Fluid, Electrolytes, Acid-Base Disorders & Renal Disease

Question 1

A 72-year-old male undergoing abdominal surgery exhibits a sudden decrease in blood pressure accompanied by tachycardia. The nurse anesthesiologist notes the patient’s
preoperative labs indicated slightly elevated serum osmolality (295 mOsm/kg) and normal sodium levels. In response to the hypotension, vasopressin is administered. Considering the patient’s osmolal status, what is the most likely immediate effect of vasopressin administration in this scenario?

Answer 1

Decreased serum osmolality due to vasopressin-induced water retention and vasoconstriction, improving blood pressure

Question 2

A patient with severe hypovolemia due to gastrointestinal loss is receiving fluid resuscitation in the perioperative setting. The nurse anesthesiologist opts for a balanced
crystalloid solution. Considering the pathophysiological principles of water and electrolyte homeostasis, what is the most likely rationale behind choosing a balanced crystalloid
solution over normal saline?

Answer 2

To prevent hyperchloremic metabolic acidosis

Question 3

A 55-year-old man with a history of chronic alcoholism is admitted for emergency surgery due to a ruptured appendix. He appears dehydrated, and his lab results show elevated serum osmolality. As a Nurse Anesthesiologist, you are concerned about the administration of mannitol for intraoperative management of potential cerebral edema due to his osmolal state. Which of the following is the MOST appropriate management strategy for this patient?

Answer 3

Assess the patient’s preexisting serum osmolality and consider alternatives to mannitol

Question 4

A 72-year-old female patient is admitted with symptoms of hyponatremia, and initial tests confirm a serum sodium concentration of 128 mmol/L. She has a history of chronic heart failure and presents with signs of fluid overload. The hyponatremia is deemed hypervolemic. As her Nurse Anesthesiologist, you are considering her fluid management strategy. Which of the following is the MOST appropriate initial treatment approach?

Answer 4

Restrict fluid intake and consider administration of a loop diuretic

Question 5

During the perioperative management of a patient with acute symptomatic hyponatremia, which of the following strategies is MOST critical to avoid the risk of osmotic demyelination syndrome?

Answer 5

Limiting the correction of serum sodium concentration to not exceed 1-1.5 mEq/L/hr with a daily max increase of 12 mEq/L

Question 6

A 40-year-old male patient with a history of psychogenic polydipsia presents with euvolemic hyponatremia. Serum sodium concentration is measured at 130 mmol/L. He is
scheduled for an elective surgical procedure. Which of the following management strategies should be PRIORITIZED before surgery?

Answer 6

Gradual correction of hyponatremia by restricting fluid intake and monitoring serum sodium levels closely

Question 7

A 53-year-old woman with a history of chronic, mild hyponatremia, secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), was admitted for the management of acute gastroenteritis. During her emergency room treatment, she received a rapid infusion protocol intended for acute hyponatremia. Several hours post-infusion, she exhibits neurological signs including brisk deep tendon reflexes, altered mental status, and
difficulty speaking. Her recent serum sodium levels show a significant increase from her baseline. The patient’s current presentation could be indicative of several complications.
Which of the following is the MOST appropriate next step in managing this patient’s condition?

Answer 7

Initiate desmopressin and infuse hypotonic saline to cautiously lower the serum sodium concentration monitoring for signs of cerebral edema while preparing for diagnostic imaging to evaluate

Question 8

A 78-year-old man with a history of hypertension and recent severe gastroenteritis is admitted with signs of acute hypernatremia, with a serum sodium concentration of 162
mEq/L. Neurological examination reveals restlessness, muscle twitching, and disorientation. His medical history includes the chronic use of loop diuretics for blood pressure management. Given the rapid onset and the severity of his hypernatremia, which of the following management strategies should be initiated first?

Answer 8

Administer hypotonic saline

Question 8

During preoperative assessment, a 55-year-old man scheduled for elective surgery exhibits signs of muscle weakness and cramps. His serum potassium is found to be 3.1 mmol/L. He denies the use of diuretics or any history of renal disease but mentions episodes of nocturnal muscle cramps and frequent daytime thirst. Which of the following approaches should be prioritized to manage his hypokalemia?

