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

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
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Answer: c, d  The neuroendocrine response to shock attempts to achieve restoration of effective blood volume, mobilization of metabolic substrates, and maintenance of central profusion. Both peripheral and central afferent stimuli to the central nervous system are involved in inducing this response. Hypotension, associated with a decrease in impulses from the aortic and carotid baroreceptors, disinhibits the vasomotor center. This disinhibition results in increased adrenergic output and decreased vagal activity. Sympathetic nerve endings release norepinephrine, inducing peripheral and splanchnic vasoconstriction which is responsible for greater than 80% of systemic vascular resistance and is a major contributor to maintenance of central organ perfusion and venous return. Plasma levels of both epinephrine and norepinephrine are elevated with injury, and the degree of the catecholamine elevation corresponds to the magnitude of injury. In shock the effects of endogenous epinephrine are largely metabolic. In addition to initiating autonomic nervous activity, the hypothalamus secretes releasing hormones, which induce the stress hormone release of the pituitary. As part of this response, adrenocorticotropic hormone (ACTH) secretion by the anterior pituitary is increased stimulating cortisol secretion by the adrenal cortex. In conjunction with elevated plasma levels of cortisol and epinephrine, increased pancreatic secretion of glucagon accelerates hepatic gluconeogenesis and further aggravates the glucose intolerance that follows injury and sepsis. The secretion of renin is increased in responses to adrenergic discharge and decreased perfusion of the juxtaglomerular apparatus in the kidney. Renin allows formation of angiotensin I in the liver, which is then converted to angiotensin II in the lungs. Angiotensin II is an extremely effective vasoconstrictor that further augments sympathetic-mediated vasoconstriction
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A 68-year-old male who underwent a repair of an abdominal aortic aneurysm 5 days ago, develops tachycardia, tachypnea, hypotension with cool, pale, mottled cyanotic extremities. He is agitated and complains of shortness of breath. Which of the following statement(s) is/ are correct concerning his diagnosis and management? a. Myocardial ischemia secondary to preexisting coronary artery disease is most likely the underlying cause of this problem b. Invasive hemodynamic monitoring with a Swan-Gantz catheter will demonstrate a low cardiac output, a high systemic vascular resistance, and elevated cardiac filling pressures c. The use of morphine sulphate and nitrates should be part of the initial management d. The primary pharmacologic treatment involves the use of moderate doses of inotropic ag

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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

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All of the following contribute to the antihypertensive action of propranolol except: A. Direct vasodilatation B. Decreased renin release from kidney C. Adaptation of blood vessels to reduced cardiac output D. Less noradrenaline release from sympathetic nerve endings

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Last Answer : A. Direct vasodilatation

All of the following contribute to the antihypertensive action of propranolol except: A. Direct vasodilatation B. Decreased renin release from kidney C. Adaptation of blood vessels to reduced cardiac output D. Less noradrenaline release from sympathetic nerve endings

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Last Answer : A. Direct vasodilatation

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

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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.

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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 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

Fight-or-flight reactions cause activation of (a) the parathyroid glands, leading to increased metabolic rate (b) the kidney, leading to suppression of renin- angiotensin-aldosterone pathway (c) the adrenal medulla, leading to increased secretion of epinephrine and norepinephrine (d) the pancreas leading to a reduction in the blood sugar levels.

Description : Fight-or-flight reactions cause activation of (a) the parathyroid glands, leading to increased metabolic rate (b) the kidney, leading to suppression of renin- angiotensin-aldosterone pathway (c) ... epinephrine and norepinephrine (d) the pancreas leading to a reduction in the blood sugar levels.

Last Answer : (c) the adrenal medulla, leading to increased secretion of epinephrine and norepinephrine

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 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 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

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

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

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

The following statement(s) is/are true concerning 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

The primary stimulus for insulin secretion is increased. (A) Blood level of epinephrine (B) Blood level of glucagon (C) Blood level of glucose (D) Water intake

Description : The primary stimulus for insulin secretion is increased. (A) Blood level of epinephrine (B) Blood level of glucagon (C) Blood level of glucose (D) Water intake

Last Answer : Answer : C

Which of the following statement(s) is/are true concerning pharmacologic agents used in the treatment of shock? a. The primary difference between dopamine and dobutamine is the absence of significant a adrenergic activity b. The renal and mesenteric vasoconstrictive effects of norepinephrine complicate and sometimes restrict its use c. The apparent paradoxical use of vasodilators, such as nitroprusside, in shock is indicated as a means to augment cardiac function d. Isoproterenol with its potent b-adrenergic effect, is a particularly useful agent in the treatment of all forms of shock

Description : Which of the following statement(s) is/are true concerning pharmacologic agents used in the treatment of shock? a. The primary difference between dopamine and dobutamine is the absence of significant a ... b-adrenergic effect, is a particularly useful agent in the treatment of all forms of shock

Last Answer : Answer: a, b, c Therapeutic adjustments of intravascular volume (preload) and systemic vascular resistance (afterload) form the basis of the treatment strategies for all ... careful constant monitoring of arterial pressure and repeated hemodynamic measurements with a pulmonary artery catheter

The following are true about pupil reaction to light: a. secretion of acetylcholine is responsible for pupil dilatation b. constriction of the pupil is mediated by nerve fibres travelling in the short ciliary nerve c. dilatation of the pupil is mediated by nerve fibres travelling in the long ciliary nerve d. the sympathetic nerve innervates the dilator muscles

