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

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
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Answer: b, c  A number of complications of TPN can occur which can be divided into three types: mechanical, metabolic, and infectious
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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 statement(s) is/are true concerning the results of a National Institute of Health Consensus Conference on venous thrombosis and low-dose heparin prophylaxis? a. The odds of developing deep venous thrombosis with low-dose heparin prophylaxis decreases by 67% b. The risk of pulmonary embolism is decreased by almost 50% c. There is no increase in mortality from other causes found in patients treated with low-dose heparin d. There was no difference in the incidence of bleeding complications

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

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

Which of the following statements are true of elevated–anion gap metabolic acidosis? A. Hypoperfusion from the shock state rarely produces an elevated anion gap. B. Retention of sulfuric and phosphoric acids may lead to this form of acidosis. C. Copious diarrhea does not produce this condition. D. Rapid volume expansion may produce this form of acidosis. E. Use of lactated Ringer's solution is inappropriate in the treatment of lactic acidosis.

Description : Which of the following statements are true of elevated-anion gap metabolic acidosis? A. Hypoperfusion from the shock state rarely produces an elevated anion gap. B. Retention of sulfuric and phosphoric ... E. Use of lactated Ringer's solution is inappropriate in the treatment of lactic acidosis.

Last Answer : Answer: BC DISCUSSION: An elevated anion gap may be produced by lactic acidosis from shock or by retention of inorganic acids from uremia. Lactated Ringer's solution rapidly corrects the ... . Bicarbonate loss from diarrhea and dilutional acidosis are non-anion gap types of metabolic acidosis

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 is true of loss of gastrointestinal secretions? A. Gastric losses are best replaced with a balanced salt solution. B. Potassium supplementation is unnecessary in replacement of gastric secretions. C. Bicarbonate wasting is an unusual complication of a high-volume pancreatic fistula. D. Balanced salt solution is a reasonable replacement fluid for a small bowel fistula. E. A patient with persistent vomiting usually requires hyperchloremic replacement fluids.

Description : Which of the following is true of loss of gastrointestinal secretions? A. Gastric losses are best replaced with a balanced salt solution. B. Potassium supplementation is unnecessary in ... bowel fistula. E. A patient with persistent vomiting usually requires hyperchloremic replacement fluids.

Last Answer : Answer: DE DISCUSSION: Gastric secretions are relatively high in chloride and potassium. Other than an isolated pancreatic fistula, gastrointestinal tract losses below the pylorus ... Although potassium concentrations are low, copious losses require potassium supplementation to prevent hypokalemia

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

Essential fatty acid deficiency may complicate total parenteral nutrition (TPN). Which of the following statements are true? A. Essential fatty acid deficiency may be prevented by the administration of 1% to 2% of total calories as fat emulsion. B. Fat-free parenteral nutrition results in the appearance of plasma abnormalities, indicating essential fatty acid deficiency, within 7 to 10 days of initiation. C. An abnormal plasma eicosatrienoic-arachidonic acid ratio is always associated with essential fatty acid deficiency. D. Following initiation of fat-free parenteral nutrition, dry, scaly skin associated with a maculopapular rash indicates essential fatty acid deficiency.

Description : Essential fatty acid deficiency may complicate total parenteral nutrition (TPN). Which of the following statements are true? A. Essential fatty acid deficiency may be prevented by the ... , dry, scaly skin associated with a maculopapular rash indicates essential fatty acid deficiency.

Last Answer : Answer: BD DISCUSSION: Biochemical evidence of essential fatty acid deficiency may occur as early as 7 to 10 days following initiation of fat-free parenteral nutrition. The decrease in ... essential to the diagnosis of essential fatty acid deficiency, but this plasma abnormality is often present

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

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

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

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

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

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

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

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

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

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

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

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

Which of the following statements about the presence of gallstones in diabetes patients is/are correct? A. Gallstones occur with the same frequency in diabetes patients as in the healthy population. B. The presence of gallstones, regardless of the presence of symptoms, is an indication for cholecystectomy in a diabetes patient. C. Diabetes patients with gallstones and chronic biliary pain should be managed nonoperatively with chemical dissolution and/or lithotripsy because of severe complicating medical conditions and a high operative risk. D. The presence of diabetes and gallstones places the patient at high risk for pancreatic cancer. E. Diabetes patients with symptomatic gallstones should have prompt elective cholecystectomy, to avoid the complications of acute cholecystitis and g

Description : Which of the following statements about the presence of gallstones in diabetes patients is/are correct? A. Gallstones occur with the same frequency in diabetes patients as in the ... have prompt elective cholecystectomy, to avoid the complications of acute cholecystitis and gallbladder necrosis.