Answer 8

Initiate oral potassium supplementation and evaluate for causes of hypokalemia including potential undiagnosed primary hyperaldosteronism given his symptoms and history

Question 8

In managing a patient with euvolemic hypernatremia due to untreated diabetes insipidus, which of the following interventions is MOST appropriate to correct the hypernatremia while minimizing the risk of developing cerebral edema?

Answer 8

Gradual water replacement orally or via 5% dextrose in water IV, with careful monitoring of serum sodium

Question 9

During a transurethral resection of the prostate (TURP) procedure that extended beyond 90 minutes, a 68-year-old man under general anesthesia exhibits signs consistent with the onset of TURP syndrome, including hypertension, acute onset of confusion, and evidence of fluid overload. His current serum sodium concentration is reported as 118 mEq/L, and the operative team has been using a glycine irrigating solution. Given the critical nature of his condition, which of the following management strategies is MOST appropriate to address the immediate life-threatening aspects of his presentation?

Answer 9

Cease further absorption of the irrigating fluid by concluding the surgical procedure if possible initiate administration of hypertonic saline cautiously to address severe hyponatremia and consider loop diuretics for symptoms of volume overload

Question 10

A 59-year-old woman with a recent history of severe vomiting and diarrhea presents with profound weakness and palpitations. An EKG shows U waves and flattened T waves, indicative of hypokalemia, confirmed by a serum potassium level of 2.8 mmol/L. Her medical history is notable for chronic atrial fibrillation, for which she takes digoxin. Given the complexity of her presentation, which of the following management strategies most appropriately addresses both the acute management of her hypokalemia and her increased risk for digoxin toxicity?

Answer 10

Administer IV potassium chloride to correct the hypokalemia rapidly, alongside continuous cardiac monitoring an assess her digoxin levels and renal function to guide further dosing adjustments

Question 11

A 65-year-old man with chronic kidney disease on hemodialysis presents for emergency surgery with a serum potassium level of 6.8 mEq/L and ECG changes indicative of
hyperkalemia, including peaked T waves. Given the urgency of his surgical need and the acute management required for his hyperkalemia, which of the following strategies should be implemented first?

Answer 11

Administer calcium gluconate IV to stabilize cardiac membranes, followed by insulin with glucose to promote potassium shift intracellularly, and prepare for immediate dialysis if necessary

Question 12

During preoperative assessment for elective surgery, a 58-year-old woman with a history of hypertension controlled with ACE inhibitors is found to have a serum potassium level of 6.2 mEq/L. No ECG changes are noted. Given her stable cardiac status but elevated potassium, which of the following management plans is MOST appropriate?

Answer 12

Discontinue the ACE inhibitor temporarily administer kayexalate to reduce serum potassium and consider saline diuresis to enhance potassium elimination while monitoring for any development of ECG changes

Question 13

A 72-year-old woman presents to the post-anesthesia care unit following a total thyroidectomy. She reports perioral numbness and exhibits Chvostek’s sign. Her serum calcium is reported as 7.2 mg/dL, with an albumin level of 3.0 g/dL. Given the surgical history and clinical presentation indicative of hypocalcemia, which of the following is the
MOST appropriate management plan?

Answer 13

Administer IV calcium gluconate monitor serum calcium albumin levels closely and calculate corrected calcium levels to guide further supplementation

Question 14

During a routine health examination, a 65-year-old male with chronic kidney disease stage 3 is found to have a serum calcium level of 8.0 mg/dL and an albumin level of 3.5 g/dL. He reports occasional muscle cramps but no other symptoms. Which of the following interventions should be considered FIRST to manage his hypocalcemia?

Answer 14

Calculate the correct calcium level to accurately assess his hypocalcemia, and if confirmed, start oral calcium and Vitamin D supplementation to address potential underlying causes

Question 15

A 72-year-old woman with chronic obstructive pulmonary disease (COPD) is admitted to the ICU for exacerbation and is receiving parenteral nutrition. She develops signs of
hypomagnesemia, including muscle twitching and weakness, despite no evident renal losses. Her current serum magnesium level is 0.7 mEq/L. Given the clinical context and the need for rapid correction of her hypomagnesemia to prevent further neuromuscular
complications, which of the following is the MOST appropriate initial treatment?

