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Flashcards in Fluid Managment Deck (100):
1

The standard SI unit of concentration is:

-molarity
-molality
-equivalency
-grams per liter

The standard SI unit of concentration is: molarity

The system of international units(SI) is gradually gaining acceptance in clinical practice. The standard SI unit of concentration is molarity, which expresses the number of moles of solute per liter of solution. Molality is an alternative term that expresses moles of solute per kilogram of solvent.

pg. 663
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

2

A 24 year old female is scheduled for resection of a mandibular tumor. The surgeon is expecting a large blood loss, and normovolemic hemodilution to minimize the need for transfusion is suggested. The target hematocrit after normovolemic hemodilution should be approximately:

-15 - 18%
-21 - 25%
-26 - 29%
-30 - 35%

21 - 25%

pg. 703
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

3

An acute reduction in serum potassium levels can be achieved with:

-phenylephrine administration
-isoproterenol administration
-calcium chloride administration
-hypoventilation

isoproterenol administration

B-2 stimulation has been shown to enhance cellular uptake of potassium. Although calcium chloride is effective in the management of the membrane effects of hyperkalemia, it does not lower the serum potassium concentration.

pg. 682
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 355
Hines, RL, and Marschall, KE. Stoelting's Anesthesia and Co-existing Disease. 2008


4

Clinically significant hypocalcemia should be suspected in the transfusion rate exceeds:

-1 unit per hour
-1 unit every 30 minutes
-1 unit every 15 minutes
-1 unit every 5 minutes

1 unit every 5 minutes

Rapidly transfused blood can result in citrate intoxication that presents as hypocalcemia. Because citrate is primarily metabolized in the liver, patients with hepatic disease may require calcium infusion during massive transfusion.

pp. 378-379
Barash, PG, Cullen, BF Stoelting, RK, Calahan, MK and Stock, MC. Clinical Anesthesia 2009

5

Cations, such as potassium and sodium, penetrate the cell membrane through:

-direct diffusion through the membrane
-specialized protein channels
-reversible binding to a carrier protein
-losing their charge and entering as a salt

specialized protein channels

Diffusion between extracellular fluid and intracellular fluid may take place through one of several mechanisms:
-directly through the membrane
-through specialized protein channels
-reversible binding to a carrier protein
Cations penetrate the membrane poorly and can diffuse only through specific protein channels.

Pg. 665.
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

6

A list of estimates of the rate(per donor exposure) of transfusion-transmitted infectious disease in North America is shown below. By dragging & reordering the selections in yellow, match the estimated rate with the corresponding infectious process.

-Cytomegalovirus
-Hepatitis B
-Hepatitis C
-HIV

(1:269,000)
(1:1,600,000)
(1:14)
(1:1,780,000)

Cytomegalovirus-1:14
Hepatitis B-1:269,000
Hepatitis C-1:1,600,000
HIV-1:1,780,00

pg. 370
Barash, Clinical Anesthesia, 2009

7

The most common cause of hypernatremia with normal total body sodium content is:

-hyperglycemia
-diabetes insipidus
-syndrome of inappropriate ADH secretion
-mannitol administration

diabetes insipidus

Diabetes insipidus causes the loss of water resulting in hypernatremia despite normal total body sodium stores.

Pg. 670
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

8

Post-transfusion purpura:

-is due to inactivation of platelets by transfused leukocytes
-is typically seen several hours after transfusion
-is most commonly the result of ABO or Rh incompatibility
-is typically associated with a precipitous drop in the platelet count

Post-transfusion purpura: is typically associated with a precipitous drop in the platelet count.

Post-transfusion purpura is associated with profound thrombocytopenia and is due to the development of platelet antibodies. The platelet count typically falls about 1 week after transfusion therapy.

pg. 701
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

9

A 78 year old, 80 kg man is confused and combative in the post-anesthesia care unit after a transurethral prostate resection. Laboratory findings include a serum sodium concentration of 118 mEq/L. Correction of the sodium concentration to 125 mEq/L would require approximately:

_____ mEq of sodium

335 mEq of sodium

the sodium deficit can be estimated by the following formula:
Na deficit = TBW x (desired Na - present Na)
Na deficit = (80 x 60%) x (125 -118)=336 mEq

pg. 674
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

10

In the average adult male, the percentage of body weight composed of water is:

_____%

55-65%

The average adult male is approximately 60% water by weight, females are about 50%

pg. 878-879
Barash, Clinical Anesthesia, 2009

11

In the plasma, the majority of inorganic phosphorus is in the form of:

-H3PO4
-H2PO4-
-HPO4-2
-PO4-3

In the plasma, the majority of inorganic phosphorus is in the form of: HPO4-2

Plasma phosphorus exists in both organic and inorganic forms. Organic phosphorus is mainly in the form of phospholipids. The majority of inorganic phosphorus is in the form of HPO4-2

Pg. 686
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

12

Extra hepatic synthesis of clotting factors is seen with:

-factor II
-factor VII
-factor VIII
-factor XII

Extra hepatic synthesis of clotting factors is seen with: factor VIII

Most clotting factors are synthesized by the liver, however factor VIII also has some extra hepatic synthesis.

Pg. 224
Barash, Clinical Anesthesia, 2006

13

In the distal renal tubule, calcium reabsorption is controlled by:

-parathyroid hormone
-aldosterone
-renin
-thyroid hormone

parathyroid hormone

In the distal tubules, calcium reabsorption is dependent on parathyroid hormone secretion, whereas sodium reabsorption is dependent on aldosterone secretion.

pg. 1284
Brash, Clinical Anesthesia, 2006

14

The most common cause of ABO incompatibility reactions is:

-blood typing error
-unknown antibodies in donor serum
-unknown antibodies in recipient serum
-patient misidentification

patient misidentification

pg. 700
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

pg. 372
Brash, Clinical Anesthesia, 2009

15

A list of pathophysiologic conditions is shown below. By dragging & reordering the selections in yellow, match the coag test with the corresponding condition.

