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AS9.1-4 | Fluids, Blood Products and Vascular Access — Practice Quiz
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A 68-year-old woman with diabetes and peripheral vascular disease requires urgent peripheral IV access for antibiotic administration. Her veins in the antecubital fossa are sclerosed. Which of the following sites is most appropriate as the next choice for peripheral IV cannulation?
Dorsal hand veins (dorsal metacarpal veins) are the appropriate next peripheral site when antecubital veins are inaccessible. They remain a peripheral access point and avoid central line risks.
Peripheral IV cannulation (AS9.1) proceeds from distal to proximal: dorsal hand → forearm → antecubital fossa. Central access is a different skill (AS9.2) with distinct indications and risks.
Femoral, internal jugular, and subclavian veins are central venous sites (AS9.2), not peripheral. The next peripheral option after the antecubital fossa is the dorsal hand, followed by forearm veins.
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During a simulated peripheral IV cannulation exercise, a student inserts a 16G cannula into the cephalic vein at the wrist. On withdrawal of the stylet, blood flushes back freely but the infusion does not run. What is the most likely explanation?
Kinking at the hub is a common cause of positional obstruction — blood flashes back on insertion (stylet in correct position) but the softer plastic cannula kinks when bent over a joint, stopping infusion flow.
Avoid placing peripheral cannulae directly over a joint; if unavoidable, splint the limb to prevent kinking, and always confirm free flow after stylet removal.
Posterior wall puncture or extravasation would cause swelling and pain; air embolism is not caused by cannula kinking. Hub kinking over the wrist joint is the classic positional block with this presentation.
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A 55-year-old man is being prepared for right internal jugular (IJV) central venous catheter insertion under real-time ultrasound guidance. Which patient position optimises venous filling of the IJV and reduces air embolism risk?
Trendelenburg (head-down tilt) distends the IJV, improves first-attempt success, and raises venous pressure at the insertion site, reducing the risk of air entrainment. Head turned contralaterally (left) exposes the right IJV.
For IJV central line: Trendelenburg position + head contralateral + ultrasound guidance is the evidence-based standard that maximises success and minimises mechanical and embolic complications.
Sitting upright or reverse Trendelenburg collapses the IJV and raises the risk of air embolism. Lateral decubitus is not standard for IJV cannulation.
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After inserting a central venous catheter via the right subclavian vein, a post-procedure chest X-ray is obtained. Which finding would confirm correct catheter tip placement?
The ideal central venous catheter tip lies at the cavoatrial junction or in the distal SVC, confirmed on CXR as approximately at the level of the right main bronchus/carina. This avoids intra-atrial arrhythmias and SVC perforation.
Post-CVC insertion CXR serves two purposes: confirm tip at cavoatrial junction/distal SVC, and exclude pneumothorax (especially after subclavian or internal jugular attempts).
A tip at the clavicle is too proximal; right atrial placement risks arrhythmia and perforation; brachiocephalic positioning gives inaccurate CVP readings and risks venous spasm.
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A 45-year-old man is scheduled for elective laparoscopic cholecystectomy. He last ate a full meal 8 hours ago and had clear fluids 3 hours ago. According to ASA fasting guidelines, what is the correct preoperative fasting status for proceeding with surgery?
ASA '2-4-6-8' guidelines: clear fluids require 2 hours, a light meal 6 hours, a fatty/fried meal 8 hours. This patient meets both criteria — solids 8 hours ago and clear fluids 3 hours ago.
Apply ASA fasting guidelines exactly: clear fluids 2 h, breast milk 4 h, formula/light meal 6 h, fatty meal 8 h. Individualise for gastric dysmotility, obesity, or emergency cases.
The blanket '8-hour nil by mouth' rule is outdated. Clear fluids clear the stomach within 2 hours in healthy adults; extending the fast unnecessarily causes dehydration and patient discomfort.
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A 70 kg adult patient undergoing a 4-hour open bowel resection has received 2 litres of normal saline intraoperatively. Postoperatively, he is oliguric (urine output 15 mL/hour). His blood pressure is 105/60 mmHg and JVP is low. Which fluid strategy is most appropriate next?
Goal-directed fluid therapy: a small, targeted bolus (250–500 mL balanced crystalloid) with reassessment of haemodynamic response is the evidence-based approach to hypovolaemia-related oliguria after major surgery.
Balanced crystalloids (Hartmann's/Lactated Ringer's) are the default perioperative fluid. Treat oliguria with a haemodynamic assessment first; give small boluses and reassess rather than fixed large-volume prescriptions.
Large rapid saline boluses risk hyperchloraemic acidosis and fluid overload. Furosemide treats volume overload, not hypovolaemia. Dextrose distributes to the intracellular space and does not expand intravascular volume effectively.
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A 32-year-old woman with sickle cell disease undergoing elective splenectomy has a preoperative haemoglobin of 6.2 g/dL. She is symptomatic with dyspnoea on minimal exertion. Which blood product is most appropriate to correct her anaemia?
Packed red blood cells (PRBCs) are the component used specifically to increase oxygen-carrying capacity and treat symptomatic anaemia. Each unit raises haemoglobin by approximately 1 g/dL in an adult.
Blood component therapy targets the specific deficit: PRBCs for oxygen-carrying capacity (Hb <7 g/dL generally, or higher if symptomatic/cardiac disease); FFP for coagulopathy; platelets for thrombocytopenic bleeding.
FFP provides clotting factors; platelets treat thrombocytopenia; cryoprecipitate provides fibrinogen and factor VIII. None of these correct anaemia — PRBCs are the correct component.
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During a transfusion of packed red blood cells, a patient develops fever (temperature 38.9°C), rigors, hypotension, and flank pain 10 minutes into the transfusion. What is the most important immediate action?
The presentation — fever, rigors, hypotension, flank pain early in transfusion — is the classic acute haemolytic transfusion reaction (ABO incompatibility), a life-threatening emergency. STOP the transfusion immediately, keep the IV line with normal saline, and notify the blood bank to check for misidentification.
Acute haemolytic transfusion reaction: STOP transfusion → saline via same IV → send remaining blood + patient sample to bank → supportive care (fluids, monitoring urine output). Distinguishing haemolytic from febrile non-haemolytic reaction requires clinical and lab assessment.
Slowing, continuing, or restarting the transfusion risks fatal haemolysis. Antihistamine alone is appropriate for a simple allergic (urticarial) reaction, not haemolysis. The hallmark of haemolytic reaction is early onset with haemodynamic compromise.
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