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

Which of the following are determinants of the host response to surgical stress? a. Gender b. Age c. Nutritional status d. Body composition
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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 factors specific to the patient may determine the nature of the host response to stress. Body composition is a major determinant of the metabolic responses observed during surgical illness. Post-traumatic nitrogen excretion is directly related to the size of the body protein mass. A strong relationship between protein depletion and postoperative complications has been demonstrated in nonseptic, nonimmunocompromised patients undergoing elective major gastrointestinal surgery. Protein-depleted patients have significantly lower preoperative respiratory muscle strength and vital capacity, increased incidence of postoperative pneumonia, and longer postoperative hospital stay. Impaired wound healing and respiratory, hepatic, and muscle function in protein-depleted patients awaiting surgery has also been reported. Many of the changes in the metabolic responses to surgical illnesses that occur with aging can be attributed to alterations in body composition and to long-standing patterns of physical activity. Fat mass tends to increase with age and muscle mass tends to decrease. Loss of strength that accompanies immobility, starvation and acute surgical illness may have marked functional consequences. Furthermore, the prevalence of cardiovascular and pulmonary diseases increase with age. Thus, the delivery of oxygen to tissues may be impaired in the elderly. Finally, observed differences in metabolic responses of men and women generally reflect differences in body composition. Lean body mass is lower in women than in men; and this difference is thought to account for the net loss of nitrogen after major elective abdominal surgery generally being lower in women than in men
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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

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

The neurohormonal arm of the stress response is well defined. Less is known about the inflammatory arm mediated primarily by cytokines. Which of the following statement(s) is/are true concerning this arm of the surgical stress response? a. Cytokines primarily work locally via direct cell-to-cell communication b. Cytokines are never detectable in the systemic bloodstream c. Cytokines are produced only by immune cells attracted to the site of injury d. Cytokine release may stimulate the release of other cytokines leading to an important cascade of events

Description : The neurohormonal arm of the stress response is well defined. Less is known about the inflammatory arm mediated primarily by cytokines. Which of the following statement(s) is/are true ... Cytokine release may stimulate the release of other cytokines leading to an important cascade of events

Last Answer : Answer: a, d Cytokines, which are produced at the site of injury by endothelial cells and by diverse immune cells throughout the body, also occupy a pivotal position in the stress response ... act as hormones and spill over into the systemic circulation and become detectable in the bloodstream

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

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)

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

Which of the following are not determinants of a postoperative cardiac complication? A. Myocardial infarct 4 months previously. B. Clinical evidence of congestive heart failure in a patient with 8.5 gm. per dl. hemoglobin. C. Premature atrial or ventricular contractions on electrocardiogram. D. A harsh aortic systolic murmur. E. Age over 70 years.

Description : Which of the following are not determinants of a postoperative cardiac complication? A. Myocardial infarct 4 months previously. B. Clinical evidence of congestive heart failure in a patient with 8.5 gm ... on electrocardiogram. D. A harsh aortic systolic murmur. E. Age over 70 years.

Last Answer : Answer: B DISCUSSION: Clinical evidence of congestive heart failure in a patient with 8.5 gm. per dl. hemoglobin concentration is a misleading sign. Evidence of congestive ... or ventricular contractions on the electrocardiogram are less strong determinants of a postoperative cardiac complication

Which of the following statement(s) is/are true concerning excessive scarring processes? a. Keloids occur randomly regardless of gender or race b. Hypertrophic scars and keloid are histologically different c. Keloids tend to develop early and hypertrophic scars late after the surgical injury d. Simple reexcision and closure of a hypertrophic scar can be useful in certain situations such as a wound closed by secondary intention

Description : Which of the following statement(s) is/are true concerning excessive scarring processes? a. Keloids occur randomly regardless of gender or race b. Hypertrophic scars and keloid are histologically different ... scar can be useful in certain situations such as a wound closed by secondary intention

Last Answer : Answer: d True keloids are uncommon and occur predominantly in dark skinned people with a genetic predisposition for keloid formation. In most cases, the gene appears to be ... subside. Hypertrophic scars usually develop within the first month after wounding and often subside gradually

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

Determinants of cerebral blood flow include: A. Preoperative neurologic dysfunction. B. Arterial CO 2 tension. C. Arterial O 2 tension. D. Systemic arterial pressure. E. All of the above.

