Answer: b Metabolic response to injury results in increased energy expenditure. If energy intake is less than expenditure, oxidation of body fat stores and erosion of lean body mass will occur with resultant loss of weight. When weight loss exceeds 10–15% of body weight, the complications of malnutrition interact with disease processes, with increased morbidity and mortality rates. The goal of nutritional support is maintenance of body cell mass and limitation of weight loss to less than 10% preinjury. The major impact of nutritional support in the trauma patient is to aid host defense. Under-nutrition may compromise the available host defense mechanism and may thus increase the likelihood of invasive sepsis, multiple organ system failure, and death. Resuscitation, oxygenation and arrest

Answer: b  Metabolic response to injury results in increased energy expenditure. If energy intake is less than expenditure, oxidation of body fat stores and erosion of lean body mass will occur with resultant loss of weight. When weight loss exceeds 10–15% of body weight, the complications of malnutrition interact with disease processes, with increased morbidity and mortality rates. The goal of nutritional support is maintenance of body cell mass and limitation of weight loss to less than 10% preinjury. The major impact of nutritional support in the trauma patient is to aid host defense. Under-nutrition may compromise the available host defense mechanism and may thus increase the likelihood of invasive sepsis, multiple organ system failure, and death. Resuscitation, oxygenation and arrest of hemorrhage are immediate priorities for survival. Nutritional support is an essential part of the metabolic care of the critically ill patient and should be instituted after resuscitation before significant weight loss occurs. The nutritional requirements of a trauma patient can be determined by determining basal metabolic rate with appropriate increases based on extent of injury and hospital activity. After initial determination of nitrogen requirements, caloric requirements should be distributed at a ratio of 70% as glucose and 30% as fat
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Which of the following statement(s) is/are true concerning body fuel reserves? a. The largest fuel reserve in the body is skeletal muscle b. Fat provides about 9 calories/gram c. Free glucose and glycogen stores are a trivial fuel reserve d. Body protein is a valuable storage form of energy
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Related questions

In the nutritional support of patients with cancer, which of the following statements is/are true? A. Nutritional support benefits the patient's lean body mass but does not enable the tumor to grow. B. In experimental animals, the growth of implanted tumors is directly proportional to the amount of calories and protein supplied. C. Prospective randomized trials of nutritional support utilizing chemotherapy and radiation therapy have revealed benefits to patients receiving total parenteral nutrition. D. Studies of nutritional support for patients with cancer about to undergo surgery revealed decreased morbidity and mortality, especially morbidity from sepsis.

Description : In the nutritional support of patients with cancer, which of the following statements is/are true? A. Nutritional support benefits the patient's lean body mass but does not enable ... with cancer about to undergo surgery revealed decreased morbidity and mortality, especially morbidity from sepsis.

Last Answer : Answer: B DISCUSSION: The problem with the patient with cancer is a very vexing one. Clearly, one of the metabolic effects of cancer, cachexia, affects patients in the last quartile ... undoubtedly reveal that there are certain nutrients that tumors require, which probably should be best avoided

A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ failure. Which of the following statement(s) is/are true concerning necessary changes to be made in his nutritional management? a. Carbohydrate load should be reduced in the face of respiratory failure b. In patients with renal failure, protein intake should be diminished c. During hemodialysis protein intake should be limited to the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Description : A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ ... the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Last Answer : Answer: a, b The most severe complication of sepsis is multiple system organ dysfunction syndrome, which may result in death. The development of organ failure requires changes in the ... should be provided as fat emulsion. If encephalopathy develops, protein load should also be reduced0

Which of the following statements about the role of the gut in shock and sepsis are true? A. Selective decontamination of the digestive tract with the use of oral antibiotics has been shown to reduce nosocomial pneumonias and to improve mortality rates. B. Enteral nutrition, as compared with parenteral nutrition, preserves the villus architecture of the gut. C. Gut dysfunction may be an effect of shock, but it may also contribute to the development of MODS by the mechanism of bacterial translocation. D. As compared with parenteral nutrition, enteral nutrition is associated with a reduction in septic morbidity.

Description : Which of the following statements about the role of the gut in shock and sepsis are true? A. Selective decontamination of the digestive tract with the use of oral antibiotics has been ... As compared with parenteral nutrition, enteral nutrition is associated with a reduction in septic morbidity.

Last Answer : Answer: BCD DISCUSSION: The gut has a vital role in the pathophysiology of shock. The splanchnic circulation is very vulnerable to the circulatory redistribution that occurs in shock, thus, gut ... , enteral feeding is more cost effective and is associated with a lower rate of septic morbidity

Sepsis causes a marked metabolic response. Which of the following statement(s) is/are true concerning the metabolic response to sepsis? a. Oxygen consumption is increased in the face of infection b. In a patient with a maximal metabolic rate secondary to trauma, the presence of infection will increase the rate further c. Metabolic rate increases at a rate of approximately 10% for each increase of 1°C in central temperature d. The extent of increase in oxygen consumption relates to the severity of the infection

Description : Sepsis causes a marked metabolic response. Which of the following statement(s) is/are true concerning the metabolic response to sepsis? a. Oxygen consumption is increased in the face of infection ... d. The extent of increase in oxygen consumption relates to the severity of the infection

Last Answer : Answer: a, c, d Oxygen consumption is usually elevated in the infected patient. The extent of this increase is related to the severity of the infection, with peak elevations reaching 50% ... suggest that the metabolic rate increases 10% to 13% for each elevation of 1°C in central temperature

A 47-year-old patient undergoing a complicated laparotomy for bowel obstruction develops a postoperative enterocutaneous fistula. Which of the following statement(s) is/are true concerning parenteral nutritional support in the postoperative period? a. Oral intake can result in severe dehydration, electrolyte abnormalities, and perifistula skin injury b. Total parenteral nutrition increases the spontaneous closure rate of intestinal fistula c. Total parenteral nutrition decreases mortality rate in patients with intestinal fistulas d. The use of TPN better prepares the patient for surgery if surgical intervention proves necessary

