately guide peri-operative fluid replacement? What approach helps accurately guide peri-operative fluid replacement?
Parched mucus membranes indicate a fluid loss of _____%. 15
Proteins are (diffusable/non-diffusable) solutes. Non-diffusable
The intracellular concentration of protein is nearly _____ x greater than the extracellular concentration. 2
How does hypoxemia or ischemia lead to swelling? Interferes with Na/K pump, resulting in cellular swelling
What are late signs of hypervolemia? Tachycardia, pulmonary crackles, wheezing, cyanosis, pink frothy sputum
How much of the body’s total water volume is contained in the ICF? 2/3
What are the 3 primary intracellular electrolytes? Potassium, magnesium, phosphate
Dehydration is a concentration d/o where there is an insufficient ratio of _____ to ______. H20; sodium
How long do crystalloids remain in the intravascular space? 30min
How long do colloids remain in the intravascular space? 3+ hours
True/False: Crystalloids are not as effective as colloids in restoring intravascular volume. False=may be as effective w/sufficient amounts
What is the ratio of replacement to blood loss for crystalloids? Colloids? Crystalloid:Blood=3:1; Colloid:Blood=1:1
Primary water loss is replaced with (hypo/iso/hyper)tonic solutions. hypo
Water and electrolyte deficits are replaced with (hypo/iso/hyper)tonic solutions. iso
What is primary water loss? Water loss w/o concomitant loss of significant quantities of electrolytes
What are examples of primary water loss? Water deprivation, sweating, DI, heatstroke, fever
Which patients are more likely to develop hypoglycemia w/preop fasting? Women and children
What are the benefits of glucose solutions? Prevent hypoglycemia and ketoacidosis; maintain tonicity
What can large volumes of NS lead to? Hyperchloremic acidosis
Plasma levels of _______ decrease as chloride increases with NS boluses. Bicarbonate
What solution is used to replace water deficits and as maintenance is sodium restricted patients? D5W
What solution is used for patients in hypovolemic shock? 3 to 7.5% saline
What is the risk of giving hypertonic saline? May cause crenation of red cells (give slowly)
When are colloid solutions employed? Severe intravascular fluid deficits or before blood transfusion
How many liters of crystalloids should be infused before giving a colloid? 3-4L
True/False: Colloids do not contribute to hyperchloremic acidosis. False=colloids contain NS
What are colloids derived from? Plasma proteins or synthetic polymers
How is albumin prepared and why? Heat treated for 10h at 60C to reduce viral entities
Why can some patients become hypotensive w/albumin? Plasma proteins may cause histamine release and activation of prekallikrein (vasodilates)
Describe the difference between the terms “hypovolemia” and “dehydration”. Hypovolemia is the loss of ECF d/t an absolute or relative loss of body fluids from redistribution; dehydration is a concentration d/o where insufficient water is present relative to Na levels
What are causes of absolute fluid loss? GI loss, polyuria, diaphoresis
Name an effective plasma expander, besides albumin. 6% hetastarch
What is the most abundant electrolyte in the ECF? Na
Hetastarch is known to be (antigenic/nonantigenic). Non-antigenic—allergic reactions are rare
Bleeding times are not affected with Hetastarch with volumes less than ______ L. 1
What is now given for fluid management in replacement of hetastarch and why? Pentastart d/t lower molecular weight
Intraoperative fluid losses are (hypo/iso/hyper)tonic. Iso
What is the best solution to administer when large volumes of fluid are necessary? RL
How much free water is in each liter of RL? 100ml, therefore it is slightly hypotonic
How does RL help avoid hyperchloremic acidosis? Broken down to bicarbonate in the liver
Patients with severe hepatic disease should not receive periop infusions of ____. RL
What fluid is used to replace GI secretions, sweat, and insensible losses and why? Hypotonic dextrose b/c these losses are normally hypotonic (water loss > salt loss)