-Liver Disease
-Hemphilia A
-DIC
-ASA Use

(Increased Bleeding Time)
(Increased aPTT)
(Increased PT)
(decreased Fibrinogen)

Increased PT--->Liver Disease
Increased aPTT--->Hemophilia A
Decreased Fibrinogen--->DIC
Increased Bleeding Time--->ASA Use

pg. 395
Barash, Clinical Anesthesia, 2009

16

A single unit of platelets can be expected to raise the platelet count by:

-5,000 to 10,000
-10,000 to 20,000
-30,000 to 50,000
-75,000 to 100,000

10,000 to 20,000

Each single unit of platelets may be expected to increase the count by 10,000 to 20,000. Platelet pheresis units contain the equivalent of six regular, single donor units.

pg. 669
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

17

An anesthesia consultation is requested for a 48 yer old man who has had a resection of an astrocytoma 12 hours earlier. The patient's urine output is 500 mL/hour. The diagnosis of diabetes insipidus is suggested by:

-hyponatremia
-hyperglycemia
-urinary osmolality lower than plasma osmolality
-proteninuria

urinary osmolality lower than plasma osmolality

Diabetes insipidus causes the loss of water resulting in hypernatremia, increased serum concentration and urinary osmolality lower than plasma osmolality.

pg. 670
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

pg. 1301 - 1302
Brash, Clinical Anesthesia, 2009

18

The goal of fresh frozen plasma therapy is to achieve:
-20% of the normal coagulation factor concentration
-30% of the normal coagulation factor concentration
-50% of the normal coagulation factor concentration
-75% of the normal coagulation factor concentration

30% of the normal coagulation factor concentration

The initial therapeutic dose of FFP is usually 10-15 mL/kg. The goal is to achieve 30% of the normal coagulation factor concentration.

pg. 699
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

pg. 385
Brash, Clinical Anesthesia, 2009

19

In healthy patients, a urinary sodium concentration of 8 mEq/L is indicative of:

-decreased intravascular volume
-high cardiac output
-renal tubular dysfunction
-obstructive nephropathy

decreased intravascular volume

Urinary sodium concentration reflects circulating volume in the healthy patient. A low urinary sodium concentration(

20

In the average adult, interstitial fluid pressure is approximately:

-20 mmHg
-5 mmHg
10 mmHg
20 mmHg

-5 mmHg

Interstitial fluid pressure is generally thought to be negative, about -5 mmHg. As interstitial fluid volume increases, interstitial pressure rises and eventually becomes positive. When this happens, the free fluid increases rapidly and presents as edema.

pg. 664
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

21

Approximately 50% of the body's magnesium is located in:

-bone
-intravascular fluid
-interstitial fluid
-striated muscle

bone

Only about 1 - 2% of total body magnesium stores are in the ECF. About 50% is located in bone and the remainder is located intracellularly.

pg. 320
Barash, Clinical Anesthesia, 2009

22

When properly stored, the shelf-life of a unit of platelets is approximately:

-5 days
-14 days
-21 days
-28 days

5 days

When properly stored at 20 - 24 degrees Celsius, the shelf-life of platelets is approximately 5 days.

pg. 385
Barash, Clinical Anesthesia, 2009

23

The percentage of free ionized calcium in the plasma is approximately:

-10%
-25%
-50%
-80%

50%

The normal plasma calcium concentration is 8.5 - 10.5 mg/dL. Approximately 50% is in the free ionized form, 40% is protein bound and 10% is complexed with citrate and amino acids.

pg. 314 - 315
Barash, Clinical Anesthesia, 2009

24

Vitamin K dependent clotting factor include(Select 4)

-Factor I
-Factor II
-Factor III
-Factor IV
-Factor V
-Factor VII
-Factor VIII
-Factor vWF
-Factor IX
-Factor X
-Factor XI
-Factor XII

II, VII, IX and X

Factors II, VII, IX and X undergo a final enzymatic addition of a carboxyl group that requires the presence of vitamin K. Without vitamin K, these factors are produced in normal amounts, but are nonfunctional.

pg. 389
Barash, Clinical Anesthesia, 2009

25

Factors that increase the rate of diffusion of a substance across the membrane include:

-a minimal concentration of differential
-a minimal pressure difference between both sides of the membrane
-positive ionic charge of the diffusing substance
-low molecular weight of the diffusing substance

low molecular weight of the diffusing substance

The rate of diffusion of a substance across a membrane depends on:
-the permeability of that substance across a membrane(depends on molecular weight)
-the concentration differential between the two sides of the membrane
-the electrical potential across the membrane for charged substances

pg. 665
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

26

The incidence of serious hemolytic reactions after transfusion of ABO- and Rh- compatible blood with a negative type and screen test, but without a crossmatch is:

-less than 1%
-2 to 5%
-7 to 10%
-10 to 12%

less than 1%

The likelihood that the antibody screen will miss a potentially dangerous antibody has been estimated to be much less than 1:10,000.

pg. 384
Barash, Clinical Anesthesia, 2009

27

An anesthesia consultation is requested for a 78 year old, 70 kg man with a history of diabetes insidious. Significant laboratory findings include a serum sodium of 153 mEq/L. The water deficit in this patient is approximately:

_____ Liters

3.6 L

Diabetes insipidus causes the loss of water resulting in hypernatremia with the total body osmoles remaining unchanged. Free water loss can be calculated as follows:

Normal TBW x 140 = present TBW x 153
(70 x 0.6) x 140 = present TBW x 153
present TBW - 38.4 L

Normal TBW = 70 x 0.6 = 42L
Free water deficit = 42.0 - 38.4 = 3.6L

pg. 671
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

28

Redistribution and evaporative fluid losses during an inguinal herniorrhaphy are approximately:

-0 to 2 mL/kg/hour
-2 to 4 mL/kg/hour
-4 to 6 mL/kg/hour
-8 to 12 mL/kg/hour

4 to 6 mL/kg/hour

Although recent data suggests a more restrictive approach to fluid management in patients undergoing intra-abdominal surgery, congenitally, surgical fluid losses can be estimated as follows:

Minimal(herniorrhaphy)---> 4 to 6 mL/kg/hr
Moderate(cholecystectomy)--->6 to 8 mL/kg/hr
Severe(bowel resection)--->8 to 12 mL/kg/hr

29

The physiological effects of angiotensin II include:(select 2)

-renal efferent arteriolar vasodilation
-stimulation of ADH release
-increased glomerular filtration rate
-decreased sodium reabsorption
-increased aldosterone secretion
-reduction in plasma volume

stimulation of ADH release, increased aldosterone secretion

Angiotensin II induces renal efferent arteriolar vasoconstriction, promotes ADH release, stimulates aldosterone release resulting in intravascular volume expansion as well as increased sodium reabsorption.

pg. 1349
Barash, Clinical Anesthesia, 2009

30

Protein entering the interstitial space is returned to the vascular system by:

-reabsorption into the capillaries
-absorption into the arterial bed
-transfer into the intracellular compartment
-the lymphatic system

the lymphatic system

Only small quantities of proteins can normally cross capillary clefts. The protein content of interstitial fluid is relatively low, about 2 g/dL. Protein entering the interstitial space is returned to the vascular system via the lymphatics.

pg. 664-665
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

pg. 301-302
Barash, Clinical Anesthesia, 2009

31

Clinical manifestations of hypermagnesemia include(Select 2):

-hyperreflexia
-bradycardia
-vasoconstriction
-potentiation of non depolarizing muscle relaxants
-hypertension

bradycardia, potentiation of non depolarizing muscle relaxants

Clinical manifestations of hypermagnesiemia include hyporeflexia, sedation, weakness, vasodilation, bradycardia, myocardial depression and depressed release of acetylcholine with potentiation of non depolarizing neuromuscular blockade.

pg. 321-322
Barash, Clinical Anesthesia, 2009

32

Body fluids that may contain a higher concentration of sodium than found in plasma include:

-sweat
-saliva
-high acidity gastric juice
-pancreatic secretions

pancreatic secretions

Pancreatic secretions contain a large amount of bicarbonate and chloride anions and as a result have a high concentration of sodium as well, as much as 180 mEq/L. Other body fluids with high sodium content are biliary secretions, ill fluid and diarrhea stool.

pg. 695
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

33

After induction of anesthesia, the patient's pH falls from 7.40 to 7.20 secondary to hypoventilation. As a result of the pH change, the free ionized calcium will?

increase from 5.0 to 5.3 mg/dL

Changes in plasma pH directly affect the degree of protein binding of calcium and thus the ionized free calcium concentration. Ionized calcium increases approximately 0.16 mg/dL for each decrease of 0.1 unit in plasma pH.

pg. 683
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 314-315
Barash, Clinical Anesthesia, 2009

34

The use of 6% hetastarch in volumes greater than 20 mL/kg has been associated with:

-coagulopathy
-interference with blood typing
-adrenocortical depression
-high incidence of anaphylactoid reactions

coagulopathy

Large doses of hetastarch have been associated with coagulopathy. In contrast to dextran, hetastarch is non antigenic and anaphylactic reactions are rare.

pg. 694
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 302
Barash, Clinical Anesthesia, 2009

35

In the normal adult, daily fluid loss secondary to evaporation from the respiratory tract is approximately:

-100 mL
-200 mL
-400 mL
-800 mL

400 mL

Daily water loss averages 2500 mL and can roughly be accounted for by 1500 mL in urine, 400 mL in respiratory tract evaporation, 400 mL in skin evaporation, 100 mL in sweat and 100 mL in feces.

pg. 667
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

36

When a patient is first started on warfarin therapy, the first clotting factor to become inactivated is:

-II
-VII
-IX
-XI

VII

Vitamin K dependent clotting factors are II, VII, IX and X. Factor VII has the shortest half-life(6 hours) and is the first to become inactivated by warfarin therapy.

pg. 386, 400
Barash, Clinical Anesthesia, 2009

37

Causes of hyponatremia with increased total body sodium content include:

-syndrome of inappropriate ADH secretion
-diuretic use
-mineralocorticoid deficiency
-congestive heart failure

congestive heart failure

Hyponatremia despite increased total body stores of sodium occurs in the presence of impaired renal excretion of free water. This can be seen in CHF, cirrhosis, renal failure and nephrotic syndrome.

pg. 306
Barash, Clinical Anesthesia, 2009

38

Laboratory evidence of dehydration includes:(select 2)

-falling hematocrit
-urinary osmolarity > 450 mOsm/L
-hyponatremia
-urinary sodium > 10 mEq/L
-BUN:creatine ratio > 10:1
-progressive metabolic alkalosis

urinary osmolality > 450 mOsm/L, BUN:creatine ratio > 10:1

Laboratory signs of dehydration include a rising hematocrit, progressive metabolic acidosis, urinary specific gravity > than 1.010, urinary sodium 450 mOsm/L, hypernatremia and a BUN:creatinine > 10:1.