Last Answer : Answer: E DISCUSSION: Gallstones have been found to be very prevalent in patients with type II (non-insulin-dependent) diabetes mellitus, perhaps related to the dyslipoproteinemia in ... added mortality associated with it. There is no causal relationship between diabetes and pancreatic cancer

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

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

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

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

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

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

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

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

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

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

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

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

A 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

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)

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

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

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

Which of the following statements about respiratory acidosis are true? A. Compensation occurs by a shift of chloride out of the red blood cells. B. Renal compensation occurs rapidly. C. Retention of bicarbonate and increased ammonia formation are normal compensatory mechanisms. D. Narcotic administration is an unusual cause of respiratory acidosis. E. The ratio of bicarbonate to carbonic acid is less than 20:1.

Description : Which of the following statements about respiratory acidosis are true? A. Compensation occurs by a shift of chloride out of the red blood cells. B. Renal compensation occurs rapidly. C. Retention of ... of respiratory acidosis. E. The ratio of bicarbonate to carbonic acid is less than 20:1.

Last Answer : Answer: CE DISCUSSION: Renal compensation for acute hypoventilation is relatively slow. Depression of the respiratory center by morphine can lead to respiratory acidosis. Renal retention of bicarbonate, ... into red cells combine to increase the ratio of bicarbonate to carbonic acid to 20:1

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

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

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

All of the following are true about neurogenic shock except: A. There is a decrease in systemic vascular resistance and an increase in venous capacitance. B. Tachycardia or bradycardia may be observed, along with hypotension. C. The use of an alpha agonist such as phenylephrine is the mainstay of treatment. D. Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic shock.

Description : All of the following are true about neurogenic shock except: A. There is a decrease in systemic vascular resistance and an increase in venous capacitance. B. Tachycardia or bradycardia may be ... Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic shock.

Last Answer : Answer: C DISCUSSION: Neurogenic shock occurs when severe head injury, spinal cord injury, or pharmacologic sympathetic blockade leads to sympathetic denervation and loss of vasomotor tone. ... of treatment. The use of alpha-adrenergic agonist is infrequently necessary to treat neurogenic shock

Appropriate guidelines for the use of TPN in cancer patients include: a. Long-term TPN in patients with rapid progressive tumor growth unresponsive to other therapy b. Mildly malnourished patients undergoing surgery for a curable cancer c. Preoperatively administered TPN prior to surgery or other therapy in patients with severe malnutrition d. Patients in whom treatment toxicity precludes the use of enteral nutrition

Description : Appropriate guidelines for the use of TPN in cancer patients include: a. Long-term TPN in patients with rapid progressive tumor growth unresponsive to other therapy b. Mildly malnourished ... with severe malnutrition d. Patients in whom treatment toxicity precludes the use of enteral nutrition

Last Answer : Answer: c, d As a general rule, the most important factor to consider when making decisions about the use of TPN in patients with cancer is the response of the tumor to antineoplastic ... . Long-term TPN is not indicated with rapidly progressive tumor growth which is unresponsive to such therapy

Which of the following statements about hypertension in diabetes patients is/are correct? A. Hypertension worsens the macrovascular disease of diabetes patients. B. Hypertension accelerates the progression of diabetic nephropathy. C. Hypertension is associated with sodium retention in diabetes patients. D. Angiotensin-converting enzyme (ACE) inhibitors should be used in all patients with chronic hyperglycemia, regardless of the presence of hypertension. E. Diuretics, as single-drug therapy, are not indicated in the treatment of hypertension in diabetes patients.

Description : Which of the following statements about hypertension in diabetes patients is/are correct? A. Hypertension worsens the macrovascular disease of diabetes patients. B. Hypertension accelerates the ... single-drug therapy, are not indicated in the treatment of hypertension in diabetes patients.