Description : A 47-year-old patient undergoing a complicated laparotomy for bowel obstruction develops a postoperative enterocutaneous fistula. Which of the following statement(s) is/are true concerning parenteral ... use of TPN better prepares the patient for surgery if surgical intervention proves necessary

Last Answer : Answer: a, b, d Patients with gastrointestinal-cutaneous fistulas represent the classical indication for TPN. In such patients, oral intake of food almost invariably results in increased ... treated more aggressively surgically after a defined period of nutritional support (unless closure occurs)

A major problem in nutritional support is identifying patients at risk. Recent studies suggest that these patients can be identified. Which of the following findings identify the patient at risk? A. Weight loss of greater than 10% over 2 to 4 months. B. Serum albumin of less than 3 gm. per 100 ml. in the hydrated state. C. Malnutrition as identified by global assessment. D. Serum transferrin of less than 220 mg. per 100 ml. E. Functional impairment by history.

Description : A major problem in nutritional support is identifying patients at risk. Recent studies suggest that these patients can be identified. Which of the following findings identify the patient at risk? A. Weight ... transferrin of less than 220 mg. per 100 ml. E. Functional impairment by history.

Last Answer : Answer: ABCDE DISCUSSION: All of these are at least partially correct. It is not clear whether weight loss of 10% or 15% is the required threshold, but it certainly is close. Serum ... the hands of an experienced observer is quite a reasonable way of approaching and identifying patients at risk

Answer: e The role of nutritional support in the cancer patient remains an important component of overall therapy. Preoperative nutritional support should be given only to those patients who do not require an emergency operation and who have severe weight loss (> 15% of pre-illness body weight) and a serum albumen < 2.9 mg%. Preoperative nutrition (enteral or parenteral) should not be given for longer than 7 to 10 days. Enteral nutrition is always the preferred route of feeding cancer patients if the GI tract is functional. There are several benefits of using the bowel lumen for nutrient delivery. The trophic effects of enteral feeding on small bowel mucosa have been well described. The integrity of the mucosal lining is maintained and it may provide an effective barrier to intraluminal

Description : Answer: e The role of nutritional support in the cancer patient remains an important component of overall therapy. Preoperative nutritional support should be given only to those patients who ... of bowel rest; this atrophy is not reversed by currently available total parenteral nutrition solutions

Last Answer : Which of the following hormones can be expected to be released as part of the stress response? a. Antidiuretic hormone (ADH) b. Aldosterone c. Insulin d. Epinephrine nswer: a, b, d ... This hormone has the exact opposite effect of insulin, which promotes glucose storage and uptake by the cells

The following statement(s) is/are true concerning gram-negative bacterial sepsis. a. Mortality due to this condition has almost been eliminated due to therapeutic intervention with antibiotics, aggressive hemodynamic monitoring and fluid resuscitation b. Recent series have noted a decrease in the incidence of this condition c. Predisposing factors include old age, malnutrition, and immunosuppression d. Pseudomonas bacteremia is the most common cause of gram-negative sepsis e. Polymicrobial sepsis is generally considered a more serious problem than sepsis due to a single organism

Description : The following statement(s) is/are true concerning gram-negative bacterial sepsis. a. Mortality due to this condition has almost been eliminated due to therapeutic intervention with antibiotics, aggressive ... sepsis is generally considered a more serious problem than sepsis due to a single organism

Last Answer : Answer: c, e Gram-negative bacterial sepsis is a serious disease process that produces substantial morbidity and mortality in both normal and immunocompromised patients (10% to 20% and ... and most investigators agree that polymicrobial sepsis is more lethal than infection with a single organism

Which of the following statement(s) is/are true concerning the treatment of MOFS? a. Prevention and therapy of MOFS requires control of the infectious or inflammatory source b. Restoration of normal clinical parameters such as blood pressure, pulse rate, and urine output ensures optimal resuscitation in most patients c. Branch chain amino acids play and important role in the nutritional support of the patient d. Because of the nature of gut injury, total parenteral nutrition is preferred for most patients with MOFS

Description : Which of the following statement(s) is/are true concerning the treatment of MOFS? a. Prevention and therapy of MOFS requires control of the infectious or inflammatory source b. Restoration of normal ... of the nature of gut injury, total parenteral nutrition is preferred for most patients with MOFS

Last Answer : Answer: a, c The therapy of MOFS is directed towards interrupting the involving pathophysiologic process and providing an optimal physiologic environment for healing and recovery. ... Enteral absorption and processing of nutrients appears superior to TPN and lessens overall complications

Which of the following statements regarding cytokines is incorrect? A. Cytokines act directly on target cells and may potentiate the actions of one another. B. Interleukin 1 (IL-1) is a major proinflammatory mediator with multiple effects, including regulation of skeletal muscle proteolysis in patients with sepsis or significant injury. C. Platelet-activating factor (PAF) is a major cytokine that results in platelet aggregation, bronchoconstriction, and increased vascular permeability. D. Tumor necrosis factor alpha (TNF-a), despite its short plasma half-life, appears to be a principal mediator in the evolution of sepsis and the multiple organ dysfunction syndrome because of its multiple actions and the secondary cascades that it stimulates.

Description : Which of the following statements regarding cytokines is incorrect? A. Cytokines act directly on target cells and may potentiate the actions of one another. B. Interleukin 1 (IL-1) ... organ dysfunction syndrome because of its multiple actions and the secondary cascades that it stimulates.

