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

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
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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% to 60% above normal. If the patient’s metabolic rate is already elevated to a maximal extent because of severe injury, no further increase will be observed. In patients with only a slightly accelerated rate of oxygen consumption, the presence of infection will cause a rise in metabolic rate added to the preexisting state. A portion of the increase in metabolism may be ascribed to increase in reaction rate associated with fever. Calculations suggest that the metabolic rate increases 10% to 13% for each elevation of 1°C in central temperature
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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

Description : 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 ... requirements, caloric requirements should be distributed at a ratio of 70% as glucose and 30% as fat

Last Answer : 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

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 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

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

Which of the following statement(s) is/are true concerning oxygen kinetics in a critically ill, febrile patient? a. Oxygen consumption will likely exceed three times normal b. The high cardiac output and pulse rate are designed to increase oxygen delivery c. The hyperdynamic response may actually increase oxygen delivery to exceed the increase in oxygen consumption d. The patient can maintain adequate compensation as long as the oxygen delivery/oxygen consumption rate is greater than 2:1

Description : Which of the following statement(s) is/are true concerning oxygen kinetics in a critically ill, febrile patient? a. Oxygen consumption will likely exceed three times normal b. The high cardiac ... adequate compensation as long as the oxygen delivery/oxygen consumption rate is greater than 2:1

Last Answer : Answer: b, d In critically ill patients oxygen consumption may be elevated or depressed, but slight to moderate elevations in oxygen consumption is the most common abnormality in critically ill patients. ... however, and the patient will remain stable as long as the ratio is greater than 2:1

Which of the following statement(s) is/are true concerning tumor necrosis factor (TNF)? a. TNF is a product of activated macrophages secreted in response to contact with endotoxin or lipopolysaccharide, antibody complexes, or inflammatory stimuli b. The liver and gut appear to be a major source of TNF following hypoperfusion c. Circulating levels of TNF correlate well with severity of tissue injury in shock d. Recently completed clinical trials of anti-TNF antibody in septic patients shows a marked improvement in survival

Description : Which of the following statement(s) is/are true concerning tumor necrosis factor (TNF)? a. TNF is a product of activated macrophages secreted in response to contact with endotoxin or ... completed clinical trials of anti-TNF antibody in septic patients shows a marked improvement in survival

Last Answer : Answer: a, b Tumor necrosis factor (TNF), a protein product of activated macrophages, is secreted in response to contact with endotoxin or lipopolysaccharide, antibody complexes, or ... patients utilizing infusion of monoclonal antibodies to the TNF molecule have shown no overall survival benefit

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

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 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

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

A 55-year-old renal transplant patient has been hospitalized in a Surgical Intensive Care Unit, receiving a prolonged course of antibiotics following an attack of acute cholecystitis. The following statement(s) is/are true concerning his management. a. Due to the potential risk of Candida infection, prophylaxis with oral nystatin should be instituted early in the patient’s course b. A Candida urinary tract infection should be treated with systemic amphotericin B c. Changes of Candida retinitis are of little significance d. The presence of a virulent Candida bacteremia should suggest a dosage reduction in immunosuppressive agents until the infection can be adequately controlled

Description : A 55-year-old renal transplant patient has been hospitalized in a Surgical Intensive Care Unit, receiving a prolonged course of antibiotics following an attack of acute cholecystitis. The ... suggest a dosage reduction in immunosuppressive agents until the infection can be adequately controlled

Last Answer : Answer: a, d Infections due to fungal pathogens have become increasingly common during the past decade, frequently occurring in patients undergoing prolonged hospitalization in the Surgical ... agents should be discontinued until evidence of infection is absolutely controlled or is eradicated

Which of the following statement(s) is/are true concerning the autoregulation necessary to maintain oxygen consumption and oxygen delivery? a. A change in oxygen consumption is followed by a proportionate change in oxygen delivery b. A change in oxygen delivery is followed by a change in oxygen consumption c. Increases in oxygen delivery are due solely to an increase in cardiac output d. The normal ratio of oxygen delivery to consumption is 2:1

