IV fluids

potassium

WHO (electrolyte) LIVES INSIDE THE CELL

Sodium

WHO (electrolyte) LIVES OUTSIDE THE CELL

0.5 mL/kg/hr (like 1L per hour)

Urinary Output is estimated at _______ for an adult for fluid resuscitation

under 1% (reflects the kidney is trying to retain volume)

A FENa (fractional excretion of Na+) of _____ indicates prerenal azotemia

tachycardia, hypotension, orthostatic hypotension, dry mucous membranes, decreased skin turgor, increased urine specific gravity (1.020+)

Physical Exam findings for Hypovolemia - reminder that vitals are not an early indicator

Volume depleted (tachycardia, hypotensive, decreased skin turgor, oliguria), NPO for 12+ hours, increased insensible loss (fever, tachypnea, burns)

Reasons to start IV fluids

Pulmonary Artery Catheter (Swan-Ganz catheter - central venous pressure, pulmonary wedge pressure, right ventricular SV), eFAST, TEG (measures viscoelastic changes in whole blood as it clots)

How can we measure hydration status?

prolonged clotting times, low platelets, decreased fibrinogen

Signs of intravascular coagulation

transfusion time!

Hemoglobin under 7 means?

indwelling foley (for accurate I/Os, prolonged immobilization, pre-op)

How are we monitoring urinary output?

Oliguria

What is the most reliable signs of moderate shock?

treat with free water restrictions (should self-regulate), Treat with bolus of IVF if urinary output is decreased

Game plan for Hyponatremia in a post-op patient

GI losses, excessive diuretics, prolonged malnutrition, prolonged alkalosis

Total body K+ is decreased by

Parental K, if refractory give Mg

Treatment plan for hypokalemia?

Renal insufficiency (get repeat testing)

What causes hyperkalemia?

IV D50 in water, 10 units of insulin, calcium gluconate, inhaled beta-adrenergic agonist (albuterol)

Initial treatment for hyperkalemia

Warmed Crystalloid solution (NS/LR - LR is preferred in trauma), blood transfusion (active hemorrhage, profound anemia)

Initial fluid resuscitation - Standards remain elusive

LR, NS (watch for hyperchloremic metabolic acidosis)

Which crystalloids are used for resuscitation (2/2 hypovolemia)?

D5 ½ NS (0.45% sodium chloride - add 20 mEq to prevent hypokalemia but NOT during the 1st 24 hours post surgery)

Which crystalloids are used for maintenance?

30 ml/Kg/24 hrs (maintain with dextrose 5% in 0.45% NaCl + 20 mEq K)

What is the Maintenance rate (use for dehydration or NPO for 12 hours)?

replace fluid loss at a faster rate and similar amount (use LR)

What is the replacement rate?

Start with 1L isotonic crystalloid (2025) then empiric blood transfusion 1:1:1 (RBC:plasma:platelets)

Massive Transfusion Protocol

Hypothermia, acidosis, coagulopathy (crystalloids worsen this)

What is the bloody vicious triad (trauma triad?)

Cold stored low titer O- (+ if we must) whole blood, Pre-screen low titer O- (+ if we must) fresh whole blood, 1:1:1 ratio, plasma and RBC 1:1 ratio, Plasma or RBC alone

Preferred resuscitation fluids for casualties in hemorrhagic shock per Nov 2020 TCC Guidelines

Whole blood (walking donor)

Which colloid is characterized by RBCs + plasma + antigens (increased immunologic activity)?

Pack red blood cells (PRBC)

Which colloid is normally used over whole blood and tends to raise Hgb 1 g/dL per unit?

Fresh Frozen Plasma (FFP)

Which colloids contains clotting factors and must be thawed for at least 30 min?

Platelets (PLT)

Which colloid is usually reserved for active bleeding with less than 50K platelet count and tends to raise PLT count by ~25k?

Albumin

Which colloid is used for volume expansion in liver failure, burns, and nephrotic syndrome?

Hextend (6% hetastarch in lactated electrolyte - nobody is using this rn)

Which fluid type contains starch molecules to increase intravascular volume and is associated with increased mortality and AKI - max does is 1500/24 hr

TXA

What is proven to improve survival in trauma patients if given within 3 hours of injury because it strengthens the clot?

Hypertonic Saline (3-23.4%)

Which fluid draws fluid into the intravascular space (helpful for head injuries)

DDVAP

Which fluid type stimulates endothelial cells to release vWF - good for uremic bleeding (platelet dysfunction, ASA head injury,) and persistent oozing in the OR

Cryoprecipitate

Which fluid type contains vWF, fibrinogen, fibronectin, and factors VIII and XIII - use for multiple factor deficiencies

Aminocaproic Acid (antifibrinolytic agent)

Which fluid is known to reduce transfusion requirements in the setting of elective operations - good for cardiac procedure

Peripheral vein (AC, forearm, hand), IO (sternum, tibia, humerus), Saphenous vein cutdown, central line, PICC line, implantable port

Sites for vascular access

fracture in the bone in which IO is placed (lead to compartment syndrome)

C/I for IO

No peripheral access, hemodynamic monitoring, parental nutrition, administration of potent vasoactive and chemotherapeutic drugs, transvenous cardiac pacemakers, temporary hemodialysis

Indications for central line

Pneumo, arterial puncture, cath-related sepsis

Complications of central ines

subclavian, IJ, femoral, external jugular, cephalic vein

Sites for central line placement

Infection, break, air emboli

Complications of a PICC line - threaded to the SVC

continuous arterial pressure monitoring, repeated blood gas samples

Indication for arterial line

radial artery (do an allen test), axillary artery, femoral

Common sites for placement of an A line

1 week (if prolonged think J or G tube)

IV hydration is good for up to

Total Enteral Nutrition (TEN - monitor electrolytes and pre-albumin)

The provision of nutrients into GI tract via feeding tube (stomach, duodenum, jejunum) - place a PEG or J tube

intestinal ischemia, high output proximal enterocutaneous fistula, hemodynamic instability, bowel obstruction, inability to obtain access, intestinal perf, bowel doesn’t work

C/I for TEN

Use for short form feeding, radiopaque tip, normally gravity fed

Characteristics of a duodenal/jejunal nasoenteric tube (Dobhoff tube)

Gastric tube (NG, OG)

A tube that is used to decompress the stomach - placed on low intermittent suction to relieve nausea and vomiting

cribriform plate or basilar skull fracture

C/I for gastric tube

esophageal/stomach injury, hypokalemia

Complications of gastric tubes

PEG, Percutaneous gastrostomy, jejunostomy

Longer feeding feeding tubes

start on the 2nd day post-op to maintain gut integrity and decrease pneumonia and sepsis

How are feeding tubes used?

patients who cannot have EN

You should use TPN in who?

check weekly liver enzymes, monitor electrolytes (refeeding syndrome)

What do we need to check in nutrition patient?