Last Answer : Answer: C DISCUSSION: Cytokines are soluble peptide molecules that are synthesized and secreted by a number of cell types in response to injury, inflammation, and infection. Cytokines, which ... is thought to play a central role in the stress response, particularly in response to endotoxemia

In contrast to a patient undergoing an elective operation, which of the following statement(s) is/are true concerning a patient who has suffered a multiple trauma? a. Basal metabolic rates are similar b. The patient is highly sensitive to insulin c. Utilization of the amino acids, glutamine and alanine, is similar to their composition in skeletal muscle d. Fat and protein stores are rapidly depleted

Description : In contrast to a patient undergoing an elective operation, which of the following statement(s) is/are true concerning a patient who has suffered a multiple trauma? a. Basal metabolic rates are ... is similar to their composition in skeletal muscle d. Fat and protein stores are rapidly depleted

Last Answer : Answer: b, d The degree of hypermetabolism is generally related to the severity of injury. Patients with long-bone fractures have a 15-25% increase in metabolic rate, whereas metabolic ... in injured subjects, if unfed, severely injured patients rapidly deplete their fat and protein stores

Which of the following statement(s) is/are true concerning the various types of shock? a. Traumatic shock is more commonly associated with subsequent organ injury and multiorgan failure syndrome than hemorrhagic shock b. Cardiogenic shock can be of either an intrinsic or compressive nature c. Hypodynamic septic shock is associated with a decreased mortality risk when compared with hyperdynamic septic shock d. Hypoadrenal shock usually responds quickly to resuscitation e. Neurogenic shock occurs with the absence of sympathetic activity

Description : Which of the following statement(s) is/are true concerning the various types of shock? a. Traumatic shock is more commonly associated with subsequent organ injury and multiorgan failure ... responds quickly to resuscitation e. Neurogenic shock occurs with the absence of sympathetic activity

Last Answer : Answer: a, b, d, e Classification schemes of shock based on cause have been developed for the seemingly dissimilar processes leading to circulatory collapse and the shock state. ... and pressor agents. The response to exogenous corticosteroids is usually dramatic and potentially life-saving

Which of the following statements are true of the multiple organ dysfunction syndrome (MODS)? A. The “two-hit” model proposes that secondary MODS may be produced when even a relatively minor second insult reactivates, in a more amplified form, the systemic inflammatory response that was primed by an initial insult to the host. B. The systemic inflammatory response syndrome (SIRS), shock due to sepsis or SIRS, and MODS may be regarded as a continuum of illness severity. C. Prolonged stimulation or activation of Kupffer cells in the liver is thought to be a critical factor in the sustained, uncontrolled release of inflammatory mediators. D. The incidence of MODS in intensive care units has decreased owing to increased awareness, prevention, and treatment of the syndrome.

Description : Which of the following statements are true of the multiple organ dysfunction syndrome (MODS)? A. The two-hit model proposes that secondary MODS may be produced when even a relatively ... intensive care units has decreased owing to increased awareness, prevention, and treatment of the syndrome.

Last Answer : Answer: ABC DISCUSSION: MODS is part of a clinical continuum that begins with the systemic inflammatory response syndrome, which is the host's stress response to any major insult such ... pathogenesis of MODS, the incidence of MODS continues to increase without a significant improvement in outcome

Under certain circumstances, the gut may become a source of sepsis and serve as the motor of systemic inflammatory response syndrome. Microbial translocation is the process by which microorganisms migrate across the mucosal barrier to invade the host. Which of the following mechanisms can promote bacterial translocation? a. An increased number of gut bacteria b. Altered intestinal mucosal permeability c. Decreased host defense mechanisms d. Lack of enteral feeding

Description : Under certain circumstances, the gut may become a source of sepsis and serve as the motor of systemic inflammatory response syndrome. Microbial translocation is the process by which microorganisms ... intestinal mucosal permeability c. Decreased host defense mechanisms d. Lack of enteral feeding

Last Answer : Answer: a, b, c, d 99 Translocation is promoted in three general ways: 1) altered permeability of the intestinal mucosa as caused by shock, sepsis, distant injury, or cell toxins; 2) ... trauma patient d. Fifty percent of non-nitrogen caloric requirements should be provided in the form of fat

Which of the following complications of TPN are appropriately managed with the listed treatment? a. Air embolism—place patient in reverse Trendelenburg and the left lateral decubitus position and aspirate venous air b. Hyperchloremic metabolic acidosis—give sodium and potassium as acetate salts c. Carbon dioxide retention—decrease glucose calories and replace with fat d. Line sepsis—intravenous antibiotics

Description : Which of the following complications of TPN are appropriately managed with the listed treatment? a. Air embolism-place patient in reverse Trendelenburg and the left lateral decubitus position ... dioxide retention-decrease glucose calories and replace with fat d. Line sepsis-intravenous antibiotics

Last Answer : Answer: b, c A number of complications of TPN can occur which can be divided into three types: mechanical, metabolic, and infectious

Glucose overload results in increased CO 2 production. Which of the following statements are true? A. In patients with respiratory insufficiency, administration of glucose as a principal calorie source is contraindicated. B. In patients with pulmonary infection and sepsis, calorie support should consist of 95% fat and 5% glucose. C. In Askanazi's study, increased CO 2 production and difficulty in weaning was associated only with pronounced overfeeding. D. CO 2 production should be measured in most patients who are supported by respirators in intensive care units and are receiving nutritional support.

Description : Glucose overload results in increased CO 2 production. Which of the following statements are true? A. In patients with respiratory insufficiency, administration of glucose as a principal calorie ... who are supported by respirators in intensive care units and are receiving nutritional support.