Description : Which of the following statement(s) is/are true concerning the autoregulation necessary to maintain oxygen consumption and oxygen delivery? a. A change in oxygen consumption is followed by a proportionate ... increase in cardiac output d. The normal ratio of oxygen delivery to consumption is 2:1

Last Answer : Answer: a The relationships between oxygen consumption and oxygen delivery represent one of the most interesting regulation systems in homeostasis. First of all, if one of the three components ... in oxygen consumption. The normal ratio of oxygen delivery to consumption is approximately 5:1

A striking feature of living cells is a marked difference between the composition of the cytosol and the extracellular milieu. Which of the following statement(s) concerning the mechanisms of maintenance of these differences is/are true? a. The cell membrane is able to maintain a 10,000 fold gradient between the extracellular concentration of ionized calcium and the intracellular concentration b. The key to these differences is the fact that the plasma membrane is normally impermeable to sodium, potassium and calcium c. The selectivity of biologic membranes is highly consistent and seldom changes d. The selectivity of cell membranes relates only to ions and not organic compounds

Description : A striking feature of living cells is a marked difference between the composition of the cytosol and the extracellular milieu. Which of the following statement(s) concerning the mechanisms of maintenance ... d. The selectivity of cell membranes relates only to ions and not organic compounds

Last Answer : Answer: a The survival of the cell requires that cytosolic composition be maintained within narrow limits, despite the constant influx of nutrients and the simultaneous outflow of waste. A ... be altered drastically as a result of regulatory or signaling processes that occur within the cell

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 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

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 the vascular response to injury? a. Vasoconstriction is an early event in the response to injury b. Vasodilatation is a detrimental response to injury with normal body processes working to avoid this process c. Vascular permeability is maintained to prevent further cellular injury d. Histamine, prostaglandin E2 (PGE2) and prostacyclin (PGI2) are important mediators of local vasoconstriction

Description : Which of the following statement(s) is/are true concerning the vascular response to injury? a. Vasoconstriction is an early event in the response to injury b. Vasodilatation is a ... Histamine, prostaglandin E2 (PGE2) and prostacyclin (PGI2) are important mediators of local vasoconstriction

Last Answer : Answer: a After wounding, there is transient vasoconstriction mediated by catecholamines, thromboxane, and prostaglandin F2 (PGF2a). This period of vasoconstriction lasts for only five to ten minutes. Once ... and mast cells and enhance the egress of cells and substrate into the wound and tissue

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

A 55-year-old male undergoes a total abdominal colectomy. Which of the following statement(s) is/are true concerning the hormonal response to the surgical procedure? a. Adrenocorticotropic hormone (ACTH) is secreted from the anterior pituitary gland b. ACTH stimulation results in elevation of serum cortisol levels for up to a week after the operation c. An increased secretion of aldosterone and ADH may contribute to postoperative fluid retention d. An increase in serum insulin and a fall in glucagon accelerate hepatic glucose production and maintain gluconeogenesis

Description : A 55-year-old male undergoes a total abdominal colectomy. Which of the following statement(s) is/are true concerning the hormonal response to the surgical procedure? a. Adrenocorticotropic ... in serum insulin and a fall in glucagon accelerate hepatic glucose production and maintain gluconeogenesis

Last Answer : Answer: a, c One of the earliest consequence of a surgical procedure is the rise in levels of circulating cortisol that occur in response to a sudden outpouring of ACTH ... hepatic glucose production, and, with other hormones (epinephrine and glucocorticoids), gluconeogenesis is maintained

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

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

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)

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

Which of the following statement(s) is/are true concerning the effects of MOFS? a. Pulmonary dysfunction tends to arise early and may resolve within 7 to 10 days b. Unless the precipitating insult has prompted oliguric acute tubular necrosis, renal function tends to be maintained early in the course of MOFS c. Although hepatic dysfunction is common with MOFS, the GI tract plays little role in this process d. Intercurrent nosocomial infection, most commonly pulmonary, is a common complication providing a “second hit” to the patient

Description : Which of the following statement(s) is/are true concerning the effects of MOFS? a. Pulmonary dysfunction tends to arise early and may resolve within 7 to 10 days b. Unless the precipitating ... infection, most commonly pulmonary, is a common complication providing a second hit to the patient

