Questions and Answers
What is the formula for calculating the acceptable blood loss (ABL)?
ABL = EBV (Hcti - Hctf)/ Hcti
What is the goal of goal-directed fluid therapy?
To use hemodynamic values to guide fluid administration with fluid responsiveness tested with fluid bolus and relies on the Frank-Starling curve
What is the purpose of the Frank-Starling curve?
To determine fluid responsiveness
What is the estimated blood loss in a short, uncomplicated laparoscopic procedure?
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What is the primary concern when storing platelets at room temperature?
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What is the minimum platelet count required before performing a high-risk procedure?
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What is the primary components of Cryoprecipitate?
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What is the leading cause of death in transfusion complications?
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What is the recommended ratio for replacement therapy in massive hemorrhage?
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What is the primary concern when giving vasodilatory drugs in a patient with small bowel obstruction?
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What is the primary concern when using starch products as colloids?
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What is the advantage of using hypertonic saline over other crystalloids?
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Why is LR contraindicated in PRBC transfusion?
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What is the primary reason for the left shift in PRBC transfusion?
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What is the pediatric dose of PRBC transfusion to increase Hct by 10%?
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What is the primary reason for not using dextrose-containing solutions in fluid management?
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What is the primary indication for using Fresh Frozen Plasma (FFP)?
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What is the half-life of crystalloids in fluid management?
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What is the primary concern when giving vasodilatory drugs in a patient with small bowel obstruction?
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Why is LR contraindicated in PRBC transfusion?
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What is the primary reason for the left shift in PRBC transfusion?
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What is the half-life of crystalloids in fluid management?
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What is the minimum platelet count required before performing a moderate risk procedure?
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What is the estimated blood volume in a preterm neonate and a term neonate ?
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What is the most common type of shock in anesthesia?
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What is the purpose of the Frank-Starling curve?
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What is the primary difference between ERAS and traditional anesthesia?
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What is the estimated blood loss in a moderately invasive procedure?
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What is the formula to estimate fluid deficit in a patient?
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What is the correct method for administering maintenance fluid and deficit in surgery?
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What is the estimated blood volume of adults in milliliters per kilogram?
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What is considered moderate surgical blood loss?
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What is the typical blood loss volume in prolonged and highly invasive surgical procedures?
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What is true about hypovolemic shock in anesthesia?
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What are common causes of hypovolemic shock in surgical patients?
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What happens to the contractility of the heart in the Frank-Starling curve when the preload is at the top of the curve and more fluid is added?
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What is unique about the Frank-Starling curve in heart failure?
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What are the components of ERAS (Enhanced Recovery After Surgery) in anesthesiology?
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What are some the traditional strategies for managing blood loss and fluid management in anesthesiology?
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Which type of acid-base imbalance is associated with the administration of normal saline?
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What is the primary difference between Lactated Ringer's (LR) and Plasmalyte?
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What is the main difference between crystalloid replacement ratios and colloid replacement ratios?
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What is the half-life of colloids?
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What are the risks associated with the use of albumin?
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Why would you avoid using lidocaine (LR) in patients with renal or liver disease?
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What does one unit of blood do to hemoglobin and hematocrit levels in adults?
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What is true about the potassium levels in older packed red blood cells (PRBCs)?
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Why would you need to give calcium or bicarbonate during the administration of PRBCs?
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Why does hematocrit (Hct) change more with hydration status?
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What are the indications for the infusion of concentrates of platelets?
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In the presence of thrombocytopenia or platelet dysfunction, what interventions can be done to mitigate bleeding?
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What is the minimum platelet count before low-risk procedures?
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What is Platelet Rich Plasma (PRP) and what are the indications for its use?
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Why is crossmatching more extensive than type and screen testing?
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What is TRALI defined as?
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Is TRALI (transfusion related acute lung injury) more common than anaphylaxis as a transfusion reaction?