Last Answer : Answer: C DISCUSSION: Few papers have excited as much interest as that by Askanazi, Kinney, and co-workers, which demonstrated that glucose calories given to patients with severe respiratory ... the caloric requirement and glucose for the remainder, without much fear of excessive CO 2 production

Although TPN has major beneficial effects to the patient and specific organ systems, TPN has a downside which is related to intestinal disuse. Which of the following statement(s) is/are true concerning the effects of TPN on the GI tract? a. Patients receiving TPN have an accentuated systemic response to endotoxin challenge compared to enterally fed volunteers b. TPN can result in disruption of intestinal microflora c. In experimental models, bacterial translocation from the gut is increased d. Effects of TPN on the gut may lead to multiple organ failure

Description : Although TPN has major beneficial effects to the patient and specific organ systems, TPN has a downside which is related to intestinal disuse. Which of the following statement(s) is/are true concerning the ... from the gut is increased d. Effects of TPN on the gut may lead to multiple organ failure

Last Answer : Answer: a, b, c, d A number of studies have examined the effects of TPN on intestinal function and immunity. Although most of these studies have been done in animal models, ... the release of bacteria and/or cytokines leading to pronounced systemic responses and possibly multiple organ failure

Which of the following statement(s) is/are true concerning metabolic derangements in sepsis and the systemic inflammatory response syndrome which may follow progressive shock? a. Alterations in glucose metabolism lead to the development of efficient substrate utilization b. A progressive rise in serum triglyceride levels result from less efficient clearance and increased hepatic lipogenesis c. A net negative nitrogen balance occurs due to the oxidative metabolism of proteins to meet energy needs d. The serum aromatic amino acids fall rapidly as they are actively used in oxidative metabolism

Description : Which of the following statement(s) is/are true concerning metabolic derangements in sepsis and the systemic inflammatory response syndrome which may follow progressive shock? a. Alterations in glucose ... The serum aromatic amino acids fall rapidly as they are actively used in oxidative metabolism

Last Answer : Answer: b, c A broad spectrum of metabolic abnormalities become apparent in sepsis and the systemic inflammatory response syndrome following shock. Disruption of the normal cycles of carbohydrate, ... acetyl coenzyme A. This results in reduced serum level of leucine, isoleucine and valine

A 16-year-old boy suffers a mid-gut volvulus with massive loss of small intestine. Which of the following statement(s) is/are true concerning his nutritional requirements and management? a. If at least 18 inches of residual small intestine survives, the patient may tolerate some form of enteral nutrition b. A nutritional regimen consisting of supplemental glutamine, growth hormone, and a modified high carbohydrate, low fat diet may be beneficial in this patient c. The regimen described above may decrease the cost of care d. TPN needs will increase after discontinuation of growth hormone

Description : A 16-year-old boy suffers a mid-gut volvulus with massive loss of small intestine. Which of the following statement(s) is/are true concerning his nutritional requirements and management? a. If ... above may decrease the cost of care d. TPN needs will increase after discontinuation of growth hormone

Last Answer : Answer: a, b, c Prior to the availability of TPN, most patients developing short bowel syndrome from either surgery or catastrophic event died. In selected patients, however, with ... the growth hormone did not increase TPN needs in patients once they had undergone successful gut rehabilitation

Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be masked by the hyponatremia. C. Oliguric renal failure is an unlikely complication. D. Rapid correction of the hyponatremia may prevent central pontine injury. E. This patient is best treated by restriction of water intake.

Description : Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be ... central pontine injury. E. This patient is best treated by restriction of water intake.

Last Answer : Answer: A DISCUSSION: Acute symptomatic hyponatremia is characterized by central nervous system signs of increased intracranial pressure. Changes in blood pressure and pulse are secondary to ... lead to central pontine myelinolysis. Oliguric renal failure may rapidly develop in severe hyponatremia

Which of the following is/are not associated with increased likelihood of infection after major elective surgery? A. Age over 70 years. B. Chronic malnutrition. C. Controlled diabetes mellitus. D. Long-term steroid use. E. Infection at a remote body site.

Description : Which of the following is/are not associated with increased likelihood of infection after major elective surgery? A. Age over 70 years. B. Chronic malnutrition. C. Controlled diabetes mellitus. D. Long-term steroid use. E. Infection at a remote body site.

Last Answer : Answer: C DISCUSSION: Controlled diabetes mellitus has been shown repeatedly not to be associated with increased likelihood of incisional infection provided one avoids operations on body parts ... site-are well-recognized adverse predictive factors and are identified in tables within the chapter

A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the following statement(s) is/are true concerning the patient’s management? a. Feeding into the stomach results in stimulation of the biliary/pancreatic axis which is probably trophic for small bowel b. Gastric secretions will dilute the feedings increasing the risk of diarrhea c. The major risk in this patient is tracheobronchial aspiration d. Placement of the feeding catheter through the pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Description : A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the ... pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Last Answer : Answer: a, c, d The use of transnasal feeding catheters for intragastric feeding or for duodenal intubation are popular adjuncts for providing nutritional support by the enteral route. The ... the fourth portion of the duodenum reduces the risk of regurgitation and aspiration of feeding formulas

The complement system consists of a series of serum proteins that exist in a quiescent or very low-level state of activation in the uninfected host. Which of the following statement(s) is/are true concerning complement activation? a. The alternate (properdin) pathway of complement activation can occur directly through contact with fungal or bacterial cell wall compounds b. Complement component fragments may serve to decrease vascular permeability c. Excessive complement activation can produce deleterious effects d. Fragments of certain complement components serve as chemoattractants to additional cellular components of the host defense mechanism

Description : The complement system consists of a series of serum proteins that exist in a quiescent or very low-level state of activation in the uninfected host. Which of the following ... certain complement components serve as chemoattractants to additional cellular components of the host defense mechanism

Last Answer : Answer: a, c, d Complement activation can occur through either classic or alternate (properdin) pathways, both of which eventuate in deposition of terminal complement pathway components on the ... and release of lysosomal enzymes that can directly damage certain target tissues, such as the lung

