To maintain adequate:

Intravascular fluid volume

Left ventricular filling pressure

Cardiac output

Systemic blood pressure

Oxygen delivery to the tissues

Skin turgor

Mucous membranes

Peripheral pulses

Resting HR and BP (orthostatics)

Urine output

NPO status

Name effects of hypovolemia seen

on blood lab results

Increased Hct

Metabolic acidosis

Hypernatremia

BUN/creatinine ratio > 10:1

Name effects of hypovolemia on

urine lab results

Specific gravity > 1.010

Urine sodium < 10 mEq/L

Urine Osmolality > 450 mOsm/kg

Pitting edema

Presacral edema

Later signs:  Tachycardia

Crackles

Wheezing

Pulmonary edema

What are some manifestations of hypervolemia that may be seen

on x-ray?

• Kerley B lines (increased pulmonary and interstitial markings)
• Diffuse alveolar infiltrates

Intracellular fluid is approximately ___ of

the body's water and ___% of body weight

potassium (140 mEq)

magnesium (26 mEq)

sodium (10 mEq)

sodium (140 mEq)

potassium (3.5-5.5 mEq)

calcium (8.4-10.5 mEq)

What fluid surrounds the cells and does not circulate?

It comprises ___ of the ECF.

Interstitial fluid

3/4

The extracellular component of blood.

It comprises ___ of the ECF

Plasma

1/4

The typical male will be ___% water

Female?  ___%

Infant?  ___%

60

50

80

Obese adults will have ___ (more/less) water per kg of body weight.

A patient with DM will have ___ (more/less) water per kg of body weight

less

less

Name the formula for Free Water Deficit

This cation affects resting

membrane potential

What are the major anions of

extracellular fluid?

chloride (108 mEq)

bicarbonate (24 mEq)

proteins (16 mEq)

What are the major anions of

intracellular fluid?

chloride (4 mEq)

bicarbonate (12 mEq)

phosphate (40-95 mEq)

proteins (54 mEq)

What is the hallmark sign for

hypernatremia?

Name and describe three types

of hyponatremia

1. hypovolemic:  ↓ total Na⁺
2. isotonic/pseudohyponatremia:  normal total Na⁺
3. hypervolemic:  ↑ total Na⁺ 

Name some clinical manifestations of

hypernatremia

Neuro:  thirst, weakness, ICB, disorientation, hallucination, irritability

CV:  hypovolemia

Renal:  polyuria, oliguria, renal insufficiency

How should hypernatremia with increased total body sodium be corrected?

With a loop diuretic along with

intravenous D5W

Seizures, cerebral edema, coma, death

No faster than 0.5-1 mEq/L/hr

* Be sure to check serum Na⁺ osmolalities during treatment

Prolonged PR interval

Widening QRS complex

Peaked T waves

Ventricular Arrhythmias

Ca²⁺ will decrease excitability

Moves threshold away from threshold

Protects the heart from hyperkalemia

*CaCl is 10% solution, thus 1 amp = 1 gm

1.  Calcium 500-1000 mg IV (effects rapid but short-lived, Ca²⁺ potentiates digoxin toxicity)

2.  Sodium bicarb when metabolic acidosis present (45 mEq)

3.  Beta agonists

4.  IV infusion of 30-50 gm glucose and 10 units insulin (can take up to 1 hour)

5.  hemodialysis

6.  hyperventilation

7.  Kayexalate

8.  Furosemide

1. T wave flattening and inversion

2. Increasingly prominent U wave

3. ST segment depression

4. Widened QRS complexes

5.  Ventricular ectopy

Resting membrane potential is less negative

Cell depolarizes & resting potential moves towards threshold

Resting membrane potential becomes more negative

Cell hyperpolarizes, RMP moves away from threshold

Cell becomes less excitable - harder to reach threshold

Oral replacement with potassium chloride (60-80 mEq/day)

Intravenous potassium:  peripheral (no greater than 8 mEq/hr)

central (10-20 mEq/hr)

Hypoparathyroidism

Pancreatitis

Renal Failure

Decreased serum albumin levels?

