Term
|
Definition
- Extracellular water (33% of water)
- Intracellular water (67% of water)
- Interstitial water (25% of water)
- Intravascular water (8% of water) |
|
|
Term
| Interstitial space is aka __ __. |
|
Definition
|
|
Term
| do females or males have more body water? |
|
Definition
|
|
Term
| does an overweight or lean person have more body water? |
|
Definition
| lean person has more body water |
|
|
Term
| 3 determinants of body water: |
|
Definition
- age
- sex
- body composition |
|
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Term
|
Definition
| 135-145 mEq/L OR 40mEq/kg |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| normal daily fluid requirements: |
|
Definition
|
|
Term
| normal bicarbonate levels: |
|
Definition
|
|
Term
| __ represents 97% of osmotically active articles. |
|
Definition
|
|
Term
|
Definition
| Osmolarity= 2(Na) + (glucose/18) + (BUN/2.8) |
|
|
Term
| Regulators of osmolarity: |
|
Definition
- Aldosterone
- RAAS
- Antidiuretic hormone (Vasopressin) |
|
|
Term
| Aldosterone causes __ resorption and __ and __ secretion in the __ tubules of the kidneys. |
|
Definition
- sodium resorption
- hydrogen and potassium secretion in the distal tubules of the kidneys |
|
|
Term
| Antidiuretic hormone (ADH/vasopressin) is secreted from the __ __ and __ water resorption. |
|
Definition
- posterior pituitary
- increases water resorption |
|
|
Term
|
Definition
- conserve sodium
- concentrate urine
- excrete waste (creatinine and urea) |
|
|
Term
| __ __ is used to measure osmoloarity. |
|
Definition
|
|
Term
| Tests of kidney function: |
|
Definition
- urinalysis
- specific gravity
- spot UA
- creatinine
- BMP
- uric acid |
|
|
Term
| The __ __ of __(FNa) measures the performance of the kidneys during episodes of __ __ __. Order this before administering __. This helps distinguish __ __ __ from __ __ __. It may be indicative of __ __ __. ARF complicating CRF. |
|
Definition
- Fractional Excretion of Sodium
- low urine output
- before administering diuretics
- low cardiac output from low creatinine clearance
- acute tubular necrosis |
|
|
Term
| What test should you order when a pt has low urine output? This should be ordered before diuretics are started. |
|
Definition
| Fractional Excretion of Sodium (FNa) |
|
|
Term
| Low urine output in a surgical patient suggests __ __ __ until proven otherwise. |
|
Definition
|
|
Term
| Orders involved with a fractional excretion of sodium: |
|
Definition
- BMP (creatinine and serum Na)
- Urine Na+ and creatinine (random)
- Urine specific gravity (random)
- Urine osmolarity (random) |
|
|
Term
| Formula for fractional excretion of sodium (FNa): |
|
Definition
| FNa= (urine Na x serum creatinine)/(serum Na x urine creatinine) |
|
|
Term
| A FNA less than one means there is __ and __ renal function. |
|
Definition
- hypovolemia
- normal renal function |
|
|
Term
| FNa over one suggests their is __ renal function. |
|
Definition
|
|
Term
Lactated ringers – 1 job description – rapid vol expansion of a person who is severely hypovolemic, if don’t get vol soon heart will stop when mean arterial BP goes below 50, these numbers are a basic metabolic panel, what do you use it for and what is in it??
If no lactate pt would become acidotic, bc lactate is a buffer, it creates homeostasis, use ringers for intraoperative management |
|
Definition
|
|
Term
Pt comes in hypernatremic with sodium at 150> d5water, can’t just give free water b/c this would pop all the RBCs b/c solution is too hypotonic.