Description : Determinants of cerebral blood flow include: A. Preoperative neurologic dysfunction. B. Arterial CO 2 tension. C. Arterial O 2 tension. D. Systemic arterial pressure. E. All of the above.

Last Answer : Answer: BCD DISCUSSION: Determinants of cerebral blood flow include arterial CO 2 and O 2 tensions, systemic arterial pressure, and temperature. Other factors that may affect cerebral ... and intracranial pressure are head position, jugular venous obstruction, and positive end-expiratory pressure

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

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 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 statements about total body water composition are correct? A. Females and obese persons have an increased percentage of body water. B. Increased muscle mass is associated with decreased total body water. C. Newborn infants have the greatest proportion of total body water. D. Total body water decreases steadily with age. E. Any person's percentage of body water is subject to wide physiologic variation.

Description : Which of the following statements about total body water composition are correct? A. Females and obese persons have an increased percentage of body water. B. Increased muscle mass is associated with ... age. E. Any person's percentage of body water is subject to wide physiologic variation.

Last Answer : Answer: CD DISCUSSION: Since fat contains little water, lean persons with a proportionately greater muscle mass have a greater than expected volume of total body water. Likewise, the ... decreases steadily and significantly with age. The actual figure for a healthy person is remarkably constant

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

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

Advantages of epidural analgesia include: A. Earlier mobilization after surgery. B. Earlier return of bowel function. C. Shorter hospitalizations. D. Decreased stress response to surgery. E. All of the above.

Description : Advantages of epidural analgesia include: A. Earlier mobilization after surgery. B. Earlier return of bowel function. C. Shorter hospitalizations. D. Decreased stress response to surgery. E. All of the above.

Last Answer : Answer: E DISCUSSION: Epidural analgesia include excellent pain relief, decreased sedation with more rapid recovery to presurgical levels of consciousness, earlier mobilization after surgery ... , shorter hospitalizations, and decreased morbidity have all been associated with epidural analgesia

The treatment of the following patient should include: a. Initial empiric therapy directed against both aerobes and anaerobes b. The addition of anti-fungal therapy in an elderly patient c. A minimum of two weeks of antibiotic therapy is indicated d. The addition of appropriate antibiotic therapy has made surgical therapy unnecessary in such cases e. Either a single agent or combination therapy is appropriate if the agents selected possess activity against both aerobic and anaerobic bacteria

Description : The treatment of the following patient should include: a. Initial empiric therapy directed against both aerobes and anaerobes b. The addition of anti-fungal therapy in an elderly patient ... therapy is appropriate if the agents selected possess activity against both aerobic and anaerobic bacteria

Last Answer : Answer: a, e The primary treatment for a perforated viscus is surgical, however antimicrobial therapy is an extremely important adjunct. Empiric antibiotic therapy for secondary ... whereas longer periods are indicated for immunosuppressed patients and with patients with extensive contamination

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

The use of prophylactic antibiotics has become commonplace. Which of the following statement(s) is/are true concerning the prophylactic use of antibiotics? a. The appropriate use of prophylactic antibiotics must include the initiation of the agent prior to the surgical procedure b. Continuing the antibiotic into the postoperative period has led to improved results in antibiotic prophylaxis c. The prophylactic administration of broad-spectrum agents (third-generation cephalosporins) has been shown to be particularly advantageous d. The topical use of antimicrobial agents is of no advantage in the prophylactic setting

Description : The use of prophylactic antibiotics has become commonplace. Which of the following statement(s) is/are true concerning the prophylactic use of antibiotics? a. The appropriate use of prophylactic ... d. The topical use of antimicrobial agents is of no advantage in the prophylactic setting

Last Answer : Answer: a Intravenous administration of an antibiotic is clearly indicated for patients undergoing clean contaminated operations. These antibiotics should be administered prior to surgery ... of antimicrobial agents is equivalent to the administration of intravenous antimicrobial agent antibiotics