pg. 691
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

39

The physiological effects of atrial natriuretic peptide include:

-arterial vasoconstriction
-decreased urinary sodium excretion
-increased water excretion
-increased plasma volume

increased water excretion

Actions of atrial natiruetic peptide(ANP) include: arterial vasodilation, increased urinary sodium excretion, increased water excretion, inhibition of renin release, decreased aldosterone production and antagonism of ADH. ANP is released by the atria in response to distention.

pg. 297, 1349
Barash, Clinical Anesthesia, 2009

40

The most important determinant of intracellular osmotic pressure is:

-sodium
-potassium
-cytoplasmic protein
-glucose

potassium

Because cell membranes are relatively impermeable to sodium, and to a lesser extent potassium, potassium is concentrated intracellularly. As a result, potassium is the most important determinant of intracellular osmotic pressure and sodium is the most important determinant of extracellular osmotic pressure.

pg. 663
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

pg. 296
Barash, Clinical Anesthesia, 2009

41

The effects of hypermagnesemia can be antagonized with the intravenous administration of:

-sodium bicarbonate
-potassium chloride
-potassium phosphate
-calcium chloride

calcium chloride

IV calcium administration can temporarily antagonize most of the effects of hypermagnesemia. Diuresis with normal saline is not recommended because it can cause hypocalcemia and worsen the effects of hypermagnesemia.

pg. 322
Barash, Clinical Anesthesia, 2009

42

A fully saturated 4x4 surgical sponge contains approximately:

-3 mL of blood
-10 mL of blood
-15 mL of blood
-20 mL of blood

10mL of blood

A fully soaked 4x4 surgical sponge contains approximately 10 mL of blood, whereas a saturated "lap" holds 100 - 150 mL.

pg. 695
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

43

The two most important regulators of plasma calcium concentration are:(select 2)

-parathyroid hormone
-calcitonin
-cholecalciferol
-calcitriol
-triiodothyronine
-cyanocobalamin
-Vitamin D1

parathyroid hormone, calcitriol

Serum calcium is regulated by multiple factors including a calcium receptor and several hormones. Parathyroid hormone and calcitriol, the most important neurohumoral mediators of serum calcium, mobilize calcium from bone, increase renal tubular reabsorption of calcium and enhance intestinal absorption of calcium.

pg. 389
Barash, Clinical Anesthesia, 2009

44

A 7 year old 27kg male is scheduled for a tonsillectomy and adenoidectomy. He has had no food or fluid intake for the last 12 hours. His estimated fluid deficit is approximately:

_____ mL

804 mL

First 10 kg -----> 4 mL/kg/hr
Next 10-20 kg--->2 mL/kg/hr
Each kg above 20--->1 mL/kg/hr

In this question:(10 x 4) + (10 x 2) + (7 x 1) = 67 mL/hour deficit
67 mL/hour x 12 hours = 804 mL

pg. 695
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 299
Barash, Clinical Anesthesia, 2009

45

An 80 kg man is scheduled for an orchiectomy. His laboratory analysis reveals: Na-140 mEq/L, K-3.8 mEq/L, BUN-28 mg/dL, and glucose-180 mg/dL. His approximate plasma osmolality is:

_____ mOsm/L

300 mOsm/L

An accurate approximation of plasma osmolality can be found with the equation:
Osm=Na x 2 + BUN/2.8 + Glucose/18
(please note error in Barash text with formula:BUN/2.3)

pg. 667
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 389
Barash, Clinical Anesthesia, 2009

46

The use of Dextran for volume replacement has been associated with:

-reduction in bleeding time
-interference with blood typing
-increased blood viscosity
-cerebral edema

interference with blood typing

Dextran has been shown to improve microcirculation by decreasing blood viscosity. In addition, both Dextran 40 and 70 have been associated with an anti platelet activity, increased bleeding time and interference with blood typing. The dextran may also be antigenic and precipitate severe anaphylactoid reactions. Hypertonic dextran solutions have been shown to lower ICP.

pg. 694
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 1024
Barash, Clinical Anesthesia, 2009

47

Findings consistent with the syndrome of inappropriate ADH(SIADH) include:

-urine sodium concentration > 20 mEq/L
-urine osmolality

urine sodium concentration > 20 mEq/L

A variety of malignant tumors, pulmonary disease and CNS disorders are associated with SIADH. Because of the retention of free water, plasma osmolality falls while urine osmolality and sodium content rises.

pg. 672
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006
pg. 307
Barash, Clinical Anesthesia, 2009

48

Tissue plasminogen activator:

-activates circulating plasminogen
-is synthesized by hepatocytes
-is released by vascular endothelial cells
-is unable to bind to fibrin

is released by vascular endothelial cells.

Tissue plasminogen activator, t-PA, is produced by vascular endothelial cells. It is important in the maintenance of a "non-thrombogenic" endothelial surface. t-PA is unable to activate circulating plasminogen, but can bind to fibrin and activate plasminogen at the site of the clot. t-PA is released in response to activated protein C.

pg. 389
Barash, Clinical Anesthesia, 2009

49

Daily urinary excretion of potassium in the adult is approximately:

-10 to 20 mEq/day
-50 to 150 mEq/day
-200 to 300 mEq/day
400 to 500 mEq/dat

50 to 150 mEq/day

Daily urinary excretion of potassium averages 50 to 150 mEq/day in adults and closely matches dietary potassium intake. A small amount is also lost by fecal elimination.

pg. 311
Barash, Clinical Anesthesia, 2009

50

A difference of 1 mOsm/L between two solutions results in an osmotic pressure difference of:

-12.2 mmHg
-19.3 mmHg
-26.4 mmHg
-38.3 mmHg

19.3 mmHg

Osmotic pressure is the pressure that must be applied to the side with more solute to prevent a net movement of water across a membrane. A difference of 1 mOsm/L between two solutions results in an osmotic pressure difference of 19.3 mmHg.

pg. 663
Morgan, GE, Mikhail, MS and Murray, Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

51

In the preoperative evaluation, an orthostatic decrease in blood pressure of 15 mmHg implies a:

-very mild fluid deficit
-5% fluid deficit
-10% fluid deficit
-15% fluid deficit

In the preoperative evaluation, an orthostatic decrease in blood pressure of 15 mmHg
implies a: 15% fluid deficit Orthostatic changes of 15 beats/min in heart rate or 10 mmHg in
blood pressure imply severe dehydration with a 15% or more fluid deficit (expressed as a
percentage of body weight)

pg. 691
Morgan, Clinical Anesthesiology, 2006

52

The ratio of the calcium concentration of 10 mL of 10% calcium chloride to 10 mL of 10% calcium gluconate is approximately:

-1:1
-2:1
-3:1
-4:1

The ratio of the calcium concentration of 10 mL of 10% calcium chloride to 10 mL of 10%
calcium gluconate is approximately: 3:1 Ten mL of 10% CaCl2 contains 272 mg of Ca+2,
whereas 10 mL of 10% calcium gluconate contains only 93 mg of Ca+2.

pg 685
Morgan, Clinical Anesthesiology, 2006

53

Calcitonin:

-enhances bone reabsorption
-decreases urinary excretion of calcium
-secretion is stimulated by hypercalcemia
-promotes absorption of calcium in the intestines

Calcitonin: secretion is stimulated by hypercalcemia. Calcitonin is a polypeptide hormone secreted by the parafollicular cells of the thyroid. Its secretion is stimulated by
hypercalcemia. Calcitonin inhibits bone reabsorption and increases urinary calcium
excretion.

pg. 683
Morgan, Clinical Anesthesiology, 2006
pg. 1285
Barash, Clinical Anesthesia, 2009

54

Cardiac effects of hyperkalemia are most effectively treated with:

-Mg+2
-Ca+2
-normal saline
-hypoventilation

Cardiac effects of hyperkalemia are most effectively treated with: Ca+2 Calcium gluconate or calcium chloride antagonizes the cardiac effects of hyperkalemia. Care must be exercised
in patients taking digoxin, as calcium potentiates digoxin toxicity.

pg. 314
Barash, Clinical Anesthesia, 2009

55

A 53 year old man is scheduled for an emergent laparotomy for small bowel obstruction. He has been vomiting for the past 36 hours and his serum potassium concentration is 2.9 mEq/L. Intraoperative management should include:

-replacement of half of the potassium deficit in the first hour
-administration of a dextrose containing solution
-increased recuronium administration
-maintenance of end-tidal CO2 at 40 mmHg

maintenance of end-tidal CO2 at 40 mmHg

Intraoperative management of hypokalemia requires vigilant ECG monitoring, judicious
administration of potassium, use of glucose-free intravenous solutions and the avoidance of hyperventilation. Increased sensitivity to NMBAs may be seen and NMBA dosages should be reduced 20 -50%.

pg. 680
Morgan, Clinical Anesthesiology, 2006
Pg. 293
Barash, Clinical Anesthesia, 2009

56

In the adult, IV potassium replacement should not exceed:

-80 mEq/day
-160 mEq/day
-240 mEq/day
-360 mEq/day

240 mEq/day

Current recommendations suggest that intravenous potassium replacement should not exceed 240 mEq/day.

pg. 679
Morgan, Clinical Anesthesiology, 2006
pg. 313
Barash, Clinical Anesthesia, 2009

57

Plasma potassium concentrations are increased by:

-insulin administration
-catecholamine administration
-respiratory alkalosis
-mannitol administration

mannitol administration

Plasma potassium concentrations are increased by: acidosis and acute increases in plasma osmolality. Plasma potassium concentrations are decreased by alkalosis, insulin administration, catecholamine administration, acute volume contraction and
mineralocorticoid administration.

pg. 677
Morgan, Clinical Anesthesiology, 2006

58

Causes of increased plasma osmolality in the absence of hypernatremia include:

-hyperglycemia
-nephrogenic diabetes insipidus
-syndrome of inappropriate ADH secretion
-hyperthermia with intense sweating

hyperglycemia

Hyperglycemia can cause hyperosmolality without hypernatremia. For every 100 mg/dL increase in plasma glucose, plasma sodium concentration decreases about 1.6 mEq/L.

pg 669
Morgan, Mikhail, Clinical Anesthesiology, 2006
pg 301
Barash, Clinical Anesthesia, 2009

59

Normally, the volume of lipids and protein in the plasma is approximately:

-2%
-7%
-12%
-18%

7%

The water phase of plasma is normally only 93% of its volume; the remaining 7% consists of plasma lipids and proteins

pg 669
Morgan, Clinical Anesthesiology, 2006

60

Bacterial contamination of blood components:

-occurs much less frequently than viral contamination
-has a substantially higher incidence with platelet than RBC transfusions
-is rare if leukoreduction has been performed
-is associated with a very low morbidity and mortality

has a substantially higher incidence with
platelet than RBC transfusions

Bacterial contamination occurs at a much higher frequency than any other transfusion-transmitted infection. The incidence of sepsis is substantially greater with platelet than RBC administration.

pg. 371
Barash

61

In patients with sickle cell anemia, the goal of preoperative transfusion is to achieve a:

-10 to 15% HbA1 concentration
-hematocrit of 30%
-75 to 90% HbA1 concentration
-hematocrit of 40% or greater

hematocrit of 30%
The goals of preoperative transfusion management have changed in recent years. Transfusion strategies aimed at increasing the ratio of normal Hb to sickle Hb have found no benefit compared to the more conservative goal of achieving a preoperative hematocrit of 30%

pg 412
Hines, RL, and Marschall, KE. Stoeling's Anesthesia and Co-Existing Disease, New York and Philadelphia: Churchill Livingstone, 2008

62

ECG evidence of hypercalcemia includes:

-a shortened QT interval
-T wave inversion
-the presence of a Q wave
-the presence of a delta wave

a shortened QT interval

ECG signs of hypercalcemia include shortened ST segment and shortened QT interval.

pg. 1285
Barash

63

The most consistent acid-base abnormality after massive blood transfusion is postoperative:

-metabolic alkalosis
-metabolic acidosis
-respiratory alkalosis
-respiratory acidosis

metabolic alkalosis

Stored blood is acidic as a result of the added citrate and accumulation of red cell metabolites. However, once transfused, the citrate and lactate are converted in the liver to bicarbonate, resulting in a metabolic alkalosis.

pg. 703
Morgan

64

Factors that favor the renal excretion of potassium include:(select 2)

-alkalosis
-low urinary flow rates
-increased sodium intake
-hypoaldosteronism
-hypokalemia

alkalosis, increased sodium intake

Potassium secretion into the distal convoluted tubules and cortical collecting
ducts is increased by hyperkalemia, aldosterone, alkalemia, increased delivery of sodium to the distal tubule, high urinary flow and the presence in luminal fluid of nonreabsorbable anions such as phosphates.

pg. 311
Barash

65

The most common cause of bleeding following massive blood transfusion is:

-dilution of clotting factors
-calcium chelation by citrate
-dilutional thrombocytopenia
-enhanced fibrinolysis and plasmin activity

dilution of clotting factors

Administration of large volumes of fluid deficient in platelets and clotting factors will result in a coagulopathy as a consequence of dilution. In contemporary practice, in which patients receive principally PRBCs with only very limited amounts of residual plasma, factor deficiences develop before thrombocytopenia.

pg. 377
Barash

66

Renal excretion of potassium occurs largely through:

-filtration at the glomerulus
-passive transfer in the proximal convoluted tubule
-active secretion in the ascending loop of Henle
-secretion by tubular cells in the distal nephron

secretion by tubular cells in the
distal nephron

Potassium is secreted by tubular cells in the distal nephron, under the control of aldosterone. High tubular urinary flow rates, as seen with osmotic diuresis, also may enhance potassium excretion.

pg. 677
Morgan & Mikhail

67

Transfusion of leukocyte-containing blood products has been associated with:

-immunosuppression
-decreased graft survival after renal transplantation
-inactivation of latent viruses in the recipient
-a reduction in cytomegalovirus transmission

immunosuppression

Transfusion of leukocyte-containing blood products has been associated with immunosuppression. This results in improved renal-transplant survival, activation of latent viruses, increased incidence of infections and recurrence of malignant growths. The incidence of CMV transmission is nearly cut in half by leukoreduction.

pg. 372, 376
Barash

68

Release of ADH from the posterior pituitary can be increased by:

-decreased plasma osmolality
-hypertension
-hypovolemia
-ACTH secretion

hypovolemia

With increasing plasma osmolality, hypothalamic cells cause the release of ADH from the pituitary. Other factors that stimulate ADH secretion, although none as powerfully as plasma tonicity, include hypotension, hypovolemia and nonosmotic stimuli such as nausea, pain, and medications, including opiates.

69

Graft vs Host disease:

-is believed to be secondary to transfusion of antibodies
-can be prevented with the use of leukocyte filters
-does not occur with the transfusion of platelets
-can be prevented by prior irradiation of the donor blood

can be prevented by prior irradiation of the donor blood

Graft-versus-host disease may be seen in immune-compromised patients. It is believed to
be secondary to the transfusion of lymphocytes capable of mounting an immune response
against the compromised recipient. Leukocyte filters are not effective in preventing the
syndrome, but prior irradiation of the blood effectively inactivates the lymphocytes.

pg 701
Morgan

70

In contrast to acute respiratory distress syndrome(ARDS), transfusion-related acute lung injury:

-does not result in hypoxemia
-typically resolves within 12 - 48 hours with supportive therapy
-is not associated with pulmonary edema
-is thought secondary to platelet aggregation in the pulmonary capillaries.

typically resolves within 12 - 48 hours with supportive therapy

Transfusion related acute lung injury (TRALI) is thought to be secondary to transfusion of anti leukocyte antibodies that cause white cells to aggregate in the pulmonary capillaries, resulting in damage to the alveolar-capillary membrane. Clinically this syndrome is similar to ARDS, however it typically resolves within 12 - 48 hours.

pg. 701
Morgan
Pg. 374
Barash

71

Anaphylactic transfusion reactions:

-usually occur after only a few mL of blood is given
-are not seen when FFP is given
-are most common when deglycerolized frozen red cells are given
-occur more commonly in patients without a history of previous transfusion

usually occur after only a few mL of blood are given

An anaphylactic transfusion reaction usually occurs when the transfusion is first started. It is
typically seen in IgA deficient patients and is the result of anti-IgA antibodies reacting with
IgA from the donor blood. Patients with IgA deficiency should receive thoroughly washed
packed red calls, deglycerolized frozen cells or IgA-free blood units.

pg 701
Morgan
pg. 374
Barash

72

Antithrombin III binds and inactivates:(select 4)

-Factor Ia
-Factor IIIa
-Factor IVa
-Factor Va
-Factor VIIa
-Factor VIIIa
-Factor vWF
-Factor IXa
-Factor Xa
-Factor XIa
-Factor XIIa