D5water can be given to give more free water. |
|
Definition
|
|
Term
| Most common cause of hyponatremia? |
|
Definition
iatrogenic
second most common is idiopathic |
|
|
Term
| At night, patients urine output drops. If the nurse notices the urine output to be less than ___, the doctor must be called. If the urine output stays this low there will be kidney damage. |
|
Definition
|
|
Term
| AFTER SURGERY AND AFTER MI, STROKE, DRUG OVERDOSES, MAJOR TRAUMA, MAJOR BURNS> STRESS RESPOSNSES> CATECHOLAMINES, ALODSTOERONE, ADH, CORTISOL, THYROID HORMONE> HANG ONTO FLUIDS AND SODIUM, HANG ON TO SODIUM AND EXCESS FLUIDS |
|
Definition
|
|
Term
| SO WHEN URINE DROPS BLOW .5 CC/KG/HR> INTERVENE, HAVE TO KNOW IF THE KIDNEY OR IF CARDIAC OUTPUT IS THE PROBLEM. LOW URINE MEANS LOW CARDIAC OUTPUT UNTIL PROVEN OTHERWISE. |
|
Definition
|
|
Term
| Postive U sign with a folley cath means: |
|
Definition
| - the patient IS making 0.5cc/kg/hour of urine |
|
|
Term
| Formula for total body water: |
|
Definition
TBW= weight in kg x 0.6
usually 55-65% body weight |
|
|
Term
| How to correct for hyponatremia: |
|
Definition
| mEq sodium needed = (140-current serum sodium) x TBW |
|
|
Term
| For a symptomatic hyponatremic pt, use __ __ (__mEq/L). |
|
Definition
| - 3% Normal Saline (NS) (462mEq/L) |
|
|
Term
| For an asymptomatic hyponatremic pt, use __ __ (___mEq/L). |
|
Definition
|
|
Term
| When correcting hyponatremia, correct for 1/2 over the first __ hours, then __ __ __, then correct the rest over the next __ hours. |
|
Definition
- 12 hours
- repeat Na level
- 24 hours |
|
|
Term
| You don't want to give sodium too rapdily b/c it may cause __. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| If a pt has had low urine output for 3 hours, what tests should be ordered? |
|
Definition
- BMP
- urine Na/creatinine
- urine specific gravity
- urine osmolarity |
|
|
Term
| Fna ABOVE 1: IMPAIRED KIDNEY FUNCTION, STILL HAVE TO GIVE FLUIDS, HAVE TO PRIME KIDNEYS TO GET THEM OPEN UP, SO GIVE PROTOCOL OF FLUID + DIURETICS BUT AT THIS POINT CALL IN NEPHROLOGIST (B/C HAVE TO MAKE SURE INTRASCULAR COMPARTMENT IS PUMPED UP) |
|
Definition
|
|
Term
| what kind of fluid would you give someone in hypovolemic shock? |
|
Definition
|
|
Term
| what would you give a pt who has been vomiting K+ rich fluid, meaning they are hypovolemic and hypochloremic? |
|
Definition
| Normal saline b/c need high chloride content |
|
|
Term
| BILIARY FISTULA: BILE IS JUST LIKE THE PLASMA |
|
Definition
|
|
Term
PANCREAS: IS ALKALINE, TITRATES THE ACID THAT THE STOMACH DUMPS INTO DUODENUM, SO TO CORRECT PANCREATIC FISTULA> RINGERS LACTAT+ BICARBONATE
SMALL BOWEL OF COLON- RINGERS LACTATE
WORKING WITH LOSSES OF BODY FLUID: ALL OF THEM YOU USE RINGERS LACTATE EXCEPTS STOMACH USE NORMAL SALINE, AND PANCREASE US LR + 2 AMP BICARB. KNOW THIS SENTENCE WELL. |
|
Definition
|
|
Term
| __ artery monitoring is used to get main arterial pressure. |
|
Definition
|
|
Term
| Central venous pressure (CVP) is equal to __ __ __. |
|
Definition
| right atrial pressure (RAP) |
|
|
Term
|
Definition
|
|
Term
|
Definition
MAP= DP + 1/3(SP-DP)
MAP= 1/3(SP) + 2/3(DP) |
|
|
Term
| Pulmonary artery catheterization indications: |
|
Definition
- Early ID and tmt of life-threatening conditions like heart failure and cardiac tamponade
- Evaluation of pts immediate response to drugs/mechanical support
- Evaluate cardiac function like cardiac output/index |
|
|
Term
Need to know what kind of shock pt might have.
