AP 2 Test 2 Flashcards
What are normal hemoglobin values in men?
Greater than or equal to 14gm/dL
What are normal hemoglobin values in women?
Greater than or equal to 12gm/dL
What are normal hematocrit values in men?
Greater than or equal to 42%
What are normal hematocrit values in women?
Greater than or equal to 38%
Hematocrit is normally __ times the hemoglobin value
3
What is hematocrit?
The ratio of red blood cells to blood volume
What is hemoglobin?
Iron-containing oxygen carrying proteins
What is anemia?
Reduced oxygen carrying capacity
Severe anemia is considered as having a hemoglobin below ___ gm/dL
5.9
Transfusion is rarely indicated when Hb is more than __ gm/dL
10
Transfusion is almost always indicated when Hb is less than __ gm/dL
6
The determination of whether intermediate Hb concentrations justify or require RBC transfusion is based on what?
The patient’s risk for complications of inadequate oxygenation
According to Miller’s Anesthesia, a blood loss greater than __% of blood volume when it’s more than ___ml of blood requires the administration of PRBCs
20%, 100ml
According to Miller’s Anesthesia, Hb less than __gm/dL requires administration of PRBCs
8
According to Miller’s Anesthesia, patients with major diseases such as anemia or ischemic heart disease require PRBCs when their Hb is less than what values?
9-10gm/dL
According to Miller’s Anesthesia, patients with Hb less than __g/dL with autologous blood require PRCBs
10
According to Miller’s Anesthesia, a Hb level less than __-__g/dL when the patient is ventilator dependent requires PRBCs
11-12
What is in PRBCs?
Whole blood with the plasma removed (mostly)
What is CPDA? What does it stand for?
The additive in PRBCs. Citrate Phosphate Dextrose Adenine
What is the function of citrate as a preservative in PRBCs?
Anticoagulant
What is the function of phosphate as a preservative in PRBCs?
pH buffer
What is the function of dextrose as a preservative in PRBCs?
Nutrition
What is the function of adenine as a preservative in PRBCs?
ATP synthesis
What is the shelf life of PRBCs with CPDA at 1-6 degrees celsius?
35 days
What is the shelf life of PRBCs with CPDA-1 at 1-6 degrees celsius?
42 days
You can only give RBCs at an age that if you give them and test the patient 24 hours later, __% of the cells will still be in circulation
70
What is the hematocrit of PRBCs with CPDA?
65%
What is the hematocrit of PRBCs with CPDA-1?
40%
How do PRBCs change chemically with age?
- Decreased pH, sodium, dextrose, and DPG
- Increased hemoglobin and potassium
Type A blood has which antigens and which antibodies?
A antigen, anti-B antibody
Type B blood has which antigens and which antibodies?
B antigen, anti-A antibody
Type AB blood has which antigens and which antibodies?
A and B antigens, no antibodies
Type O blood has which antigens and which antibodies?
No antigens, A and B antibodies
What is the universal blood donor?
O- packed red blood cells
What is the universal blood recipient?
AB+
Which blood test involves the potential donor’s RBCs being mixed with recipient plasma?
Type and Crossed
When is T&C necessary?
For ABO/Rh* compatibility
What patients are at risk of a Rh reaction with uncrossed blood?
1) Previously transfused
2) Pregnant
If we can’t T&C, what is the next best option?
Type and partially crossmatched - goes through phases I & II of T&C (ABO & Rh*)
To what patient populations would we give Rh+ blood to in an emergency situation where T&C blood wasn’t available?
1) Males who have not been transfused in the past
2) Post-menopausal women who haven’t been pregnant
1 unit of PRBCs increases Hgb by __-__gm/dL or Hct by __-__%
Hgb 1-2gm/dL or Hct 3-5%
What are the negative effects of PRBCs?
1) Lower DPG levels
2) Thrombocytopenia (decreased platelets)
3) Citrate intoxication
4) Hyperkalemia
5) Hypothermia
What is the storage time for fresh whole blood?
1-5 days
When is preoperative analogous donation done?
For surgeries with high risk of blood transfusion
What is the theory behind acute normovolemic hemodilution?
It reduces RBC loss intraoperatively because blood is taken from the patient and stored before incision and then given back to the patient after the blood loss
What is the target Hct for acute normovolemic hemodilution?
28%
How is intravascular volume restored after acute normovolemic hemodilution?
Fluids - 3mL crystalloid for every 1mL taken or 1mL colloid for every 1mL taken
What’s the calculation for estimated blood volume?
Kg x average blood volume
What’s the average blood volume for adult men?
75mL/kg
What’s the average blood volume for adult women?
65mL/kg
What’s the calculation for allowable blood loss?
[EBV x (Hi-Hf)] / Hi
Cell saver suctions blood and concentrates it into ___mL units with Hct of __-__%
225mL, 50-60%
What is the max units/hr that can be used with cell saver?
12 units/hr
What are the main surgeries in which cell saver is used?
High blood loss surgeries like orthopedic and cardiac
What are the drawbacks of cell saver? (2)
1) Some surgical substances like topical collagen can cause systemic inflammation and prevent cell saver use
2) Suctioning can cause hemolysis
What lab value measures the intrinsic pathway of the coagulation cascade?
PTT
What lab values measure the extrinsic pathway of the coagulation cascade?
PT/INR
What is the normal range for PT time?
11.5-13 seconds
What is the normal range for INR?
0.8-1.1
What is the normal range for PTT time?
25-35 seconds
What is the most frequently used plasma product?
FFP (fresh frozen plasma)
What temperature is FFP stored at?
4 degrees celsius
What components of blood does FFP contain?
All plasma proteins and fibrinogen
What component of blood does FFP not contain?
RBCs
How is FFP tested?
ABO tested, Rh compatibility not necessary
According to Miller’s Anesthesia, we should give ___ to patients with generalized bleeding that cannot be controlled with surgical sutures or cautery
FFP
According to Miller’s Anesthesia, we should give FFP to patients with PTT more than __ times the normal range
1.5 times the normal range
According to Miller’s Anesthesia, we should give FFP to patients with a platelet count more than ______ in order to rule out thrombocytopenia
70,000
What is the INR of FFP?
1.3-1.7
1 unit of FFP increases a clotting factor level by __-__%
2-3%
What dose of FFP is necessary to restore clotting factors to 30-50% of normal activity with warfarin toxicity?
15-30ml/kg
What blood product is given as a reversal of warfarin therapy when severe bleeding is present?