Last Answer : Answer: ABCDE DISCUSSION: All of the answers listed are correct. By damaging endothelial cells, hypertension worsens macrovascular disease in all patients but especially in diabetics. Hypertension ... is not indicated because the chronic state of dehydration in such patients may become worse

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

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

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 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

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

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

Useful steps to optimize systemic oxygen delivery include: a. Maintaining mean arterial blood pressure between 50 and 90 mm Hg b. Optimizing PEEP levels by monitoring mixed venous saturation c. Turning the patient prone d. Sedation or paralysis

Description : Useful steps to optimize systemic oxygen delivery include: a. Maintaining mean arterial blood pressure between 50 and 90 mm Hg b. Optimizing PEEP levels by monitoring mixed venous saturation c. Turning the patient prone d. Sedation or paralysis

Last Answer : Answer: a, b, c, d Optimizing systemic oxygen delivery in relationship to oxygen requirement is the primary goal of management. Improving oxygenation of the blood itself by ... sedation, and establishing muscular paralysis decrease oxygen consumption, and decrease the need for oxygen delivery

In patients receiving massive blood transfusion for acute blood loss, which of the following is/are correct? A. Packed red blood cells and crystalloid solution should be infused to restore oxygen-carrying capacity and intravascular volume. B. Two units of FFP should be given with every 5 units of packed red blood cells in most cases. C. A “six pack” of platelets should be administered with every 10 units of packed red blood cells in most cases. D. One to two ampules of sodium bicarbonate should be administered with every 5 units of packed red blood cells to avoid acidosis. E. One ampule of calcium chloride should be administered with every 5 units of packed red blood cells to avoid hypocalcemia.

Description : In patients receiving massive blood transfusion for acute blood loss, which of the following is/are correct? A. Packed red blood cells and crystalloid solution should be infused to restore oxygen ... should be administered with every 5 units of packed red blood cells to avoid hypocalcemia.

Last Answer : Answer: A DISCUSSION: Patients who are suffering from acute blood loss require crystalloid resuscitation as the initial maneuver to restore intravascular volume and re-establish vital signs. If 2 to 3 liters ... when the infusion of blood proceeds at a rate exceeding 1 to 2 units every 5 minutes

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

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

Mini-dose heparin has been shown to be useful in the prophylaxis of postoperative venous thrombosis. Mechanism(s) by which low-dose heparin is/are thought to protect against venous thrombosis include: a. Enhancement of antithrombin III activity b. A decrease in thrombin availability c. Inhibition of platelet aggregation and subsequent platelet release action d. A mild prolongation of activated partial thromboplastin time

Description : Mini-dose heparin has been shown to be useful in the prophylaxis of postoperative venous thrombosis. Mechanism(s) by which low-dose heparin is/are thought to protect against venous ... aggregation and subsequent platelet release action d. A mild prolongation of activated partial thromboplastin time

Last Answer : Answer: a, b, c Low-dose heparin is thought to protect against venous thrombosis through three different mechanisms. First, antithrombin III activity with its inhibition of activated Factor X is ... release reaction. The standard doses of heparin administered (5000 units bid) does not affect aPTT

A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route/method of administration would be most suitable. (a) Sublingual (b) Oral (c) Intravenous bolus injection (d) Slow intravenous infusion

Description : A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route/ ... (a) Sublingual (b) Oral (c) Intravenous bolus injection (d) Slow intravenous infusion

Last Answer : Ans: D

A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route/method of administration would be most suitable: A. Sublingual B. Oral C. Intravenous bolus injection D. Slow intravenous infusion

Description : A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route ... suitable: A. Sublingual B. Oral C. Intravenous bolus injection D. Slow intravenous infusion

Last Answer : D. Slow intravenous infusion

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 statement(s) is/are true concerning the role of glutamine in total parenteral nutrition? a. Glutamine is an essential amino acid b. Glutamine appears to be of primary benefit in critical illness c. Glutamine is included in most standard TPN solutions d. Glutamine is the primary energy source for intestinal mucosal cells of the small bowel and colon

Description : Which of the following statement(s) is/are true concerning the role of glutamine in total parenteral nutrition? a. Glutamine is an essential amino acid b. Glutamine appears to be of primary ... . Glutamine is the primary energy source for intestinal mucosal cells of the small bowel and colon

Last Answer : Answer: b Glutamine is the most studied gut-specific nutrient. Glutamine has been classified as a nonessential or nutritionally dispensable amino acid since glutamine can be synthesized in adequate ... . In contrast to glutamine, short chain fatty acids are primary energy source for colonocytes