Carpopedal spasm (Trousseau's sign)

Masseter spasm (Chvostek's sign)

Laryngospasm

Decreased cardiac contractility

What is the treatment for symptomatic hypocalcemia?

Calcium chloride (3-5 mL of a 10% soln) or calcium gluconate (10-20 mL of a 10% soln)

(10 mL of 10% CaCl₂ contains 272 mg of Ca²⁺, whereas 10 mL of 10% cal gluconate contains only 93 mg of Ca²⁺)

**Follow treatment with serial ionized calcium levels

Hyperparathyroidism

Bone malignancy

Renal Failure

Thiazide diuretics

Excess calcium supplements

Shortened ST segment

Shortened QT interval

Dysrhythmias - CHB

Anorexia

N/V

Polyuria

Weakness

Hypertension

Threshold potential shifts away from resting potential

Threshold becomes less negative

Cells become less excitable

Rehydration (NS) followed by brisk diuresis (UOP 200-300 mL/hr) with a loop diuretic to accelerate calcium excretion

**Follow serial ionized calcium

Alcoholism

Chronic diarrhea

Hypercalcemia

Hyperaldosteronism

Malabsorption syndromes

Malnutrition

Certain medications

Nystagmus

Seizures

Fatigue

Muscle spasms or cramps

Muscle weakness

Magnesium sulfate IV 1-2 gm slowly over 15-60 minutes

**Monitor labs for concomitant hypokalemia and hypocalcemia

Stop all sources of mag (often antacids)

IV calcium 1gm can temporarily antagonize most effects

A loop diuretic with an infusion of D5 1/2NS enhances urinary magnesium excretion

With a patient that is hypermagnesemic, what considerations should be taken when

dosing NMBDs?

No solid food for 8 hours preop

May take oral meds with a sip of water day of surgery

**No chewing gum or mints after midnight

Clear liquids up to 2 hours preop

Breast milk up to 4 hours preop

Formula, nonhuman milk, light meal at least 6 hours preop

Full meal, carbonated drinks at least 8 hours preop

Morbidly obese

Trauma

GI dysfunction, obstruction

Emergency surgery

Diabetes

Describe the 4-2-1 Rule

(hourly maintenance)

• 4 mL/kg/hr first 10 kg of body weight
• 2 mL/kg/hr second 10 kg of body weight
• 1 mL/kg/hr for the remaining weight in kg

Shortcut:  Patient's weight in kg + 40

Number of hours x hourly maintenance rate

Administer:

50% during the first hour

25% in the second hour

25% in the third hour

Describe the guidelines for replacing redistributive and evaporative

surgical fluid losses

small incision/minimal tissue trauma: 2-4 mL/kg/hr

moderate incision/moderate tissue trauma:  4-6 mL/kg/hr

large incision/severe tissue trauma:  6-8 mL/kg/hr

major vascular case/extreme tissue trauma: 8-10 mL/kg/hr

Differentiate between crystalloid and

colloid fluids

Crystalloids contain electrolytes dissolved in water or dextrose and water (e.g. NS, LR)

Colloids are natural or synthetic molecules; impermeable to vascular membrane; determine osmotic pressure that balances distribution of water between intravascular and interstitial spaces (e.g.albumin, Hespan, Hextend)

Major surgical procedures:  aortic, radical cancer surgeries

Shock

Slow correction of hyponatremia

TURP syndrome

Reduction in perioperative edema

Reduction in ICP

Hypernatremia, hyperchloremia, hyperosmolality

Hypokalemia

Increased cardiac output

Decreased SVR/PVR; improved microcirculatory blood flow

Decreased ICP

Increased solute to kidneys

A soaked 4x4 contains ___ of blood

A soaked lap sponge contains ___ of blood

10 mL

100 mL

When replacing fluids, what is the ratio of crystalloid replacement : blood lost?

colloid replacement : blood lost?