Cardiogenic- heart not working
Hypovolemiic- bleeding out or very poor fluids
Septic- capillaries not working, caps are semipermeable
Neurogenic- rare, with spinal cord injuries |
|
Definition
|
|
Term
| Pulmonary Artery Catheterization is aka __ __ __. |
|
Definition
| Swan Ganz Catheterization |
|
|
Term
| Functions of the Swan Ganz (pulmonary artery) catheter include __ __ __ monitoring (vascular tone, myocardial contractility, fliud balance), measuring __ __ __ and __ __ __ which allows for hemodynamic calcuations to be done, determining __ __ via thermodilution, performing __ __. |
|
Definition
- continuous bedside hemodynamic monitoring
- measuring pulmonary artery pressure and central venous pressure so hemodynamic calculations can be done
- determining cardiac output via thermodilution
- transveous pacing |
|
|
Term
| only takes 30 seconds to bleed out with ruptured aorta |
|
Definition
|
|
Term
| The pulmonary artery mean pressure is the same as the __ __ __ __ __. |
|
Definition
| right ventricular end diastolic pressure |
|
|
Term
| The pulmonary capillary wedge pressure is an indirect measurement of the __ __. |
|
Definition
|
|
Term
| FILLING PRESSURE= PRELOAD= PRESSURE ON THE VENTRICLES WHEN THEY GET READ TO EJECT= END DIASTOLIC PRESSURE. THIS IS THE NUMBER YOU PLAY WITH WITH HEMODYNAMIC MANAGEMENT B/C TELLS YOU WHERE YOU ARE ON STARLING CURVE. |
|
Definition
|
|
Term
| Diastolic on left and right are very similar. Left side of heart is high pressure system but this is for vents only. Left atrium doesn’t have much more pressure on it than right atrium does. |
|
Definition
|
|
Term
| At bedside and have heart that is failing or pt in shock> shock is really the failure of perfusion of cells leading to metabolic dysfunction within the cells (so its actually not a bp number it’s the failur of metabo pathways in cells). Normally the mean arterial pressure belw 50> coronaries stop perfusing (most critical). |
|
Definition
|
|
Term
| boudning pulse may indicate: |
|
Definition
|
|
Term
| A narrow pulse pressure may indicate issues with __ __. |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Right atrial pressure is basically the same as __ __. |
|
Definition
|
|
Term
| In heart failure, what would happen to right atrial pressure/venous pressure: |
|
Definition
|
|
Term
| Why does right ventricular diastolic pressure dip lower than venous pressure? |
|
Definition
| to create negative pressure to suck in blood for filling |
|
|
Term
| Pulmonary artery wedge is a reflection of pressure in __ __ and __ __. |
|
Definition
- pulmonary veins
- left atrium |
|
|
Term
| Complications of Swan Ganz Placement: |
|
Definition
- Hemothorax b/c hit subclavian artery and chest fills with blood: drop in BP, diaphoresis
- Pneumothroax: O2 saturation, Xray, chest tube
- Air embolism: air block phenomenon
- Pulmonary embolism |
|
|
Term
| Long term complications of Swan Ganz placement: |
|
Definition
- swollen arm
- catheter related sepsis
- lymphocele
- brachial plexopathy
- subclavian artery puncture |
|
|
Term
| Central venous pressure is a measurement of the pressure in the __ __ reflecting the __ __ __ __ pressure. It can be used to assess __ __. It is respresentative of the __ on the right ventricle. |
|
Definition
- right atrium
- right ventricular end diastolic pressure
- fluid balance
- preload |
|
|
Term
| Causes of CVP elevation are all related to increased __ and include: |
|
Definition
Preload
- fluid overload
- right heart failure
- tricuspid stenosis
- pulmonary embolism
- pericardial tamponade |
|
|
Term
| Pulmonary Capillary Wedge Pressure (PCWP)has a similar wavform but is dampened and has delayed trasmission through the lungs. |
|
Definition
|
|
Term
| PCWP measures __ __ __ or __ __ __ __ __. |
|
Definition
- left ventricular preload
- left ventricular end diastolic pressure |
|
|
Term
|
Definition
|
|
Term
| Causes of decreased PCWP aka decreased left ventricular end diastolic volume/preload: |
|
Definition
- hypovolemia: hemorrhage, surgery, diuresis, dehydration, vomiting, diarrhea
- vasodilation
- hypothermia
- sepsis |
|
|
Term
| Causes of increased PCWP/left ventricular preload: |
|
Definition
- vasoconstriction
- heart failure
- renal problems |
|
|
Term
