Quiz 8

Question 1

Which of the following are optimal indications for cell salvage techniques, such as Cell Saver? Select two.

A. Hip replacement with an anticipated blood loss of >500mL
B. Surgical debulking of a malignant peritoneal tumor
C. Exploratory laparotomy following a gunshot wound to the abdomen
D. Jehovah’s Witness patient undergoing a spinal fusion

Answer 1

Correct Answer: A & D

Rationale

Cell salvage techniques are utilized to reduce the amount of allogenic red blood cell transfusions in cases with high expected blood loss (>500mL) (Elisha et al., 2023, p. 404). These practices are also beneficial in maintaining hemodynamic stability in patients who do not consent to allogenic blood transfusion, such as Jehovah’s Witnesses (Elisha et al., 2023, p. 404). Relative contraindications to cell salvage techniques include the contamination of the surgical field by malignant tumor cells and possible exposure of bowel contents (Elisha et al., 2023, p.404).

Question 2

Select All That Apply (Pick 3)

Which are common indications for using colloid fluids over crystalloids?

A. Sepsis

B. Severe hypoalbuminemia

C. Massive third spacing

D. Fluid replacement under 2 liters

E. Buying time before blood availability

Answer 2

Correct Answers:

B. Severe hypoalbuminemia

C. Massive third spacing

E. Buying time before blood availability

Rationale: Colloids are reserved for specific situations such as oncotic pressure loss, significant fluid shifts, or immediate volume expansion while awaiting blood products. Crystalloids are generally reserved for burns and sepsis.

Question 3

Which of the following are causes of hypocalcemia? [Select 2]

A. Hyperparathyroidism

B. Vitamin D deficiency

C. Hyperphosphatemia

D. Thiazide diuretic administration

Answer 3

Answer: B and C

Rationale: Hypocalcemia should be diagnosed based upon the ionized plasma calcium concentration. If hypocalcemia is present based upon this, common causes include hypoparathyroidism, vitamin d deficiency, hyperphosphatemia, precipitation of calcium, and chelation of calcium. Thiazide diuretic administration, and hyperparathyroidism are common causes of hypercalcemia.

Question 4

Which of the following are chloride-sensitive causes for metabolic alkalosis? (SATP)

a. Vomiting

b. Diuretics

c. Hyperaldosteronism

d. Cystic fibrosis

Answer 4

Answer: a., b., d.

Rationale: Chloride sensitive mechanisms of metabolic alkalosis include conditions that deplete extracellular fluid. In response to fluid depletion, the renal tubules reabsorb Na+; when not enough chloride anions are present to accompany the Na+, H+ ions must be excreted to maintain electrical neutrality. Urine chloride concentrations are typically low (<10mEq/L). Conditions can can lead to this fall into three categories: Gastrointestinal, renal, and sweat. While diuretic therapy is the most common cause, other triggers include vomiting (gastrointestinal) and cystic fibrosis (sweat). Hyperaldosteronism falls into the “chloride resistant” category, causing metabolic alkalosis by way of promoting sodium retention and K+ and H+ excretion. In this instance, urine chloride is typically elevated (>20 mEq/L).

Question 5

Which of the following relationships is the basis for the Frank-Starling mechanism?

A. Systemic vascular resistance (SVR) and left ventricular end-diastolic volume (LVEDV)

B. Cardiac output and left ventricular end-systolic volume (LVESV)

C. Myocardial contractility and systemic vascular resistance (SVR)

D. Left ventricle end-diastolic volume (LVEDV) and Myocardial contractility

Answer 5

Answer: D

Rationale: The relationship between LVEDV and myocardial contractility is the basis of the Frank-Starling mechanism. This mechanism describes how increasing LVEDV (ventricular stretch) will increase myocardial contractility, which increases the force of contraction. It all has to do with sliding filament theory. As the sarcomeres lengthen from stretching, more actin overlaps myosin, creating more cross-bridges. The number of cross-bridges dictates the force of contraction. However, the force of contraction will decrease if the ventricle is stretched past a certain point because the myosin and actin filaments are only so long. Too much stretch ultimately causes less myosin and actin to overlap. This reduces the number of cross-bridges to form, causing a weaker contraction. The Frank-Starling mechanism explains why giving fluid volume for hypovolemia increases cardiac output, but too much volume (fluid overload) is counterproductive.

Question 6

Once a patient with hyponatremia is clinically stable, what is the recommended maximum rate at which serum sodium (Na⁺) should be increased to avoid the risk of osmotic demyelination syndrome?

A) 5-8 mmol/L in 24 hours
B) 8 mmol/L in 24 hours
C) 10–15 mmol/L in 24 hours
D) 20-25 mmol/L in 24 hours

Answer 6

Correct Answer: C) 10–15 mmol/L in 24 hours

Once the patient is clinically stable, Na+ administration should be slowed to raise serum Na+ not more than 10 to 15 mmol/L in 24 hours.