Description : The following are true about pupil reaction to light: a. secretion of acetylcholine is responsible for pupil dilatation b. constriction of the pupil is mediated by nerve fibres travelling in ... fibres travelling in the long ciliary nerve d. the sympathetic nerve innervates the dilator muscles

Last Answer : the sympathetic nerve innervates the dilator muscles

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 hormones do stimulate the production of pancreatic juice and bicarbonate? (a) Angiotensin and epinephrine (b) Gastrin and insulin (c) Cholecystokinin and secretin (d) Insulin and glucagon

Description : Which hormones do stimulate the production of pancreatic juice and bicarbonate? (a) Angiotensin and epinephrine (b) Gastrin and insulin (c) Cholecystokinin and secretin (d) Insulin and glucagon

Last Answer : (c) Cholecystokinin and secretin

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

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

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

Which of the following statement(s) is/are true concerning O2 venous saturation monitoring? a. The normal saturation of mixed venous blood is 50% b. Mixed venous blood obtained for saturation monitoring can be obtained from any peripheral vein c. If arterial blood is fully saturated, the saturation of mixed venous blood is 80% d. In less than fully saturated blood, the difference between arterial and venous saturation corresponds to oxygen extraction

Description : Which of the following statement(s) is/are true concerning O2 venous saturation monitoring? a. The normal saturation of mixed venous blood is 50% b. Mixed venous blood obtained ... than fully saturated blood, the difference between arterial and venous saturation corresponds to oxygen extraction

Last Answer : Answer: c, d The relationship between oxygen delivery and oxygen consumption is reflected in the amount of oxygen in venous blood. Under normal circumstances, oxygen delivery is 1000 ... and venous saturation corresponds to the oxygen extraction, hence the oxygen delivery/oxygen consumption ratio

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

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

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

Which of the following statement(s) is/are true concerning the multiorgan failure syndrome (MOFS)? a. Changes in the splanchnic and pulmonary microcirculation are critical to the development of MOFS b. Tissue fixed microphages, including the liver Kupffer cell, have little role in the development of MOFS c. MOFS represents systemic consequences of loss of homeostatic control of local inflammation and microcirculatory hypoperfusion d. The nature of MOFS is highly dependent upon the etiology of the underlying problem

Description : Which of the following statement(s) is/are true concerning the multiorgan failure syndrome (MOFS)? a. Changes in the splanchnic and pulmonary microcirculation are critical to the development of MOFS ... d. The nature of MOFS is highly dependent upon the etiology of the underlying problem

Last Answer : Answer: a, c The nature of multiorgan failure syndrome (MOFS) is that of a diffuse cellular injury, developing systemically as a consequence of losing homeostatic control of local ... of microorganism. In noninfectious cases, the response also appears independent of the specific underlying cause

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

Cytokines are low-molecular-weight polypeptides exerting a wide variety of biologic effects at both local and systemic levels. Which of the following statement(s) is/are true concerning the production and actions of cytokines? a. Cytokines are produced solely by macrophages b. Cytokines act only on other cells within the same local environment c. Cytokines may have both protective and deleterious effects on the host d. Each specific cytokine is produced by a single cell type

Description : Cytokines are low-molecular-weight polypeptides exerting a wide variety of biologic effects at both local and systemic levels. Which of the following statement(s) is/are true concerning the production and ... effects on the host d. Each specific cytokine is produced by a single cell type

Last Answer : Answer: c Macrophages, endothelial cells, lymphocytes, and other cells secrete a large number of different compounds, termed cytokines, that are most probably evolved for the purpose of ... host defenses, exerting both salutatory and deleterious effects on the host, has become increasingly evident

The following statement(s) is/are true concerning newer detection methods of systemic infection. a. Enzyme-linked immunosorbent assay (ELISA) is a rapid immunologic assay used for both antigen and antibody detection b. Southern, northern, and western immunoblot techniques are used to detect DNA, RNA, or proteins, respectively c. Polymerase chain reaction (PCR) is a sensitive assay used to detect small amounts of microbial DNA, thus detecting infection at its early stages d. Infectious agents currently detected using advanced molecular techniques include cytomegalovirus (CMV) and human immunodeficiency virus (HIV)

Description : The following statement(s) is/are true concerning newer detection methods of systemic infection. a. Enzyme-linked immunosorbent assay (ELISA) is a rapid immunologic assay used for ... detected using advanced molecular techniques include cytomegalovirus (CMV) and human immunodeficiency virus (HIV)

Last Answer : Answer: a, b, c, d Although the classic detection of infection based on clinical signs of infection and bacterial culture remain the most common clinical tools, increasing ... including CMV and HIV. Furthermore, preliminary investigations into possible detection of fungal pathogens are underway

External pneumatic compression has been advocated for the prevention of deep venous thrombosis during operative procedures. Which of the following statement(s) concerning the use of external pneumatic compression devices is/are true? a. Intermittent pneumatic compression is as effective as low-dose heparin in prevention of venous thrombosis b. These devices function by compressing the lower extremities therefore augmenting venous return c. Pneumatic compression devices may also exhibit their antithrombotic effect through stimulating local and systemic fibrinolysis d. The length of time that intermittent pneumatic compression should be used includes through the operation and for at least several days in the postoperative period

Description : External pneumatic compression has been advocated for the prevention of deep venous thrombosis during operative procedures. Which of the following statement(s) concerning the use of external pneumatic ... includes through the operation and for at least several days in the postoperative period

Last Answer : Answer: b, c, d In many well-controlled studies of venous prophylaxis, intermittent pneumatic compression has been found to be as effective as low-dose heparin therapy. In addition to augmentation ... be used through the operation and for at least five days in the face or prolonged immobilization

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