No totally accurate method of measuring cardiac output
Most commonly used methods are thermodilution and Fick methods
Cardiac output often corrected using body surface area and expressed as cardiac index |
|
Definition
|
|
Term
|
Definition
Cardiac Index= CO/body surface area
way to normalize CO for different body types |
|
|
Term
Pt with low cardiac output, 4 things to correct it:
preload: pressure on ventricles just as ready to eject, lower elevated preload via diuretics, Nitroglycerin reduces preload via vasodilating pulmonary vasculature
Afterload: work that heart has to overcome in order to push fluid through body, resistance, if this number is high the vents have to work to hard and lowers CO, can give vasodilator to decrease afterload so vent can eject better
Contractility: how hard the vents squeeze, maybe its not squeezing well enough even though preload/afterload are fine. Ischemia and CAD can mess up contracilty , also drugs and hypothyroidism can too. Use inotropic meds to strengthn heart contractions. Contractility is what the SV is involved with, increasing contract, increases SV> increases CO
Heart rate: co= sv xhr, so by increasing hr you can increase CO, this is where the heart failure pts have issues |
|
Definition
|
|
Term
| BED SIDE MONITORING AND FLUIDS = FIRST STEP OF HEMODYNAMICS. |
|
Definition
|
|
Term
| BED SIDE MONITORING AND FLUIDS = FIRST STEP OF HEMODYNAMICS. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Resistance= pressure/flow. This equation means that afterload is directly related to ___ and inversely related to __ __. |
|
Definition
- pressure
- cardiac output |
|
|
Term
| factors that would increase contractility: |
|
Definition
- catecholamines
- inotropic drugs
- increased preload
- decreased aferload |
|
|
Term
| Factors that would decrease contractility: |
|
Definition
- alpha/beta blockers
- calcium channel blockers
- decreased preload
- overstretched myocardium
- severe inflammation
- ischemia |
|
|
Term
| If pt has lost 10% of blood volume they need __ unit or __ cc. |
|
Definition
|
|
Term
| If a patient loses 20% of blood volume, they will have a positive __ test (meaning they are dizzy laying down and sitting up). These pts need __ units or __ cc. |
|
Definition
- positive tilt test
- 2 units
- 1000 cc |
|
|
Term
| What is a positive tilt test: |
|
Definition
| - take vitals laying down and then have pt sit up> and vitals drop 10% |
|
|
Term
| IF PT IS HYPOTENSIVE AT REST BEEN THROWING UP FOR 2 DAYS, DOWN 10 LITERS (NORMALLY HAVE 42 LITERS), SO HES DOWN 25%, SO HE IS 30% RANGE ON NEXT SLIDE. 2 IVS, 8 LITERS IN HIM STAT |
|
Definition
|
|
Term
| IF YOU BLEED ABOUT 50% OF BLOOD VOLUME> CELLS DIE IN HEART BRAIN KIDNEY LIVER, ETC> IRREVERSIBLE SHOCK> GIVE HIM CRYSTALOID AND COLLOID FOR TMT. |
|
Definition
|
|
Term
|
Definition
|
|
Term
Clinical manifestations of shock are hypotension and tissue hypoperfusion
Low cardiac output
Maldistribution of blood flow- blood ends up going to nonessential organs instead of essential organs
Defect in substrate utilization at the cellular level |
|
Definition
|
|
Term
| Reasons to suspect shock: |
|
Definition
- systolic bp less than 90mmHg
- systolic bp decrease from baseline of 30 mmHg or greater
- systolic bp maintained by drugs/mechanism support
- mean arterial pressure (MAP) less than 60 |
|
|
Term
|
Definition
- Cardiogenic
- Hypovolemic
- Distributive
- Obstructive |
|
|
Term
Cardiogenic shock is the result of severe depression in cardiac performance
Direct insult to the myocardium
Mechanical problem that overwhelms the functional capacity of the myocardium
Hemodynamically, there is increased ventricular filling ( venous pressure is elevated) but decreased cardiac output |
|
Definition
|
|
Term
| With cardiogenic shock, there is ___ ventricular filling and venous pressure, but __ cardiac output. |
|
Definition
- increased ventricular filling and venous pressure
- decreased cardiac output |
|
|
Term
| causes of Cardiogenic shock: |
|
Definition
Myocardial infarction
Contusion
Myocarditis
Cardiomyopathy
Pharmacologic
Valvular failure- MC CHORDAE TENDONAE RUPTURE
Arrhythmias |
|
|
Term
| LOOK AT SLIDES 62 AND 63 OF THIS LECTURE TO KNOW MORE CAUSES OF CARDIOGENIC SHOCK. |
|
Definition
|
|
Term
