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Physio II - Exam 1 - Lecture 3 - Blood & Electrolytes
Terms in this set (105)
what is the most important extracelluar electrolyte?
-what is the intravascular and interstitial quantity for a normal adult?
-intravascular = 145
-interstitial = 142
What is the most important intracellular electrolyte?
what is it's quantity in a normal adult at the intracellular level?
What are the 2 most common crystalloids we give?
-hartmann's ringers (LR)
what are the 3 most common colloids we give?
1. hydroxyethyl starch 6%(Haspan)
2. albumin 5%
3. dextran 10%
When it comes to sodium and calcium content in the IV fluids of both crystalloids and colloids, what is the most important factor?
they are isotonic
If you needed a fluid to stay in the intravascular space longer which one would you use: crystalloids or colloids?
When would Hespan be contraindicated?
renal insufficiency or severely ill patient
How do you calculate plasma osmolality?
Na+ x 2 + glucose/18
When you give normal saline, the sodium and water volume remain in what compartment?
when you give 1/2 normal saline, the water moves _____________ in order to equalize intra and extracellular osmolality.
Does this decrease or increase extracellular Na+ and osmolality?
When you give hypertonic saline, the water moves _____________ in order to equalize intra and extra cellular osmolality.
Does extracellular Na and osmolality increase or decrease?
True or false: volume regulation and osmoregulation happen simultaneously?
The purpose of volume regulation and osmoregulation is to control the intracellular or extracellular compartment?
Which one varies renal Na excretion and which one varies water intake/excretion?
Na excretion = volume regulation
water intake/excretion = osmoregulation
what 3 sensors are associated with volume regulation in the body?
1. afferent renal arterioles
2. carotid baroreceptors
3. atrial stretch receptors
what sensor is associated with osmoregulation in the body?
Thirst and ADH are 2 effectors for which mode of regulation:
***ADH also effects volume regulation though.
Baroreceptors at the carotid sinus modulate what for volume regulation?
SNS activity and non-osmotic ADH secretion
Baroreceptors at the afferent arterioles (juxtaglomerular apparatus) modulate what for volume regulation?
Stretch receptors at both atria modulate what for volume regulation?
release of ANP and ADH
When you are volume depleted via decrease in extracellular fluid what happens to the following:
-low pressure receptors
-high pressure receptors
-peripheral vascular resistance
true or false: increases in afferent arteriolar pressure stimulates renin release and formation of angiotensin II
Vasoconstriction from high ATII markedly decreases what 2 things?
RBF and GFR both decrease
How does the body respond to hypervolemia to maintain salt and water homeostasis?
How does the body respond to surgical stress/ischemia/sepsis to maintain salt & water homeostasis?
vasoconstriction (salt retaining)
when you have decreased extracellular volume what happens to your sympathetic activity: does it increase or decrease?
What is the difference between absolute hypovolemia and relative hypovolemia?
absolute = fluid leaves body suddenly
relative = fluid redistributes within the body
what are the 5 possible sources of absolute hypovolemia?
1. GI - vomit, diarrhea
2. renal = diuresis, diabetes inspidus
3. skin = burn, lesion
4. trauma = fractures, hemothorax, ruptured spleen
5. surgical =blood loss
what are the 3 possible sources of relative hypovolemia?
1. internal fluid shift (3rd spacing)
2. capillary leak (sepsis)
3. sequestration (intestinal obstruction)
What is the best type of fluid treatment you can give for relative hypovolemia scenarios: crystalloids or colloids?
what is an example of a non-invasive method to test for cardiac output in a patient who might have hypovolemia? What information will it give you?
what would be an invasive method to test for cardiac output
clear sight monitor = shows you cardiac index and SV
CVP (invasive method to test for hypovolemia)
-commonly placed where?
-What vessel is best to stay away from and why?
-right internal jugular vein
-subclavian vein to avoid pneumothorax
When a patient is on the ventilator and you are giving them positive pressure, will your variation of SV be higher or lower if they are hypovolemic?
higher variation of SV with a hypovolemic patient
***a euvolemic patient's SV will not change despite the positive pressure ventilation
Hydrostatic pressure effect, reduced oncotic pressures, and increased capillary permeability can all cause what?