Which of the following statements concerning perioperative nutrition is true concerning the above-described patient? a. Since the patient’s weight had been stable with no preoperative nutritional deficit, 5% dextrose intravenous solutions are adequate for the initial postoperative source of nutrition b. Preoperative immunologic status should be determined including total peripheral lymphocyte count and delayed hypersensitivity reaction to determine skin-test response to common antigens c. Routine postoperative fluid administration with intravenous 5% glucose solutions can provide the calories to meet basal energy requirements d. A jejunal feeding catheter should be placed at the time of surgery for postoperative enteral feeding

Description : Which of the following statements concerning perioperative nutrition is true concerning the above-described patient? a. Since the patient's weight had been stable with no preoperative nutritional deficit ... feeding catheter should be placed at the time of surgery for postoperative enteral feeding

Last Answer : Answer: a Most patients undergoing elective operations are adequately nourished. Unless the patient has suffered significant preoperative malnutrition, characterized by weight loss greater than ... gastrointestinal surgery, this technique would not appear indicated in the patient described above

Increasing evidence has implicated gram-negative bacterial lipopolysaccharide (LPS endotoxin) as the portion of the gram-negative bacterial cell membrane responsible for many, if not all the toxic effects that occur during gram-negative bacterial sepsis. The following statement(s) is/are true concerning LPS and the host response. a. The LPS molecule can in itself cause physiologic responses similar to that seen during gram-negative bacterial sepsis b. LPS triggers host macrophages to release a variety of cytokines including TNF-a, IL-1a, and IL-1b, IL-6, and IFN-a c. Excessive cytokine production is not associated with detrimental consequences d. TNFa and IL-1b appear to be the primary mediators within the host, exerting deleterious effects on the host when excessive amounts reach the syst

Description : Increasing evidence has implicated gram-negative bacterial lipopolysaccharide (LPS endotoxin) as the portion of the gram-negative bacterial cell membrane responsible for many, if not all the ... host, exerting deleterious effects on the host when excessive amounts reach the systemic circulation

Last Answer : Answer: a, b, d The LPS molecule exerts diverse effects on the mammalian host. Immunologic responses to LPS include nonspecific polyclonal B-cell proliferation, macrophage activation and ... deleterious effects on the host only after large amounts are secreted and reach the systemic circulation

Which of the following statement(s) is/are true concerning methods of nutritional support? a. Optimal results for enteral feedings are achieved with approximately half of calories supplied as carbohydrate and half as fat b. Diarrhea is the most common complication of enteral feeds and is due to the high osmolarity of the carbohydrate components c. The hyperosmolar nature of parenteral fat solutions requires central venous administration d. Approximately 25–50% of calories should be provided as fat emulsion in patients receiving total parenteral nutrition

Description : Which of the following statement(s) is/are true concerning methods of nutritional support? a. Optimal results for enteral feedings are achieved with approximately half of calories supplied as ... -50% of calories should be provided as fat emulsion in patients receiving total parenteral nutrition

Last Answer : Answer: a, b, d Most formulas for enteral feeding range from 1.0 to 2 cal/ml and include 3 to 7% protein. Most of the calories are supplied as glucose or sucrose, so that the solutions ... up to 25 to 50% of calories each day as fat emulsion may optimize the delivery of this caloric delivery

A number of changes in trace mineral metabolism are noted during sepsis. Which of the following change(s) may be observed in a septic or trauma patient? a. Plasma iron levels are noted to decrease b. Plasma copper levels are noted to decrease c. Plasma serum zinc levels may decrease d. Administration of iron is appropriate

Description : A number of changes in trace mineral metabolism are noted during sepsis. Which of the following change(s) may be observed in a septic or trauma patient? a. Plasma iron levels are noted to ... are noted to decrease c. Plasma serum zinc levels may decrease d. Administration of iron is appropriate

Last Answer : Answer: a, c Changes in the balance of magnesium, inorganic phosphate, zinc, and potassium generally follow alterations in nitrogen balance. Although the iron-binding capacity of transferrin ... concentrations can be ascribed almost entirely to the levels of the ceruloplasmin produced by the liver

Which of the following statements(s) is/are true concerning human energy requirement? a. In normal subjects, less than 5% of basal energy requirement is spent on cardiac output and the work of breathing b. Mechanical ventilation can decrease the energy expenditure for normal respiration c. For a 70 kg male, average resting energy consumption is almost 1500 kcal/day d. Similar increases in energy expenditures are associated with elective surgery and trauma or thermal injury

Description : Which of the following statements(s) is/are true concerning human energy requirement? a. In normal subjects, less than 5% of basal energy requirement is spent on cardiac output and the ... d. Similar increases in energy expenditures are associated with elective surgery and trauma or thermal injury

Last Answer : Answer: a, c Basal energy requirements are measured with the subject at rest when no external work is being done; the energy is used mainly for transport and synthetic work within cells. A ... average-sized adult who sustains a major burn rarely may require more than 3500 kcal/day for maintenance

Which of the following statement(s) is/are true concerning the results of a National Institute of Health Consensus Conference on venous thrombosis and low-dose heparin prophylaxis? a. The odds of developing deep venous thrombosis with low-dose heparin prophylaxis decreases by 67% b. The risk of pulmonary embolism is decreased by almost 50% c. There is no increase in mortality from other causes found in patients treated with low-dose heparin d. There was no difference in the incidence of bleeding complications

Description : Which of the following statement(s) is/are true concerning the results of a National Institute of Health Consensus Conference on venous thrombosis and low-dose heparin prophylaxis? a. The odds of ... treated with low-dose heparin d. There was no difference in the incidence of bleeding complications

Last Answer : Answer: a, b, c In a metaanalysis of 70 randomized trials in 16,000 patients comparing low-dose heparin prophylaxis with standard therapy, the odds of developing deep venous thrombosis ... Similarly, the effectiveness of prophylaxis was not influenced by either two or three times daily dosage