Which of the following statement(s) is/are true concerning the management of a patient with hemophilia A undergoing an elective surgical operation? a. Concentrates of factor VIII should be given several days prior to elective surgery b. The half-life of factor VIII concentrates is less than 24 hours c. A dose of 40–50 IU/kg of factor VIII concentrate should be given prior to the planned surgical procedure d. Factor VIII concentration administration should be given for the first 24 hours after surgery but may then be stopped if no abnormal bleeding has been observed e. A new recombinant preparation of factor VIII offers the advantage of being virus-free

Description : Which of the following statement(s) is/are true concerning the management of a patient with hemophilia A undergoing an elective surgical operation? a. Concentrates of factor VIII should be given ... observed e. A new recombinant preparation of factor VIII offers the advantage of being virus-free

Last Answer : Answer: b, c, e Although the half-life of factor VIII is 2.9 days in normal individuals, the half-life of factor VIII concentrates is 9 to l8 hours. Levels of 80% to ... infection in the hemophilia population. A new recombinant preparation of factor VIII offers the advantage of being virus-free

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

Which of the following statement(s) is/are correct concerning the management of an open wound? a. Frequent surgical debridement is usually necessary b. Water irrigation can effectively debride most wounds c. Hydrogen peroxide is particularly useful in the management of open wounds d. A number of the newer dressing products have clearly been shown to promote wound healing compared to simple moist occlusive dressing

Description : Which of the following statement(s) is/are correct concerning the management of an open wound? a. Frequent surgical debridement is usually necessary b. Water irrigation can effectively debride ... products have clearly been shown to promote wound healing compared to simple moist occlusive dressing

Last Answer : Answer: b Although there are numerous dressing products commercially available at present, no treatment has been demonstrated to improve healing beyond that of standard treatment which adheres to basic ... healing is achieved, there has been no evidence that one product is better than another

Which of the following surgical techniques lead to improved wound healing? a. Atraumatic handling of tissue b. Approximation of underlying fatty tissue to obliterate dead space c. Protecting the wound from water for at least one week d. Meticulous hemostasis

Description : Which of the following surgical techniques lead to improved wound healing? a. Atraumatic handling of tissue b. Approximation of underlying fatty tissue to obliterate dead space c. Protecting the wound from water for at least one week d. Meticulous hemostasis

Last Answer : Answer: a, d There are numerous practical implications for the care of wounds and surgical incisions. Meticulous hemostasis reduces the inflammation of phagocytosis necessary to clear the wound of ... or shower one or two days after surgery actually serves useful purpose in debriding the wound

A number of prospective clinical trials have addressed the role of total parenteral nutrition in the cancer patient. The results have been somewhat conflicting. Which of the following statement(s) have been proven correct by prospective trials? a. Preoperative TPN is beneficial in surgical patients with severe preoperative nutrition b. Postoperative TPN is of value following pancreatic resection c. Routine use of perioperative (including prior to the procedure) TPN is of benefit in patients undergoing hepatectomy for hepatoma d. TPN is of no benefit in patients undergoing bone marrow transplant

Description : A number of prospective clinical trials have addressed the role of total parenteral nutrition in the cancer patient. The results have been somewhat conflicting. Which of the following statement(s) ... hepatectomy for hepatoma d. TPN is of no benefit in patients undergoing bone marrow transplant

Last Answer : Answer: a, c Numerous clinical trials have failed to yield a consensus with regard to the efficacy of TPN in cancer patients. In 1991, a multicenter VA cooperative trial demonstrated ... patients receiving bone marrow transplantation has also been shown to be a valuable component of overall care

Ketorolac: A. Is a nonsteroidal anti-inflammatory drug (NSAID) approved for intravenous, intramuscular, and oral administration. B. Can be used indefinitely for postoperative analgesia. C. Can cause renal dysfunction. D. May decrease surgical blood loss.

Description : Ketorolac: A. Is a nonsteroidal anti-inflammatory drug (NSAID) approved for intravenous, intramuscular, and oral administration. B. Can be used indefinitely for postoperative analgesia. C. Can cause renal dysfunction. D. May decrease surgical blood loss.