What are examples of a hydrostatic pressure effect that can lead to edema?
-loss of autoregulation
what are examples of reduced oncotic pressure (low albumin) that can lead to edema?
-malnutrition/ critically ill
what are examples of increased capillary permeability that can lead to edema?
-acute lung injury
Total body sodium is regulated by what 2 things?
Sodium alone is altered by what?
Total body potassium is regulated by what 2 things?
Potassium alone is regulated by what 2 things?
-aldosterone, intrinsic renal mechanisms
true or false: if you have severe hyperlipidemia it can look like you have pseudohyponatremia
Peripheral edema, rales, and ascites are all physical signs of what?
what are physical signs of hypovolemia?
-decreased skin turgor
-flat neck veins
How do you calculate Na deficit?
TBW X (desired Na - present Na)
if your patient has low sodium levels they are likely experiencing what?
what are the 2 best fluids to replace Na with? which one can be given for rapid replacement?
-edema (could lead to cerebral edema)
-hypertonic (3%) saline ***rapid
What risk do you run if you correct hyponatremia too quickly?
brain shrinkage = central pontine myelinolysis
(demyelinating lesion in the PONS, and permanent neurologic sequelae)
Central pontine myelinolysis: how much NS to give based on severity of hyponatremia?
how would we know if a patient was experienced central pontine myelinolysis under anesthesia?
we wouldn't... we would only be able to monitor fluids you gave compared to fluids that were lost/excreted
Most physicians will not proceed with an elective surgery if the Na+ level is less than what?
what are the 4 major causes of hypernatremia?
1. impaired thirst
2. solute diuresis
3. excessive water losses
4. combined disorders (coma + hypertonic nasogastric feeding)
hypernatremia is when Na > _______ meq/L.
this is nearly always the result of what 2 things?
1. water loss
2. Na retention
1. water and Na loss?
2. water loss only?
3. Na retention only?
1. replace isotonic loss & water deficit
2. replace water deficit
3. loop diuretic & any water deficit
1. decreased extracellular volume?
2. normal extracellular volume but Na in urine is >20?
3. Increased extracellular volume (Na urine <20 = heart failure, cirrhosis)
4. increased extracellular volume (Na urine >20 = renal failure)
1. replace isotonic deficit
2. restrict water
3. restrict water & loop diuretic
4. restrict water
Sodium depletion leads to ________volemia while sodium overload leads to _______volemia
What is the best treatment for the following:
3. water deficit
4. Sodium removal
1. .9% NS
2. hypotonic fluids
3. hypotonic fluids
4. loop diuretics, dialysis
What are the 3 major causes of hypokalemia that Dr. Gomez wants us to know
1. diuresis (excess renal loss via diuretics)
2. vomiting/diarrhrea (GI losses)
3. acute alkalosis (ECF-->ICF shift)
How would hypernatremia and hypokalemia cause acute alkalosis?
Potassium goes from ECF to ICF with H & Na ions go from ICF to ECF in exchange.
The potassium leaves = hypokalemia
The Na increases= hypernatremia
the H+ ions produce formation of bicarb = alkalosis
What cardiovascular and neuromusclular effects does hypokalemia have on the body that Dr. Gomez wants us to know?
1. Cardio = ECG changes, dysrhythmias, myocardial dysfunction
2. skeletal muscle weakness
What ECG effects will you see with hypokalemia?
-prolonged P-R interval
-ST segment depression = flattened T wave
-U wave formation
What is the generally accepted treatment for hypokalemia with KCL?
10 meq per hour (give slowly over several days)
If you have to correct hypokalemia in the OR you need to use what?
an infusion pump
Generally, local practices will proceed surgery if K + > _______ or <_____ for elective surgery. Anything lower or higher, they will cancel or delay.
if you must proceed with surgery and the patient has hypokalemia what 3 things must you avoid?
3. glucose containing IVFs
what is an example of pseudohyperkalemia?
red cell hemolysis (poor blood draw)
what 2 examples of intercompartmental shifts would cause hyperkalemia?
what is the main example of decreased potassium excretion that leads to hyperkalemia?
what are you likely to see on an ECG for patient with hyperkalemia?
-peaked T waves
-sine wave formation
Once a patient has reached a potassium of 8 what physical finding would you see the most?