Last Answer : Answer: a, b, d Pulmonary dysfunction typically arises early in the development of systemic inflammation and may represent mild relatively localized acute lung injury or it may be a prelude ... is marked by progressive rise in serum bilirubin levels after a latent period of several days

The following statement(s) is/are true concerning viral infections. a. The most common post-transplantation viral infections are caused by herpes viruses and include CMV and herpes simplex virus b. Viral infections occur at equal frequency anytime during the post-transplantation period c. CMV infection in the post-transplant patient is most likely a pulmonary process d. Herpes simplex virus (HSV) infection primarily presents with a mononucleosis-type syndrome with fever, lethargy, and cough

Description : The following statement(s) is/are true concerning viral infections. a. The most common post-transplantation viral infections are caused by herpes viruses and include CMV and herpes simplex virus ... HSV) infection primarily presents with a mononucleosis-type syndrome with fever, lethargy, and cough

Last Answer : Answer: a, c, Solid organ transplant patients are prone to develop viral infection by virtue of exogenous immunosuppression. The most common post-transplantation viral infections are those ... transplant patient or as painful herpes zoster in patients who have previously developed chicken pox

Which of the following statement(s) is/are true concerning heparin-associated thrombocytopenia? a. Heparin-associated thrombocytopenia occurs only in the face of over anticoagulation with heparin b. Severe thrombocytopenia (platelet count less than 100,000) is seen in less than 10% of patients treated with heparin c. Heparin-associated thrombocytopenia is due to the aggregation of platelets and may result in thrombosis or embolic episodes d. Heparin-associated thrombocytopenia may be seen within hours of initiation of heparin therapy

Description : Which of the following statement(s) is/are true concerning heparin-associated thrombocytopenia? a. Heparin-associated thrombocytopenia occurs only in the face of over anticoagulation with heparin b. ... d. Heparin-associated thrombocytopenia may be seen within hours of initiation of heparin therapy

Last Answer : Answer: b, c Heparin-associated thrombocytopenia occurs in 0.6% to 30% of patients who receive heparin, although severe thrombocytopenia (platelet counts less than 100,000) is seen in ... as coating on pulmonary artery catheters or low rate infusion into arterial catheters may cause this syndrome

The following statement(s) is/are true concerning necrotizing fascitis. a. Mortality rates as high as 40% can be expected b. The infection involves only the superficial fascia, sparing the deep muscular fascia c. An impaired immune system is a common factor predisposing to this condition d. The infection is usually polymicrobial e. Necrotizing fascitis is most likely to develop in the face of impaired fascial blood supply

Description : The following statement(s) is/are true concerning necrotizing fascitis. a. Mortality rates as high as 40% can be expected b. The infection involves only the superficial fascia, sparing the deep ... e. Necrotizing fascitis is most likely to develop in the face of impaired fascial blood supply

Last Answer : Answer: a, c, d, e Necrotizing fascitis is an uncommon infection of the deep and superficial fascia that is associated with mortality as high as 40% in many series. ... fulminant and is frequently associated with cellulitis, myositis, fascitis, and bacteremia with attendant high mortality

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

The use of antibiotics can be based on either the clinical course of a patient without the benefit of well-defined microbiologic data (empiric therapy), or targeted at specific identified pathogens once sensitivity reports are available (directed therapy). The following statement(s) is/are true concerning these therapies. a. The issue of toxic side effects of antibiotics is only important in dealing with emperic therapy b. Single agent therapy is generally inferior to specific multi-drug therapy (aminoglycoside plus an antianaerobic agent) for the treatment of secondary bacterial peritonitis due to appendicitis, diverticulitis, penetrating gastrointestinal injury, or anastomotic leak c. With the empiric use of antibiotics, a diligent search for the septic source should be undertaken and co

Description : The use of antibiotics can be based on either the clinical course of a patient without the benefit of well-defined microbiologic data (empiric therapy), or targeted at ... which polymicrobial infection is identified, specifically-directed treatment for the predominant organism is satisfactory

