Fluid/Blood Replacement

Question 1

What is the difference between hypovolemia and

dehydration?

Answer 1

Hypovolemia describes the loss of extracellular fluid.
Dehydration is a disorder of electrolyte concentration in which
there is not enough water relative to the sodium level.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 383.

Question 2

Why are isotonic crystalloids the fluid of choice for

most cases of hypovolemia?

Answer 2

Most cases of hypovolemia (including blood loss) are isotonic
losses of extracellular fluid. Thus, the most appropriate
replacement solution in most cases is an isotonic crystalloid.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 384.

Question 3

What is the intravascular half-life of intravenous

crystalloids?

Answer 3

Crystalloid solutions remain in the circulation for about 20-30
minutes.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1165.

Question 4

What is the treatment of choice for hyponatremia in a patient with low total body sodium?

Answer 4

In patients with a decreased total body sodium content and
hyponatremia, the treatment of choice is 0.9% saline. In
patients with hyponatremia and a normal or elevated total body
sodium content, the treatment of choice is water restriction.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1117-1118.

Question 5

Rank the hypertonic crystalloids D5NS, D51/2NS,
3% Saline, 7.5% NaHCO3, and D5LR from least to
greatest according to their tonicity.

Answer 5

D51/2NS (432 mOsm/L), D5LR (525 mOsm/L), D5NS (586
mOsm/L), 3% Saline (1026 mOsm/L), and 7.5% NaHCO3 (1786
mOsm/L)
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1164.

Question 6

How will large volumes of normal saline affect pH

and electrolyte balance?

Answer 6

Normal saline contains 154 mEq/L of both sodium and chloride.
Because the body’s bicarbonate concentration decreases as
chloride increases, large volumes of saline can produce
dilutional hyperchloremic acidosis.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1165.

Question 7

What is the electrolyte composition of Plasmalyte

solution?

Answer 7

Na: 140 mEq/L, Cl: 98 mEq/L, K: 5 mEq/L, Mg: 3 mEq/L,
Acetate: 27 mEq/L, Gluconate: 23 mEq/L
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1164.

Question 8

What is the glucose content of D5W?

Answer 8

50 grams/liter
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1164.

Question 9

Name four crystalloid solutions considered to be

isotonic.

Answer 9

Normal saline (308 mOsm/L), D51/4NS (355 mOsm/L),
Lactated Ringer’s solution (273 mOsm/L), and Plasmalyte (295
mOsm/L)
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1164.

Question 10

Name three hypotonic crystalloid solutions

Answer 10

D5W (253 mOsm/L), 1/2 NS (154 mOsm/L), and 1/4 NS (77
mOsm/L)
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1164.

Question 11

As a percent of body weight, how much fluid loss
would you estimate a patient to have lost if they
exhibit an orthostatic increase in heart rate by 15
bpm and decrease in blood pressure by 10 mmHg?

Answer 11

When patients begin to exhibit increases in heart rate by 15
bpm and a decrease in blood pressure by 10 mmHg when
moving from lying to sitting, you can estimate that they have lost
15% of their body weight in fluid.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1162.

Question 12

What are the pulmonary and radiographic signs of

hypervolemia?

Answer 12

Pitting edema, increased urine flow (if renal and cardiac
function is normal), tachycardia, pulmonary crackles, pink frothy
secretions, wheezing, and cyanosis are all signs of fluid volume
overload. Prominent pulmonary vascular and interstitial
markings known as Kerly “B” lines are radiographic signs of
hypervolemia.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1162-1163.

Question 13

What are the laboratory signs of dehydration?

Answer 13

Rising hematocrit (due to concentration of cells in the vascular
space), metabolic acidosis, a urine specific gravity greater than
1.010, BUN:creatinine ratio that exceeds 10:1, hypernatremia,
urine sodium less than 10 mEq/L, and a urine osmolarity
greater than 450 mOsm/Kg.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1162-1163.

Question 14

Is cross-matching performed on fresh frozen

plasma? Why or why not?

Answer 14

No, fresh frozen plasma (FFP) is evaluated for atypical
antibodies and should be the same type as the patient. Crossmatching
however, is not necessary. Rh typing is not always
matched because an immune response to the Rh antigen has
rarely been seen as a result of the transfusion of FFP.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1443.

Question 15

What are the indications for administration of

unmatched blood?

Answer 15

If a patient is exsanguinating and their blood type is known,
then an abbreviated crossmatch (that typically takes less than 5
minutes) may be performed. If there is not time to perform any
testing, then Type O Rh-negative blood may be administered.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1170.

Question 16

What is the incidence of nonhemolytic transfusion

reactions and what are the most common symptoms?