Question 7

Which of the following regulate or contribute to the release of ADH and, thereby, control plasma osmolality? (select all that apply)

Osmoreceptors in the hypothalamus
The anterior pituitary
The renal collecting tubules
Carotid baroreceptors
The posterior pituitary
Low pressure volume receptors in the atria, vena cavae, and pulmonary arteries.

Answer 7

Correct Answer: A, D, E, F

Rationale: “Specialized neurons in the hypothalamus are sensitive to changes in extracellular osmolality. When ECF osmolality increases, these cells shrink and cause ADH release from the posterior pituitary. ADH markedly increases water reabsorption in renal collecting tubules which reduces plasma osmolality back to normal. Conversely, a decrease in extracellular osmolality causes osmoreceptors to swell and suppresses the release of ADH. Decreased ADH secretion allows water diuresis, which increases osmolality to normal. Peak diuresis occurs once circulating ADH is metabolized (90–120 minutes). With complete suppression of ADH secretion, the kidneys can excrete up to 10 to 20 L of water per day. Carotid baroreceptors (volume receptors), as well as low-pressure volume receptors in the atria, vena cavae, and pulmonary arteries, also influence ADH release. A fall in wall tension results in a reflex increase of ADH secretion from the posterior pituitary. An increased stretch of these receptors not only suppresses ADH secretion, but the increased atrial volume receptor stretch also increases secretion of atrial natriuretic peptide (ANP; see later discussion), which promotes renal excretion of sodium and water” (Butterworth, 2022)

Question 8

What daily fluid volume would a 100 kg patient need in order to maintain Total Body Water homeostasis? Assume the person is healthy, normothermic, and has standard metabolic function.

A. 2 Liters

B. 3 Liters

C. 4 Liters

D. 5 Liters

Answer 8

Answer: B. 3 Liters.

Rationale: The fluid requirement for person who is healthy, normothermic, and has standard metabolic function is 25-35 ml/kg a day. Thus, a 100 kg patient would require 2.5 - 3.5 Liters of fluid to maintain Total Body Water Homeostasis.

Question 9

What is the most common electrolyte abnormality in hospitalized patients?

A. Hyperkalemia

B. Hypocalcemia

C. Hyponatremia

D. Hyperphosphatemia

Answer 9

Correct Answer: C

Rationale:

Hyponatremia is the most common electrolyte abnormality in hospitalized patients.

Question 10

Which of the following best distinguishes nephrogenic diabetes insipidus (DI) from central DI?

A. Nephrogenic DI often develops due to lesions in the brain
B. Central DI shows no response to antidiuretic hormone (ADH) administration
C. Nephrogenic DI involves impaired renal response to normal ADH levels
D. Central DI is commonly associated with lithium therapy

Answer 10

Correct Answer: C. Nephrogenic DI involves impaired renal response to normal ADH levels

Rationale:
In nephrogenic DI, ADH secretion is normal, but the kidneys fail to respond to it, and urinary concentrating ability is impaired. It can be congenital or secondary to chronic conditions, such as CKD, hypokalemia, or lithium use. Central DI is due to decreased ADH secretion, commonly resulting from brain lesions or brain death. An increase in urine osmolality following the administration of exogenous ADH confirms the diagnosis of central DI. In nephrogenic DI, the kidneys fail to produce hypertonic urine following the administration of exogenous ADH.

Question 11

Which of the following is a key component of patient blood management (PBM) in the perioperative period?

A. Delaying anemia treatment until after surgery
B. Routine transfusion of all patients undergoing major surgery
C. Optimization of the patient’s red blood cell production
D. Ignoring mild anemia if the patient is asymptomatic

Answer 11

Correct Answer: C. Optimization of the patient’s red blood cell production

Rationale: Addressing patient blood management (PBM) throughout the perioperative period allows practitioners to identify and treat conditions—such as anemia or coagulopathy—that increase the risk of bleeding or transfusion. The key aspects of PBM during this time include optimization of the patient’s red blood cell (RBC) production, minimization of blood loss, and treatment of anemia. These strategies help improve oxygen delivery, reduce transfusion requirements, and ultimately enhance patient outcomes.

Question 12

A trauma patient is receiving massive transfusion of packed red blood cells intraoperatively. Which electrolyte imbalance is most likely to occur due to the citrate preservative in the blood products?

A) Hyperkalemia
B) Hypocalcemia
C) Hypernatremia
D) Hypomagnesemia

Answer 12

Answer: B) Hypocalcemia

Rational: Citrate is used as a preservative in packed red blood cells. The citrate chelates or binds calcium. During massive rapid transfusion, the excess citrate can significantly reduce the serum calcium levels, leading to acute hypocalcemia. Correction of serum calcium should be guided by ionized calcium levels.

Question 13

Which of the following is NOT a recommended indication for platelet transfusion?

A. Platelet count <10 × 10⁹ cells/L in a non-bleeding patient

B. Platelet count <50 × 10⁹ cells/L with active bleeding

C. Mild thrombocytosis without bleeding

D. Platelet dysfunction

Answer 13

Answer: C. Mild thrombocytosis without bleeding

Rationale: Platelet transfusion is not indicated in thrombocytosis. Examples of some indications for platelet transfusion are platelet dysfunction, thrombocytopenia, or platelet count <50 × 10⁹ cells/L with active bleeding.