IXa, Xa, XIa, XIIa

Antithrombin III is able to bind and inactivate each of the activated clotting factors of the intrinsic pathway - factors IXa, Xa, XIa and XIIa. AT also has a binding site that reacts with thrombin (factor IIa) in the presence of heparin activation.

pg. 390-391
Barash

73

Delayed hemolytic transfusion reactions typically occur:

-1 to 6 hours after the transfusion
-6 to 12 hours after the transfusion
-12 to 24 hours after the transfusion
-2 to 21 days after the transfusion

2 - 21 days after the transfusion

A delayed hemolytic reaction is caused by antibodies to non-D antigens or to foreign alleles in other systems such as the Kell, Duffy or Kidd antigens. The hemolytic reaction requires the formation of these new antibodies and typically requires 2 - 21 days to manifest.

pg 701
Morgan
pg. 373-374
Barash

74

Causes of hyperkalemia include:(select 4)

-spironolactone administration
-metabolic alkalosis
-respiratory acidosis
-hyperaldosteronism
-cyclosporine administration
-respiratory alkalosis
-hyperglycemia
-administration of terbutaline
-NSAID administration

Causes of hyperkalemia include: (Select 4) spironolactone administration, respiratory
(and metabolic) acidosis, cyclosporine administration, NSAID administration

Acidosis causes hyperkalemia by causing an intercompartmental ion shift; as H+ moves into the cells, K+ moves into the plasma. NSAIDS cause a decrease in potassium excretion.
Cyclosporine causes an increase in chloride reabsorption with secondary potassium
reabsorption. Spironolactone is a competitive inhibitor of aldosterone.

pg. 680
Morgan
pg. 355-356
Hines, RL, and Marschall(2008) Stoelting's Anesthesia and Co-Existing Disease

75

Following transfusion, platelets generally survive:

-1 to 7 days
-7 to 14 days
-14 to 21 days
-28 to 35 days

1 -7 days
ABO compatibility of the platelets may increase platelet survival.

pg. 699
Morgan
pg. 385
Barash

76

Serum potassium concentrations below 3.0 mEq/l represent a total body potassium deficit of:

-20 to 80 mEq
-80 to 160 mEq
-200 to 400 mEq
- > 600 mEq

200 - 400 mEq

Because potassium is largely intracellular, small changes in extracellular
potassium concentration reflect a large change in total body potassium. A decrease in
plasma potassium from 4 mEq/L to 3 mEq/L usually represents a 100 - 200 mEq deficit,
whereas plasma potassium below 3 mEq/L can represent a deficit anywhere between 200 -400 mEq.

pg. 677
Morgan
pg. 311-312
Barash

77

Increased blood loss during surgery has been associated with platelet counts less than:

-250,000
-150,000
-50,000
-25,000

50,000 x 109/L

Platelet counts less than 50,000 are associated with increased blood loss during surgery. Thrombocytopenic patients should receive platelet transfusions preoperatively to raise the platelet count over 100,000.

pg. 699
Morgan
pg. 389
Barash
pg. 422
Hines(2008)

78

The major defense mechanism against plasma hyperosmolality and hypernatremia is:

-thrist
-ADH release
-mineralocorticoid release
-increased osmolality of the renal medulla

thirst

Thirst is the major defense mechanism against hyperosmolality and hypernatremia, because
it is the only mechanism that increases water intake.

pg. 669
Morgan
pg. 297
Barash

79

In adults, a unit of fresh frozen plasma generally increases the level of each clotting factor by:

-2 to 3 %
-5 to 10%
-15 to 20%
-25 to 30%

2 - 3%

pg. 699
Morgan
pg. 380
Barash

80

Once thawed, fresh frozen plasma must be infused within:

-1 hour
-4 hours
-12 hours
-24 hours

24 hours

One unit of whole blood yields about 200 mL of plasma, which is frozen for storage. Once thawed, it must be transfused within 24 hours.

pg. 699
Morgan
pg. 380
Barash

81

The rapid freezing of plasma to make fresh frozen plasma help to prevent the inactivation of coagulation factor:

-II
-VIII
-IX
-XII

VIII

The rapid freezing of fresh frozen plasma helps prevent inactivation of labile coagulation factors V and VIII.

pg. 699
Morgan
pg. 385
Barash

82

Causes of hypocalcemia include:

-fat embolism
-adrenal insufficiency
-chronic lithium use
-sarcoidosis

fat embolism

Fat embolism has been associated with
hypocalcemia and is thought to be due to precipitation of calcium with the fat. Adrenal
insufficiency, sarcoidosis and lithium use have all been associated with hypercalcemia.

pg. 683-684
Morgan

83

The hematocrit of packed red blood cells is approximately:

-30%
-45%
-70%
-90%

70%

One unit of packed red blood cells (PRBCs) has a volume of about 250 mL, although this amount is variable, and a hematocrit of 70%. Newer storage techniques have reduced the hematocrit of PRBCs to about 60%, but this has resulted in fewer microaggregates and a longer shelf life (42 days)

84

ECG changes associated with hyperkalemia include:

-T wave flattening
-narrowing of the QRS complex
-prolongation of the PR interval
-presence of a U wave

prolongation of the PR interval

ECG changes from hyperkalemia progress from peaked T waves, to QRS complex widening, to PR interval prolongation, to ST segment depression and finally V -fib and asystole

85

In situations that require emergent blood transfusion, where the recipient's blood type is not known, transfusion can be most safely accomplished by using:

-type A, Rh-negative blood
-type AB, Rh-negative blood
-type AB, Rh-positive blood
-type O, Rh-negative blood

type O, Rh-negative blood


Type O, Rh-negative blood has the fewest antigens on the red cells and is referred to as
"universal donor" blood.