What are the common agents used to treat hyperkalemia?
true or false: beta agonists can treat hyperkalemia
What is kayexalate and what is it used for?
-Sodium polystyrene sulfonate = Potassium exchange resin agent
-used for definitive elimination of extra potassium to treat hyperkalemia
How much calcium do you give to treat sever hyperkalemia?
10 ml of 10% CaCl over 10 minutes
how much glucose and insulin do you give to treat severe hyperkalemia?
D10W + 5-10 U reg insulin per 25-50 g glucose
how much sodium bicarb do you give to treat severe hyperkalemia?
50-100 meq over 5-10 min
If a patient is 45 y/o getting a lipoma excision and has K+ = 6 do you proceed or not?
if a 45 y/o patient is coming in for an elective AAA repair with K+ = 6, do you proceed or not?
I would redraw the blood work one more time before deciding to cancel or proceed.
What hormone mobilize calcium from the bone, and increases calcium reabsorption in the distal tubules
PTH = parathyroid hormone
true or false: parathyroid hormone will directly increase intestinal calcium absorption
false = INDIRECTLY
Which vitamin augments intestinal calcium absorption?
Vitamin D facilitates the action of ______ on the bone and augments renal absorption of ________
What hormone inhibits bone reabsorption and increases urinary Ca excretion?
How does hypocalcemia and hypercalcemia differ on an ECG?
hypo = longer QT
hyper = short QT
List the primary example Dr. Gomez wants us to know for the clinical manifestations of hypocalcemia based on the following category:
1. digitalis insensitivity (digoxin)
3. laryngeal spasm
How much calcium would you give to treat acute hypocalcemia?
IV = 10 ml 10% over 10 min --> .3-2 mg/kg/hr infusion
Oral = 500-100 mg every 6 hours
what are the 3 types of Vitamin D you can give to treat acute hypocalcemia?
How much would you give?
What is the T 1/2 of each one?
1. ergocalciferol - 1200 mcg/day (t1/2 = 30 days)
2. dihydrotachysterol = 200-400 mcg/day (t1/2 = 7 days)
3. 1,25 diydroxycholecaclciferol = .25-1 mcg/day (t1/2 = 1 day)
Third spacing in controversial except in a patient with _________ or ___________
-severely infected tissue
With surgical fluid losses, what 3 reasons make it difficult to get a good estimate of EBL?
1. occult blood loss
2. blood under drapes
3. lap sponges
for an 18X18 lap sponge, what is the percentage of area covered in blood based on blood amount:
100% and dripping
Generally we don't transfuse unless Hgb < ______ ... but is also circumstantial
80 y/o patient with acute MI needs emergent ex lap.
Hgb = 8
would you transfuse or not?
true or false: you almost never need to transfuse with Hgb > 10 unless you are expecting rapid blood loss
Why do platelets have a different filter when delivered to the patient
-needs 170 micron filter... anything smaller will cause breakage of platelets.
The most severe transfusion reactions are due to what?
ABO incompatibility most likely due to clerical error
***ALWAYS DOUBLE CHECK UNITS BEFORE TRANSFUSION
What is the "type" in Type and screen?
What test is used to detect common antibodies associated with non-ABO hemolytic reactions?
antibody screen (type and screen)
For a type and cross match:
the donor/recipient cells are mixed with the donor/recipients serum?
-donor cells with recipients serum
Which test detects rare antibodies or antibodies low titers?
type and crossmatch
Which test has a lower incidence of serous hemolytic reactions to the patient: T&S or T&C?
type and cross
which test takes longer and is more expensive: T&C or T&S
type and cross
True or false: liver transplants require massive transfusion protocol?
what types of coagulopathy should you be worried about with a massive transfusion protocol?
For massive transfusion protocol what are the 4 H's you want to avoid?
How can citrate toxicity affect a massive transfusion protocol?
will cause hypocalcemia and reduce contractility
How does acid base imbalance affect a massive transfusion protocol?
will cause hypoperfusion
When performing a massive transfusion protocol what are you worried about the most for every unit of blood being given?
hyperkalemia = the older the blood the more potassium leaves the ICF and results in hemolysis.
***Supplment each unit of blood with Calcium drip
What is the most common name for a rapid transfuser?
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