Answer 16

Nonhemolytic transfusion reactions occur in about 1-5% of all
transfusions. The patient typically exhibits symptoms such as
fever, urticaria, and chills.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 398.

Question 17

What are the signs and symptoms of a hemolytic

transfusion reaction?

Answer 17

Fever, chills, nausea, vomiting, diarrhea, hypotension, and
tachycardia. The histamine response may result in flushing and
bronchospasm. Cytokine release may result in chest and back
pain. The patient may also develop hemoglobinuria. As many
of these signs are masked during anesthesia, hypotension and
signs of microvascular bleeding may be the only symptoms
evident.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 426.

Question 18

What are the primary reasons that blood products
should be warmed when administered in large
quantities?

Answer 18

One unit of PRBCs at 4 degrees Celsius will drop the core
temperature of a 70 Kg patient by about 0.25 degrees Celsius.
Administering large quantities of cold blood products can
produce hypothermia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 429.

Question 19

How does the administration of stored blood affect

the recipient’s oxygen delivery mechanism?

Answer 19

The storage of blood is associated with a progressive decrease
in adenosine triphosphate (ATP) and 2,3 DPG levels. This
results in a leftward shift in the oxyhemoglobin dissociation
curve in the red blood cells. Even though the administration of
hemoglobin will increase the ability of the blood to transport
oxygen, the longer the blood is stored and the more of it that is
given, the more the patient’s oxyhemoglobin dissociation curve
shifts to the left, thereby decreasing the effectiveness of the
blood given.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia,

Question 20

How much blood will a full-soaked 4X4 sponge hold?

Answer 20

10 mL
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1167.

Question 21

Why are packed red blood cells mixed with a
combination of dextrose and adenine (Nutricell or AS-
3) or a combination of dextrose, adenine, and
mannitol (Adsol or AS-1)?

Answer 21

Packed red blood cells are mixed with about 100 mL of either
combination which extends the shelf-life of the blood to 42 days
and gives the fluid flow properties similar to that of whole blood.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1439.

Question 22

Which presents the greatest risk of transfusionrelated

infection, HIV, Hepatitis B, or Hepatitis C?

Answer 22

Hepatitis B carries the greatest risk with an incidence of about 1
in 205,000 per unit administered. Hepatitis C carries an
incidence between 1:1,935,000 and 1:3,100,000. No new HUV
infections have been attributed to screened blood products
since the 1980s.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1448.

Question 23

How can infusions of large amounts of banked blood
administration affect the patient’s ionized calcium
level?

Answer 23

Banked blood contains an anticoagulant containing sodium
citrate which binds to calcium in the bloodstream. As a result,
the administration of large quantities of banked blood can result
in sharp decreases in the patient’s ionized calcium level.
Normally, however, a healthy, normothermic patient can
metabolize the amount of citrate found in 20 units of blood per
hour.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 397.

Question 24

What immunoglobulin is primarily responsible for the

antibodies associated with a transfusion reaction?

Answer 24

The antibodies produced against a blood type that does not
match the recipient’s are primarily IgM antibodies.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1169.

Question 25

With regards to blood product administration, what is

leukocyte reduction and why would it be performed?

Answer 25

Leukoreduction is the reduction of white blood cells in
transfused blood through the use of filters. It is performed to
reduce the incidence of nonhemolytic transfusion reactions.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 398-399.

Question 26

How much of an increase in hemoglobin and
hematocrit would you expect to see after
administering a unit of packed RBCs?

Answer 26

In general, each unit of PRBCs elevates the hematocrit by 2-3%
and the hemoglobin by 1 mg/dL.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 396.

Question 27

What blood antibodies do patients with Type A blood

naturally possess? Type B? Type AB? Type O?

Answer 27

Persons with Type A blood possess anti-B antibodies.
Conversely, patients with Type B blood possess anti-A
antibodies. Persons with Type AB blood do not possess
antibodies to either blood type and persons with Type O blood
possess both anti-A and anti-B antibodies.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1169.

Question 28

Are blood products screened in the laboratory for

West Nile Virus? Malaria?

Answer 28

It is tested for West Nile virus, but not malaria. Rapidly
developed testing procedures have reduced the risk of
transmission of West Nile virus by transfusion. Donated blood
is not currently tested for malaria. Instead, donors are screened
during the interview process for relevant symptoms or travel to
areas where the diseases are more prevalent. Malaria is
relatively uncommon in the United States.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 399.

Question 29

What is CPDA and why is it added to blood
products? What is a disadvantage conferred by the
addition of CPDA?