Last Answer : Answer: AC DISCUSSION: Ketorolac tromethamine, an NSAID, is approved by the FDA for intravenous, intramuscular, and oral administration. The agent is an effective analgesic with minimal side ... Additionally, it is recommended that ketorolac should not be used for more than 5 consecutive days

Absolute indications for a double-lumen endotracheal tube during thoracic surgery are: A. Massive hemorrhage from one lung. B. Unilateral lung infection. C. Facilitation of surgical exposure. D. Unilateral bronchopulmonary lavage. E. All of the above.

Description : Absolute indications for a double-lumen endotracheal tube during thoracic surgery are: A. Massive hemorrhage from one lung. B. Unilateral lung infection. C. Facilitation of surgical exposure. D. Unilateral bronchopulmonary lavage. E. All of the above.

Last Answer : Answer: ABD DISCUSSION: The absolute indications for a double-lumen tube are for the purposes of protecting one lung from the other. These indications include ventilation with ... include facilitation of surgical exposure, for pneumonectomy, upper lobectomy, and thoracic aneurysm repair

Muscle relaxants can be used for which of the following? A. To facilitate intubation. B. To provide optimal surgical conditions. C. To optimize ventilator support. D. To provide sedation.

Description : Muscle relaxants can be used for which of the following? A. To facilitate intubation. B. To provide optimal surgical conditions. C. To optimize ventilator support. D. To provide sedation.

Last Answer : Answer: ABC DISCUSSION: Muscle relaxants are administered to facilitate endotracheal intubation, to provide the surgeon with optimal working conditions during anesthesia, and to optimize ... amnesia. Therefore, muscle paralysis should not be performed without sedation or general anesthesia

What is the major determinant in an individual patient's risk for perioperative complications? A. The surgical procedure. B. The length of the surgical procedure. C. The anesthetic technique (e.g., general, regional). D. The length of anesthesia. E. All of the above.

Description : What is the major determinant in an individual patient's risk for perioperative complications? A. The surgical procedure. B. The length of the surgical procedure. C. The anesthetic technique (e.g., general, regional). D. The length of anesthesia. E. All of the above.

Last Answer : Answer: A DISCUSSION: The planned surgical procedure is the major determining factor in assessing an individual patient's risk for perioperative complications and in deciding which anesthetic technique will be ... than anyone else the extent of the operation and the length of time it will require

A modified amino acid solution with increased equimolar branched-chain amino acids and decreased aromatic amino acids has been proposed for patients with hepatic insufficiency. Which of the following statements is/are true? A. This formulation is proposed for the use of patients with fulminant hepatitis. B. Nitrogen balance is achieved in such patients with amounts of 40 gm. of amino acids per 24 hours. C. The use of 80 to 100 gm. of such solutions is associated with hepatic encephalopathy. D. In some studies of surgical patients, improvements in mortality have been reported.

Description : A modified amino acid solution with increased equimolar branched-chain amino acids and decreased aromatic amino acids has been proposed for patients with hepatic insufficiency. Which of the following ... D. In some studies of surgical patients, improvements in mortality have been reported.

Last Answer : Answer: D DISCUSSION: The use of modified amino acid solutions is based on the false neurotransmitter hypothesis of the cause of hepatic coma. According to this hypothesis, the imbalance ... in a group of patients with cirrhosis, decreasing morbidity and showing a trend toward decreased 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

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

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) 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%

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

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

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

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

The transfusion of fresh frozen plasma (FFP) is indicated for which of the following reasons? A. Volume replacement. B. As a nutritional supplement. C. Specific coagulation factor deficiency with an abnormal prothrombin time (PT) and/or an abnormal activated partial thromboplastin time (APTT). D. For the correction of abnormal PT secondary to warfarin therapy, vitamin K deficiency, or liver disease.

Description : The transfusion of fresh frozen plasma (FFP) is indicated for which of the following reasons? A. Volume replacement. B. As a nutritional supplement. C. Specific coagulation factor deficiency ... the correction of abnormal PT secondary to warfarin therapy, vitamin K deficiency, or liver disease.