Which of the following statement(s) is/are true concerning the diagnosis and management of hypovolemic shock? a. A fall in hematocrit or hemoglobin always accompanies hemorrhagic shock b. The treatment of shock is generic regardless of the etiology c. Pharmacologic intervention to increase myocardial contractility in hypovolemic shock is an important part the early management d. Complications are less frequent after treatment of hemorrhagic shock than septic or traumatic shock

Description : Which of the following statement(s) is/are true concerning the diagnosis and management of hypovolemic shock? a. A fall in hematocrit or hemoglobin always accompanies hemorrhagic shock b. The ... d. Complications are less frequent after treatment of hemorrhagic shock than septic or traumatic shock

Last Answer : Answer: d Hypovolemic shock is readily diagnosed when there is an obvious source of volume loss and overt signs of hemodynamic instability and increased adrenergic output are present. ... response systems and consequences of their disseminated, indiscriminate cellular injury can be quite profound

Tests of coagulation are used to monitor anticoagulation treatment and detect intrinsic abnormalities in coagulation. Which of the following statement(s) is/are true concerning coagulation tests? a. Prothrombin time (PT) measures both the intrinsic and extrinsic clotting pathways and fibrinogen b. Activated partial thromboplastin time (aPTT) can be used to monitor both oral anticoagulation with Warfarin and intravenous anticoagulation with heparin c. Thrombin clotting time (TCT) is a measurement of the time it takes for exogenously administered thrombin to turn plasma fibrinogen into fibrin clot d. Whole blood activated clotting time (ACT) is a measurement of the ability of whole blood to clot and is used to monitor heparin levels intraoperatively during cardiovascular and peripheral vascu

Description : Tests of coagulation are used to monitor anticoagulation treatment and detect intrinsic abnormalities in coagulation. Which of the following statement(s) is/are true concerning ... is used to monitor heparin levels intraoperatively during cardiovascular and peripheral vascular operations

Last Answer : Answer: a, c, d Coagulation tests include prothrombin time (PT), which measures the intrinsic and extrinsic pathways of fibrinogen production and is the most common method for ... more while for peripheral vascular applications, values of 250 seconds or greater are considered appropriate

The standard management oral anticoagulant therapy for chronic treatment of venous thromboembolism is with the drug warfarin. Which of the following statement(s) is/are true concerning the administration of warfarin? a. An important complication of warfarin therapy is skin necrosis in patients with protein C deficiency b. Warfarin interferes with vitamin K dependent clotting factors II, VII, IX, X c. For effective anticoagulation the prothrombin time (PT) should be kept at 2 control d. It is recommended that warfarin be continued for at least one year after initial episode of deep venous thrombosis

Description : The standard management oral anticoagulant therapy for chronic treatment of venous thromboembolism is with the drug warfarin. Which of the following statement(s) is/are true concerning the administration ... warfarin be continued for at least one year after initial episode of deep venous thrombosis

Last Answer : Answer: a, b Warfarin interferes with the vitamin K dependent clotting factors II, VII, IX and X, protein C, and protein S. An important complication of warfarin is skin ... the benefit from anticoagulant therapy and thus is the basis for discontinuing warfarin administration at this time

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

A diabetic develops a severe perineal infection with skin necrosis, subcutaneous crepitance, and drainage of a thin, watery, grayish and foul-smelling fluid. Management should consist of: a. Gram stain of the fluid, which will likely demonstrate multiple bacteria including predominantly gram-positive rods b. A CT scan is indicated in a stable patient to define the extent of the disease c. Broad spectrum antibiotics followed with prompt extensive debridement is indicated d. A safe guideline is to resect infected necrotic tissue so that a several centimeter margin of grossly normal, healthy tissue can be achieved e. A colostomy is of little benefit in this situation

Description : A diabetic develops a severe perineal infection with skin necrosis, subcutaneous crepitance, and drainage of a thin, watery, grayish and foul-smelling fluid. Management should consist of: a. Gram stain ... normal, healthy tissue can be achieved e. A colostomy is of little benefit in this situation

Last Answer : Answer: a, b, c, d The presence of severe perineal infection (referred to as Fournier gangrene when this process involves the perineum and scrotum in males) is associated with a ... often provides improved wound care and patient management, although it is not invariably a positive outcome