ABS1 Flashcards
1
Q
TBW in adult females
A
50%
*Males = 60%
2
Q
Clinical manifestations of hypokalemia are primarily related to
A
Failure of normal contractility of GI smooth muscle (ileus, constipation) skeletal muscle (decreased reflexes, weakness, paralysis), and cardiac muscle (arrest)
3
Q
Parameters in Harris-Benedict equation
A
W = actual weigh in kg
H = actual height in cm
A = age in years
4
Q
The most abundant amino acid in the human body
A
Glutamine
5
Q
Nutritional formula used to treat pulmonary failure typically increase the fat intake of a patient’s total caloric intake to
A
50%
6
Q
Early sign of hyperkalemia
A
Peaked T waves
7
Q
Normal saline is
A
154 mEq NaCl/L
8
Q
Fluid resuscitation for hypovolemic shock using albumin can lead to
A
Pulmonary edema
9
Q
Hydroxyethyl starch solutions are associated with
A
Postoperative bleeding (in cardiac and neurosurgery patients)
10
Q
Water constitutes what percentage of total body weight
A
50–60%
11
Q
A cation exchange resin that binds potassium, either given enterally or as an enema
A
Kayexalate
12
Q
A patient who has spasms in the hand when a blood pressure cuff is blown up most likely has
A
Hypocalcemia
13
Q
The effective osmotic pressure between the plasma and interstitial fluid compartment is primarily controlled by
A
Protein
14
Q
The metabolic derangement most commonly seen in patients with profuse vomiting
A
Hypochloremic, hypokalemic metabolic acidosis
15
Q
Best determinant of whether a patient has a metabolic acidosis versus alkalosis
A
Arterial pH
16
Q
Excessive administration of normal saline for fluid resuscitation can lead to what metabolic derangement
A
Metabolic acidosis
17
Q
The first step in the management of acute hypercalcemia should be
A
Correction of deficit of extracellular fluid volume
18
Q
The vagus nerve mediates which in the setting of systemic inflammation
A
The vagus nerve exerts several homeostatic influences including:
Enhancing gut motility
Reducing heart rate
Regulating inflammation
19
Q
Cytokines are what type of hormone
A
Polypeptide
*Polypeptide = Cytokines, glucagon, and insulin
*Amino acids = Epinephrine, serotonin, and histamine
*Fatty acids = Glucocorticoids, prostaglandins, and leukotrienes
*NO carbohydrate hormones
20
Q
Function of heat shock proteins
A
Binding of autologous proteins to improve ligand binding
*HSPs bind both autologous and foreign proteins and thereby function as intracellular chaperones for ligands such as bacterial DNA and endotoxin
21
Q
Eicosanoids
A
Prostaglandins, prostacyclins, hydroxyeicosatetraenoic acids (HETEs), thromboxanes, and leukotrienes
22
Q
Omega-3 fatty acids have what effects on the inflammatory response
A
Decreased inflammatory response
*In a study of surgical patients, preoperative supplementation with omega-3 fatty acid was associated with:
Reduced need for mechanical ventilation
Decreased hospital length of stay
Decreased mortality with a good safety profile
23
Q
Known effects of tumor necrosis factor (TNF)
A
Enhances the expression of eicosanoids
24
Q
Are adhesion molecules (i.e., cells that mediate leukocyte to endothelial adhesion)
A
L-selectin
There are 4 families of adhesions molecules:
Selectins
Immunoglobulins
Beta (CD18) integrins
Beta (CD29) integrins
25
The primary physiologic effect of nitric oxide (NO) is
Increased smooth muscle relaxation
26
Prostacyclin has what effects in systemic inflammation
Inhibition of platelet aggregation
*Prostacyclin is an effective vasodilator and also inhibits platelet aggregation
*Primarily produced by endothelial cells
27
If 1 liter of 0.9% NaCl solution is given intravenously, how much will be distributed to the interstitial space
750 cc
*Sodium is confined to the ECF compartment, and because of its osmotic and electrical properties, it remain associated with water
*One liter of normal saline will be distributed 3:1 to the interstitial space – 750 mL to the interstitial space and 250 mL will remain in the intravascular volume
28
The principal determinants of osmolality are the concentrations of
Sodium, glucose, and urea (or BUN)
29
A patient develops a high output fistula following abdominal surgery. The fluid is sent for evaluation with the following results: Na 135, K 5, Cl 70. Most likely source of the fistula
Pancreas
