Anesthesiology Blood Loss and Fluid Management
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Questions and Answers

What is the formula for calculating the acceptable blood loss (ABL)?

  • ABL = EBV - (Hcti + Hctf)
  • ABL = EBV - (Hcti - Hctf)
  • ABL = EBV / (Hcti - Hctf)
  • ABL = EBV (Hcti - Hctf)/ Hcti (correct)

    • What is the goal of goal-directed fluid therapy?

  • To achieve a certain blood pressure
  • To maintain a certain oxygen saturation
  • To maintain a certain heart rate
  • To use hemodynamic values to guide fluid administration with fluid responsiveness tested with fluid bolus and relies on the Frank-Starling curve (correct)

    • What is the purpose of the Frank-Starling curve?

  • To measure cardiac output
  • To monitor blood pressure
  • To determine fluid responsiveness (correct)
  • To assess heart rate

    • What is the estimated blood loss in a short, uncomplicated laparoscopic procedure?

    <p>0-2 mL/kg</p> Signup and view all the answers

    What is the primary concern when storing platelets at room temperature?

    <p>Risk of infection</p> Signup and view all the answers

    What is the minimum platelet count required before performing a high-risk procedure?

    <p>75-100k</p> Signup and view all the answers

    What is the primary components of Cryoprecipitate?

    <p>FXIII</p> Signup and view all the answers

    What is the leading cause of death in transfusion complications?

    <p>TACO</p> Signup and view all the answers

    What is the recommended ratio for replacement therapy in massive hemorrhage?

    <p>1 RBC:1 FFP:1 platelets</p> Signup and view all the answers

    What is the primary concern when giving vasodilatory drugs in a patient with small bowel obstruction?

    <p>Hypotension and tachycardia due to 6 L of fluid accumulation</p> Signup and view all the answers

    What is the primary concern when using starch products as colloids?

    <p>They cause renal impairment, anaphylaxis, and inhibit platelet function</p> Signup and view all the answers

    What is the advantage of using hypertonic saline over other crystalloids?

    <p>It increases MAP, decreases swelling, and improves regional blood flow</p> Signup and view all the answers

    Why is LR contraindicated in PRBC transfusion?

    <p>It can crystalize in the presence of blood due to calcium</p> Signup and view all the answers

    What is the primary reason for the left shift in PRBC transfusion?

    <p>Hypothermia and decreased 2,3 DPG and alkalosis</p> Signup and view all the answers

    What is the pediatric dose of PRBC transfusion to increase Hct by 10%?

    <p>10mL/kg</p> Signup and view all the answers

    What is the primary reason for not using dextrose-containing solutions in fluid management?

    <p>They can cause hyperglycemia-induced ischemia and neurological damage</p> Signup and view all the answers

    What is the primary indication for using Fresh Frozen Plasma (FFP)?

    <p>To correct a deficiency in coagulation factors or to treat shock</p> Signup and view all the answers

    What is the half-life of crystalloids in fluid management?

    <p>30-60 minutes</p> Signup and view all the answers

    What is the primary concern when giving vasodilatory drugs in a patient with small bowel obstruction?

    <p>Hypotension</p> Signup and view all the answers

    Why is LR contraindicated in PRBC transfusion?

    <p>It can crystalize in the presence of blood due to calcium in LR</p> Signup and view all the answers

    What is the primary reason for the left shift in PRBC transfusion?

    <p>All of the above</p> Signup and view all the answers

    What is the half-life of crystalloids in fluid management?

    <p>30-60 minutes</p> Signup and view all the answers

    What is the minimum platelet count required before performing a moderate risk procedure?

    <p>50k</p> Signup and view all the answers

    What is the estimated blood volume in a preterm neonate and a term neonate ?

    <p>90-100 mL/kg (preterm)</p> Signup and view all the answers

    What is the most common type of shock in anesthesia?

    <p>Hypovolemic shock</p> Signup and view all the answers

    What is the purpose of the Frank-Starling curve?

    <p>To demonstrate the relationship between ventricular volume (preload) and cardiac contractility</p> Signup and view all the answers

    What is the primary difference between ERAS and traditional anesthesia?

    <p>ERAS uses purposeful IV fluids and opioid-free techniques</p> Signup and view all the answers

    What is the estimated blood loss in a moderately invasive procedure?

    <p>2-4 mL/kg</p> Signup and view all the answers

    What is the formula to estimate fluid deficit in a patient?