Question 14

According to Enhanced Recover After Surgery (ERAS) protocol, which of the following is NOT correct regarding the preoperative fluid management fasting intervals?

A. Clear liquids: 2 hours
B. Breast milk: 2 hours
C. Formula/non-human milk/light meal: 6 hours
D. Heavy meal (fried foods, fatty foods, meats): 8 hours.

Answer 14

Answer: B. Breast milk: 2 hours

Rationale: The preoperative fasting guidelines recommend the following fasting intervals: clear liquids 2 hours, breast milk 4 hours, infant formula/nonhuman milk/light meal 6 hours, and heavy meal (fried foods, fatty foods, meats) 8 hours. Also, supplying a carbohydrate drink (such as Gatorade) 2 hours prior to surgery has the added benefit of maintaining adequate preoperative glucose and insulin levels, thereby reducing preoperative thirst, hunger, and anxiety levels.

Question 15

A patient presented to the emergency department 2 days prior with heart failure and fluid overload. The patient has been NPO during this time and is receiving loop diuretics to offload fluid. The patient is preparing for a heart cath when the nurse anesthetist notices the patient’s ECG: A pronounced P wave, a flattened T wave, and a prominent U wave. What condition should the CRNA suspect?

A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
E. Wolff-Parkinson-White Syndrom

Answer 15

Answer:

B. Hypokalemia. The ECG represents a classic presentation of hypokalemia. Assumably, the hypokalemia was brought on by a decreased dietary potassium intake and the administration of loop diuretics. Conversely, hyperkalemia is presented with a flattened P wave, widened QRS, shortened QT interval, and peaked T wave.

Question 16

Which of the following findings is most consistent with Transfusion-Associated Circulatory Overload (TACO) rather than Transfusion-Related Acute Lung Injury (TRALI)?

A. Hypotension
B. Fever and chills
C. Hypertension
D. Acute hypoxemia within 6 hours of transfusion

Answer 16

Answer: C. Hypertension

Rationale: TACO is estimated to occur in 1% to 4% of patients receiving a transfusion and occurs higher in those who are critically ill and in ICUs.It should be suspected in any patient experiencing respiratory distress or hypertension 6 to 12 hours after completion of a transfusion. Although hypertension is a distinguishing feature between TRALI and TACO, hypotension and shock can also occur with TACO.’’ Other findings may include hypoxia, tachycardia, widened pulse pressure, jugular vein distension, or rales/wheezing within the lungs (Elisha,

Question 17

The anesthesia provider is looking at the patient’s history and medication list. The anesthesia provider confirmed with the nurse that the patient is taking a scheduled dose of an ACE inhibitor (lisinopril) and a Beta blocker (metoprolol) to control their blood pressure. The patient is scheduled for surgery in the next 10 hours. What electrolyte abnormality would you see in the patient if it is not corrected by goal-directed fluid therapy?

A. hyponatremia and hyperkalemia

B. hypernatremia and hypokalemia

C. hypernatremia and hyperkalemia

D. hypercalcemia and hypocalcemia

Answer 17

Answer: A. hyponatremia and hyperkalemia

Rationale: Medications such as ACE inhibitors, beta blockers (specifically Beta 1 receptor antagonism), ARBs, and digoxin can cause an increase in extracellular potassium. ACE inhibitors and ARBs can cause a decrease in angiotensin, and beta blockers inhibit renin release, which decreases the release of aldosterone. A decrease in aldosterone can cause hyperkalemia and hyponatremia.

Question 18

What is the ultimate goal of perioperative goal-directed fluid therapy (GDFT)?

A. To administer a fixed volume of fluids to all patients.
B. To utilize individual hemodynamic end points to achieve an optimal cardiac output and oxygen delivery to tissues.
C. To minimize the use of vasopressors during surgery, thus decreasing increased oxygen demand.
D. To aim for a “zero balance” between intake and output to minimize excess fluid administration by only replacing the estimated blood loss during surgery.

Answer 18

Correct Answer: B. To utilize individual hemodynamic end points to achieve an optimal cardiac output and oxygen delivery to tissues.

Rationale: Perioperative goal-directed fluid therapy (GDFT) aims to optimize each individual’s hemodynamic status by tailoring fluid administration to achieve specific hemodynamic end points, thus decreasing oxygen demand and optimizing cardiac output and tissue oxygenation during surgery. Administering a fixed volume of fluids has historically been used in the past, but it may have unintended physiologic consequences since it is not tailored to each individual’s hemodynamic needs. Focusing solely on replacing estimated blood loss does not account for individual patient needs, and is related to the “zero balance” approach of fluid management. Minimizing vasopressor use is not the primary objective of GDFT. However, GDFT will allow the provider to determine if the patient requires fluid therapy or inotropy support.