FFP
What is the normal range for platelet count?
150,000-400,000/microliter
How many days after collection do platelets expire?
7 days
When is prophylactic platelet transfusion ineffective?
When thrombocytopenia is due to increased platelet destruction or decreased platelet production
Patients with microvascular bleeding usually require platelet transfusion if the platelet count is less than what amount?
50,000
At what platelet count is there an increased chance of subdural hematoma with administration of an epidural?
70,000
A platelet count below what amount requires prophylactic transfusion?
10,000
1 unit of platelet concentrate increases platelet count by what amount?
7,000-10,000
Pooled and apheresis platelet bags usually contain how many units?
4-6
How many units of platelets are needed for a 100,000 increase in platelet count?
10 units (~2 bags)
What is the recommended transfusion ratio for PRBCs and FFP?
1.5 PRBCs:1 FFP
What is the recommended transfusion ratio for PRBCs and platelets?
6 PRBCs:1 bag platelets
What is the normal range for fibrinogen levels?
200-400mg/dL
What are the components of cryoprecipitate?
Factor VIII, factor XIII, and vWF
How many units come in each bag of cryoprecipitate?
5 units
How much fibrinogen is contained in each unit of cryoprecipitate?
300mg/unit
How is cryoprecipitate stored?
Frozen at -40 degrees celsius
Once cryoprecipitate is thawed, how long until it expires?
6 hours
What type of testing is often done on cryoprecipitate?
ABO
Is Rh compatibility important in cryoprecipitate administration?
Yes
When do we give cryoprecipitate? (3)
- Factor VIII deficiency
- Hemophilia A
- Low fibrinogen
In what surgeries would we most likely give cryoprecipitate?
- Major aortic surgery
- Open heart surgery involving more than 1 valve
- Redo open heart surgery
What is the target level of fibrinogen for patients who are actively bleeding and consuming fibrinogen?
More than or equal to 250mg/dL
3 grams (10 units) of cryoprecipitate raises fibrinogen levels by how much?
80-100mg/dL
If we plan to give FFP and cryo, which do we give first?
Cryo because the Factor VIII and vWF in cryo helps platelets adhere to epithelium
What factors does Prothrombin Complex Concentrate contain?
II, VII, IX, X - the vitamin-K dependent factors
When do we give PCC?
- Factor IX deficiency
- Hemophilia B
- Severe acute anemia/bleeding
- Warfarin reversal
What are the risks associated with PCC?
- Hepatitis
- Massive thrombosis
What is the blood product that you can give to a Jehova’s witness?
Factor VII
When do we give Factor VII?
- Hemophilia A
- Factor VII deficiency
- Inherited qualitative platelet disorders
- An adjunct with thrombocytopenia
- Profuse bleeding
- Warfarin reversal
What is the dosing range for factor VII?
15-180 micrograms/kg
What blood product do you not give with factor VII, and why?
Don’t give factor VII with PCC because it cause intracranial hemorrhage
What is the most serious hemolytic transfusion reaction?
TRALI
Hemolytic transfusion reactions can occur with more than __mL of the wrong PRBCs
10mL
What occurs during hemolytic transfusion reactions?
Patient’s antibodies lyse donor RBCs
What are the symptoms of hemolytic transfusion reactions?
- Anemia
- Hypotension
- Hemoglobin nephrotoxicity (hemoglobinuria, renal failure)
- DIC and bleeding
- Flu-like symptoms
What is the first thing you should do when you suspect a hemolytic transfusion reaction?
Stop the transfusion
If your patient is experiencing a hemolytic transfusion reaction, you should maintain the urine output at a minimum of __-___mL/hr
75-100ml/hr
What drugs can be used to maintain optimal urine output and concentration during a hemolytic transfusion reaction?
Mannitol, furosemide, sodium bicarbonate (to alkanize the urine)
What type of blood reaction may occur in patients who were formerly pregnant or have been previously given PRBCs?
Delayed hemolytic transfusion reaction
How many days could it take for delayed hemolytic transfusion reactions to occur?
2-21 days
Hemolytic transfusion reactions occur with administration of which blood product?
PRBCs
How do delayed hemolytic transfusion reactions affect hemoglobin levels?
Decreased
What are less common side effects of delayed hemolytic transfusion reactions?
Jaundice, hemoglobinuria, renal dysfunction
Non-hemolytic transfusion reactions can occur with administration of what blood products?
PRBCs, FFP, platelets, cryo
What are the symptoms of non-hemolytic transfusion reactions?
Fever, flu-like symptoms, urticaria, itching. anaphylactic rxns
What blood products can cause TRALI?
PRBCs, FFP, platelets, cryo
With what blood products does TRALI most often occur?
FFP
What is the most common cause of transfusion related deaths?
TRALI
What is TRALI?
Transfusion Related Acute Lung Injury - occurs when donor antibodies interact with recipient WBCs, causing WBCs to aggregate in the lungs
What are the effects of TRALI?
Noncardiogenic pulmonary edema, hypoxia, fever, respiratory failure
When do symptoms of TRALI begin?
1-2 hours after transfusion
What is the first thing you should do if you suspect TRALI?
Stop the transfusion
What is TACO? What blood products can cause it?
Transfusion-associated circulatory overload - all blood products can cause it
What is TRIM? What blood products can cause it?
Transfusion-related immunomodulation - PRBs and platelets
What blood products can cause microchimerism?
All
What blood products can cause post-transfusion purpura?
PRBCs and platelets
What blood products can cause transfusion-associated graft-versus-host disease?
PRBCs and platelets
What blood products can cause alloimmunization?
PRBCs
What blood products can cause iron overload?
PRBCs
What is the most common infection risk associated with blood products?
Hep B
Which blood products have the highest risk of heavy bacterial contamination because they are stored at room temperature?
Platelets
Most sepsis cases involves platelets that are more than __ days old
5
What fraction of body fluids are intracellular?
2/3
What fraction of body fluids are extracellular?
1/3
What is the ratio of blood volume to interstitial fluid?
1:2
What is the ratio of plasma to interstitial fluid?
1:4
What is the action of hydrostatic pressure in the capillaries?
Forces fluid out of the capillaries on the arterial side, less so on venous side
What is the action of oncotic pressure in the capillaries?
The pressure of the proteins pulls fluid into the capillaries
What determines the osmolality of fluid (whether it goes into cells or pulls fluid out of them)?
The Na+ content of the fluid
What fluids help keep fluid in the blood vessels longer?