*Composition of GI Secretions
30
What diagnosis would be most likely in a patient who presents with normovolemic hyponatremia
Syndrome of inappropriate anti-diuretic hormone secretion (SIADH)
31
A patient is admitted with a glucose of 500 and a sodium of 151. Best approximation of the patient’s actual serum sodium level is
145
*For every 100 mg/dL increment in plasma glucose above normal, the plasma sodium should decrease 1.6 mEq/L
*For this patient, serum glucose of 500 is roughly 400 mg/dL above normal: 4 x 1.6 = 6.4 subtracted from 151 to obtain a corrected serum sodium of 144.6
32
Most likely diagnosis in a patient with serum sodium of 152 mEq/L, a urine sodium concentration of >20 mEq/L, and a urine osmolality of >300 mOsm/L
Cushing’s syndrome
*Hypervolemic hypernatremia usually is caused either by:
Iatrogenic administration of sodium-containing fluids, including sodium bicarbonate
Mineralocorticoid excess – hyperaldosteronism, Cushing’s syndrome, and congenital adrenal hyperplasia
33
Medications that can contribute to hyperkalemia, particularly in the presence of renal insufficiency
Potassium-sparing diuretics
Angiotensin-converting enzyme inhibitors
NSAIDs
*Aspirin and CCBs have no significant effect on potassium levels
34
Which metabolic electrolyte imbalance would cause decreased deep tendon reflexes
Hypokalemia
*Hypomagnesemia and hypocalemia cause increased deep tendon reflexes
35
Is an early ECG change seen in hyperkalemia
Peaked T waves
*ECG changes that may be seen with hyperkalemia include:
High peaked T waves (early)
Widened QRS complex
Flattened P wave
Prolonged PR interval (first-degree block)
Sine wave formation
Ventricular fibrillation
36
A postoperative patient with a potassium of 2.9 is given 1 mEQ/kg replacement with KCl (potassium chloride). Repeat test after the replacement show the serum K to be 3.0. The most likely diagnosis is
Hypomagnesemia
*In case in which potassium deficiency is due to magnesium depletion, potassium repletion is difficult unless hypomagnesemia is first corrected
37
What is the actual serum calcium level in a patient with an albumin of 2.0 and a serum calcium level of 6.6
8.2
*Adjust total serum calcium down by 0.8 mg/dL for every 1 g/dL decrease in albumin: 0.8 x 2 = 1.6 + 6.6 = 8.2
38
Hypomagnesemia clinically resembles
Hypocalcemia
39
A patient presents obtunded to the ER with the following labs: Na 130, Cl 105, K 3.2, HCO3 15. Most likely diagnosis is
GI losses
*This is a normal anion gap acidosis
40
Should be the first treatment administered to a patient with potassium level of 6.3 and flattened P waves on their ECG
Insulin and glucose
*The goal of therapy include reducing the total body potassium, shifting potassium from the extracellular to the intracellular space, and protecting the cells from the effects of increased potassium
*Treatment of symptomatic hyperkalemia:
Potassium removal – Kayexalate, dialysis
Shift potassium – Glucose, insulin, bicarbonate
Counteract cardiac effects – Calcium gluconate
41
Basal caloric requirement of a normal healthy adult
25-30 kcal/kg/day
42
Deficiency often due to malabsorption from prior gastric surgery (e.g., bariatric surgery)
Acquired copper deficiency
*Hypochromic microcytic anemia occurs from copper deficiency-induced impairment of iron absorption
43
Characteristics of central parenteral nutrition includes
Dextrose content: 15-25%
High osmolarity (1500-2800 mOsm/L)
Requires administration into large veins with high blood flow (2- 6 L/min)
Provides complete nutritional requirements
44
Primary source of calories during acute starvation (<5 days fasting) is
Fat
45
Primary fuel source in prolonged starvation
Ketone bodies
46
Primary fuel source after acute injury
Fat
47
Sepsis increases metabolic needs by approximately what percentage
50%
48
Most abundant amino acid in the human body
GlutaMINE
*Synthesized within the skeletal muscles (70%) and the lungs
*Precursor for glutathione
49
Cortisol is elevated in response to severe injury. How long can this response persist in a patient with a significant burn
1 month or 4 weeks
50
What vitamin can be used to mitigate cortisol effects on wound healing
Vitamin A
*Cortisol reduces TGF-β and IGF-I in the wound → Impaired wound healing
51
Laboratory findings in adrenal insufficiency