Last Answer : Answer: CD DISCUSSION: The use of FFP as a volume expander is not indicated. There are currently several preparations (both crystalloid and colloid) that are equally effective and do not carry the infectious and ... vitamin K-dependent factors II, VII, IX, and X, as well as protein C and protein S

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

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

There are two properties of the cell necessary to maintain nonequilibrium cellular composition; the first is selectivity and the second is energy conversion. Which of the following statement(s) is/are true concerning energy converting transport? a. The site of energy conversion and transport in the plasma membrane involves the phospholipid component b. The Na+-K++-ATPase derives energy from hydrolysis of extracellular ATP c. In some systems, energy inherent in the transmembrane ion gradient can be used to drive transport of a second species d. Examples of species transported via secondary active transport include hydrogen ions, calcium, amino acids and glucose

Description : There are two properties of the cell necessary to maintain nonequilibrium cellular composition; the first is selectivity and the second is energy conversion. Which of the following statement(s ... transported via secondary active transport include hydrogen ions, calcium, amino acids and glucose

Last Answer : Answer: c, d The selectivity of the plasma membrane, although impressive, cannot account for the nonequilibrium composition of living cells. A cell can be maintained in a nonequilibrium state only by ... to drive the transport of a second species such as protons, calcium, amino acids, or glucose

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

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

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

Which of the following physical findings are associated with the various classes of hemorrhagic shock? a. Mild shock (< 20% blood volume): Pallor, cool extremities, diminished capillary refill and diaphoresis b. Moderate shock (20%–40% blood volume): All of the above plus tachycardia and hypotension c. Severe shock (> 40% blood volume): Systemic hypotension, changes in mental status, tachycardia, oliguria d. All of the above

Description : Which of the following physical findings are associated with the various classes of hemorrhagic shock? a. Mild shock (< 20% blood volume): Pallor, cool extremities, diminished capillary refill and ... ): Systemic hypotension, changes in mental status, tachycardia, oliguria d. All of the above

Last Answer : Answer: a, c PHYSICAL FINDINGS IN HEMORRHAGIC SHOCK* Moderate Mild (40% Blood Volume) Blood Volume) Blood Volume) Pallor Pallor Pallor Cool extremities Cool extremities Cool extremities ... hypotension Mental status changes * Alcohol or drug intoxication may alter physical findings

Answer: b, c The body contains fuel reserves which it can mobilize and utilize during times of starvation or stress. By far the greatest energy component is fat, which is calorically dense since it provides about 9 calories/gram. Body protein comprises the next largest mass of utilizable energy, but amino acids yield only about 4 kcal/gram. Unlike fat reserves, body protein is not a storage form of energy but rather serves as a structural functional component of the body; loss of body protein, if severe, is associated with functional consequences. Glycogen stored in muscle and liver and free glucose have a trivial caloric value of less than 1000 kcal for a 70 kg male

Description : Answer: b, c The body contains fuel reserves which it can mobilize and utilize during times of starvation or stress. By far the greatest energy component is fat, which is calorically dense since it ... liver and free glucose have a trivial caloric value of less than 1000 kcal for a 70 kg male

Last Answer : Which of the following statement(s) is/are true concerning the indications and administration of nutritional support to cancer patients? a. Preoperative nutritional support should be provided to all ... total parenteral nutrition solutions maintain integrity of the small bowel e. None of the above

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

New treatment modalities designed to modulate host defense mechanisms that have been demonstrated conclusively to be of benefit include: a. Gut decontamination b. Anti-LPS antibody c. Anti-TNF antibody d. Thymopentin e. None of the above

Description : New treatment modalities designed to modulate host defense mechanisms that have been demonstrated conclusively to be of benefit include: a. Gut decontamination b. Anti-LPS antibody c. Anti-TNF antibody d. Thymopentin e. None of the above

Last Answer : Answer: e Selective gut decontamination involves the use of orally administered antibiotics that achieve a high intraluminal level directed against gram-negative aerobes and yeast, leaving ... but conclusive evidence that concurrent reduction of infection-related mortality occurs is not available

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