Answer 15

Administer IV Mag Sulfate as a bolus quickly to elevate her serum Mag level, and then continue a slower infusion to replenish total body mag stores closely monitoring for signs of hypermagnesemia

Question 16

During the preoperative evaluation for elective abdominal surgery, a 64-year-old man with a history of alcoholism and malnutrition presents with refractory hypokalemia and
hypocalcemia, despite ongoing supplementation. Laboratory tests reveal a serum magnesium level of 1.0 mEq/L. Recognizing the central role of magnesium in potassium and calcium homeostasis, which of the following interventions should be prioritized to effectively manage his electrolyte abnormalities?

Answer 16

Administer IV Mag to correct the hypomagnesemia with the expectation that correct of Mag levels will facilitate the resolution of hypocalcemia and hypokalemia

Question 17

A 56-year-old male with a history of chronic obstructive pulmonary disease (COPD) and on β-adrenergic blockers for hypertension is admitted to the ICU with acute respiratory acidosis. You review the patient prior to potential surgery. Arterial blood gas analysis reveals a pH of 7.28, Paco2 of 55 mm Hg, and bicarbonate of 26 mEq/L. Given the patient’s deteriorating condition and the potential adverse effects of acidosis on his cardiovascular
system, especially considering his use of β-adrenergic blockers and underlying COPD, which of the following is the MOST appropriate initial management strategy?

Answer 17

Admin IV Bicarb to correct acidosis optimize bronchodilator therapy for COPD management and adjust the mechanical vent settings to decrease PaCO2 and improve acidosis

Question 18

A 63-year-old woman undergoing recovery from abdominal surgery develops metabolic alkalosis with a blood gas showing a pH of 7.52, Paco2 of 45 mm Hg, and bicarbonate of 32 mEq/L. She is experiencing difficulty weaning from mechanical ventilation. Considering the potential consequences of severe systemic alkalosis and her current condition, which of the following management strategies should be prioritized to correct her alkalosis and facilitate
weaning from mechanical ventilation?

Answer 18

Administer acetazolamide to increase renal excretion of bicarb thereby reducing serum bicarb levels and correcting alkalosis while optimizing ventilation settings to prevent further respiratory compensation

Question 19

A 68-year-old man with a history of chronic obstructive pulmonary disease (COPD) is admitted for elective abdominal surgery. In the postoperative period, he becomes drowsy and is noted to have shallow breathing. Arterial blood gas (ABG) analysis reveals a pH of 7.32, Paco2 of 50 mm Hg, bicarbonate of 29 mEq/L, and PaO2 of 60 mm Hg. The patient is receiving oxygen therapy via nasal cannula at 2 L/min. His serum potassium is 3.5 mEq/L,
and chloride is 95 mEq/L. Given these findings, which of the following is the MOST appropriate management to address his condition?

Answer 19

Initiate non-invasive positive pressure ventilation to improve alveolar ventilation decrease PaCO2 gradually, and consider potassium chloride and sodium chloride supplementations to correct potential metabolic alkalosis and electrolyte imbalance

Question 20

During routine post-operative monitoring, a 60-year-old female with no known history of diabetes but who underwent a prolonged surgery for a bowel obstruction, exhibits signs of confusion and respiratory distress. Her ABG analysis shows a pH of 7.25, Paco2 of 28 mm
Hg, bicarbonate of 14 mEq/L, and an anion gap of 30. Her serum glucose level is unexpectedly high at 380 mg/dL. Intravenous fluids containing dextrose were used liberally
during surgery. Her serum potassium is 5.5 mEq/L. Based on these findings, which of the following management approaches should be prioritized?

