Fluid replacement

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Intravascular fluid volume

5L (3L plasma, 2L erythrocytes)

How can you assess for fluid volume status?

Skin turgor, mucous membranes, edema, lung sounds, vital signs, UO, HCT, urine specific gravity, BUN/Creatinine

What are the sources of intraop fluid requirements?

Maintenance, fluid deficit, blood loss, evaporative loss (3rd spacing)

How do you calculate maintenance fluids?

4-2-1 rule:
4cc/kg/hr for 1st 10kg
2cc/kg/hr for 2nd 10kg
1cc/kg/hr for the remaining kgs

How much maintenance would a 75kg patient need?

4x10=40
2x10=20
1x55=55
Sum=115cc/hr

How do you calculate fluid deficit?

maintenance requirement x hours NPO

How do you replace the fluid deficit?

1/2 deficit replaced in 1st hour
1/4 in 2nd hour
1/4 in 3rd hour

Soaked 4x4 and soaked lap tape hold how much blood?

4x4: 10cc of blood
lap tape: 100-150cc blood

EBV of neonates, infants, children, and adults

Women: 65ml/kg
Men: 75ml/kg
Children: 70ml/kg
Infants: 80ml/kg
Term neonates: 85ml/kg
Premature neonates: 95ml/kg

How do you calculate allowable blood loss (ABL)?

ABL=EBV x ((pts HCT-allowable HCT)/pts HCT)

Evaporative loss is related directly to ____ and ____

surface area of surgical wound and duration of exposure

How do you account for 3rd spacing evaporative loss?

Minimal loss (eye cases, lap chole, knee scope: 0-2ml/kg/hr
-Moderate loss (open chole, appendectomy): 3-5ml/kg/hr
-Severe loss (bowel surgery, THR): 6-9ml/kg/hr
-Emergency (gun shot, MVC): 10-15ml/kg/hr

How do you replace blood?

replace 3:1 crystalloid
replace 1:1 blood
replace 1:1 colloid

What are different classes of crystalloids?

Hypotonic (253), isotonic (300), hypertonic

What is an example of hypotonic solution? What would it replace?

D5W, these would replace water loss

What is an example of isotonic solution? What would it replace?

LR and NS, these can replace water and electrolyte loss

What is an example of hypertonic solution? What would it replace?

D51/2NS (432) and 3%NS (1026), for hyponatremia or shock

What solution is most similar to ECF?

LR

What are some considerations with LR?

Provides 100cc free water per liter of solution, tends to lower Na+, lactate is converted to bicarbonate
Avoid in ESRD as contains K+

What is the preferred solution for diluting PRBCs?

0.9% NS

In large volumes NS can produce what?

high Cl- content dilutional hyperchloremic acidosis

What can D5W cause?

free water intoxication and hyponatremia

How do we get albumin?

obtained from fractionated human plasma

Is albumin reactive?

Does not contain coagulation factors or blood group antibodies

How is albumin available?

5% and 25%

What are the two types of Dextran used for?

Dextran 70 used for volume expansion
Dextran 40 used to prevent thrombosis

Side effects of Dextran?

Anaphylactoid reaction (1/3000)
Platelet inhibition
Noncardiac pulmonary edema
Intereference with crossmatching

Hetastarch (Hespan 6%) benefits

As effective as albumin for volume expansion, but way cheaper
Nonantigenic

What are indications for blood product treatment/transfusion?

Expanding intravascular volume, increasing oxygen carrying capacity, stabilizing hemoglobin and hematocrit

blood transfusion rarely indicated if Hgb>___ and almost always indicated if Hgb<___

rarely: 10g/dL
always: 6g/dL

I unit PRBC increases Hgb how much?

1gm/dL

Complications of autologous transfusion

-anemia
-preop myocardial ischemia from anemia
-adm wrong unit (1:100,000)
-Need for more frequent blood transfusion
-Febrile and allergic reactions

How are platelets obtained?

centrifuging single unit of whole blood

Uses for platelets?

-Thrombocytopenia
-dysfunctional platelets
-active bleeding
-platelet count <50,000

How much does one unit increase platelet count?

7,000-10,000 one hour after transfusion

Bacterial contamination risk with platelets?

1:2,000

What does FFP contain?

clotting factors and plasma proteins (no platelets)

Uses of FFP?

-Emergent reversal of warfarin
-known coagulation factor deficiencies
-correction of microvascular bleeding in the presence of increased PT or PTT
-correction of microvascular bleeding in the pt transfused with more than one blood volume when PT and PTT cannot be obtained in a timely fashion

Each unit of FFP increases each clotting factor level by ____

2-3%

Do you give FFP to augment plasma volume?

No

How is cryoprecipitate derived?

precipitate remaining after FFP is thawed

What does cryoprecipitate contain?

Factor VIII
Fibrinogen
vWF

When is cryoprecipitate used?

von Willebrand's disease
fibrinogen disease

How do you administer cryoprecipitate?

through a filter rapidly (200ml/h) and complete within 6 hours

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