Fluid and Blood Product Management
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| Water is the major component of the body. What percentage of total body weight does it make up? | 50 - 70%; the percentage is influenced by gender, age and tissues of the patient
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| What holds more water, fat or lean tissue? | lean tissue
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| Which type of fluid volume makes up about 2/3 of total body water? | intracellular fluid volume
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| Which type of fluid volume makes up about 1/3 of total body water? | extracellular fluid volume
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| What are the two compartments of extracellular fluid volume? | plasma volume and interstitial fluid volume
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| What the CRNA actually replaces with IV fluids is what type of body fluids? | plasma volume and interstitial fluid volume
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| What are the two forces that influence the movement of water between different fluid compartments? | hydrostatic pressure and osmotic pressure
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| The pressure within the capillaries from the weight of the blood and the pressure from the cardiac pumping mechanics. | hydrostatic pressure
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| The minimum pressure which needs to be applied to a solution to prevent water movement across a semipermeable membrane. | osmotic pressure
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| Does the sodium content in our body water account for the osmotic force mostly in the intracellular or extracellular space? | extracellular (plasma and interstitial)
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| Does the potassium content in our body water account for the osmotic force mostly in the intracellular or extracellular space? | intracellular
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| True or false: usually all compartments of body water are isoosmolar. | true
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| Compares the osmolality of solutions.... | tonicity
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| These type of solutions have the same osmolality of body fluids. | Isotonic; NS, LR, Plasmalyte
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| These types of solutions have an osmolality that is higher than body fluids. What is the name of these solutions, what do they cause to happen in the body, and what are some examples? | hypertonic; they cause water to move out of cells so that they shrink; 5% NS, 10% mannitol
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| What type of cases would warrant the administration of hypertonic solutions? | Euro cases; given to aid in shrinking the brain
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| These type of solutions have a lower osmolality than body fluids. What is their name, what do they cause to happen to the body and what are some examples? | hypotonic; they cause water to move into the cells and swell; .45% NS, D5W
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| < 5% loss of body weight, dry mouth, malaise, decreased urine output, but normotensive and normal capillary refill is classified as what type of dehydration? | mild
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| 5 - 10% reduction in body weight, lethargy, loss of appetite, thick mucous membranes, HR increased, capillary refill slowed, but normotensive is what type of dehydration? | moderate
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| > 10% reduction in body weight, hypotension (< 60 mmHg), tachycardia, mottled skin, slowed capillary refill, anuria is considered what type of dehydration? | severe
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| If severe dehydration is suspected, what size bolus do you give? | 10 - 20 ml/kg bolus
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| What type of anesthetic choice is considered the better option for patients in volume over load and why? | regional....this way you can easily evaluate any sodium changes because you can talk to the patient and evaluate their mental status
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| When electrolyte free water is lost, such as in burns, inadequate intake, or fever, the serum sodium and serum osmolality __________ | increase
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| When water is present in the body fluids in excess, the serum sodium and serum osmolality ____________ | decrease
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| When a patient loses electrolyte rich fluids through vomiting, diarrhea, or fistula drainage and then the volume is replaced with water, what kind of state can occur? | hyponatremic/hypovolemic
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| What is the proper treatment for a hypovolemic/hyponatremic state? | replacement fluids with electrolytes (like LR)
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| What state results from the kidneys failure to conserve sodium? | hyponatremic/normovolemic
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| Absorption of fluids from a TURP results is what state? | hyponatremic/hypervolemic
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| Why is in inappropriate to give LR with blood? | contains calcium, which binds with the citrate in blood
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| Why is it inappropriate to give a renal failure patient LR? | because it contains potassium
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| Why is it inappropriate to administer D5W to a patient undergoing neurosurgery? | It acts like a hypotonic fluid, which will cause water to move into the cells and swell them; particularly bad in neurosurgery because you want the ICP low and the brain tissue shrunken down
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| ____________ is more physiologic in large volumes than normal saline. | Lactated Ringers
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| Large volumes of this IV fluids can cause dilution hyperchloremic acidosis. | Normal Saline