Hespan, hextan (starches)
The relative percentage of body water varies with what 3 factors?
1) Age
2) Gender
3) Adiposity
What does MDLEANS stand for regarding fluid management?
- Maintenance fluid (type and rate)
- Deficit replacement
- Losses - monitor and replace
- Electrolytes
- Acid/base status
- Nutritional needs
- Special patient/procedure considerations
What are the physiologic effects from giving hypotonic NaCl?
- Increases Na+ and Cl-
- Decreases pH
- Can cause metabolic acidosis and hyperchloremia
What is the only maintenance fluid with Ca2+?
Lactated Ringer’s
Which maintenance fluid should you not mix with blood products?
Lactated Ringer’s because of the Ca2+
What is the osmolality of plasma?
290
What is the osmolality of hypertonic saline?
2,567
What is the osmolality of NS?
308
What is the osmolality of LR?
273
What is the osmolality of Plasma-lyte?
295
In what cases should you use NS for fluids?
- Neurosurgery/ICP
- When giving blood products
- If patient has high Ca2+, or low Na+/Cl-
What fluids should be avoided when the patient has cerebral edema?
Hypotonic
What fluids should be given when the patient has cerebral edema?
Hypertonic saline (3-23%) via a pump through a central line
What is the standard recommended maintenance fluid rate in ml/kg/hr?
2ml/kg/hr
What rule for maintenance fluid rate should you use in pediatrics?
4:2:1
What are the main sources of fluid deficit?
Fasting, long NPO time, bleeding, emesis, diarrhea, bowel prep
What is the estimated fluid deficit for bowel prep?
500-1500ml
What percentage of the fluid deficit should you correct in the first hour?
50% (then remaining 50% over the next 2 hrs)
What type of fluids are albumin and starches?
Colloids
Why have colloid starches (hextend, hespan) fallen out of favor?
Renal impairment
If using colloids for fluid deficits, what is the limit in ml/kg?
20ml/kg
Which fluid type (crystalloid or colloid) may be more effective in replacing intravascular losses?
Colloid
Which fluid type (crystalloid or colloid) may require more total fluid overall?
Crystalloid
Which fluid type (crystalloid or colloid) is human derived?
Colloid
Fully soaked 4 inch surgical sponges holds how much estimated blood volume?
10mL
Fully soaked 12 inch gauze laparotomy tape holds how much estimated blood volume?
100-150mL
You usually give FFP if giving equal to or more than __ units of PRBCs
4
You usually give platelets if giving more than or equal to __ units of PRBCs
6
What ratio of PRBCs to FFP should you try to maintain when giving large volumes of blood products?
1:1
How much normal saline stays in the blood vessel?
1/4
How much D5W stays in the blood vessel?
1/10
How much hypertonic NS stays in the blood?
It’s a volume expander - so it pulls fluid out of the interstitium into the blood (almost 5x infused volume)
How much albumin stays in the blood vessel?
Most of it (700ml)
Your break anesthetist wonders if your patient is “third-spacing”…what do they mean?
If fluid is shifting into the tissues/interstitial space
In what situations is third spacing most common?
- Septic patients
- Malnourished patients
- Patients with hypoalbuminemia
- More invasive surgeries (i.e. peritoneal stripping)
What is the rate of evaporation/insensible losses in ml/kg/hr?
0.5-1
What fluid should you use to replace ascites? How much?
25% albumin - 5-8 grams for every liter lost over 5 liters
After an inadvertent dose of mannitol, the urine output is 200ml/hr…what do you do?
Monitor for hypovolemia and replace as needed
The blood pressure is low and you wonder if the patient is dry…how do you assess?
- Check vitals (low BP, high HR)
- Check labs and look for a high hematocrit
- Check urine output
- Look for PPV, SPV, delta down, SVV
Is CVP known to be a good predictor of circulating blood volume or fluid responsiveness?
No, there has been no found association
Blood loss less than 15% or 0.75L is classified as what hemorrhage class?
Class I
What are the hemodynamic responses to a class I hemorrhage?
Minimal fast HR, normal BP
Blood loss ranging from __-__% is classified as hemorrhage class II
15-30% (0.75-1.5L)
What are the hemodynamic responses to a class II hemorrhage?
Fast heart rate, minimal drop in BP
What percent blood loss is classified as a class III hemorrhage?
30-40% (1.5-2L)
What are the hemodynamic responses to a class III hemorrhage?
Very fast HR, low BP, confusion
Blood loss greater than __% is classified as a class IV hemorrhage
40% (2L)
What are the hemodynamic changes during a class IV hemorrhage?
Critical blood pressure and heart rate
What labs do you assess to diagnose hypovolemia?
Lactate, base deficit, hematocrit
What lactate result would hint at hypovolemia?
Increased lactate (metabolic acidosis)
What urine output should you maintain?
0.5ml/kg/hour
What is systolic pressure variation (SPV)?
The percent change that you get in systolic pressure with each breath. With each positive pressure breath, there is a decrease in venous return, preload, and cardiac output.
What is pulse pressure variation (PPV)?
The percent change in pulse pressure with each mechanical breath
What is stroke volume variation (SVV)?
The change in stroke volume as a result of inspiration and expiration
What are the 4 requirements for using PPV and SPV to diagnose hypovolemia?
1) Must have an a-line
2) No sustained arrhythmias
3) Controlled mechanical ventilation
4) 8ml/kg tidal volume
Pulse pressure variation greater than __% indicates fluid responsiveness
10-12%
PPV less than __% indicates the patient will most likely not be fluid responsive
8%
An SPV greater than __-__ indicates fluid responsiveness
7.5-10
What extra monitors can we use to monitor fluid status?
- PVI (pleth variability index)
- PiCCo (pulse index continuous cardiac output)
- PA catheter
- TEE
- Esophageal doppler (measures flow into descending aorta and indicates cardiac output)
- Flow-track/Vigeleo
- Cheetah
When should you fluid restrict? (4)
- Liver resection (keep low CVP until resection is complete)
- Intrathoracic surgery (keep the lungs dry)
- Renal failure/dialysis
- Heart failure
When can you be liberal with your fluids? (4)
- Kidney transplant donor
- Kidney transplant recipient
- Sepsis
- Outpatient same day surgery (20-30ml/kg)
What are the benefits of being generous with fluids for outpatient same day surgery?
Decreases PONV
How much fluid should you consider for a kidney transplant recipient?
~3L crystalloid
How does stroke volume predict if a patient will be fluid responsive?