Bleeding complications are frequently associated with fibrinolytic therapy. Which of the following statement(s) concerning complications of fibrinolytic therapy is/are true? a. Careful monitoring of prothrombin time and aPTT time are necessary to avoid bleeding complications b. A level of serum fibrinogen less than 100 mg/dl is associated with an increased risk of bleeding c. Recent (less than 10 days) major surgery is a contraindication to systemic but not regional fibrinolytic therapy d. A patient with a cerebrovascular event occurring less than two months ago can be treated with fibrinolytic therapy if head CT scan is normal

Description : Bleeding complications are frequently associated with fibrinolytic therapy. Which of the following statement(s) concerning complications of fibrinolytic therapy is/are true? a. Careful monitoring of prothrombin time ... months ago can be treated with fibrinolytic therapy if head CT scan is normal

Last Answer : Answer: b Fibrinolytic therapy induces a hemostatic defect through a combination of factors. Hypofibrinogenemia and fibrin degradation products inhibit fibrin polymerization and, in combination ... is considered a major relative contraindication to either regional or systemic thrombolytic therapy

Which of the following metabolic effects may be observed in patients with sepsis? a. Increased gluconeogenesis b. Accelerated proteolysis c. Increased lipolysis d. Impaired gut metabolism of glutamine

Description : Which of the following metabolic effects may be observed in patients with sepsis? a. Increased gluconeogenesis b. Accelerated proteolysis c. Increased lipolysis d. Impaired gut metabolism of glutamine

Last Answer : Answer: a, b, c, d A number of metabolic responses to sepsis have been defined. Glucose production is increased in infected patients which appears to be additive to the ... metabolism of lipids from peripheral fat stores is especially prominent during a period of inadequate nutritional support

A 65-year old patient has colon carcinoma metastatic to the liver and lungs. He has had a weight loss of 10 kg. Cytokine-dependent tumor cachexia is attributable to which of the following? a. Increased glucose uptake and increased glycogen breakdown occur in this circumstance. b. Suppressed activity of lipoprotein lipase results from TNFa c. TNFa stimulates lipolysis d. The differentiation process of pre-adipocytes is impaired e. Partial reversal of differentiated adipocytes to pre-adipocyte morphology and gene expression occurs

Description : A 65-year old patient has colon carcinoma metastatic to the liver and lungs. He has had a weight loss of 10 kg. Cytokine-dependent tumor cachexia is attributable to which of the ... is impaired e. Partial reversal of differentiated adipocytes to pre-adipocyte morphology and gene expression occurs

Last Answer : Answer: a, b, c, d, e Tumor cachexia appears to be mediated by TNFa. Lipopolysaccharide (LPS), as well as other cytokines, activate a variety of inflammatory cells, most ... chronic syndromes of anorexia, weight loss, and cachexia that are associated with both chronic infection and malignancy

Which of the following statement(s) is/are true concerning the outcome in patients with acute renal failure? a. Mortality for ischemic acute tubular necrosis without other organ failure is approximately 6% b. Multiple organ failure complicated with acute renal failure is associated with mortality ranging from 50% to 90% c. Recovery of renal function after six weeks is unlikely d. There is no difference in survival between oliguric and nonoliguric renal failure

Description : Which of the following statement(s) is/are true concerning the outcome in patients with acute renal failure? a. Mortality for ischemic acute tubular necrosis without other organ failure is ... is unlikely d. There is no difference in survival between oliguric and nonoliguric renal failure

Last Answer : Answer: a, b, c Survival of patients with acute renal failure is a function of the successful treatment of the primary disease from which the renal failure was derived. The mortality ... is unlikely. Nonoliguric renal failure is usually limited in its extent and is almost always reversible

A 32-year-old man suffers a spinal cord injury with a resultant paraplegia in a motorcycle accident. He presents to the emergency room with hypotension. Which of the following statement(s) is/are true concerning his diagnosis and management? a. The low blood pressure can be assumed to be due to neurogenic shock b. The sole cause of hypotension is the loss of sympathetic input to the venous system c. Despite significant hypotension, secondary organ injury will be uncommon d. There is no role for pharmacologic intervention to maintain blood pressure

Description : A 32-year-old man suffers a spinal cord injury with a resultant paraplegia in a motorcycle accident. He presents to the emergency room with hypotension. Which of the following statement(s) is/ ... injury will be uncommon d. There is no role for pharmacologic intervention to maintain blood pressure

Last Answer : Answer: c Neurogenic shock results from interruption of sympathetic vasomotor input and develops after spinal cord injury, spinal anesthesia, and severe head injury. Under normal conditions, baseline ... the cause is not neurogenic and search for occult blood loss or cardiogenic causes of shock

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

Description : The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention ... the energy source is seen after a burn injury; interventions are instituted to decrease catabolism.

Last Answer : a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

Which of the following statement(s) is/are true concerning ischemia reperfusion injury? a. During ischemia, ATP degradation results in increased plasma and intracellular levels of hypoxanthine and xanthene b. Oxygen free radicals such as the superoxide radical are involved in the expression of the proinflammatory phenotype of endothelial cells, macrophages and neutrophils c. The intracellular adhesion molecule-1 (ICAN-1) contributes to injury and disruption of the endothelial lining, with extensive capillary leak and resultant interstitial edema d. Animal models have demonstrated that passive immunization with antibodies to neutrophil adhesive complex lessen the ischemic/reperfusion microvascular injury

Description : Which of the following statement(s) is/are true concerning ischemia reperfusion injury? a. During ischemia, ATP degradation results in increased plasma and intracellular levels of ... immunization with antibodies to neutrophil adhesive complex lessen the ischemic/reperfusion microvascular injury

Last Answer : Answer: a, b, c, d During the ischemia and hypoperfusion phase, degradation of ATP stores essential to maintain cell integrity and significant loss of diffusible ... either the neutrophil adhesive complex or the endothelial selectins dramatically lessens ischemia/reperfusion microvascular injury

Which of the following statements about delivery-dependent oxygen consumption are true? A. Below the critical oxygen delivery (D(overdot)O 2crit), one would expect to see a decrease in the lactate-pyruvate ratio. B. D(overdot)O 2crit may be increased in patients with sepsis. C. A desirable goal in the treatment of shock is to achieve delivery-independent oxygen consumption. D. The oxygen extraction ratio remains constant as long as oxygen delivery remains above D(overdot)O 2crit.