    <p>Maintenance fluid requirement x fasting hours</p> Signup and view all the answers

    What is the correct method for administering maintenance fluid and deficit in surgery?

    <p>Give 1/2 total in 1st hour and 1/4 in 2nd and 3rd hour of surgery</p> Signup and view all the answers

    What is the estimated blood volume of adults in milliliters per kilogram?

    <p>70mL/kg</p> Signup and view all the answers

    What is considered moderate surgical blood loss?

    <p>2-4 mL/kg</p> Signup and view all the answers

    What is the typical blood loss volume in prolonged and highly invasive surgical procedures?

    <p>4-8 mL/kg</p> Signup and view all the answers

    What is true about hypovolemic shock in anesthesia?

    <p>It is the most common type of shock and is easily treatable</p> Signup and view all the answers

    What are common causes of hypovolemic shock in surgical patients?

    <p>Preoperative fasting</p> Signup and view all the answers

    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?

    <p>Contractility remains the same</p> Signup and view all the answers

    What is unique about the Frank-Starling curve in heart failure?

    <p>It is pathophysiologic and shifts to the right</p> Signup and view all the answers

    What are the components of ERAS (Enhanced Recovery After Surgery) in anesthesiology?

    <p>All of the above</p> Signup and view all the answers

    What are some the traditional strategies for managing blood loss and fluid management in anesthesiology?

    <p>All of the above</p> Signup and view all the answers

    Which type of acid-base imbalance is associated with the administration of normal saline?

    <p>Hyperchloremic metabolic acidosis</p> Signup and view all the answers

    What is the primary difference between Lactated Ringer's (LR) and Plasmalyte?

    <p>Electrolyte composition - LR has calcium, Plasmalyte has magnesium</p> Signup and view all the answers

    What is the main difference between crystalloid replacement ratios and colloid replacement ratios?

    <p>Colloids replaced 1:1; Crystalloids replaced 3:1</p> Signup and view all the answers

    What is the half-life of colloids?

    <p>Several hours/days</p> Signup and view all the answers

    What are the risks associated with the use of albumin?

    <p>Risk of allergic reaction and infection</p> Signup and view all the answers

    Why would you avoid using lidocaine (LR) in patients with renal or liver disease?

    <p>Due to impaired metabolism/clearance</p> Signup and view all the answers

    What does one unit of blood do to hemoglobin and hematocrit levels in adults?

    <p>Increases hemoglobin by 1 g/dL and hematocrit by 2-3%</p> Signup and view all the answers

    What is true about the potassium levels in older packed red blood cells (PRBCs)?

    <p>The potassium levels increase due to cell breakdown and acidosis.</p> Signup and view all the answers

    Why would you need to give calcium or bicarbonate during the administration of PRBCs?

    <p>To counteract the preservative (citrate-induced) hypocalcemia and acidosis</p> Signup and view all the answers

    Why does hematocrit (Hct) change more with hydration status?

    <p>Because hydration affects the percentage of red blood cells in the blood.</p> Signup and view all the answers

    What are the indications for the infusion of concentrates of platelets?

    <p>All of the above</p> Signup and view all the answers

    In the presence of thrombocytopenia or platelet dysfunction, what interventions can be done to mitigate bleeding?

    <p>Administer platelet transfusions</p> Signup and view all the answers

    What is the minimum platelet count before low-risk procedures?

    <p>30k</p> Signup and view all the answers

    What is Platelet Rich Plasma (PRP) and what are the indications for its use?

    <p>A concentrate of platelets, clotting factors, and other plasma proteins that can help in wound healing, used in orthopedic and dental surgery</p> Signup and view all the answers

    Why is crossmatching more extensive than type and screen testing?

    <p>It is a slower and more labor-intensive process that involves mixing the donor RBC and pt's serum for antibody screening</p> Signup and view all the answers

    What is TRALI defined as?

    <p>An acute onset of lung injury within 6 hours after blood product administration</p> Signup and view all the answers

    Is TRALI (transfusion related acute lung injury) more common than anaphylaxis as a transfusion reaction?

    <p>True</p> Signup and view all the answers

    Lowest acceptable Hct (i.e. Hctf) is 21-24 in healthy patients and 30 with CAD

    <p>True</p> Signup and view all the answers

    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

    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

    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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    Description

    This quiz covers the formulas and guidelines for estimating blood volume, fluid deficits, and maintenance fluid rates during surgery. Topics include ABL, EBV, and the 4/2/1 rule.

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