If a patient is fluid responsive, there will be a 10% or greater increase in stroke volume after a fluid bolus
According to ERAS EDM Fluid Optimization Protocol, how much crystalloid should be given during preop/induction?
No more than 500ml
According to ERAS EDM Fluid Optimization Protocol, what fluid and how much should you give to determine fluid responsiveness based on SV change?
250ml of 5% albumin over 5 minutes
According to ERAS EDM Fluid Optimization Protocol, once your patient is fluid stable, you should record SV every __ minutes
15
If your patient is undergoing an open surgery rather than lap/robot, what fluid rate should you maintain in ml/kg/hr?
4ml/kg/hr
According to ERAS EDM Fluid Optimization Protocol, a PPV greater than or equal to __% predicts fluid responsiveness
13
What should you use to avoid fluid overdose in pediatric cases?
Buretrols
What do you base pediatric dosing of fluids and blood products off of?
Weight
What fluid requires a vented spike adaptor?
Albumin and any other glass bottles
When should 0.9% NaCl be used as a maintenance fluid?
Neurosurgery
What do you assess during preop to estimate fluid deficit?
- H&P
- NPO time
What are the additional surgical fluid requirements for a minimally traumatic surgery such as a hemiorrhaphy?
0-2ml/kg
What are the additional surgical fluid requirements for a moderately traumatic surgery such as a cholecystectomy?
2-4ml/kg
What are the additional surgical fluid requirements for a severely traumatic surgery such as a bowel resection?
4-8ml/kg
What is an acid?
Any substance that acts as a H+ donor
What type of acids are HCl, H2SO4, and H3PO4?
Strong
What type of acids are H2CO3 and CH3COOH?
Weak
What is a base?
Any substance that acts as a proton recipient
What kind of bases are NaOH and KOH?
Strong
What type of bases are NaHCO3 (bicarb), NH3, and CH3COONa?
Weak
What is pH?
The negative decimal logarithm of the H+ concentration
How do you calculate pH?
-log[H+]
What is the normal pH range for blood?
7.35-7.45
How many moles of CO2 does the human basal metabolism produce per day?
13
Which types of acids and bases can easily dissociate?
Weak
What buffer system is more efficient in treating acid load due to a low pKa content?
Bicarbonate
Which protein buffer systems are negatively charged and can accept a proton?
Aspartic and Glutamic acid
Which protein buffer systems are positively charged?
Asparagine, Histidine, Lysine
What is the pKa of the phosphate buffer process?
7.21
Where is phosphate a major buffer?
Intracellular environment
Hemoglobin is rich with what protein buffer?
Histidine
What is the pKa of hemoglobin?
6.8
What is the second most important plasma buffer after bicarb?
Hemoglobin
What buffer system is most important in chronic metabolic acidosis?
Bone buffering system
Which acid/base disorders involve CO2?
Respiratory
Which acid/base disorders involve all body acids except CO2?
Metabolic
What is the anion gap?
Difference between the sum of major cation and anions
How do you calculate the anion gap?
Na+ - (Cl- + HCO3-)
What is the normal anion gap?
8-12mmol/L
What 3 values from the ABG do you assess to diagnose acid/base disorder?
pH, pCO2, HCO3
What 4 serum electrolyte values do you assess to diagnose acid/base disorder?
Na+, K+, Cl-, CO2
What do you add to the anion gap in order to diagnose acid/base disorders?
(4-albumin level) x 2.5
How do you calculate the expected compensatory drop in CO2 when HCO3 drops?
(24-patient’s bicarb) x 1.2
If a patient’s bicarb is 16, what is the expected compensatory drop in CO2?
(24-16) x 1.2=9.6
If a patient has a pH of 7.31, a bicarb of 16, and a pCO2 of 33 - what is their acid/base disorder
- pH is acidic
- bicarb is decreased (normal value is 24)
- pCO2 is decreased (normal value is 40)
- Since both bicarb and pCO2 is decreased, the patient has metabolic acidosis (with respiratory compensation since the CO2 dropped by the appropriate amount)
How do you calculate the expected compensatory rise in CO2 when a patient has metabolic alkalosis?
(Patient’s value of bicarb - 24) x 0.7 = expected rise in CO2
A beauty queen has numbness in extremities and unsteadiness - her lab values show a pH of 7.55, pCO2 50, and HCO3 of 41 - what is her diagnosed acid/base disorder?
- pH is alkalotic
- pCO2 is slightly high
- bicarb is high
-both pCO2 and bicarb is increased, she has metabolic alkalosis
If your CO2 and HCO3 levels both increase, you could have which 2 disorders?
- Respiratory acidosis (increase CO2)
- Metabolic alkalosis (increase HCO3)
If your CO2 and HCO3 levels both decrease, you could have which 2 disorders?
- Respiratory alkalosis (decreased CO2)
- Metabolic acidosis (decrease HCO3)
What is the normal baseline bicarb level used to estimate the adequate compensation?
24
What is the normal CO2 level used to estimate adequate compensation?
40
What molecule is the main constituent of the anion gap?
Albumin
A malnourished patient has an albumin level below what?
4g/dL
What does the mnemonic MUD PILES stand for?
M- methanol U- uremia D - diabetic ketoacidosis P - propylene glycol I - isoniazid iron L - lactate E - ethanol S - salicylate
What do you use MUD PILES for?
To help diagnose gap metabolic acidosis
What renal changes can cause non-gap metabolic acidosis?
- Renal tubular acidosis
- Carbonic anhydrase inhibitor diuretics
What GI problems can cause non-gap metabolic acidosis?
- Severe diarrhea
- Uretero-enterostomy or obstructed ileal conduit
- Drainage of pancreatic or biliary secretions
- Small bowel fistula
The addition of what compounds to the body can cause non-gap metabolic acidosis
HCl, NH4Cl
What 3 things can cause metabolic alkalosis by adding base to extracellular fluid?
- Milk-alkali syndrome
- Excess NaHCO3 intake
- Massive blood transfusion (citrate)
What 2 things can cause metabolic alkalosis via chloride depletion?
- Loss of acidic gastric juice
- Diuretics
What 4 things can cause metabolic alkalosis due to potassium depletion?
- Hyperaldosteronism
- Cushing’s syndrome
- Kaliuretic diuretics
- Excessive licorice intake (glycyrrhizic acid)
What device used in surgery can cause metabolic alkalosis due to chloride depletion?
NG suction
What diuretics can cause metabolic alkalosis due to chloride depletion?