Last Answer : Answer: c The use of empiric therapy without the benefit of well-defined microbiologic data is appropriate when there is sufficient clinical evidence to support the diagnosis such that it would ... components of the infection if the body site is such that these microorganisms may be present

Which of the following statement(s) is/are true concerning the remodeling phase of wound healing? a. Total collagen content increases steadily through this phase b. The normal adult ratio of collagen is approximately 4:1 of type I to type III collagen. c. Eventually a scar will achieve the strength of unwounded skin d. The proteoglycans are responsible for the ground substance of the extracellular matrix

Description : Which of the following statement(s) is/are true concerning the remodeling phase of wound healing? a. Total collagen content increases steadily through this phase b. The normal adult ratio ... unwounded skin d. The proteoglycans are responsible for the ground substance of the extracellular matrix

Last Answer : Answer: b, d The transition from the proliferative phase to the remodeling phase of wound healing is defined by reaching collagen equilibrium. Collagen accumulation within the wound becomes maximal by ... in strength for six months or more, eventually reaching 70% of the strength of unwounded skin

Which of the following statement(s) is/are true concerning oxygen delivery? a. The amount of oxygen delivered to peripheral tissues is dependent upon the oxygen content in arterial blood and cardiac output b. Oxygen content is commonly measured in arterial blood c. The normal arterial-venous difference is 4 cc O2/dL d. Normal systemic oxygen delivery for a typical adult is approximately 1000 cc/min

Description : Which of the following statement(s) is/are true concerning oxygen delivery? a. The amount of oxygen delivered to peripheral tissues is dependent upon the oxygen content in arterial blood and cardiac ... O2/dL d. Normal systemic oxygen delivery for a typical adult is approximately 1000 cc/min

Last Answer : Answer: a, c, d The amount of oxygen that is delivered to peripheral tissues is the product of the oxygen content in arterial blood times the cardiac output. Normally, oxygen content of arterial blood is ... of venous blood is 16 cc/dL. Hence, the normal arterial-venous difference is 4 cc O2/dL

Which of the following statement(s) is/are true concerning the pulmonary response to shock? a. The acute pulmonary vascular response to shock differs markedly from that of systemic vasculature b. The pulmonary edema of ARDS occurs in the face of elevated left heart pressures c. The initial physiologic changes of ARDS involve the capillary endothelial cells and the type I pneumocyte d. Mechanisms proposed in the pathogenesis of ARDS include injury from mediators of inflammation elsewhere and from activated cellular elements e. A decrease in lung compliance may result from the loss of type I pneumocytes

Description : Which of the following statement(s) is/are true concerning the pulmonary response to shock? a. The acute pulmonary vascular response to shock differs markedly from that of systemic vasculature b. The ... elements e. A decrease in lung compliance may result from the loss of type I pneumocytes

Last Answer : Answer: c, d, e Contributing pathophysiologic processes to the pulmonary manifestations of shock include the pulmonary component of the cardiovascular response, disruption of the normal ... injury from mediators of inflammation elaborated elsewhere, and from activated cellular blood elements

Which of the following statement(s) concerning laboratory studies used in monitoring a patient with intravenous heparinization is/are correct? a. The platelet count should be followed because of the risk of heparin-associated thrombocytopenia b. The prothrombin time should be observed if prolonged treatment is necessary c. The activated partial thromboplastin time (aPTT) should be maintained at approximately 1.5 times normal d. The serum creatinine should be measured daily to allow adjustments in dose based on renal function

Description : Which of the following statement(s) concerning laboratory studies used in monitoring a patient with intravenous heparinization is/are correct? a. The platelet count should be followed because of the ... serum creatinine should be measured daily to allow adjustments in dose based on renal function

Last Answer : Answer: a, c In monitoring the effect of heparin, an activated partial thromboplastin time (aPTT) of 1.5 control or a thrombin clotting time (TCT) of 2 times control reflects adequate ... system. Therefore the dose of heparin need not be adjusted in cases of liver or renal dysfunction