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Lowest acceptable Hct (i.e. Hctf) is 21-24 in healthy patients and 30 with CAD
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Study Notes
Fluid Management and Blood Transfusion
ABL and EBV Calculation
- ABL (Allowable Blood Loss) = EBV (Estimated Blood Volume) x (Hcti - Hctf) / Hcti
- Hctf (Lowest acceptable Hct) is 21-24 in healthy patients and 30 in patients with CAD
- Maintenance fluid rate: 4/2/1 rule
Estimated Blood Volume (EBV)
- Know estimated blood volume by age:
- Neonates: 90-100 mL/kg (premature), 80-90 mL/kg (term)
- Infants: 80 mL/kg
- Adults: 70 mL/kg
- Surgical losses of blood can be 2-8 mL/kg:
- Minimal loss: 0-2 mL/kg (short procedure)
- Moderate loss: 2-4 mL/kg (uncomplicated laparoscopic/orthopedic procedure)
- Severe loss: 4-8 mL/kg (prolonged and highly invasive)
Hypovolemia and Goal-Directed Fluid Therapy
- Hypovolemia is the most common type of shock in anesthesia, but it's also the easiest to fix
- Causes: preoperative fasting, greater fluid loss than fluid replacement
- Goal-directed fluid therapy: uses hemodynamic values to guide fluid administration with fluid responsiveness tested with fluid bolus and relies on the Frank-Starling curve
ERAS vs Traditional Approach
- ERAS (Enhanced Recovery After Surgery):
- NPO guidelines: drink up to 2 hours before
- Purposeful IV fluids
- Opioid-free/sparing techniques
- Regional anesthesia
- Opioid-free adjuncts (e.g., lidocaine, magnesium, precede, ketamine)
- Traditional approach:
- NPO after midnight
- Load fluids in preop and liberal fluids in OR
- Use of opioids for pain control
Fluid in Small Intestines
- Normally, 7-9L of fluid is secreted in the upper GI tract
- Fluid reabsorbed into the large bowel, with only 0.4L passing in the ileocecal valve
- Fluid shifts in small bowel obstruction:
- Early SBO: 1.5L accumulates in bowel
- With vomiting: 3L accumulated
- Hypotension/tachycardia: 6L accumulated (CAUTION when giving vasodilatory drugs)
Crystalloids vs Colloids
- Parenteral fluids:
- Crystalloids:
- Examples: NS, LR, Plasmalyte, normalyte, dextrose in water
- Indications: replace 3:1 in blood loss, half-life of 30-60 mins
- Avoid LR in renal/liver disease due to impaired metabolism/clearance
- Colloids:
- Examples: albumin, dextran, hetastarch, hepsan
- Indications: replace 1:1 in blood loss, half-life of several hours/days
- Risk of allergic reaction and infection with albumin
- Crystalloids:
Transfusing/Different Types of Blood Products
- Human blood:
- RBCs: increase the amount of RBCs
- PRBC transfusion: use filter and fluid warmer, only use normal saline, and avoid LR due to Ca crystallization
- One unit increases Hg by 1g/dL and Hct by 2-3%
- Pediatric dose: 10mL/kg increases Hct by 10%
- Fresh Frozen Plasma (FFP): correct a deficiency in coagulation factors or to treat shock
- Concentrate of platelets: to treat or prevent bleeding due to low platelet levels
- Cryoprecipitate: to treat fibrinogen deficiencies and contains vWF, fibrinogen, fibronectin, FXIII, FVIII
- Platelet Rich Plasma (PRP): platelets, clotting factors, and other plasma proteins
Blood Bank and Transfusion Reactions
- Type and screen: screen for ABO, Rh, antibody, takes 5 mins, and has a 1:1k chance of reaction
- Crossmatch: type and screen plus, takes 45 mins, and has a 1:10k chance of reaction
- Best ratio is 1 RBC:1 FFP: 1 platelets for replacement therapy
- Transfusion reactions:
- TRALI (transfusion-related acute lung injury): more common than anaphylaxis