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| What is the half life of crystalloid fluids in the intravascular space? | 20 - 30 minutes
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| What is the intravascular half life of colloids and what accounts for their difference from crystalloids in terms if intravascular half life? | 3 - 6 hours; they have a higher molecular weight than crystalloids
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| Why do you have to have a good reason to use colloids? | they carry an increased risk for anaphylaxis and/or coagulopathy
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| What are the two concentrations of albumin? | 25% or 5%
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| What is the major concern with the administration of albumin? | infection - its a natural product that is spun down from the blood of several donors
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| Is dextrose a natural or synthetic product? | synthetic - dextrose starches
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| How does dextran improve microcirculation? | it decreases blood viscosity and platelet effects
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| At what threshold dose of dextran should you begin checking bleeding times to ensure that they are not increased? | 1.5 gms/kg
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| What is the maximum dose of dextran 40 that can be given in a 24 hour period? | 20 mL/kg
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| Does dextran carry the potential for anaphylactic reaction? | yes
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| Is hespan (hetastarch) a natural or synthetic product? | synthetic plant starch (IV potato)
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| True or False: hespan has a dilution effect of coagulation but does not directly inhibit platelets or clot formation. | False! It does have a dilution effect of coagulation and it does inhibit platelets and clot formation
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| What is the maximum amount of hespan you can infuse in order to avoid an issue with coagulopathy? | 20 mL/kg (500 - 1000mL)
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| Does hespan carry the risk for anaphylaxis? | No - no antigen effect so anaphylaxis rare
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| How can hespan contribute to elevated amylase levels? | it can bind with amylase and prevent its normal excretion
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| What is voluven and how does it differ from both hespan and dextran? | a colloid that is a tetrastrach, so it does not affect coagulation as much as hespan or dextran
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| What is the maximum daily dose of voluven? | 50 mL/kg per day
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| What are the 4 requirements of fluid management? | maintenance fluid infusion, correction of pre-existing volume deficit, replacement of ongoing fluid losses, adjustment of amount and composition of fluids
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| There is a _________ association between metabolic rate and water requirements. | direct
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| So the smaller the size of the patient, the _________ the metabolic rate and water requirements. | greater
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| What is the 4-2-1 rule of maintenance fluids? | 4 mL/kg/hr for the first 10kg, then 2 mL/kg/hr for the next 10 kg, then 1 mL/kg/hr for each kg above 20
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| How do you account for preoperative fluid deficits in the fluid plan for a patient in the OR? | calculate the maintenance rate and multiply by the number of hours NPO
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| If replacing blood loss with crystalloids, what is the ratio of crystalloid given to blood lost? | 3 to 1; so give 3 times the amount of crystalloid as blood lost
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| When replacing blood loss, what is the ratio of colloids given to blood lost? | 1 to 1; so give same amount of colloid as blood lost
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| What is meant by the term "third spacing"? | distribution change of isotonic solution from a functional fluid compartment to a nonfunctional space
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| What is the ideal urine output to maintain during a case? | 0.5 - 1 ml/kg/hr
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| What is the average blood volume for adult men and women? | women 65 mL/kg and men 75 mL/kg
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| What is an allowable HCT, below which transfusion could be considered, in a healthy patient? | 25
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| What is an allowable HCT, below which transfusion could be considered, in a CAD/pulmonary disease/elderly patient? | 29
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| A person with type AB + blood has which antigens present on the membranes of their RBCs? | A, B, Rh
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| A person with type A + blood has which antibodies present in their plasma? | anti-B
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| What is the most common antigen? | D (Rh +) found on 85% of patient's RBCs
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| Do people who do not have D antigens automatically develop D antibodies? | No; only if they are exposed to the D antigen, and even with exposure only 70% of the time
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| What is more specific: a type and screen or a type and crossmatch? | type and crossmatch
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| Crossmatches are _____ specific | unit
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| What are the 3 phases of crossmatch? | major (donor's RBCs with recipients plasma), minor (recipient's RBCs with donor's plasma) and IgE ( checking for antibodies like Kell or Kidd)