- Furosemide
- Thiazides
What causes psuedohyperaldosteronism?
Increased cortisol levels exhibiting a mineralocorticoid effect
What causes hyperaldosteronism?
Increased Na+ reabsorption in the distal tubule and increased loss of K+ and H+
What can cause respiratory acidosis due to impaired elimination?
- CNS depression (opiates, anesthetics, CNS trauma, hypoventilation, obesity)
- Nerve/muscle disorders (myasthenia gravis, muscle relaxants)
- Mechanical (pneumothorax, RLD, aspiration, upper airway obstruction, laryngospasm, asthma)
What can cause respiratory acidosis due to overproduction?
- Hypermetabolic disorders (MH, fever)
- Increased intake (rebreathing, absorption from laparoscopy)
What acid/base disorder is caused by hypoxemia?
Respiratory alkalosis
What central causes can cause respiratory alkalosis?
- Injury
- Stroke
- Anxiety hyperventilation
- Pain/fear/stress
- Analeptics, salicylate
- Progesterone during pregnancy
- Cytokines during sepsis
What pulmonary causes can cause respiratory alkalosis?
- PE
- Pneumonia
- Asthma
- Pulmonary edema
How do central causes cause resp. alkalosis?
Directly via respiratory center
How do pulmonary causes cause resp. alkalosis?
Via intrapulmonary receptors
What iatrogenic factors can cause resp. alkalosis?
Excessive controlled ventilation
A compensatory mechanism will never do what?
Overcorrect pH
How does the body compensate for respiratory acidosis?
Increase pH, increase bicarb - pCO2 unchanged
How does the body compensate for metabolic acidosis?
Increase pH, decrease pCO2 - bicarb unchanged
Name the possible disorders based on these lab results: pH 7.2 pCO2 39 pO2 27 HCO3 14.9
Uncompensated metabolic acidosis or respiratory and metabolic acidosis
If the anion gap is elevated, what acid/base disorder should you look for?
Metabolic acidosis
An intubated patient has a pH of 7.56, pCO2 of 23, and an HCO3 of 21. What is his acid/base disorder?
- pH is alkalotic
- co2 is decreased
- bicarb is decreased
-Since Co2 and bicarb both decreased, the patient has respiratory alkalosis
How do you calculate the expected compensatory drop in HCO3 when a patient has respiratory alkalosis?
(40-the patient’s CO2)/10 x 2
An intubated patient has a pH of 7.56, pCO2 of 23, and an HCO3 of 21. He has respiratory alkalosis, what is his expected compensatory HCO3 drop?
(40-23)/10 x 2 = 3.4
A homeless man presents with N/V an poor oral intake, His Na is 132, Cl 104, HCo3 16, albumin 1.0. Since he is malnourished, what acid/base problem might you expect?
A gap disorder
A homeless man presents with N/V an poor oral intake, His Na is 132, Cl 104, HCo3 16, albumin 1.0. What is his corrected acid/base gap?
132 - (104-16) = 12
Albumin correction 2.5 * (4-1) = 7.5
Corrected gap = 12 + 7.5 = 19.5
Patients taking thiazide or K+ sparing diuretics would most likely have which acid/base disorder?
Metabolic alkalosis
Patients with myasthenia gravis would most likely have which acid/base disorder?
Respiratory acidosis
Patients with asthma or pneumonia would most likely have which acid/base disorder?
Respiratory alkalosis
Pregnant patients would most likely have which acid/base disorder?
Respiratory alkalosis
Patients who are stressed, in pain, or highly anxious would most likely have which acid/base disorder?
Respiratory alkalosis
Patients with a small bowel fistula would most likely have which acid/base disorder?
Metabolic acidosis
Patients on carbonic anhydrase inhibitor would most likely have which acid/base disorder?
Metabolic acidosis
Which with acid/base disorder do you take into account the anion gap?
Metabolic acidosis
What is hemostasis?
Physiological process that balances the opposing forces of coagulation and anticoagulation to protect the vasculature from uncontrolled bleeding on the one hand and excessive clotting on the other
What occurs during primary hemostasis?
Formation of a platelet plug
What occurs during secondary hemostasis?
Coagulation
What occurs during tertiary hemostasis?
Fibrinolysis
What are the 3 steps to the formation of a platelet plug?
- Platelet adhesion
- Platelet activation
- Platelet aggregation
What is von Willebrand factor?
A glycoprotein
Von willebrand factor protects which coagulation factor from rapid inactivation?
Factor VIII
What makes vWF bind to platelets?
Change in shear rate
What 2 molecules contribute to platelet adhesion?
- vWF
2. Collagen
What is the most common congenital bleeding disorder?
Von willebrand’s disease
What is von willebrand’s disease?
A deficiency in vWF that manifests as impaired platelet function
What is the treatment for vWF disease?
DDAVP or transfusion of FFP, cryo, or vWF/FVIII concentration
What occurs during platelet activation?
Platelets become activated by agonists at the site of the injury
What 4 agonists activate platelets? (CATE)
- Collagen
- ADP
- Thrombin
- Epinephrine
During platelet activation, they change morphology and release contents of which granules?
Alpha granules and dense granules
What substance is released by platelet activation and synthesized in the cytosol?
Thromboxane A2
What is expressed on the surface membrane of platelets after activation?
New negatively-charged receptors
What part of primary hemostasis does aspirin block?
Platelet aggregation
What molecules bind to the surface receptors of platelets after activation?
Fibrinogen
ADP
Thrombin
What platelet surface receptor mediates platelet aggregation?
Glycoprotein IIb/IIIa
What are the primary adhesive molecules of platelet aggregation?
Fibrinogen, vWF
What do the adhesive molecules on platelets do?
Form bridges between platelets to create a platelet plug
What factor is the fibrin stabilizing factor?
Factor XIII
What adhesive molecule does aspirin effect?
Aspirin acetylates fibrinogen which loosens the clot structure and makes it easier to lyse (the reason aspirin increases bleeding)
What are coagulation factors?
Plasma proteins involved in the coagulation cascade
Where are most coagulation factors synthesized?
In the liver
What are the contact activation factors?
Factors XII and XI
What are the vitamin K-dependent factors?
Factors II, VII, IX, and X
What is the only factor that has an extra-hepatic origin?
Factor VIII
What are the 2 functions of factor VIII?
The higher weight portion serves as a CARRIER and the smaller weight portion serves for COAGULANT ACTIVITY
What component of a factor makes it possible to bind calcium?