* Hypoglycemia – from decreased gluconeogenesis
* Hyponatremia – from impaired renal tubular sodium resorption
* Hyperkalemia – from diminished kaliuresis
* Calcium levels – not affected
52
Overfeeding (RQ>1) in a critically ill patient can result in
Increased risk of infection
53
Initial enteral formula for the majority of surgical patients
Low-residue isotonic formula
54
Which nutrient is proportionally increased in “pulmonary failure” enteral formula
Fat
*The goal is to reduce carbon dioxide production and alleviate ventilation burden for failing lungs
55
Which vitamin is not present in commercially prepared intravenous vitamin preparations and, therefore, must be supplemented in a patient receiving TPN
Vitamin K
*Should be supplemented on a weekly basis
56
New onset of glucose intolerance in a TPN dependent patient can be due to
Chromium deficiency
57
A potential physiologic effect of anabolism (positive nitrogen balance)
Glycosuria
*Anabolism requires a large shift of potassium into the new cells – leading to serum hypokalemia
*Hypokalemia may cause glycosuria – treated with potassium, not insulin
*Before giving insulin, the serum potassium level must be checked to avoid exacerbating the hypokalemia
58
The only anticoagulant reversal agent for dabigatran
Idarucizumab
59
Most common adverse transfusion reaction
Febrile nonhemolytic transfusion reaction (FNHTR)
*Prevention is best achieved by using leukoreduced blood products for future transfusions
60
Minimum threshold for transfusion for hemodynamically stable patients
7 g/dL
61
Minimum threshold for transfusion for patients undergoing cardiac surgery, orthopaedic surgery, and with pre-existing CVD
8 g/dL
62
The vitamin K-dependent coagulation factors are
Factors II, VII, IX, X, proteins C and S
63
Required for platelet adherence to injured endothelium
von Willebrand factor (vWF)
*vWF binds to glycoprotein (GP) I/IX/V on the platelet membrane
64
The first factor common to both intrinsic and extrinsic pathway
Factor X (Stuart-Prower factor)
65
What congenital factor deficiency is associated with delayed bleeding after initial hemostasis
Factor XIII
66
In a previously unexposed patient, when does the platelet count fall in heparin-induced thrombocytopenia (HIT)
5-7 days
67
Best laboratory test for determining the degree of anticoagulation with dabigatran and rivaroxaban
None
68
Most common intrinsic platelet defect
Storage pool disease
69
Leading cause of transfusion-related deaths
Transfusion-related acute lung injury
70
Most common cause for transfusion reaction is
Human error
71
Frozen plasma prepared from freshly donated blood is necessary when a patient requires
Factor VIII (antihemophilic factor) or factor V (proaccelerin)
72
What clotting factor is labile, and 60-80% of activity is gone 1 week after collection
Factor VIII
73
Best choice to prepare a patient with type I von Willebrand’s disease for surgery
Desmopressin
*vWD is classified into three types:
* Type I – Partial quantitative deficiency = Desmopressin acetate
* Type II – Qualitative defect = May respond depending on particular defect
* Type III – Total deficiency = Usually unresponsive
*Treatment for vWD:
An intermediate-purity factor VIII concentrate such as Humate-P that contains vWF as well as factor VIII
Desmopressin acetate – raises endogenous vWF levels by triggering release of the factor from endothelial cells
74
Hemophilia C is caused by a deficiency of
Factor XI
*Treatment: Fresh-frozen plasma (FFP) – each mL of plasma contains 1 unit of factor XI activity
75
Factor XIII deficiency most commonly present as
Delayed bleeding after injury or surgery
*Bleeding typically is delayed, because clots form normally but are susceptible to fibrinolysis
*Treatment: FFP, cryoprecipitate, or a factor XIII concentrate
76
Bleeding in patients with thrombasthenia is treated with
Platelet transfusion
*Thrombasthenia or Glanzmann thrombasthenia – either lacking or present but dysfunctional platelet glycoprotein IIb/IIIa complex → leads to faulty platelet aggregation and subsequent bleeding
77
Bleeding in patients with the Bernard-Soulier syndrome is treated with
Platelet transfusion
*Caused by a defect in the glycoprotein Ib/IX/V receptor for vWF, is necessary for platelet adhesion to the subendothelium