Answer 20

Begin IV fluid replacement with 0.9% normal saline and insulin therapy to address the hyperglycemia and suspected metabolic acidosis of mixed origin adjusting potassium supplementation based on continuous monitoring

Question 21

A 73-year-old male with a history of hypertension and chronic heart failure is scheduled for a nephrectomy due to a renal mass. Preoperatively, he is found to have a serum creatinine of 1.8 mg/dL, indicating reduced renal function. Given his renal impairment and the surgical intervention planned, which of the following is the MOST appropriate anesthesia management strategy?

Answer 21

Implement a neuraxial blockade extending from T8 to L4 provide anesthesia and postoperative analgesia, minimize systemic opioid use, and avoid potential hemodynamic fluctuations and associated with general anesthesia that could further compromise renal perfusion

Question 22

A patient in the ICU with a history of advanced age and CKD is at risk for AKI due to a recent episode of hypovolemia following gastrointestinal bleeding. The patient is currently stable, with improved volume status, but requires ongoing monitoring and management to prevent further renal insult. Considering the key homeostatic roles of the kidneys and the potential impact of medications on renal perfusion and function, which of the following interventions
should be prioritized to minimize the risk of AKI?

Answer 22

Avoid the use of NSAIDS for pain managements due to their prostaglandin mediated effects on the renal blood flow options instead for acetaminophen and cautious use of opioids while ensuring adequate hydration and monitoring renal function closely

Question 23

A 54-year-old male with a history of non-insulin-dependent diabetes mellitus is admitted with severe dehydration following a prolonged bout of gastroenteritis. His laboratory tests reveal a serum creatinine of 2.2 mg/dL, blood urea nitrogen (BUN) of 45 mg/dL, and a
fractional excretion of sodium (FENa) of 0.5%. His urine specific gravity is 1.025, and urinalysis shows no significant proteinuria or hematuria but has a few granular casts. Given these findings, which of the following is the MOST appropriate initial management strategy to address his renal function and hydration status?

Answer 23

Administer intravenous isotonic saline to rehydrate and improve renal perfusion, closely monitor renal function and electrolytes, and adjust fluid type and rate based on urine output and serum electrolyte trends.

Question 24

You get a call from the preop clinic about a 70-year-old female with advanced chronic kidney disease (CKD) presents with fatigue and anorexia with a planned hysterectomy in a month. Her recent labs show a GFR of 20 mL/min, serum creatinine of 4.5 mg/dL, and a blood urea nitrogen (BUN) of 60 mg/dL. She has a urine specific gravity of 1.010 and persistent microalbuminuria. Given her stage of CKD and current symptoms, which of the following interventions should be prioritized to manage her renal function and related symptoms?

Answer 24

Optimize her Blood Pressure control and protein intake, initiate treatment for anemia if present and consider phosphate binders to manage her CKD progression and symptoms

Question 25

A 68-year-old man with a history of coronary artery disease and chronic kidney disease is undergoing elective hernia repair under general anesthesia. Post-operatively, he exhibits signs of acute kidney injury (AKI) with a serum creatinine rise from a baseline of 1.8 mg/dL to 2.9 mg/dL, and oliguria. He received NSAIDs for pain management intraoperatively. His blood pressure has been on the lower side during surgery, managed with fluids and occasional vasopressors. Which of the following is the MOST appropriate next step in managing his renal function while considering the surgical and anesthesia context?

Answer 25

Discontinue NSAIDS and manage pain with acetaminophen and low-dose opioids if necessary ensure aggressive hydration to optimize renal perfusion and closely monitor hemodynamics and urine output

Question 26

During a prolonged abdominal surgery for bowel resection, a 65-year-old man develops oliguria. His preoperative serum creatinine was 1.0 mg/dL, but 48 hours post-operatively, it has increased to 1.8 mg/dL. The patient has been on norepinephrine to maintain mean arterial pressure (MAP) and received significant amounts of 0.9% normal saline for fluid resuscitation during surgery. Post-operative management has included the use of NSAIDs
for pain control. Ultrasound of the renal tract shows no signs of obstruction, but there is evidence of increased echogenicity of the renal parenchyma. Which of the following is the MOST appropriate management strategy considering the potential cause of acute kidney
injury (AKI) in this surgical patient?