Which of the following statement(s) is/are true concerning oxygen consumption (O2)? a. O2 is normally 100–120 cc2/m2/min b. Resting O2 is controlled by the level of thyroid and catecholamine hormones c. Under steady state conditions the amount of oxygen consumed exceeds the amount of oxygen taken up by the pulmonary capillaries d. O2 is dependent on the status of pulmonary function

Description : Which of the following statement(s) is/are true concerning oxygen consumption (O2)? a. O2 is normally 100-120 cc2/m2/min b. Resting O2 is controlled by the level of thyroid and catecholamine ... of oxygen taken up by the pulmonary capillaries d. O2 is dependent on the status of pulmonary function

Last Answer : Answer: a, b Oxygen consumed in the process of metabolism is expressed as the volume of oxygen per minute (O2). O2 is normally 100-120 cc2/m2/min, or 200 cc/min for a typical adult. ... , so we measure O2 across the lung and assume that it is exactly the amount consumed in the systemic metabolism

Interleukin-6 is recognized as the cytokine primarily responsible for the alteration in hepatic protein synthesis recognized as the acute phase response. Which of the following statement(s) is/are true concerning acute phase protein response to surgical stress? a. Glucocorticoid hormones inhibit this response b. Proteins such as albumin and transferrin which serve in serum transport are generally increased in this response c. Examples of acute phase proteins include fibrinogen and C-reactive protein d. In general, the physiologic role of acute phase proteins are to reduce the systemic effects of tissue damage

Description : Interleukin-6 is recognized as the cytokine primarily responsible for the alteration in hepatic protein synthesis recognized as the acute phase response. Which of the following statement(s) is/are true ... physiologic role of acute phase proteins are to reduce the systemic effects of tissue damage

Last Answer : Answer: c, d IL-6 is now recognized at the cytokine primarily responsible for the alteration in hepatic synthesis recognized as the acute phase response. Glucocorticoid hormones augment ... that generally inhibit the tissue destruction that is associated with the local initiation of inflammation

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

There are a multitude of various dressings available. Which of the following statement(s) is/are true concerning options for surgical dressings? a. Hydrocolloids, such as karaya compounds, offer the primary advantage of increased absorptive ability b. Films, such as Op-site, provide a water impermeable environment to achieve a dry wound c. Impregnates are fine gauze impregnated with a variety of substances such as antibiotics or moisturizing agents that adhere tightly to the wound and do not require a secondary dressing d. Absorptive powders and paste are highly useful in debriding necrotic and fibrous material from wounds and absorbing wound serum

Description : There are a multitude of various dressings available. Which of the following statement(s) is/are true concerning options for surgical dressings? a. Hydrocolloids, such as karaya compounds, offer ... are highly useful in debriding necrotic and fibrous material from wounds and absorbing wound serum

Last Answer : Answer: a, d Although the simplest dressing of gauze and tape combined with the use of antibacterial ointment can achieve moist wound healing in most patients. A multitude of other ... agents have high absorbency for tissue wound fluid and debride necrotic and fibrous material from the wound

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

The following statement(s) is/are true concerning HIV infection. a. Initial screening with ELISA is highly sensitive but can be associated with a false positive rate of 25% b. Treatment with azidothymidine (AZD) appears to prolong survival when administered early in the disease c. Predisposition to infection in HIV infection is primarily due to reduction in the number of helper T cells d. Common infections in patients with AIDS are Pneumocystis, carinii pneumonia, CMV pneumonitis, Cryptococcus meningitis, and disseminated infection due to atypical mycobacteria

Description : The following statement(s) is/are true concerning HIV infection. a. Initial screening with ELISA is highly sensitive but can be associated with a false positive rate of 25% b. ... , carinii pneumonia, CMV pneumonitis, Cryptococcus meningitis, and disseminated infection due to atypical mycobacteria

Last Answer : Answer: b, c, d Acquired immunodeficiency syndrome (AIDS) is a syndrome caused by the human retrovirus (HIV-1) that infects T lymphocytes and causes severe immunosuppression. Individuals who ... to prolong survival when administered early in the course of disease and is considered routine therapy