Description : Which of the following statements about delivery-dependent oxygen consumption are true? A. Below the critical oxygen delivery (D(overdot)O 2crit), one would expect to see a decrease in the ... oxygen extraction ratio remains constant as long as oxygen delivery remains above D(overdot)O 2crit.

Last Answer : Answer: BC DISCUSSION: Oxygen consumption is said to be delivery dependent below a critical point, D(overdot)O 2crit, at which anaerobic metabolism supervenes. Above this point, oxygen ... the therapeutic benefit of trying to achieve supranormal oxygen delivery has not been firmly established

Which of the following statement(s) is/are true concerning the assessment of protein reserve? a. Conventional serum proteins such as albumin and globulin are early indicators of malnutrition b. The total lymphocyte count reflects immune status and not nutrition c. Antigen skin testing reflects patient immunity and not nutrition d. Measurement of urea excretion in urine can be used as a measurement of protein breakdown

Description : Which of the following statement(s) is/are true concerning the assessment of protein reserve? a. Conventional serum proteins such as albumin and globulin are early indicators of malnutrition b. The ... d. Measurement of urea excretion in urine can be used as a measurement of protein breakdown

Last Answer : Answer: d Since protein is the functional and structural chemical of the body, most nutritional assessment techniques are estimates of protein reserves. The actual nitrogen balance can ... patients convert from reactive to anergic, and reactivity can be restored by nutritional repletion

Rank the clinical scenarios in order of greatest likelihood of serious postoperative pulmonary complications. A. Transabdominal hysterectomy in an obese woman that requires 3 hours of anesthesia time. B. Right middle lobectomy for bronchogenic cancer in a 65-year-old smoker. C. Vagotomy and pyloroplasty for chronic duodenal ulcer disease in a 50-year-old who had chest film findings of old, healed tuberculosis. D. Right hemicolectomy in an obese 60-year-old smoker. E. Modified radical mastectomy in a 58-year-old woman who is obese.

Description : Rank the clinical scenarios in order of greatest likelihood of serious postoperative pulmonary complications. A. Transabdominal hysterectomy in an obese woman that requires 3 hours of anesthesia time. B. Right ... smoker. E. Modified radical mastectomy in a 58-year-old woman who is obese.

Last Answer : Answer: BDCAE DISCUSSION: If one considers the constellation of risk factors for pulmonary complications that is provided in tabular form in the accompanying chapter, one should ... is associated with relatively little postoperative pain, and provides free and unrestricted respiratory function

Which of the following statements about septic shock are true? A. A circulating myocardial depressant factor may account for the cardiac dysfunction sometimes seen with shock due to sepsis or SIRS. B. A cardiac index (CI) of 6 liters per minute per square meter of body surface, a pulmonary capillary wedge pressure of 15 mm. Hg, and a systemic vascular resistance index (SVRI) of 800 dynes-sec/(cm 5-m 2) is a hemodynamic profile consistent with septic shock. C. An increase in SvO 2 in septic patients may be explained by the finding of anatomic arteriovenous shunts. D. Results of human trials employing antimediator therapy, such as antiendotoxin antibodies, IL-1 receptor antagonist, and tumor necrosis factor (TNF) antibodies, have confirmed animal studies that demonstrate a significant im

Description : Which of the following statements about septic shock are true? A. A circulating myocardial depressant factor may account for the cardiac dysfunction sometimes seen with shock due to sepsis or ... animal studies that demonstrate a significant improvement in survival with the use of such agents.

Last Answer : Answer: AB DISCUSSION: Shock due to sepsis or SIRS frequently manifests as a hyperdynamic cardiovascular response, consisting of an elevated CI and a decreased SVR or SVRI. Occasionally, ... been encouraging thus far in human clinical trials, despite the promising results from many animal studies

Which of the following statement(s) is/are true concerning the neuroendocrine responses to shock? a. Sympathetic nerve endings release epinephrine which is responsible for greater than 80% of systemic vascular resistance b. Endogenous epinephrine is the primary contributor to systemic vascular resistance c. Increased pancreatic secretion of glucagon contributes to glucose intolerance associated with injury and sepsis d. The renin-angiotensin axis further augments the sympathetic-mediated vasoconstriction

Description : Which of the following statement(s) is/are true concerning the neuroendocrine responses to shock? a. Sympathetic nerve endings release epinephrine which is responsible for greater than 80% ... injury and sepsis d. The renin-angiotensin axis further augments the sympathetic-mediated vasoconstriction

Last Answer : Answer: c, d The neuroendocrine response to shock attempts to achieve restoration of effective blood volume, mobilization of metabolic substrates, and maintenance of central ... . Angiotensin II is an extremely effective vasoconstrictor that further augments sympathetic-mediated vasoconstriction

Which of the following statement(s) concerning intravenous nutritional support is/are true? a. Concentrations of glucose no higher than 5% should be used to avoid peripheral vein sclerosis b. A major disadvantage of the peripheral technique is limited caloric delivery c. If total parenteral nutrition is required, access to the superior vena cava via the external jugular vein is the most suitable site d. Venous thrombosis is an uncommon complication for long-term central vein catheterization