| Most common type of shock that is also known as classic shock: |
|
Definition
|
|
Term
| With hypovolemic shock preload is markedly __, leading to __ ventricular filling. Systemic, venous, and intracardiac pressures are all __. Manifestations include __ and __. |
|
Definition
- preload is decreased
- decreased ventricular filling
- decreased
- tachycardia and hypotension |
|
|
Term
| with cardiogenic shock, preload __ and cardiac output __. |
|
Definition
|
|
Term
| causes of hypovolemic shock: |
|
Definition
Hemorrhagic
Trauma
Gastrointestinal
Retroperitoneal
Fluid depletion
Vomitting/dirrhea
Dehydration
Burns
Vasodilation
Sepsis
Toxins |
|
|
Term
| Distributive shock is characterized by profound ___. The 2 main causes are __ and __. |
|
Definition
- vasodilation
- sepsis
- anaphylaxis |
|
|
Term
| __ __ is most common cause of death in ICU. |
|
Definition
|
|
Term
| With distributive shock, cardiac output may be __ or even __, but organ tissue perfusion is ___. |
|
Definition
- normal or elevated
- inadequate |
|
|
Term
| Obstructive shock results from obstruction to flow in the __ __ which leads to __ heart filling. There is also __ systolic function due to __ afterload. Thus there is inadequate __ __ and __. |
|
Definition
- obstruction to flow in the cardiovascular circuit
- decreased heart filling
- decreased systolic function
- increased afterload
- inadequate cardiac output and hypotension |
|
|
Term
| Causes of obstructive shock: |
|
Definition
Impaired diastolic filing
Tumors (Myxoma)
Tension pneumothorax
Constrictive pericarditis
Cardiac tamponade
Impaired systolic contraction
Pulmonary embolus
Acute pulmonary hypertension
Aortic dissection |
|
|
Term
| Flat pulmonary HTN: acute problem with really high pulmonary HTN. |
|
Definition
| could lead to obstructive shock via decreased systolic function |
|
|
Term
|
Definition
CNS
Change in mental status due to decreased perfusion, electrolyte abnormalities, or inflammatory mediators
Cardiac
Tachycardia
Chest pain
Ischemia leads to low cardiac output which worsens ischemia
Depressed contractility secondary to cytokines
Pulmonary
Acute lung injury leads to impaired gas exchange, decreased compliance, and shunting to underventilated areas
hypoxemia
Renal
Acute renal failure occurs with hypoperfusion and preferential shunting of blood to the brain/heart
GI
Ileus, gastritis, pancreatitis
Shock liver
Hematological
Thrombocytopenia
Metabolic
Hyperglycemia
Hyoglycemia |
|
|
Term
| with shock always do an echo |
|
Definition
|
|
Term
| With obstructive shock, if the atrium is blocked, PCWP would __ b/c filling is prevented. But if the arterial side is blocked, PCWP would __. |
|
Definition
|
|
Term
|
Definition
1. Compensated
2. Progressive
3. Irreversible |
|
|
Term
| In compensated shock, the body is able to maintain __. |
|
Definition
|
|
Term
| In progressive shock, the body loses its ability to __ and inadequate __ begins. |
|
Definition
- compensate
- inadequate perfusion begins |
|
|
Term
| In irreversible shock, __ and __ __ result in __ __ __. |
|
Definition
| - cell and tissue damage result in multi-system organ failure |
|
|
Term
| When you get below ___, the kidneys lose their ability to autoregulate. |
|
Definition
|
|
Term
|
Definition
Adequate volume restoration
IV fluids
Blood transfusions
Hgn > 10
Aggressive evaluation to determine source of bleeding |
|
|
Term
|
Definition
Cardiogenic Shock
IV fluids/ pressor support
Intra aortic balloon pump
Counterpulsation that increases diastolic coronary artery perfusion pressure, decreases LV afterload, and improves cardiac output
Percutaneous Intervention
CABG |
|
|
Term
| The intra aortic balloon pump works by increasing pressure during __, __ afterload and __ cardiac output. |
|
Definition
- increasing pressure during diastole
- decreasing afterload
- increasing cardiac ouptut |
|
|
Term
Treatment of Extracardiac Obstructive Shock
Tamponade
IVF / vasopressors
Pericardiocentesis
Severe Pulmonary Embolism
Anticoagulation with heparin
Thrombolytic therapy
Surgical embolectomy |
|
Definition
|
|
Term
|
Definition
Septic Shock
Antibiotics
Eliminating cause of infection
IV fluids/ pressor support |
|
|
Term
|
Definition
Septic Shock
Antibiotics
Eliminating cause of infection
IV fluids/ pressor support |
|
|