Crystalloid - 3:1

Colloid - 1:1

A type & screen matches the patient's blood with compatible ABO and Rh blood for transfusion.

A type & cross does the same as a T&S but mimics the transfusion but mixing donor cells with recipient serum

ABL = [EBV x (H_i-H_f)]/H_i

EBV = weight (kg) x average blood volume

State the average blood volume for:

Preterm neonates

Term neonates

Infants & children

Adult males

Adult females

Preterm neonates:  95 mL/kg

Term neonates: 85 mL/kg

Infants & Children: 80 mL/kg

Adult males: 75 mL/kg

Adult females: 65 mL/kg

It will increase Hgb by 1g/dL and Hct by 2-3%

(in adults)

Hct 70%

Reconstitute with NS to decrease viscosity

Use fluid warmer to avoid hypothermia

Use 170 micron filter to trap clots and debris

1 unit should increase Hgb by 1 gm/dL or Hct by 3%

• Glucose solutions may cause RBC hemolysis

• LR contains calcium and may induce clot formation

40% Hct

Used primarily in hemorrhagic shock

Contains all factors (RBCs WBCs, platelets, plasma, clotting factors)

1 unit will raise Hct 3-4% and Hgb 1 gm/dL

Contains plasma proteins and clotting factors

No platelets

Used in coagulation deficiencies, reversal of warfarin therapy

1 unit will increase clotting factors by 3%

Hypernatremia could result in massive transfusion

Given for thrombocytopenia

Each unit contains about 50 mL of plasma

The presence of plasma poses a risk of transfusion reaction

Platelets

(1 unit can increase platelet count by 5,000 to 10,000)

Fraction of plasma that precipitates once FFP is thawed

High concentrations of Factor VIII to treat Hemophilia A

High concentrations of fibrinogen to treat hypofibrinogenemia

Febrile reactions - an increase in temperature without evidence of hemolysis (1-3%)

Urticarial reactions - pruritis, hives, erythema without fever (1%)

1.  Stop transfusion

2. Treat hypotension with fluids and vasopressors. Consider steroids.

3. Send unused donor blood and a fresh patient sample to the blood bank to be recrossmatched

4. Sent patient blood samples for free Hgb, haptoglobin, Coombs test, DIC screen

5. Preserve renal function by maintaining brisk urine output (IVF, lasix, mannitol)

6. Follow hospital protocols

• Transfusion-Related Acute Lung Injury (TRALI)
• TRALI is a noncardiogenic form of pulmonary edema associated with blood product administration
• Occurs most frequently with RBCs, FFP and platelets
• The clinical appearance is similar to ARDS
• Treatment is largely supportive - the patient should receive oxygen and ventilatory support as necessary, usually with a low tidal volume strategy
  

Calcium binding by the citrate preservative can theoretically become significant following transfusion of large volumes of blood.

Clinically significant hypocalcemia, causing cardiac depression, does not occur in most normal patients unless the transfusion rate exceeds 1 unit every 5 minutes

Hypocalcemia

Hypomagnesemia

Hypotension

Increased LVEDP

Increased CVP

Prolonged QT interval

Calcium (and magnesium)

**Citrate will be metabolized quickly in Kreb's Cycle so symptoms may abate before treatment needed.

Microvascular bleeding

Hematuria

Bleeding at IV sites

Increased PT/PTT

Decreased platelets

Clinically oozing

**Seen with massive transfusions > 1 EBV (>10 units)

Surgically control the bleeding

Keep patient warm

Maintain perfusion and euvolemia

Do not overhydrate and dilute patient

Consider FFP, platelets

Consider Vitamin K, DDAVP

Normovolemic hemodilution

Cell saver (intraop salvage)

Autolagous donation (preop)

Complete circuit -> Jehovah's Witness

Postop salvage (chest tube drainage system)

Oxygen-carrying substitutes (bovine blood)