Answer 26

Discontinue NSAIDs and switch to acetaminophen for pain management, reevaluate the need for continued norepinephrine support with a goal to minimize its use, and initiate balanced crystalloid for further fluid resuscitation to prevent hyperchloremic metabolic acidosis and reduce the risk of AKI progression.

Question 26

During a complex spine surgery involving substantial blood loss, a 75-year-old female with a history of mild chronic kidney disease exhibits a significant drop in urine output to less than 0.5 mL/kg/hr, suggesting possible intraoperative AKI. The surgery requires the patient to be in a prone position for an extended period. Blood pressure has been maintained with fluid resuscitation and intermittent vasopressors. Which of the following management
strategies is MOST appropriate to mitigate the risk of AKI in this setting?

Answer 26

Optimize hemodynamic management by adjusting fluid therapy to ensure adequate renal perfusion and consider low dose dopamine to support renal blood flow while minimizing the use of nephrotoxic agents

Question 27

A 59-year-old female undergoes major orthopedic surgery under general anesthesia. Post-operatively, she is noted to have anuria with a significant increase in serum creatinine from 0.9 mg/dL preoperatively to 2.4 mg/dL 24 hours post-operation. Review of the intraoperative course reveals minimal urine output despite adequate fluid resuscitation. A post-operative renal ultrasound excludes obstruction but shows bilateral renal swelling suggestive of acute tubular necrosis (ATN). Given these findings and the absence of pre-existing renal disease, which of the following interventions should be prioritized to support renal recovery?

Answer 27

Ensure optimal fluid management to support renal perfusion avoid further use of nephrotoxic agents including NSAIDS and closely monitor serum creat and urine output to assess for signs of renal recovery

Question 28

A 68-year-old man with chronic kidney disease, currently experiencing acute kidney injury (AKI), is scheduled for urgent vascular surgery due to a suspected aortic aneurysm. His baseline serum creatinine is elevated, and his potassium levels are at the upper limit of normal. Anesthesia considerations are critical to avoid exacerbating his renal condition. Which of the following anesthesia management strategies would be most appropriate for this patient?

Answer 28

Opt for cisatricurium for NMB due to its independent elimination pathway from the renal function and use balanced crystalloids to manage fluid status while strictly avoiding the use of succinylcholine

Question 29

A 59-year-old patient with stage 3b chronic kidney disease (CKD) is undergoing a laparoscopic cholecystectomy. Given the concern for renal hyperfiltration and its complications, what anesthetic management strategy is most appropriate to mitigate the risk of further renal damage in this patient?

Answer 29

Utilization of low dose dopamine infusion to improve renal blood flow and minimize hyperfiltration stress

Question 30

During a major orthopedic surgery, a patient with advanced CKD develops acute hyperkalemia. Which of the following interventions is most appropriate to address hyperkalemia intraoperatively

Answer 30

Serum potassium should not ex- ceed 5.5 mEq/L on the day of surgery (p. 429)
Treatment:
Membrane Stabilization: Immediate administration of calcium (chloride or gluconate) to counteract potassium’s effects on cardiac muscle. Potassium Shifting: Insulin (with glucose to prevent hypoglycemia) and sodium bicarbonate can temporarily shift potassium into cells. Potassium Elimination: Diuretics, sodium polystyrene sulfonate (Kayexalate), and dialysis can reduce total body potassium (Fluid, electrolyte, acid-base disorders & Renal disease PPT, part 1, slide 45)

Question 31

A 70-year-old patient with stage 4 CKD is scheduled for a vascular bypass surgery. The patient’s preoperative evaluation reveals a prolonged bleeding time due to uremia. Which perioperative management strategy best addresses the increased risk of bleeding in this patient?

Answer 31

Preoperative administration of desmopressin (DDAVP) to enhance platelet function.

Question 32

A 65-year-old patient with CKD stage 4 is scheduled for elective hip replacement surgery. In preparing for surgery, which of the following preoperative interventions is most
appropriate to mitigate the risk of cardiovascular complications during and after the procedure?