78
A patient with partial albinism and a bleeding disorder most likely has
Dense granule deficiency
*The most common intrinsic platelet defect is storage pool disease – involves loss of dense granules (storage sites for ADP, adenosine triphosphate (ATP), Ca2+, and inoerganic phosphate) and α-granules
*Treatment: Desmopressin acetate, platelet transfusion with more severe bleeding
79
First line therapy in an adult with idiopathic thrombocytopenia purpura includes
IV immunoglobulin
*First line therapy for ITP in adults is = Corticosteroids and IV immunoglobulin
*Splenectomy is second line therapy
*Desmopressin is not used in the treatment of ITP
80
The diagnosis of heparin-induced thrombocytopenia is made by
Positive serotonin release assay or an enzyme-linked immunosorbent assay (ELISA)
81
In addition to stopping the heparin, a patient with heparin-induced thrombocytopenia (HIT) should be treated with
Lepirudin
*Stopping heparin without adding another anticoagulant is not adequate to prevent thrombosis
*Alternative anticoagulants are primarily thrombin inhibitors = Lepirudin, argatroban, bivalirudin, danaparoid
*Because of warfarin’s early induction of a hypercoagulable state, only once full anticoagulation with an alternative agent has been accomplished and the platelet count has begun to recover should warfarin be instituted
82
The most effective treatment for bleeding secondary to thrombotic thrombocytopenic purpura is
Plasmapheresis
*Platelet transfusions are contraindicated
83
In a 70-kg patient, transfusion of 1 unit of platelets should raise the circulating platelet count by approximately
10,000
*One unit of platelet concentrate contains approximately 5.5 x 1010 platelets
84
Which is a common initiating event for disseminated intravascular coagulation (DIC)
Amniotic fluid embolization
*Embolized materials are potent thromboplastins that activate the DIC cascade
*The presence of an underlying condition that predisposes a patient to DIC is required for the diagnosis
CNS injuries with embolization of brain matter
Fractures with embolization of bone marrow
Amniotic fluid embolization
Malignancy
Organ injury (such as severe pancreatitis)
Liver failure
Certain vascular abnormalities (such as large aneurysms)
Snakebites
Illicit drugs
Transfusion reactions
Transplant rejections
Sepsis
85
A patient with prolonged aPTT and deep venous thrombosis should be evaluated for what condition
Antiphospholipid syndrome
*The hallmark of antiphospholipid syndrome (APLS) is – prolonged aPTT in vitro but an increased risk of thrombosis in vivo
86
A patient on chronic warfarin therapy presents with acute appendicitis. INR is 1.4. Most appropriate management
Proceed immediately with surgery without stopping the warfarin
87
Which devices is most advantageous for hemostasis during a thyroidectomy
Harmonic scalpel
*Harmonic scalpel – cuts and coagulates tissue via vibration at 55 kHz (converts electrical energy into mechanical motion) → the motion of the blade causes collagen molecules within the tissue to become denatured, forming a coagulum
Thyroidectomy
Hemorrhoidectomy
Transection of the short gastric veins during splenectomy
Transecting hepatic parenchyma
88
Topical anticoagulating agent that is best for use in patients with a coagulopathy
Fibrin sealant
89
What percent of the population is Rh negative
15%
90
What is the maximum number of units of blood that can be autologously donated for elective surgery as long as the patient’s haemoglobin is >11 g/dL or if the haematocrit is >34%
5 donations can be made, 3-4 days apart, starting 6 weeks before surgery
91
Best assess clot strength
Thromboelastogram (TEG)
*The only test measuring all dynamic steps of clot formation until eventual clot lysis or retraction
92
When should cryoprecipitate be given to a patient needing a massive transfusion of packed RBCs
After 6 units of PRBCs, cryoprecipitate should be given if the serum fibrinogen level is <100 mg/dL
93
↓ Warfarin effect
↑ Warfarin requirements
Barbiturates, oral contraceptives, estrogen-containing compounds, corticosteroids, adrenocorticotropic hormone
94
↑ Warfarin effect
↓ Warfarin requirements
Phenylbutazone, clofibrate, anabolic steroids, L-thyroxine, glucagons, amiodarone, quinidine, cephalosporins