What is rule that is used to calculate estimated IVF maintenance? 4-2-1 rule
What is the 4-2-1 rule? 4ml/kg for the 1st 10kg of body weight, 2ml/kg for the 2nd 10kg, 1ml/kg for each kg thereafter
A meal of solids with no fat requires a fasting time of at least ____ hrs. 6
Replacement fluids should be _________ in composition to fluids that are lost. Similar
How much blood does a saturated 4x4 hold? 10ml
How much blood does a saturated lap sponge hold? 100-150ml
What should blood loss in canisters account for? Irrigation solutions
Internal redistribution of fluids is also known as _____. 3rd spacing
3rd spaced fluids leave the intravascular and intracellular compartments and (do/do not) readily equilibrate with other compartments. Do not
What are the guidelines for estimating redistributed and evaporated fluid losses? Surgery:Minor=2ml/kg/hr, Moderate=2-4ml/kg/hr, Extensive=4-8ml/kg/hr
What are guidelines for estimating redistributed and evaporated fluid losses based on? Degree of tissue trauma
What is the estimated blood volume for a premature baby? Full term baby? Infant? Premature=95ml/kg, Full=85ml/kg, Infant=80ml/kg
What is the estimated blood volume for an adult male? Female? M=75ml/kg, F=65ml/kg
What is the normal HCT for men? Women? M=47%, W=42%
What is the equation for calculating MABL? EBV x [Starting HCT – Target HCT]/Starting HCT
How much of the estimated maintenance fluid is given in the first 1hr? 2nd hr? 3rd hr? ½; ¼; ¼
What are acceptable Hgb levels? 5-8g/dl
A Hgb of 10g/dl should be maintained for what 3 patient populations? Elderly, cardiac dz, co-morbidities
When are patients w/normal hematocrits generally transfused? After blood losses of 10-20% blood volume
What has the most important influence over water content in brain tissue? Sodium
SIADH contributes to (hypo/hyper)natremia by means of ________. Hyponatremia; water retention
SIADH (does/does not) result in edema. Does not
What are other conditions/procedures that increase the risk for hyponatremia? CHF, cirrhosis, renal failure, TURP, glucocorticoid deficiency, GI Na loss
What situation may develop with rapid correction of sodium levels? Serious permanent neurologic damage (Central pontine myelinolysis)
Hyponatremic patients may develop symptoms when sodium levels are below ______. 120
What is the sodium correction for mild symptoms? 0.5 mEq/L/Hr
What is the sodium correction for moderate symptoms? 1.0 mEq/L/Hr
What is the sodium correction for severe symptoms? 1.5-2 mEq/L/Hr
What solution is infused to treat hyponatremia and how fast is it given? 3% NS at 1-2ml/kg/hr
What is the goal of treatment for hyponatremia? Return sodium levels to >120 mEq/L
Severe symptomatic hyponatremia usually occurs at what levels? < 115
What is the usual rate of replacement for hyponatremia and why is it given at this rate? 0.5-1.0 mEq/L/hr; prevents CNS symptoms and pulmonary edema
What is the equation used to calculate the amount of sodium necessary to achieve desired sodium levels in hyponatremia? ? 0.6 ((0.5 for women)) x weight(kg) x (Desired Na – Actual Na) **Yields total Na necessary to achieve desired Na level**
What is the equation for the safe rate of sodium infusion in meq/hr? 0.6 (0.5 for women) x weight(kg) x 1.0 meq/L/hr **Yields patient specific safe rate in meq/hr**
How much sodium is contained in a 1L bag of 3% hypertonic saline? 513meq
What is the equation for the safe rate of sodium infusion in ml/hr? [meq/hr]/513 x 1000 **This yields the hourly rate to run the infusion in ml/hr**
What is the equation for total infusion time at the desired rate for hyponatremic repletion w/hypertonic saline? (total meq needed to reach target meq)/(meq/hr) ** This yields the total amount of time to run the infusion **
Rapid rises in Na may precipitate what 4 conditions? Pulmonary edema, hypokalemia, metabolic acidosis, transient hypotension, CPM