Answer 32

Optimization of blood pressure with an ACE inhibitor or ARB, especially if proteinuria is present.

Question 33

A 67-year-old patient with stage 5 CKD on hemodialysis presents for urgent surgery due to a gastrointestinal bleed. The patient’s history is notable for uremic platelet dysfunction. Which perioperative management strategy is most appropriate to mitigate the risk of further bleeding?

Answer 33

Preoperative administration of DDAVP to enhance platelet function, along with correction of anemia to a target hemoglobin of 10 g/dL.

Question 34

In managing a patient with CKD stage 3 who is presenting for a vascular access procedure for hemodialysis, which of the following strategies is most appropriate for addressing
anemia preoperatively?

Answer 34

EPO administration to target a hemoglobin level of 10-11 avoiding higher targets to reduce the risk of hypertension

Question 35

A 73-year-old patient with stage 4 CKD is scheduled for elective abdominal surgery. The patient’s history includes diabetes mellitus, hypertension, and a previous myocardial
infarction. In the preoperative assessment, which of the following actions is most critical to optimizing patient outcomes?

Answer 35

Ensuring dialysis within 24 hours before surgery to achieve optimal volume status and electrolyte balance

Question 36

In the context of a 70-year-old patient with advanced chronic kidney disease undergoing elective surgery for AV fistula creation, considering the altered pathophysiological state and its impact on anesthetic drug pharmacokinetics and pharmacodynamics, which induction strategy most appropriately addresses the challenges posed by CKD?

Answer 36

Use of a carefully titrated dose of remifentanil in combination with low dose propofol taking into account remifentanil’s rapid metabolism independent of renal function and propofol’s short half-life while minimizing hemodynamic instability

Question 37

In managing a patient undergoing renal transplantation, which of the following anesthesia management strategies is most appropriate, given the intricacies of renal physiology and the need for immediate graft function post-transplantation?

Answer 37

Incorporation of low dose dobutamine infusion for inotropic support if not responsive to fluid therapy

Question 38

Given the potential for hyperkalemia upon reperfusion of the transplanted kidney, which strategy is optimal for mitigating this risk while ensuring stable hemodynamic and
electrolyte management?

Answer 38

Prophylactic admin of calcium gluconate prior to the release of the vascular clamps to protect against cardiac effects of hyperkalemia

Question 39

Considering a patient with nephrotic syndrome undergoing surgery, which of the following anesthetic management strategies addresses the altered drug-binding characteristics due to hypoalbuminemia?

Answer 39

Careful titration of drugs with a high degree of protein binding, such as benzodiazepines, to account for an increased fraction of unbound, active drug.

Question 40

In the context of perioperative fluid management for a patient with nephrotic syndrome, which approach best mitigates the risk of hypovolemia while avoiding exacerbation of edema and thromboembolic complications?

Answer 40

Infusion of albumin will improve these acute signs of hypovolemia; thromboembolic complications are major risks in patients with nephrotic syndrome, particularly in those whose albumin concentrations is less than 2 g/dl.

Question 41

Given the pathophysiological basis of acute glomerulonephritis involving antigen-antibody complex deposition in the glomeruli, which treatment approach best aligns with interrupting this disease process?

Answer 41

Prompt diagnosis is important, as immunosuppressive drugs may help prevent permanent kidney damage (p.433)
(Treat infection if caused by exogenous source?)

Question 42

In the perioperative management of a patient with Bartter syndrome undergoing elective surgery, which approach is essential for addressing the characteristic electrolyte
imbalances?

Answer 42

Aggressive supplementation of potassium and magnesium preoperatively to correct hypokalemia and hypomagnesemia, minimizing the risk of cardiac and neuromuscular complications.

Question 43

For a patient with Type 4 Renal Tubular Acidosis (RTA) undergoing a non-renal surgical procedure, which anesthesia management consideration is paramount given the associated hyperkalemia?

Answer 43

Avoidance or cautious use of drugs that may exacerbate hyperkalemia such as succ and close monitoring of potassium levels perioperatively