86

Causes of metabolic alkalosis include:

-hepatic failure
-nasogastric suctioning
-cyanide poisoning
-aspirin intoxication

nasogastric suctioning

Common causes of metabolic alkalosis include hypovolemia, vomiting, nasogastric suction, diuretic therapy, bicarbonate administration, hyperaldosteronism and chloride-wasting diarrhea.

87

Almost all individuals with type O blood will develop anti-A and anti-B antibodies:

-within the first year of life
-only after exposure to Type A or B blood
-if they are also Rh positive
-after puberty

within the first year of life

Almost all individuals not having A or B antigens produce antibodies, mainly
IgM, against those antigens within the first year of life, even without previous blood
exposure. In contrast, Rh antibody formation usually requires previous antigen exposure

88

With complete suppression of ADH release, the daily excretion of water by the kidneys is approximately:

-3 to 5 L/day
-10 to 20 L/day
-25 to 30 L/day
-over 40 L/day

10 - 20 L/day

With ADH suppression, peak diuresis occurs after the circulating ADH is metabolized (90 - 120 min). Complete suppression of ADH release can result in the excretion of up to 10 - 20 L of water per day.

89

An 85 kg man has a preoperative hct of 40%. With euvolemic crystalloid replacement, the volume of blood loss necessary to reduce the hct to 30% is approximately:

_____ mL

1911 mL

90

A list of patients is show below. By dragging and reordering the selections in yellow, match the blood volume with the corresponding patient.

-Full term Neonate
-Infant
-Adult Female
-Adult Male

(65 mL/kg)
(75 mL/kg)
(80 mL/kg)
(85 mL/kg)

The average blood volume of a full-term neonate is approximately: 85 mL/kg

Premature Neonate--->95 mL/kg
Full term Neonate--->85 mL/kg
Infant--->80 mL/kg
Adult Male--->75 mL/kg
Adult Female--->65 mL/kg

pg. 696
Morgan

91

Febrile transfusion reactions are usually the result of:

-ABO incompatibility
-Rh incompatibility
-sensitization to white cells or platelets
-an IgA deficiency

sensitization to white cells or
platelets

White cell or platelet sensitization is typically manifested as a febrile reaction.
These reactions are quite common and seen in 1 - 3% of transfusions

92

Collected blood that is anti coagulated with CPDA-1 can be stored up to:

-21 days
-28 days
-35 days
-60 days

35 days

The most commonly used preservative-anticoagulant solution is CPDA-1. Blood preserved with CPDA-1 can be stored for up to 35 days. Alternatively, use of either Adsol or Nitric extends the shelf-life to 42 days.

93

When given in large volumes, normal saline can produce:

-hyperchloremic acidosis
-hyperchloremic alkalosis
-hypochloremic acidosis
-hypochloremic alkalosis

hyperchloremic acidosis

When given in large volumes, normal saline produces a dilutional hyperchloremic acidosis
because of its high chloride content; plasma bicarbonate decreases as chloride increases.

94

As compared with crystalloid solutions, restoration of intravascular volume with isotonic colloid solution requires approximately:

-100% more volume
-the same volume
-25% less volume
-70% less volume

70% less volume

Replacing an intravascular volume deficit with crystalloids generally requires 3 to 4 times the volume needed when using colloids.

95

Management of symptomatic hypercalcemia includes:

-volume restriction
-parathyroid hormone replacement therapy
-diuresis induced with D5W
-diuresis induced with normal saline

diuresis induced with normal saline

The most effective initial treatment of hypercalcemia is rehydration followed by a
brisk diuresis with the administration of normal saline. A loop diuretic may be administered after adequate hydration, to accelerate calcium excretion. Additional therapy with
biphosphonate or calcitonin may be required.

96

From the thromboelastogram patterns below, hemophilia A is best represented by:

2nd from the right pic

pg. 394
Barash

97

ECG findings suggestive of hypokalemia include:

-T wave peaking
-the presence of a U wave
-ST segment elevation
-the presence of a J wave

the presence of a U wave

ECG findings consistent with hypokalemia include T wave flattening and inversion, increasingly prominent U waves, ST segment depression, increased P wave amplitude and prolongation of the PR interval. Increased myocardial cell automaticity and delayed repolarization promote both atrial and ventricular arrhythmias.

98

Inhibition of platelet function has been associated with the use of:

-vitamin A
-vitamin C
-vitamin E
-vitamin K

vitamin E
Vitamin E use has been associated with platelet dysfunction and should be discontinued prior to surgery. Ginkgo biloba, ginseng, garlic and ginger have also been associated with platelet
dysfunction.

99

Heparin-induced thrombocytopenia/thrombosis(HITT):

-is more common in patient who have never previously received heparin
-should not be treated with warfarin
-is more common with the use of low molecular weight heparin
-is more common with porcine heparin than with bovine heparin

should not be treated with warfarin

HITT is seen in approximately 5% of patients who receive heparin for 5 days.
Onset requires several days in the heparin-naive patient, but may appear in 10 - 12 hours in patients previously exposed to heparin. HITT is more commonly seen with bovine heparin than with porcine heparin. Warfarin should be avoided in HITT patients as it may aggravate thrombosis.

100

In cases where an absolute contraindication to heparin use exists, anticoagulation for cardiopulmonary bypass may be achieved with:

-bivalirudin
-warfarin
-sodium citrate
-aprotonin

bivalirudin

Direct thrombin inhibitors are
the agents most commonly used when there are contraindications to heparin. Direct
thrombin inhibitors include hirudin, argatroban, lepirudin and bivalirudin.