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CHAPTER 47 QUIZ 6 Perioperative Fluid Therapy

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What are the different fluid requirements encountered in the perioperative journey influenced by?

Patient weight and surgical factors

In major surgery, what is one focus of fluid administration?

Postoperative morbidity

What is one goal of fluid therapy for major surgery?

Supporting cellular O2 delivery

Which iatrogenic side effect of fluid administration should be avoided?

Excessive intravascular volume

Apart from fluid volume, what else may need to be manipulated in major surgery according to the text?

Cardiac output and vascular resistance

Which of the following is a potential toxicity related to fluid administration according to the text?

nonphysiologic quantities of anions (lactate, acetate, gluconate).

What is the primary focus of fluid therapy for major surgery according to the text?

To ensure adequate cellular O2 delivery

Apart from edema, what is another iatrogenic side effect of fluid administration mentioned in the text?

Excess Na+ or Cl− load

In the RELIEF trial, what was the median IV fluid intake in the restrictive group?

3.7 liters

What is a common consequence of excessive postoperative fluid?

Increased hospital length of stay

What does one study show regarding postoperative infusions with limited water and sodium levels?

Earlier return to gut function

What is the goal of Goal-Directed Therapy (GDT) in fluid administration?

To target defined physiologic end-points

Which tool is considered the gold standard hemodynamic monitor but is declining in use due to various reasons?

Pulmonary artery catheter (PAC)

Why is the use of Pulmonary artery catheter (PAC) declining?

Concerns about catheter-associated morbidity

Which measurement is derived by integrating transesophageal ultrasound measurement of descending aorta blood velocity with estimated aortic cross-sectional area?

Stroke volume

Which measurement is derived using the Esophageal Doppler monitor (EDM) according to the text?

Peak velocity as an indicator of ventricular contractility

Which measurement is derived by integrating Arterial pressure and waveform analysis?

stroke volume variation

Which method is poorly predictive of IV blood volume & fluid responsiveness

CVP readings

Echocardiography: used for guiding fluid therapy and yielding information on cardiac performance & filling. what is the disadvantages?

requires operator expertise

Lactate concentration used intraoperatively

reduction in lactate concentrations is used as a marker of successful resuscitation.

Inadequate tissue O2 delivery may be reflected by

increased O2 extraction and mixed or central venous O2 desaturation.

Low mixed or central venous O2 is associated with

poor outcomes after high-risk surgery

What is the primary goal of administering 250 mL boluses of colloid or crystalloid in Goal-Directed Therapy (GDT)?

To increase stroke volume by 10% or more

In the context of GDT, what indicates that ventricular filling has reached the flatter part of the Starling curve?

A plateau in stroke volume despite fluid administration

What is a highlighted benefit of Goal-Directed Therapy (GDT) according to recent meta-analyses?

Reduced number of patients with postoperative complications

What outcome was found to be reduced by Goal-Directed Therapy (GDT) as revealed by a Cochrane systematic review?

Postoperative mortality

Which type of fluid is the most rational choice for replacement of evaporative losses and maintenance fluid requirements?

Crystalloids

Why does crystalloid administration typically require 40% to 50% more fluid than colloid for the same clinical volume effect?

Increased propensity of crystalloids to filter across capillary membrane

What is one disadvantage of crystalloids compared to colloids in terms of volume expansion?

Greater GI mucosal edema

In studies specific to patients with sepsis, what adverse events were associated with starch-based colloids?

Increased renal replacement therapy requirement

What did the Cochrane review find regarding the use of colloids for intravascular volume expansion in unselected critical care populations?

No improvement in all-cause mortality

Why is it recommended to avoid starch colloids in perioperative patients with severe sepsis or at risk of renal failure?

To decrease the need for renal replacement therapy

What aspect of fluid administration may crystalloids specifically lead to in comparison to colloids?

Increased extravascular volume expansion

What type of fluid should be used to replace upper gastrointestinal losses?

Isotonic saline

In emergency surgery patients, what should fluid resuscitation be guided by?

Rational physiologic endpoints (BP & HR, lactate, urine output)

Why is it more rational to treat hypotension caused by anesthesia with vasopressors and/or inotropes?

Primarily related to vasodilation and reduced inotropy

For patients at higher risk in major surgery, what monitoring is suggested for fluid therapy?

Invasive pressure monitoring

What is the goal regarding achieving euvolemia by the end of surgery or early postoperative period?

Optimize cardiac output

What should be optimized by titrating boluses of colloid or balanced crystalloid during certain orthopedic and intraabdominal operations?

