Invasive hemodynamic monitoring using a Swan-Gantz catheter is essential in the optimal management of patients in shock or those suffering post-shock sequelae. Which of the following physiologic characteristics are associated with the various forms of shock? a. Hypovolemic shock: Decreased pulmonary capillary wedge pressure (PCWP), decreased cardiac output, increased systemic vascular resistance (SVR) b. Cardiogenic shock: Increased PCWP, decreased cardiac output, decreased SVR c. Septic shock (hypodynamic): Decreased cardiac output, increased SVR d. Neurogenic shock: Decreased PCWP, increased cardiac output, decreased SVR

Invasive hemodynamic monitoring using a Swan-Gantz catheter is essential in the optimal management of patients in shock or those suffering post-shock sequelae. Which of the following physiologic characteristics are associated with the various forms of shock? a. Hypovolemic shock: Decreased pulmonary capillary wedge pressure (PCWP), decreased cardiac output, increased systemic vascular resistance (SVR) b. Cardiogenic shock: Increased PCWP, decreased cardiac output, decreased SVR c. Septic shock (hypodynamic): Decreased cardiac output, increased SVR d. Neurogenic shock: Decreased PCWP, increased cardiac output, decreased SVR
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Essential amino acids have been advocated as standard therapy for renal failure. Which of the following statements are true? A. Increased survival from acute renal failure has been reported with both essential and nonessential amino acid therapy of patients in renal failure. B. Essential amino acids retard the rise of blood urea nitrogen (BUN) secondary to decreased urea appearance. C. Essential amino acids and hypertonic dextrose are a convenient form of therapy for hyperkalemia. D. Essential amino acids decrease BUN and creatinine to the same degree as solutions containing excessive nonessential amino acids.

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Which of the following statement(s) is/are correct concerning the cardiovascular response to shock? a. Changes in cardiac contractile function shift the Frank Starling curve up and down b. Venoconstriction from skeletal muscle is a significant contributor to the restoration of blood volume with shock c. Arterial vasoconstriction affects all vascular beds equally d. The total circulating blood volume is equally split between the arterial and venous system

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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

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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 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

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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 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.

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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

All of the following statements about hemorrhagic shock are true except: A. Following hemorrhagic shock, there is an initial interstitial fluid volume contraction. B. Dopamine, or a similar inotropic agent, should be given immediately for resuscitation from hemorrhagic shock, to increase cardiac output and improve oxygen delivery to hypoperfused tissues. C. The use of colloid solutions or hypertonic saline solutions is contraindicated for treatment of hemorrhagic shock. D. In hemorrhagic shock, a narrowed pulse pressure is commonly seen before a fall in systolic blood pressure.

Description : All of the following statements about hemorrhagic shock are true except: A. Following hemorrhagic shock, there is an initial interstitial fluid volume contraction. B. Dopamine, or a similar inotropic ... shock, a narrowed pulse pressure is commonly seen before a fall in systolic blood pressure.

Last Answer : Answer: BC DISCUSSION: Hemorrhagic shock is associated with a contraction of the interstitial fluid compartment because of precapillary vasoconstriction and reabsorption of interstitial fluid ... definitive evidence that such solutions are better than standard crystalloid solutions is lacking

Which of the following statement(s) is/are true concerning the physiology of the microvascular system? a. Filtration of capillary fluid into the interstitial and the subsequent reabsorption is influenced by Starling’s law of ultrafiltration b. The most important variable controlling blood to a capillary bed is the length of the vessel c. Most of the resistance to systemic blood flow occurs at the arteriolar level d. Adrenergic vasoconstriction can arrest blood flow to an entire capillary bed

Description : Which of the following statement(s) is/are true concerning the physiology of the microvascular system? a. Filtration of capillary fluid into the interstitial and the subsequent reabsorption is ... the arteriolar level d. Adrenergic vasoconstriction can arrest blood flow to an entire capillary bed

Last Answer : Answer: a, c, d Exchange of material between the vascular space and the cell of various tissues via the interstitial space is essential for organ viability and occurs at the ... contractions are potent enough that blood flow to entire capillary beds can be arrested by adrenergic vasoconstriction

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 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) 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

Laboratory monitoring of coagulation and anticoagulation includes testing of platelet function. Which of the following statements is/are true concerning tests of platelet function? a. A platelet count of 50,000/µL or more usually ensures hemostasis b. Bleeding time assays assessibility of platelets to perform hemostatic plugs and is determined from a sample of blood drawn in an EDTA coated test tube c. Aspirin therapy can be associated with a bleeding time in the range of 8–15 minutes d. Tests of platelet aggregation should be part of the standard preoperative evaluation of patients using aspirin

Description : Laboratory monitoring of coagulation and anticoagulation includes testing of platelet function. Which of the following statements is/are true concerning tests of platelet function? a. A ... platelet aggregation should be part of the standard preoperative evaluation of patients using aspirin

Last Answer : Answer: a, c Tests of platelet function include peripheral platelet counts, bleeding times, and platelet aggregation. Usually, a platelet count of 50,000/mL or more ensures adequate hemostasis ... is not available in most laboratories, probably because of the observer-dependent nature of the test

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 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

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

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

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

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

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

Which of the following 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

Angiotensin converting enzyme inhibitors reduce the following haemodynamic parameters in congestive heart failure except: A. Systemic vascular resistance B. Right atrial pressure C. Cardiac output D. Heart rate × pressure product

Description : Angiotensin converting enzyme inhibitors reduce the following haemodynamic parameters in congestive heart failure except: A. Systemic vascular resistance B. Right atrial pressure C. Cardiac output D. Heart rate × pressure product

Last Answer : C. Cardiac output

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the a) pulmonary artery wedge pressure. When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary arty until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.

Description : When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the a) pulmonary artery wedge ... Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

Last Answer : a) pulmonary artery wedge pressure. When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary arty until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.

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

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

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

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

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

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