Answer 29

CPDA (citrate-phosphate-dextrose-adenine) is added to whole
blood when collected to act as an anticoagulant and provide the
blood with a shelf-life of about 35 days. Within 24 hours of its
addition, the platelets are dysfunctional and many coagulation
factors are below normal levels.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1438.

Question 30

What is the point of administering washed red blood

cells?

Answer 30

Washed red blood cells are rinsed with isotonic saline
solutions. This removes plasma proteins, leukocytes, and
platelets. Doing so helps prevent severe allergic reactions
mediated by recipient IgE antibodies and donor plasma
proteins. It also helps prevent reactions caused by pre-existent
antibodies to IgA in the donor plasma which can result in
anaphylaxis in IgA-deficient recipients.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1439.

Question 31

What is acute normovolemic hemodilution?

Answer 31

Acute normovolemic hemodilution is an alternative to
transfusion in which whole blood is removed from the patient
prior to surgery with replacement of the lost volume in the form
of crystalloids. By diluting the vascular bed, any blood lost
during surgery will have a lower hematocrit. The previously
removed blood is then reinfused back to the patient when
intraoperative blood loss has ceased.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 400.

Question 32

What is the most common cause of bleeding

following massive transfusion?

Answer 32

The most common cause of bleeding after massive transfusion
is dilutional thrombocytopenia. Coagulation and platelet studies
should guide the administration of FFP and platelets during
massive transfusions.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1175.

Question 33

What is the incidence of bacterial contamination of

platelets and packed red blood cells?

Answer 33

Bacterial contamination is the second leading cause of death
related to transfusion. The incidence of a positive culture from
a specimen derived from a bag of platelets is 1:2000 and the
incidence is 1:7000 from packed red blood cells.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 702.

Question 34

Why is the incidence of bacterial contamination

higher with platelets than with red blood cells?

Answer 34

Platelets are stored at 22-24 degrees Celsius, which is more
supportive of bacterial growth than the refridgeration required of
packed red blood cells.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 424.

Question 35

What is the difference between blood typing and

blood crossmatching?

Answer 35

Blood typing (a type and screen) determines the patient’s blood
type and predicts compatible transfusions 99.94% of the time.
Crossmatching, which is the actual mixing of the donor and
recipient blood in a ‘trial transfusion’ increases the possibility of
a compatible transfusion by only one-hundredth of 1%.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 395.

Question 36

At what serum platelet levels would an infusion of

concentrated platelets be indicated?

Answer 36

Transfusions of platelet concentrates are usually indicated
when the platelet concentration is less than 50,000/microliter,
and are certainly not indicated at a platelet concentration higher
than 100,000/microliter.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 397.

Question 37

How long can platelets be stored at room
temperature? What is the overall risk of bacterial
contamination via platelet transfusion?

Answer 37

Platelets can be stored for a maximum of 5 days at room
temperature and have a risk of bacterial contamination of 1 in
12,000.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 399.

Question 38

What coagulation factors are present in fresh frozen
plasma and what are its general indications for
administration?

Answer 38

All coagulation factors are present in fresh frozen plasma. It
may be administered for reversal of the effects of warfarin,
bleeding due to dilutional coagulopathy, or treatment of
microvascular bleeding due to prolonged prothrombin time or
partial thromboplastin time.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 397.

Question 39

What is the recommended dose of fresh frozen
plasma for the reversal of warfarin? What is the
dose in all other disorders?

Answer 39

The dose of FFP for the reversal of warfarin is 5-8 mL/kg. For
all other purposes, the dose should be 10-20 mL/kg.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 397.

Question 40

What are the components of cryoprecipitate?

Answer 40

Cryoprecipitate contains factor VIII, factor XIII, von Willebrand
factor, and fibrinogen.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 398.

Question 41

What are the most common indications for the

administration of cryoprecipitate?

Answer 41

Cryoprecipitate is most commonly administered in the treatment
of patients with von Willebrand disease or patients with low
fibrinogen levels (less than 80 mg/dL).
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 398.

Question 42

How does the concentration of fibrinogen found in a
single unit of cryoprecipitate compare to that found in
a unit of fresh frozen plasma?

Answer 42

The normal adult dose of cryoprecipitate contains between 100
and 250 mg of fibrinogen, or about four times the amount found
in a unit of fresh frozen plasma.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1443.

Question 43

Is it necessary to match cryoprecipitate to the

recipient’s blood type?

Answer 43

Cryoprecipitate can contain anti-A or anti-B antibodies and
should therefore, be typed to the patient’s blood type. The
incidence of nonhemolytic reaction (fever, chills, etc) is similar
to that of red blood cell transfusions.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1444.