Vitamin K
What drug inhibits the carboxylation of the vitamin K-dependent factors?
Coumadin
Which vitamin K-dependent factor has the shortest half life?
Factor VII
What disease is caused by a deficiency of factor VIII?
Hemophilia A
What disease is caused by a deficiency of factor IX?
Hemophilia B
Which molecule cleaves fibrinogen into fibrin and activates platelets and many clotting factors?
Thrombin
What molecule stimulates epithelial cells to produce TF and vWF?
Thrombin
What molecule stimulates subendothelial smooth muscle constriction?
Thrombin
What are the 3 overlapping stages in the cell-based model of coagulation?
- Initiation
- Amplification
- Propagation
What occurs during initiation in the cell-based model of coagulation?
A procoagulant stimulus generates enough thrombin to initiate the coagulation process
What occurs during amplification in the cell-based model of coagulation?
Platelets and coagulation factors are activated
What occurs during propagation in the cell-based model of coagulation?
Large amounts of thrombin are generated on the activated platelet surface
What is the primary anticoagulant action of heparin?
To inhibit thrombin activity
What does heparin bind to?
Antithrombin - turns it from a slow to a rapid inhibitor of thrombin
What are the 3 quantitative age-related coagulation differences?
1) Vitamin K dependent factors
2) Contact activation factors
3) Coagulation inhibitors
What are the 3 qualitative age-related coagulation differences?
1) Platelet
2) Fibrinogen
3) Plasminogen
Neonates have low levels of which factor groups?
Procoagulant and anticoagulant factors
Neonates have __% of the contents in platelet dense granules that adults have
50%
Why do neonates have less fibrinolytic activity?
They have both quantitative and qualitative deficiencies in plasminogen
What are the FDA approved uses of recombinant activated Factor VII?
- Patients with Hemophilia A and B
- Patients with congenital Factor VII deficiency
What is one of the main off-label uses of recombinant activated factor VII?
Post-cardiopulmonary bypass
What is blunt trauma?
Impact without broken skin
What is penetrating trauma?
Object pierces skin and enters the body creating a wound
When does death most often occur following an injury?
The first 1-2 hrs
What are the ABCDEs of the primary survey of a trauma?
- Airway maintenance with c-spine protection
- Breathing and ventilation
- Circulation and hemorrhage control
- Disability/neurologic assessment
- Exposure and environmental control
A C-collar indicates that there are no bony problems, but it does not rule out what airway issue?
Soft tissue damage
A C-collar normally decreases the airway grade view by what?
1
What are the full stomach considerations for trauma?
All traumas are considered full stomach
What induction drug can maintain blood pressure in severely hypovolemic patients?
Ketamine
What induction drug is contraindicated in traumatic brain injury?
Ketamine because it may increase intracranial pressure
What induction drug can produce sedation without respiratory depression?
Ketamine
Ketamine is a direct _______ depressant
Myocardial
Which induction drug may be particularly useful in traumatic brain injury cases?
Etomidate
Which induction drug inhibits the secretion of cortisol?
Etomidate
During the primary survey of a trauma patient’s breathing and circulation, what injuries should you be looking for?
- Open or tension pneumothorax
- Massive hemothorax
- Cardiac tamponade
- Flail chest
What IV access should be obtained on trauma patients?
2 peripheral IVs 16g or bigger, or central access
Injuries to which areas produce the most bleeding and can cause hypovolemic shock?
- Thoracic cavity
- Abdominal cavity
- Pelvis
- Long bones
- External bleeding
What fluids should be used for circulation and hemorrhage control?
2 liters warm isotonic fluid, then blood if they don’t respond to the fluid
What types of shock should you assess for in trauma patients?
Cardiogenic, neurogenic, and hypovolemic
What drugs do you NOT use to maintain circulation in patients with hypovolemic shock?
Pressors
If a patient has a GCS less than __, intubate
8
What scale assesses disability and neurologic function in trauma patients?
Glasgow Coma Scale
If intubated, what is the max GCS score a patient can have?
10
The Glasgow Coma Scale is made up of what 3 components?
Eye response, verbal response, motor response
What are the best places to measure temperature in trauma patients?
Bladder or esophagus
What is a FAST test?
Focused Abdominal Sonogram for Trauma
What is FAST?
A quick 4 point ultrasound of the chest to determine why the patient needs to go to the OR (to fix the problem to to diagnose it)
What are the advantages of FAST?
- Faster and cheaper than CT
- No need for transport
- No ionizing radiation
- Easy to repeat
What position should a patient be in for a FAST test?
Supine
What are the 4 transducer positions for a FAST tesT?
- Pericardial
- Right upper quadrant (Morrison’s Pouch)
- Left upper quadrant
- Pelvis
How can you tell on an ultrasound that a patient is going to tamponade?
There is fluid between the pericardial sac and the heart
If a patient with a penetrating thoracic injury has a positive ECHO, where do they go?
OR
If a patient with a penetrating thoracic injury has a negative ECHO, how should you proceed?
Observe patient
What echo result tells us there is a pericardial window for patients with a penetrating thoracic injury?
Equivocal
If a patient with blunt abdominal trauma has a positive or equivocal FAST and they are stable, what is the next step?
CT scan
If a patient with blunt abdominal trauma has a positive FAST and they are unstable, what is the next step?
Go to OR
If a patient with blunt abdominal trauma has an equivocal FAST and they are unstable, what is the next step?
Diagnostic peritoneal lavage (DPL) or go to OR
If a patient with blunt abdominal trauma has a negative FAST, what is the next step?
Repeat ultrasound
What is a diagnostic peritoneal lavage (DPL)?
Instilling 1L of normal saline into a small infraumbilical incision and allow to drain by gravity
How much return do you need for an accurate DPL interpretation?
200-300mL
What results lead to a positive DPL interpretation?
- 100,000 RBCs/microliter
- 500 WBCs/microliter
- 175 units amylase
- bacteria
- bile
- food particles
What results lead to an intermediate DPL interpretation?
- Pink fluid on free aspiration
- 50,000-100,000 RBCs in blunt trauma
- 100-500WBCs
- 75-175 units amylase
What results lead to a negative DPL interpretation?
- Clear aspirate
- Less than 100 WBCs
- Less than 75 units amylase
What patients need damage control resuscitation?
Patients who are more likely to die from an uncorrected state of shock than from failure to complete organ repairs
Patients with a temperature below __ celsius need damage control resuscitation
35
Patients with a pH below __ need damage control resuscitation
7.2
Patients with a base deficit greater than ___ need damage control resuscitation
-15
What blood products are includes in Package 1 of the Massive Transfusion Protocol?