Cardiac output

What is a key theme in prescribing fluids for moderate-to-major surgery according to the text?

Constant reassessment of fluid status

What does the text recommend regarding oral clear fluid intake before elective surgery?

Extending up to 2 hours preoperatively

How should fluids be individualized in perioperative fluid management?

Tailored based on physiologic variables and losses

What is recommended regarding the approach to fluid management in moderate-to-major surgery?

Adapting to patient and surgical variables

How should fluid requirements be addressed during perioperative fluid management?

By individualizing based on varying needs

What should be given special consideration when prescribing fluids in moderate-to-major surgery?

The indication for giving a specific fluid

What type of fluid should be used to replace lower gastrointestinal losses?

balanced solutions

in moderate-to-major surgery, Pure “maintenance” fluid should be given at

low fixed rate

The use of preoperative bowel preparation should be

restricted to carefully selected cases

some patients have electrolytes abnormality due to The use of preoperative bowel preparation in preoperative period, how they should be prepared for the surgery?

infusion of 1 to 2 L of balanced crystalloid with K+ supplementation should be given

at which infusion rate crystalloids should be used for maintenance requirements during surgery.

1-1.5 mL/kg/h

Blood loss should be replaced with

colloid or blood products

What treatment is advised for losses to third spaces like reaccumulation of ascites?

Treated with a mixture of colloid and crystalloid

Which of the following is NOT mentioned as a supporting physiologic measurement for assessing fluid status after major surgery?

Respiratory rate

What should be considered the best approach to avoid the iatrogenic effects of postoperative fluid administration?

Early oral intake

which of the following may reduce the incidence of postoperative complications.

early oral nutrition

For patients requiring ongoing IV therapy, what should be checked daily ?

hyponatremia and other electrolyte derangements.

What volume range is recommended for 'Pure' maintenance requirements in fluid infusions postoperatively?

$1500-2500$ mL in 24 hours

What infusion rate is recommended for 'Pure' maintenance requirements in fluid infusions postoperatively?

1 to 1.2 mL/kg/h

postoperative “Pure” maintenance requirements dosing in obesity is based on ?

ideal body weight

What volume of Na+ should be given in 24 hours for maintenance intravascular fluid volume postoperative ?

50 to 100 mEq

What volume of K+ should be given in 24 hours for maintenance intravascular fluid volume postoperative ?

40 to 80 mEq

When should the maintenance intravascular fluid volume not be increased in postoperative period?

When suspicion for hypovolemia exists

How should new requirements in fluid replacement be addressed postoperatively?

By titrating replacement fluids appropriately

during Replacement of ongoing losses. which assessment of the following should be made?

intravascular volume status and adequacy of organ perfusion

What is the focus of fluid assessment for all patients after major surgery ?

Fluid status based on clinical examination and physiologic measurements

How should losses from the GI tract such as vomiting be replaced?

With isotonic saline or balanced crystalloid with K+

What should be used to replace blood loss in the context of fluid management during major surgery?

Blood, colloid, or blood products

when the Postoperative oliguria should be interpreted cautiously?

first postoperative day

Postoperative oliguria, what shouldn't be done In the absence of markers indicating hypovolemia and inadequate tissue perfusion?

large volumes of fluid challenge

Study Notes

  • Maintenance intravascular fluid volume should not be increased postoperatively if hypovolemia is suspected. Ongoing losses should be identified and treated separately.
  • Oral fluid intake increase should lead to proportionate reduction in maintenance fluid. Replacement of losses should be based on measured amounts and assessment of volume status.
  • High-risk surgical patients may benefit from goal-directed therapy targeting oxygen delivery postoperatively. Other patients should have fluid status assessed based on clinical examination and physiologic measurements.
  • Electrolytes should be checked daily for monitoring. Fluid requirements should be divided into categories for assessment and treatment.
  • "Pure" maintenance fluid should be salt-poor and contain free water based on weight. Fluid dosing in obesity should consider ideal body weight.
  • Administration of more than 3500 to 5000 mL of crystalloid solution postoperatively may lead to increased morbidity, weight gain, and delayed healing.
  • A restrictive vs. liberal IV fluid regimen study showed no difference in disability-free survival at 1 year but increased surgical site infections and need for renal-replacement therapy in the restrictive group.

Learn about the practical management of perioperative fluid therapy, including different fluid requirements in the preoperative, intraoperative, and postoperative phases. Understand how patient and surgical factors influence fluid therapy goals.

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