What is the minimum sodium level considered safe for anesthesia? 130
Levels of sodium < 130 increases the risk for ______. Cerebral edema
How does cerebral edema manifest in anesthesia? Decreased MAC requirement, post-op agitation/confusion, somnolence
Sodium excretion can vary from ____ to ___ mEq/L/day. 1; 100
What are two systems that help regulate Na balance? Renin-angiotensin-aldosterone and atrial naturetic peptide
Where and when is atrial natriuretic peptide (ANP) released? From the atria following atrial distention
What is the function of ANP? Lowers blood volume by increasing GFR, inhibits R-A-A and ADH
What is the function of the R-A-A system? Increase blood volume by retaining H20 and Na
Briefly describe the R-A-A system. Liver produces angiotensinogen -> converted to angiotensin by the hormone renin –> ACE catalyzes AI to AII –> AII stimulates release of aldosterone+ADH, retains H20 and Na, causes vasoconstriction
Name the organ(s) that secrete the following: Angiotensin, renin, ACE, aldosterone, ADH. Liver, kidneys, lungs and kidneys, adrenal cortex, pituitary
Between ADH and aldosterone, which hormone directly retains water and which one indirectly retains water? Aldosterone=indirect, ADH=direct
Between ANP and the R-A-A system, which causes vasoconstriction and which causes vasodilation? R-A-A=vasoconstriction, ANP=vasodilation
ADH is also known as _______. Vasopressin
As volume increases, sodium excretion _______. Increases
As volume decreases, sodium excretion _______. Decreases
GFR is (directly/indirectly) proportional to intravascular volume. Directly
What is the osmolarity of normal blood plasma? 290 mOsm/L
What is unique about the tonicity of D5W? Isotonic outside the body but hypotonic once infused d/t breakdown of dextrose by insulin
Major complications associated w/hypernatremia occur above ______ mEq/L. 158
What are the severe SE with hypernatremia? Restlessness, lethargy, hyperreflexia, Sz, coma, cerebral vein hemorrhage
What type of solution should be used to correct hypernatremia? Hypotonic
What 3 things can occur with rapid correction of hypernatremia? Sz, brain edema, death
How fast should hypernatremia be corrected? No faster than 0.5meq/L/hr
What is the underlying condition that should be treated in hypernatremia? Cellular dehydration
What are the anesthetic considerations w/hypernatremia 2/t hypovolemia? Vasodilation, cardiac depression, hypoperfusion
What are two reasons that anesthetic agents, IV and gas, should be decreased with hypovolemia? Decreased Vd means lower IV doses, decreased CO means increased uptake of agent for gases
Surgery should be postponed for Na levels above _____. 150 mEq/L
What is the usual cause of hypernatremia? Water loss
What is the most common cause of hypernatremia? DI
Seizures may lead to transient episodes of (hyper/hypo)natremia. hyper
How does hypervolemia impair gas exchange? Pulmonary interstitial edema, alveolar edema, pleural or ascitic fluid collections
Each molecule of NaCl is equal to _____ osmoles. 2
Which induction agent is safest to use in hypovolemic patients? Ketamine
What common anesthesia medications are notable for histamine release? Morphine, demerol, atracurium
Blockade of the (sympathetic/parasympathetic) system can occur with spinal anesthesia. Sympathetic
How does exercise affect K? Increases
How much do potassium levels change for every 0.01 change in pH? Changes 0.6 mEq/L
In reference to pH, what enters the cell and what leaves the cell in acidosis? H+ enters, K+ leaves
How does insulin affect potassium levels? Increases cellular uptake of K in the liver and muscle by enhances Na/K pump activity
What other class of medications stimulate the uptake of K+ by the muscle and liver? Beta agonists
What are the numbered phases in the cardiac action potential? 0-4
What is the electrolyte movement associated with phase 0? Na in
What is the electrolyte movement associated with phase 1? K (out), Cl (out)
What is the electrolyte movement associated with phase 2? K (out), Ca (in)