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| Type and Screen is not unit specific and just screen for _________ in general. | antibodies
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| What are the chances of a reaction with blood that is crossmatched? | 1:100,000
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| What are the chances of a reaction with blood that is type and screened? | 1:10,000
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| What are the chances of a reaction with blood that is type specific? | 1:1000
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| What are the chances of a reaction with O negative blood? | 1:500
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| True or false: once O-negative blood is given, it is best to give the patient's blood type whenever it becomes available after that. | False! stick with o-negative once it has been given
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| How long can blood last if it contains the CPD preservative? | 21 days
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| How long can blood last if it contains the CPD-A preservative? | 35 days
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| Does a unit of blood become more acidic or basic as time goes on? | acidic (pH day 1 is 7.1 --> 6.9 on day 21)
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| The potassium in a unit of blood on day 1 is around 3.9, but what is it at day 21? | 21
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| Do units of PRBCs contain viable platelets, and clotting factors? | not really, numbers decline as time goes on
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| What is the usual hematocrit of a unit of PRBCs? | 70% - 80%
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| Usually what is given in PRBCs, when would whole blood be indicated? | blood loss > 1500 mL (whole blood contains more plasma)
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| One unit of PRBCs should raise the hematocrit by about what percentage? | 3 - 4%
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| In pediatrics, 10 mL/kg of blood will increase the hematocrit by ______ | 10% (raise hemoglobin 3 g/dL)
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| One unit of platelets will increase the platelet count by ____________ one hour after administration. | 10,000 - 20,000
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| What is the half-life of platelets? | about 24 hours
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| What are the risks associated with transfusing platelets? | sensitization to HLA antigens on cell membranes and transmission of viral diseases (multiple donors)
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| What is contained in FFP? | coagulation factors except platelets
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| What should a single unit of FFP raise coagulation factor levels by? | 7 - 8%
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| What are the risks associated with FFP transfusions? | allergic reactions and transmission of viral diseases
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| Why in some cases is it necessary to give FFP after giving large amount of PRBCs? | coagulation factors are diluted out with massive transfusions and a boost is needed
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| What is contained in cryoprecipitate? | primary source of Von Willebrand factor, also contains factor VIII, fibrinogen, and fibronectin
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| What are the indications for cryoprecipitate? | hemophilia, DIC with fibrinolysis
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| Up to 60% of all fatalities due to blood administration are due to what? | clerical errors
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| What is the first sign of a hemolytic reaction under general anesthesia? | hypotension (also, hgb in urine, acute renal failure, could progress to DIC)
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| What determines the severity of the reaction? | the volume of RBCs infused
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| How do you treat a transfusion reaction? | stop it, infuse crystalloid, administer mannitol/lasix/dopamine, administer bicarb, confirm hemolysis with blood draw, return unused portion of donor blood to blood bank for re-crossmatch, treat coagulopathy with platelet and coagulation factors
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| What are the chances that a unit of blood carries the HIV antigen? | 1:1.4 million
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| What are the chances that a unit of blood carries the Hepatitis C antigen? | 1:1.9 million
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| Which is a more serious problem in blood recipients: contracting HIV or contracting Hepatitis C? | Hepatitis C
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| Why id it necessary to administer blood through a filter? | micro aggregates are associated with pulmonary function and need to be strained out
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| What are some consequences of large volume transfusions? | hypothermia, hyperkalemia, acid base changes, hypocalcemia (rare unless neonate)
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| What type of blood product is TRALI usually associated with? | plasma
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| What is TRIM? | transfusion related immunomodulation; it occurs with ALL PRBC transfusions
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| What is meant by "massive transfusion" of RBCs? | (1) replacement of blood volume in 24 hours; (2) >/= 10 units RBCs within 24 hours; (3) replacing 50% of blood volume within 3 hours or less
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| When monitoring a patient intra-operatively after a large volume of blood has been transfused, tall peaked T waves are noted on the EKG. What should the CRNA administer and why? | Calcium Chloride because most likely the patient's serum potassium is elevated r/t blood transfusion
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