- TACO (transfusion-associated circulatory overload): leading cause of death in transfusion complications
Fluid Management and Blood Transfusion
ABL and EBV Calculation
- ABL (Allowable Blood Loss) = EBV (Estimated Blood Volume) x (Hcti - Hctf) / Hcti
- Hctf (Lowest acceptable Hct) is 21-24 in healthy patients and 30 in patients with CAD
- Maintenance fluid rate: 4/2/1 rule
Estimated Blood Volume (EBV)
- Know estimated blood volume by age:
- Neonates: 90-100 mL/kg (premature), 80-90 mL/kg (term)
- Infants: 80 mL/kg
- Adults: 70 mL/kg
- Surgical losses of blood can be 2-8 mL/kg:
- Minimal loss: 0-2 mL/kg (short procedure)
- Moderate loss: 2-4 mL/kg (uncomplicated laparoscopic/orthopedic procedure)
- Severe loss: 4-8 mL/kg (prolonged and highly invasive)
Hypovolemia and Goal-Directed Fluid Therapy
- Hypovolemia is the most common type of shock in anesthesia, but it's also the easiest to fix
- Causes: preoperative fasting, greater fluid loss than fluid replacement
- Goal-directed fluid therapy: uses hemodynamic values to guide fluid administration with fluid responsiveness tested with fluid bolus and relies on the Frank-Starling curve
ERAS vs Traditional Approach
- ERAS (Enhanced Recovery After Surgery):
- NPO guidelines: drink up to 2 hours before
- Purposeful IV fluids
- Opioid-free/sparing techniques
- Regional anesthesia
- Opioid-free adjuncts (e.g., lidocaine, magnesium, precede, ketamine)
- Traditional approach:
- NPO after midnight
- Load fluids in preop and liberal fluids in OR
- Use of opioids for pain control
Fluid in Small Intestines
- Normally, 7-9L of fluid is secreted in the upper GI tract
- Fluid reabsorbed into the large bowel, with only 0.4L passing in the ileocecal valve
- Fluid shifts in small bowel obstruction:
- Early SBO: 1.5L accumulates in bowel
- With vomiting: 3L accumulated
- Hypotension/tachycardia: 6L accumulated (CAUTION when giving vasodilatory drugs)
Crystalloids vs Colloids
- Parenteral fluids:
- Crystalloids:
- Examples: NS, LR, Plasmalyte, normalyte, dextrose in water
- Indications: replace 3:1 in blood loss, half-life of 30-60 mins
- Avoid LR in renal/liver disease due to impaired metabolism/clearance
- Colloids:
- Examples: albumin, dextran, hetastarch, hepsan
- Indications: replace 1:1 in blood loss, half-life of several hours/days
- Risk of allergic reaction and infection with albumin
- Crystalloids:
Transfusing/Different Types of Blood Products
- Human blood:
- RBCs: increase the amount of RBCs
- PRBC transfusion: use filter and fluid warmer, only use normal saline, and avoid LR due to Ca crystallization
- One unit increases Hg by 1g/dL and Hct by 2-3%
- Pediatric dose: 10mL/kg increases Hct by 10%
- Fresh Frozen Plasma (FFP): correct a deficiency in coagulation factors or to treat shock
- Concentrate of platelets: to treat or prevent bleeding due to low platelet levels
- Cryoprecipitate: to treat fibrinogen deficiencies and contains vWF, fibrinogen, fibronectin, FXIII, FVIII
- Platelet Rich Plasma (PRP): platelets, clotting factors, and other plasma proteins
Blood Bank and Transfusion Reactions
- Type and screen: screen for ABO, Rh, antibody, takes 5 mins, and has a 1:1k chance of reaction
- Crossmatch: type and screen plus, takes 45 mins, and has a 1:10k chance of reaction
- Best ratio is 1 RBC:1 FFP: 1 platelets for replacement therapy
- Transfusion reactions:
- TRALI (transfusion-related acute lung injury): more common than anaphylaxis
- TACO (transfusion-associated circulatory overload): leading cause of death in transfusion complications
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