What is the electrolyte movement associated with phase 3? K (out)
What is the electrolyte movement associated with phase 4? RMP at -96mV
Which phases are the decay phases of the cardiac action potential? 1 and 3
Describe the EKG changes associated with developing hyperkalemia. Peaked T waves  shortened QT, widened QRS, dampened P and prolonged PR  absent P, sine wave
Hyperkalemia exists when K+ exceeds _____ mEq/L. 5.5
What are three possible reasons of hyperkalemia? Intra-compartment shifts, intake, decreased urinary excretion
High WBC and platelet levels may contribute to (high/low) K+ levels. High
What is the average increase of plasma K+ following succinylcholine administration? 0.5-1mEq/L
Beta blockers can (increase/decrease) potassium levels in individuals w/impaired renal function. Increase
What is the level of increase of K+ in donated blood that is aging? 30mEq/L after 21 days of storage
How does decreased GFR influence potassium levels? Decreased GFR results in decreased K+ secretion in the distal tubules
Identify how NSAIDs and ACE inhibitors influence potassium levels and how they do it. Both cause hyperkalemia; NSAIDS=inhibit prostaglandin mediated renin release, ACE inhibitors=prevents AI to AII, therefore limiting aldosterone release (excretes K)
Large doses of heparin inhibits the production of _______, which can lead to ______. Aldosterone; hyperkalemia
Hyperkalemia is manifested in ____ and ____ muscle. Cardiac, skeletal
At what level does skeletal muscle weakness manifest in hyperkalemia? > 8mEq/L
The clinical manifestation of hyperkalemia mimics that of succinylcholine in that it may eventually result in what two conditions? Ascending paralysis; quadriplegia
K+ levels above ______ mEq should always be treated. 6
Why should calcium be given with caution in treating hyperkalemia? Potentiates digoxin toxicity
How much calcium chloride is given to antagonize the cardiac effects of potassium? Chloride=3-5ml of 10%; Gluconate=5-10ml of 10%
What are 2 medications that promote cellular uptake of potassium? Beta agonists and sodium bicarbonate
What effects does epinephrine have on K and the heart? Rapidly decrease K; inotropic
What is the glucose/insulin regimen for hyperkalemia? 50gms glucose + 10units regular insulin
What is the dose of Kayexalate used to treat hyperkalemia? 20gms
How much does potassium does 1 gram of kayexalate bind to? 1gm binds to 1meq of K+
What solution is contraindicated in hyperkalemic patients? Potassium containing solutions (RL)
Metabolic or respiratory acidosis will encourage the movement of potassium (into/out of) the cell. Out of
Which NMB is contraindicated in patients w/hyperkalemia? Succinylcholine
How does increased potassium affect NMBs? Potentiates depolarizing NMBs
What is the purpose of giving calcium in a serious conduction abnormality? Stabilizes the myocardium (no effect on potassium)
When is calcium indicated with what EKG changes? Widened QRS (sine wave) or in hyperkalemic cardiac arrest
How long does it take for the membrane stabilizing effects of calcium to be realized? 15-30min
What are the potential complications of calcium administration? Bradycardia, hypotension, vasodilation
What should be given as an alternative to calcium in order to prevent digoxin toxicity? Magnesium
Besides regular insulin, what other type of insulin can be given to treat hyperkalemia? Actrapid 10-20units
What is the dose of sodium bicarbonate used to treat hyperkalemia? 50-200mmol of 8.4%
True/False: Sodium bicarbonate is effective at treating hyperkalemia in both acidotic and alkalotic states. False=only acidotic
What is the inhaled beta agonist used to treat hyperkalemia? Albuterol (Salbutamol)
What is the dose of albuterol given for hyperkalemia? 10-20mg
Which patient population responds well to albuterol for high K+? Fluid overloaded renal patients
Identify the IV beta agonist and its dose when given to treat hyperkalemia. Low dose epinephrine infusion at 1mcg.