6 PRBCs 6 FFP
What blood products are includes in Packages 2, 4, and 6 of the Massive Transfusion Protocol?
6 PRBCs 6 FFP 1 platelet
What blood products are includes in Packages 3 and 5 of the Massive Transfusion Protocol?
6 PRBCs 6FFP 10 Cryo
Why is there a black box warning on NovoSeven (recombinant factor VII)?
Thrombotic events
When is NovoSeven automatically approved?
After package 3, may repeat once
Tranexamic acid needs to be started within __ hours of surgery
3
A 24 year old patient is brought to the operating room one hour after motor vehicle accident. He has a C7 spinal cord transection and ruptured spleen. Regarding his neurologic injury, anesthetic concerns include:
A. Risk of hyperkalemia with succinylcholine administration
B. Risk of autonomic hyperreflexia with urinary catheterization
C. Need for fiberoptic intubation
D. Increased risk of hypothermia
E. All of the above
D. Increased risk of hypothermia
A risk of hyperkalemia with sux administration occurs at least __ hours after injury
24
The risk of autonomic hyperreflexia does not occur until how long after injury?
Weeks to years
True or False - There is evidence that awake fiberoptic intubation is superior to direct laryngoscopy so long as manual in-line stabilization is used.
False
Where do trauma patients lack thermoregulation?
Below the level of the spinal cord injury
How many people does it take for manual in-line stabilization? What are their jobs?
3
- One performs DL
- One holds head to prevent neck movement
- One holds cricoid pressure
An 18 year old male involved in a car accident has a cord injury at C5. His signs and symptoms include parathesias, motor weakness, a tender abdomen with equivocal tap for blood, and a femur fracture. Initial ABG shows pH 7.4, pCO2 42, and PO2 96. Over the next two hours, his weakness worsens, he is agitated, and repeat ABG shows pH 7.32, pCO2 49, and PO2 79. At this time appropriate management is to:
A. observe for another hour and reevaluate
B. intubate and ventilate
C. administer anxiolytics while cautiously withholding opioids
D. obtain an immediate chest film and evaluate it before making a decision
E. increase oxygen delivery by mask
B. Intubate and ventilate
An 18 year old male involved in a car accident has a cord injury at C5. His signs and symptoms include parathesias, motor weakness, a tender abdomen with equivocal tap for blood, and a femur fracture. Initial ABG shows pH 7.4, pCO2 42, and PO2 96. Over the next two hours, his weakness worsens, he is agitated, and repeat ABG shows pH 7.32, pCO2 49, and PO2 79. His respiratory changes may be caused by all of the following EXCEPT:
A. Hypoventilation due to cord injury
B. Hypoventilation due to upper abdominal injury
C. Fat embolus
D. Respiratory depression secondary to oxygen administration
E. Pulmonary contusion
D. Respiratory depression secondary to oxygen administration - he does not function on hypoxic drive (that’s more of a late stage COPD symptom), so supplemental O2 shouldn’t cause respiratory depression
An 18 year old male involved in a car accident has a cord injury at C5. His signs and symptoms include parathesias, motor weakness, a tender abdomen with equivocal tap for blood, and a femur fracture. This patient would be a prime candidate for respiratory failure even in the absence of a leg fracture because:
A. He has a decreased ability to cough.
B. His lesions is high enough to predispose to aspiration.
C. His treatment may lead to pulmonary oxygen toxicity.
D. He may have blood loss from his other injuries.
E. He is being kept supine for evaluation.
A. He has decreased ability to cough
True or False - A spinal cord lesion is not high enough to impair gag reflex from the glossopharyngeal nerve.
True
A 35 year old man is in the ER after a car accident. There is a contusion over the anterior thorax, he is tachypneic, and has a scaphoid abdomen. Auscultation reveals poor breaths sounds on the left. Chest x-ray shows a large air cavity in the left side. Blood pressure is 80/60 and HR is 120. Diagnoses to consider include:
A. Ruptured spleen B. Pneumothorax C. Diaphragmatic hernia D. Cardiac contusion E. All of the above
E. All of the above
What sign on a patient indicates a high velocity motor vehicle accident and can be a sign of serious underlying abdominal or chest trauma?
Seat belt sign (red mark diagonal across chest)
A diagnosis of diaphragmatic hernia is made and the patient is transported to the OR. In transport, the patient becomes apneic and is ventilated with an Ambu bag. One could expect:
A. The patient’s blood pressure to fall. B. Pulmonary compliance to decrease. C. A shift of the mediastinum D. The abdomen to become distended. E. All of the above.
E. All of the abouve
Management of the airway during induction of general anesthesia in a patient in a halo brace for non-displaced fracture of C6 incurred in a high-speed motor vehicle accident includes all of the following except:
A. Assessment of other facial injuries
B. Awake fiberoptic intubation
C. Adequate anesthesia of the trachea
D. Removal of the cervical brace for intubation
D. Removal of the cervical brace for intubation
What is required during awake intubation to prevent coughing?
Adequate anesthesia of the trachea
What is a halo used for?
To maintain complete immobility for patients with an unstable spine
During a thoracotomy, a patient becomes progressively more hypotensive after the tenth unit of blood is given within fifteen minutes. The surgeon states he has gotten the bleeding under control and that the heart feels full. Bolus doses of phenylephrine are having minimal effect. What drug will likely have the greatest effect in improving this patient’s blood pressure?
A. Potassium chloride B. Magnesium sulfate C. Calcium chloride D. Atropine E. Methylene blue
C. Calcium chloride because stored blood can cause hypocalcemia and hypotension when given faster than 1 unit/5mins
Why might stored blood potassium chloride cause hyperkalemia when transfused?
It may have lysed erythrocytes
Why might magnesium sulfate cause hypotension when transfusion?
It causes smooth muscle relaxation
In an emergency when there is a limited supply of type O-negative RBCs, type O-positive RBCs are reasonable for transfusion for each of the following patients except:
A. 60 yr old woman with diabetes involved in a car accident
B. 23 yr old man who sustained a gunshot wound to the abdomen
C. 84 yr old man with a ruptured abdominal aortic aneurysm
D. 5 yr old boy in a peds vs auto accident
E. 21 yr old G2P1 with s/p car accident with placental abruption
E. 21 year old G2P1 with placental abruption
When there is a shortage of type O negative blood cells, they should be prioritized for which patients?
