What are the 6 perfusion parameters in shock recognition?
- pulse quality
- MM color
- extremity temperature
- level of consciousness/ mental state
What are the 7 steps of fluid resuscitation?
- 1. fluids or not
- 2. what route
- 3. what type
- 4. how much
- 5. how fast
- 6. end points of resuscitation
- 7. what if it doesn't work
What types of shock indicate fluid administration? (2)
What types of shock do NOT indication fluid administration? (3)
anemic/ hypoxemic, metabolic, cardiogenic (will cause major issues)
What are the important components of triage?
For resuscitation, what route should you give fluids?
How do you deliver large volumes of fluid rapidly? (4)
- increasing pressure (slam bags, gravity)
- increase radius of catheter
- decreasing length of catheter
- increasing number of catheters
- [see Pouseuille's law]
__________ should NEVER be used for resuscitation because...
Hypotonic fluid; it extravasates and does not increase intravascular volume (volume expansion power is too low).
What is the volume expansion power of the different fluid types from least to most?
hypotonic fluids (8.3%)--> isotonic fluids (25%)--> colloids (100%)--> hypertonic saline (500-700%)
Volume given for shock is most for ____________, moderate for ___________, and least for ____________ in order to resuscitate.
isotonic; colloids; hypertonic saline
What are shock doses for isotonic fluid?
- [feline] 40-60mL/kg
What are shock doses for colloids?
- [feline] 10-20mL/kg
What are shock doses for hypertonic fluids?
- [feline] 3-5mL/kg
What are shock doses for blood products?
- [feline] 10-20mL/kg
Shock dose given depends on... (10)
- severity of shock
- speed of loss
- compensatory mechanisms (BP)
- comorbidity (heart, lungs, kidneys)
- practical aspects
- cause of shock
- monitoring ability (the more aggressive administration, the more aggressively you must monitor)
- clinical style and experience
How fast do you usually give a shock dose of fluids?
over 5-20 minutes (use same parameters as deciding what shock dose)
In general, give _________ of the shock dose initially.
What are specific considerations when using hypertonic saline? (4)
- must use full shock dose
- give it over 5 minutes
- follow up with another type of fluid (colloids or isotonic- 25% of shock dose)
- never use in foals
If you give hypertonic saline too rapidly, it can result in...
bradycardia and vasodilation...bad.
What are special considerations for using blood products? (3)
- use higher aliquot (50-100% of shock dose, or more)
- you can give it at same speed as other products
- may combine plasma and whole blood or packed RBCs
What are the end points of fluid resuscitation? (5)
- PE: HR, pulse quality, MM color, CRT, temp of extremities, level of consciousness
- urine output
- lactate level
- maintenance of oxygen carrying capacity
What if fluid resuscitation does not work initially? What are the next steps?
- more fluids?
- THIS ALL DEPENDS ON THE SPECIFIC PATIENT... assess your patient
What is permissive hypotension and when do we utilize this method?
- hypotensive patient with uncontrolled hemorrhage
- if you give blood too fast, you will disturb clot formation and worsen the bleeding; therefore, keep systolic BP 80-90mmHg until hemorrhage is controlled (keep patient alive but do not raise blood pressure back to normal)
What is damage control resuscitation?
- massive blood loss in exsanguinating patient
- give rapid administration of blood products (RBCs and plasma) and then a full shock dose of colloids (don't use crystalloids)
How is sepsis managed with fluid resuscitation? (3)
- early aggressive fluid administration (to get BP up....BP goes down with sepsis due to NO production)
- find and control source of sepsis
- early antimicrobial use
How are burn patients handled? (3)
- large volume of crystalloids to compensate loss
- base dose on body surface area that has been burnt
- be careful with colloids!
What are the pros of using isotonic crystalloids? (4)
- readily available
- rapidly eliminated (forgiving if given "too much")
- replenish interstitial also
What are the cons of using isotonic crystalloids? (4)
- large volume needed (PEV only 25%)
- can lead to fluid overload in heart/ lung/ kidney patients
When do we use isotonic crystalloids? (2)
When do we NOT use them? (3)
- DO: severe dehydration, initial bolus while investigating data
- DON'T: low albumin, concerns about active bleeding, risk of volume overload (heart murmur, lung disease)
What are the pros of using colloids? (2)
efficient plasma expander (PEV 100%), longer positive effect
What are the cons of using colloids? (6)
expensive, may not be available, longer undesirable effect (not forgiving if given too much), may cause coagulopathy risk, renal failure, anaphylaxis for dextrans or albumin
When do we use colloids? (3)
When DON'T we use colloids? (3)
- DO: small volume resuscitation, transient or no response to crystalloids, low albumin
- DON'T: Coagulopathy, cautious if sepsis or renal failure
What are the pros of using blood products? (2)
oxygen carrying capacity, efficient plasma expander (PEV 100%)
What are the cons of using blood products? (2)
expensive, risk of transfusion reaction
When do we use blood products? (3)
When DON'T we use blood products? (1)
- DO: severe blood loss, anemia, coagulopathy
- DON'T: all other circumstances
What are the pros of using hypertonic crystalloid? (3)
small volume (PEV 500%), improves CO, improves oxygen delivery to tissue
What are the cons of using hypertonic crystalloid? (4)
can only give once, hypernatremia, bradycardia and vasodilation if "flash bolus"
When do we use hypertonic crystalloids? (2)
When DON'T we use hypertonic crystalloids? (2)
- DO: large animal, head trauma
- DON'T: severe hyper-or hyponatremia