What are 4 methods or medications used to eliminate potassium from the body? Calcium resonium, lasix, NS, HD
What is the dose of calcium resonium for hyperkalemia? 15-45gm
What is calcium resonium mixed with and what are the trade names? Mixed w/sorbitol or lactulose; AKA: Kayexalate, Kionex, Marlexate
What are possible redistributive causes of hypokalemia? Alkalosis, insulin, B-agonists, hypothermia, post-RBC transfusion effects
What are renal causes of potassium loss? Hyperaldosteronism, hypomagnesemia, renal tubular acidosis, ketoacidosis
What are GI related causes of hypokalemia? Gastric suctioning, diarrhea/vomiting, laxatives, fistula
Beta-2 agonists (increase/decrease) potassium levels. Decrease
Name two inhaled beta-2 agonists. Albuterol, Ventolin
What are the EKG changes in hypokalemia? U wave, biphasic T, ST depression
What is the safest way to replete potassium? PO
What is the goal of IV potassium replacement? Remove the patient from the immediate dangers of hypokalemia
Potassium replacement should not exceed _______ mEq/hr. 8
What is the recommended ceiling for IV potassium replacement? 240 mEq/day
Laryngospasm is a symptom of (low/high) calcium levels. low
Positive Chvostek’s and Trousseau’s signs are indicative of _______. Hypocalcemia
The most severe transfusion reactions occur due to _______ incompatibility. ABO
The activation of the ______ system in a transfusion reaction results in ________. Complement; intravascular hemolysis
What is the incidence of anaphylaxis and acute hemolytic reactions with blood transfusions? A=1:150,000, AHR=1:100,000 (die)
The RH system involves the presence or absence of the ______ antigen. D
What is the incidence of the D antigen in caucasians? 80% present
Rh negative individuals develop antibodies against the _______ antigen after exposure to ___________ positive blood. D; RH
What does cross matching mimic and how is this done? Mimics transfusion by mixing donor cells w/recipient serum
How long does it take to obtain ABO and Rh typing? 5min
How long does it take to obtain antibodies to other blood groups? 45min
What is the incidence of transfusion reaction with a negative screen but without a cross match? 0.001%
What is blood fully tested for? Hep: A, B, C; HIV 1, 2; T-cell lymphotropic virus 1, 2
What is the preservative anticoagulation added to blood and how long can blood be stored? 35 days and up to 6wks
What is the Hct of RBCs? 70%
Platelet transfusion is indicated at levels less than _________. 20,000
Increased blood loss occurs with platelet levels less than ________. 50,000
Each single unit of platelets increases levels by _________. 5,000-10,000
How is the presence of dysfunctional platelets diagnosed? Checking bleeding times
How long do transfused platelets survive after transfusion? 1wk
Sensitized patients may require what type of platelet product? HLA compatible platelets
Low levels of 2,3 DPG in stored blood can cause a (left/right) shift in the oxyhemoglobin dissociation curve. Left
What occurs with a leftward shift in the oxyhemoglobin curve? Cells can’t release O2 at the tissue level, hypoxia ensues
What does 2,3 DPG help promote? Oxygen offloading at tissues
What are the products in FFP? Plasma proteins and clotting factors
How much of an increase in clotting factor is seen with one unit of FFP? 3%
What is initial dose of FFP? 10-15ml/kg
True/False: FFP has a lower infectious risk compared to whole blood. False-carries the same risk
Rapid transfusion of FFP may lead to (hyper/hypo)tension. Hypo
What electrolyte imbalance is associated w/citrate toxicity? Hypocalcemia
Patients w/(renal/hepatic) disease are at risk for citrate toxicity. Hepatic
What is more common after transfusion of red blood cells: metabolic acidosis or alkalosis. Why is it more common? Alkalosis b/c citrate and lactate in products are converted to bicarbonate in the liver
Each unit of PRBCs contains _____ mEq of K+. 4
What is the definition of massive blood transfusion (MBT)? 1 blood volume Tx over 24hrs or Tx of 10units or greater of whole blood
What is the most common cause of bleeding following MBT? Dilutional thrombocytopenia
What is the benefit of thromboelastography? Observes the quality of homeostasis as a whole dynamic process, instead of revealing information of isolated coagulation screens
What does TEG measure? Viscoelastic properties of blood as it is induced to clot under a low shear environment (sluggish venous flow)
The universal blood recipient is ______. AB
The universal donor blood is _______. O
What is the RBC antigen for RH+ individuals? D antigen
Patients who are RH+ can receive RH (+, -, + and -) blood. + and –
Patients who are RH- can receive RH (+, -, + and -) blood. - (negative)
What do individuals with AB blood types lack? Anti-A or Anti-B antibodies
What would happen if whole blood from a universal donor were given to someone w/a different blood type? Hemolytic transfusion reaction
Why can "whole blood" only be given to exact match recipients? Contains a wealth of other blood products that may induce a reaction if not given to the same blood type recipient
What do type O individuals lack? A and B surface antigens
What type of blood is given in emergency transfusions? O negative
Who can individuals with AB blood type donate to? AB recipients only
What are two things to use when administering blood? 170micron filter and blood warmer at 37C
What are 4 alternative methods of transfusing blood? Autologous, blood salvage, normovolemic hemodilution, donor directed transfusion
Created by: philip.truong