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