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

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 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 statement(s) is/are true concerning the microvascular and cellular response to shock? a. Osmodically induced mobilization of intracellular fluid is the initial response to restore intravascular volume b. With larger volume hemorrhagic shock deterioration of normal cellular transmembrane potential occurs resulting in an increase in extracellular sodium and water c. The accumulation of anaerobic metabolites override normal homeostatic vasomotor tone and contribute to the maladaptive vasodilatation d. Abnormal intracellular calcium homeostasis may contribute to the cellular dysfunction of shock

Description : Which of the following statement(s) is/are true concerning the microvascular and cellular response to shock? a. Osmodically induced mobilization of intracellular fluid is the initial ... d. Abnormal intracellular calcium homeostasis may contribute to the cellular dysfunction of shock

Last Answer : Answer: c, d Moderate hypovolemia results in a relatively rapid spontaneous restitution of intravascular volume through expansion of the plasma space. This plasma expansion by ... potassium pump. Cellular dysfunction also appears to be related to abnormal intracellular calcium homeostasis

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 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

Thrombolytic therapy has become a useful adjunct in the management of peripheral arterial occlusion. In this setting, direct intraarterial administration rather than intravenous has been advocated to decrease the risk of systemic bleeding. Which of the following true statement(s) concerning the use of thrombolytic agents for arterial occlusion is/are true? a. A standard technique involves infusing high-dose urokinase, 4000 units per minute for 1–2 hours, directly into the clot by a catheter embedded in the thrombus b. If progress is made, further fibrinolytic therapy is given at 1000 to 2000 units per minute until clot lysis has occurred c. The usual infusion time by the above-stated technique is usually in excess of 24 hours d. Successful clot lysis occurs more frequently in arterial graf

Description : Thrombolytic therapy has become a useful adjunct in the management of peripheral arterial occlusion. In this setting, direct intraarterial administration rather than intravenous has been advocated ... may be indicated for situations where complete clot evacuation cannot be accomplished surgically

Last Answer : Answer: a, b, e The most popular method for intraarterial thrombolytic therapy for arterial occlusion involves passing a guidewire through the thrombus with arteriographic guidance and ... acute arterial occlusion) or when distal vasculative is occluded and precludes appropriate inflow patency

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

Which of the following statement(s) is/are true concerning hemophilia A? a. Hemophilia A is inherited as a sex-linked recessive deficiency of factor VIII b. A positive family history for bleeding disorders present in all patients c. Laboratory tests reveal a prolongation of aPTT, prothrombin time (PT), thrombin clotting time and platelet aggregation d. Spontaneous bleeding is unusual with factor VIII levels greater than 10% of normal

Description : Which of the following statement(s) is/are true concerning hemophilia A? a. Hemophilia A is inherited as a sex-linked recessive deficiency of factor VIII b. A positive family history for ... platelet aggregation d. Spontaneous bleeding is unusual with factor VIII levels greater than 10% of normal

Last Answer : Answer: a, d Hemophilia A is inherited as a sex-linked recessive deficiency of factor VIII although 0% of cases are secondary to spontaneous mutation. The incidence of this abnormality is ... factor levels as low as 1% have been noted and patients are at risk for spontaneous bleeding

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

Fatty acids are a major energy source for the body. Which of the following statement(s) is/are true concerning the use of fatty acids as an energy source? a. Fatty acids are stored in adipocytes as triglycerides b. Hormone-sensitive lipase is present only in adipose tissue c. Fatty acids are released into the circulation traveling freely in plasma d. Approximately 25% of total nonprotein caloric needs supplied via total parenteral nutrition should be in the form of fat

Description : Fatty acids are a major energy source for the body. Which of the following statement(s) is/are true concerning the use of fatty acids as an energy source? a. Fatty acids are stored in ... 25% of total nonprotein caloric needs supplied via total parenteral nutrition should be in the form of fat

Last Answer : Answer: a, b, d In most tissues, fatty acids are readily oxidized for energy. They are especially important energy sources for the heart, liver and skeletal muscle. In ... administered to patients receiving total parenteral nutrition should comprise about 5-30% of total nonprotein caloric needs