Women of childbearing age
Upon Identification of a Tension Pneumothorax, which is the correct management pathway?
A. A chest X-ray to confirm the clinical diagnosis.
B. Insertion of a chest drain in the 5th intercostal interspace in mid-axillary line.
C. Immediate decompression with a 14g 5cm needle in the 2nd intercostal interspace in mid-clavicular line.
D. An ECG to assess for concurrent cardiac contusion.
E. Completion of a secondary survey to exclude any concurrent injury
C. Immediate decompression with a 14g 5cm needle in the 2nd intercostal interspace in mid-clavicular line.
What is shock?
Tissue hypoxia due to reduced O2 delivery, increased O2 consumption, and inadequate utilization
What are the signs of shock?
- Decreased mentation
- Capillary filling time longer than 2 seconds
- Decreased urine
- Lactic acidosis
- Low mixed venous O2 saturation
- End organ dysfunction
What is the range for normal cardiac index?
2.2-2.5
How do you calculate cardiac index?
Cardiac output x BSA
What 3 classes of drugs do we use to manipulate SVR?
1) Alpha adrenergic
2) Calcium
3) Vasopressin
What 3 classes of drugs do we use to manipulate PVR?
1) Prostaglandin
2) Nitric oxide
3) Milrinone (a phosphodiesterase inhibitor)
What 2 classes of drugs do we use to manipulate HR pharmacologically?
1) Antimuscarinics
2) Beta 1 adrenergics
How can we electrically manipulate heart rate?
Pacing - atrial, ventricular, or both
What Beta-1 adrenergic drugs can we use to manipulate ejection fraction?
Epinephrine, Dobutamine
What phosphodiesterase inhibitors can we use to manipulate ejection fraction?
Milrinone/amrinone
What is left ventricular end diastolic volume governed by?
Right ventricular cardiac output
What is atrial kick?
The priming force contributed by atrial contraction immediately before ventricular systole that acts to increase the efficiency of ventricular ejection due to acutely increased preload
Veins constitute what percentage of blood volume?
70%
Veins are __x more compliant that arterial systems
30x
Under what rhythm is atrial kick lost?
A-fib
One can use volume boluses to estimate what volume?
Right ventricular ejection fraction
What are the symptoms of acute coronary syndromes?
Chest pain, SOB, lightheadedness, nausea, sweating
What are the signs of acute coronary syndromes?
- ST elevation
- Troponinaemia
- Regional wall motion abnormality
What are the risk factors of acute coronary syndromes?
- Smoking
- HTN
- HLP
- DM
- No exercise
- Obesity
- Family hx
What are ways to manage acute coronary syndromes?
- Optimize oxygen delivery
- Manage pain
- Tests and investigations
- Manage shock
- Prevent clots
- Definitive treatment
What drug can you use to optimize oxygen delivery during management of ACS?
Nitroglycerine
What tests should you run during management of a patient with ACS?
Basic labs, troponin every 8 hours, TTE
How can you manage shock in patients with ACS?
Vasopressors, intra-aortic balloon pump
What drugs can you use to prevent clot propagation in patients with ACS?
Aspirin and heparin
What are the definitive treatments for ACS?
Cathlab, CABG
What is the oxygen delivery equation?
CO x CaO2 x 10
What is the oxygen content equation?
(Hb x 1.39 x SaO2) + PaO2*0.003
What is the alveolar gas equation?
PaO2=FiO2 (Patm-Ph2o) - PaCO2/RQ
What is your PaO2 on room air?
100
How do you calculate the P/F ratio?
PaO2/FiO2
What is the normal P/F ratio on room air?
500
What tidal volumes should you give to patients with ARDS?
6cc/kg of IBW
For management of ARDS, wean FiO2 and PEEP for a sat above what?
92%
For management of ARDS, keep RR under what?
35
For management of ARDS, you should treat pH with buffers once the pH is below what level?
7.2
What is the PaO2 in patients with a sat of 90%?
60
Why might you need to ventilate with high pressures for a patient with ARDS?
Their lung compliance is low (~10-15cmH2O)
What techniques can you use to improve oxygenation for patients with ARDS?
- Turn prone
- Neuromuscular blockade
- Advanced vent modes
What is fluid responsiveness?
The prediction that cardiac output will be augmented by fluid administration
Overall mortality is increased when patients gain over __% of their body weight during surgery as a result of fluids
20%
If your heart stops for a short period of time, what is your blood pressure?
35mmhg
What pressure is the driving force for all venous return to the heart?
Mean capillary filling pressure
MCFP is usually __mmHg above CVP
1
What is the purpose of the passive leg raise?
To determine if the patient needs further fluid resuscitation
How do you use the passive leg raise test to measure fluid responsiveness?
- Measure the patients blood pressure while they are laying with their head up at a 45 degree angle
- Flip the bed so their legs are raised and measure the blood pressure again
- If BP goes up, the patient needs further fluid resuscitation
- If BP does not change, that indicates the patients heart cannot handle the extra fluid and they need no more
What receptors are affected by norepinephrine?
- Large effect alpha receptors to affect afterload
- Small effect on beta to affect rate
Does vasopressin have any effect on HR?
No
What aspect of the heart is affected by milrinone?
Contractility
What aspect of the heart is affected by dobutamine?
Heart rate (B1 and B2)
What is the only ventilation strategy that has improved outcomes in patients with ARDS?
Lung protective ventilation (6cc/kg) with mild permissive hypercapnia
Pre-operative autologous donation can only be done if the baseline hemoglobin is over what value?
11.5
What is the max donation allowable for pre-operative autologous donation?
10.5ml/kg
The last pre-operative autologous donation must have occur over __ hours before surgery.
72
What are the benefits of pre-up autologous donation?
Avoid adverse reactions to PRBCs and lower risk of infection
What are the drawbacks of pre-op autologous donation?
Perioperative anemia and pre-op MI
Vitamin K deficiency can affect what lab value?
PT - it can increase PT time because the time for the blood to clot will increase
What are the 4 major mechanisms the body uses to steady its pH?
1) Buffering
2) Respiratory
3) Renal
4) Bone
Which pH steadying mechanism provides a rapid response to the pH disturbance to temporize the problem?
Respiratory
Which pH steadying mechanism deals with the ultimate excretion or reabsorption of acids and bases?
Renal
Which pH steadying mechanism as fast and slow response systems built in to store and release needed elements?
Bone
What is the main symptom of delayed hemolytic transfusion reactions?
Decreased hemoglobin