Description : Which of the following statement(s) concerning intravenous nutritional support is/are true? a. Concentrations of glucose no higher than 5% should be used to avoid peripheral vein sclerosis ... suitable site d. Venous thrombosis is an uncommon complication for long-term central vein catheterization

Last Answer : Answer: b Although peripheral access can be used for intravenous nutrition, the major disadvantage of this technique is limited caloric delivery to meet catabolic demands within tolerated fluid ... studies that use phlebography or radionucleotide venography indicate the incidence is as high as 35%

Which of the following statement(s) is/are true concerning septic shock? a. The clinical picture of gram negative septic shock is specifically different than shock associated with other infectious agents b. The circulatory derangements of septic shock precede the development of metabolic abnormalities c. Splanchnic vascular resistance falls in similar fashion to overall systemic vascular resistance d. Despite normal mechanisms of intrinsic expansion of the circulating blood volume, exogenous volume resuscitation is necessary

Description : Which of the following statement(s) is/are true concerning septic shock? a. The clinical picture of gram negative septic shock is specifically different than shock associated with ... mechanisms of intrinsic expansion of the circulating blood volume, exogenous volume resuscitation is necessary

Last Answer : Answer: d The clinical findings in sepsis and septic shock represent the host response to infection. Gram-positive and gram-negative bacteria, viruses, fungi, rickettsiae, and ... intravascular volume, exogenous volume resuscitation must be provided to restore venous return and ventricular filling

Which of the following are determinants of the host response to surgical stress? a. Gender b. Age c. Nutritional status d. Body composition

Description : Which of the following are determinants of the host response to surgical stress? a. Gender b. Age c. Nutritional status d. Body composition

Last Answer : Answer: a, b, c, d The pattern of physiologic changes elicited in response to surgical stress results from the specific interaction of an individual patient with a stressful stimulus. Several ... net loss of nitrogen after major elective abdominal surgery generally being lower in women than in men

In “catabolic” surgical patients, which of the following changes in body composition do not occur? A. Lean body mass increases. B. Total body water increases. C. Adipose tissue decreases. D. Body weight decreases.

Description : In “catabolic” surgical patients, which of the following changes in body composition do not occur? A. Lean body mass increases. B. Total body water increases. C. Adipose tissue decreases. D. Body weight decreases.

Last Answer : Answer: A DISCUSSION: Lean body mass represents the body compartment that contains protein. Because critical illness stimulates proteolysis and increased excretion of body nitrogen, this compartment is consistently ... of body weight, an increase in total body water, and a decrease in body fat

Reconstitution of the epithelial barrier (epithelialization) begins within hours of the initial injury. Which of the following statement(s) is/are true concerning the process of epithelialization? a. Bacteria, protein exudate, and necrotic tissue all will compromise this process b. Epithelial cells exhibit contact proliferation c. Epithelialization occurs only from the margins of the wound d. Visible scarring can occur only when the injury extends deeper than the superficial dermis

Description : Reconstitution of the epithelial barrier (epithelialization) begins within hours of the initial injury. Which of the following statement(s) is/are true concerning the process of epithelialization? a. ... d. Visible scarring can occur only when the injury extends deeper than the superficial dermis

Last Answer : Answer: a, d The initial step of epithelialization involves epithelial cells from the basal layer of the wound edge flattening and migrating across the wound, completing wound coverage within 24- ... abrasions and burns may scar significantly. Whenever the dermis is incised, a scar will form

The following statement(s) is/are true concerning host defense mechanisms to intraabdominal infection. a. Bacterial clearance can occur via translymphatic absorption b. Phagocytic activity and bacterial killing can occur via resident phagocytic cells and an influx of PMNs c. A fibrinogen-rich inflammatory exudate is released into the peritoneal cavity, trapping large numbers of bacteria and other particulate matter d. Perforations of a bowel may be walled off but are seldom sealed by the omentum and other mobile viscera

Description : The following statement(s) is/are true concerning host defense mechanisms to intraabdominal infection. a. Bacterial clearance can occur via translymphatic absorption b. Phagocytic activity and bacterial killing can ... may be walled off but are seldom sealed by the omentum and other mobile viscera

Last Answer : Answer: a, b, c The introduction of microorganisms into the normally sterile peritoneal environment invoke several potent specialized host antimicrobial defense mechanisms. Bacterial clearance, ... the contaminated enteric contents walled off, preventing continued soilage of the peritoneal cavity

Which of the following statements are true of a patient with hyperglycemia and hyponatremia? A. The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood glucose. B. With normal renal function, this patient is likely to be volume overloaded. C. Proper fluid therapy would be unlikely to include potassium administration. D. Insulin administration will increase the potassium content of cells. E. Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Description : Which of the following statements are true of a patient with hyperglycemia and hyponatremia? A. The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood ... . E. Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Last Answer : Answer: D DISCUSSION: Each 100-mg. per 100 ml. elevation in blood glucose causes a fall in serum sodium concentration of approximately 2 mEq. per liter. Excess serum glucose ... correction of the patient's associated acidosis produce movement of potassium ions into the intracellular compartment

Cytokines which play an important role in the metabolic response to injury include: a. Tumor necrosis factor—a (TNF) b. Interleukin-1 (IL-1) c. Interleukin-6 (IL-6) d. Interferon-g

Description : Cytokines which play an important role in the metabolic response to injury include: a. Tumor necrosis factor—a (TNF) b. Interleukin-1 (IL-1) c. Interleukin-6 (IL-6) d. Interferon-g

Last Answer : Answer: a, b, c, d TNF or cachetin is considered the primary mediator of the systemic effects of endotoxin, producing anorexia, fever, tachypnea, and tachycardia at low doses and hypotension, ... infected sells. IFN-g has the ability to upregulate the number of TNF receptors on various cell types