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250 Latest Surgical Background Multiple

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1. Skeletal muscle breakdown produces predominantly liberation

of which two amino acids?
A. Lysine.
B. Tyrosine.
C. Alanine.
D. Glutamine.
E. Arginine.
Answer: CD

D I S C U S S I O N : Alanine is released from skeletal muscle and

extracted by the liver, where it is converted to new glucose.
Glutamine is also released from muscle and participates in renal
acid-base homeostasis and serves as fuel for rapidly growing
cells such as enterocytes, stimulated macrophages, and
fibroblasts. Together, these two amino acids account for
approximately two thirds of the nitrogen released from skeletal
muscle.

2. In “catabolic” surgical patients, which of the following

changes in body composition do not occur?
A. Lean body mass increases.
B. Total body water increases.
C. Adipose tissue decreases.
D. Body weight decreases.
Answer: A

D I S C U S S I O N : Lean body mass represents the body

compartment that contains protein. Because critical illness
stimulates proteolysis and increased excretion of body nitrogen,
this compartment is consistently reduced, not increased. The
change in body composition is associated with a loss of body
weight, an increase in total body water, and a decrease in body
fat.

3. The hormonal alterations that follow operation and injury

favor accelerated gluconeogenesis. This new glucose is
consumed by which of the following tissues?
A. Central nervous system.
B. Skeletal muscle.
C. Bone.
D. Kidney.
E. Tissue in the healing wound.
Answer: ADE

D I S C U S S I O N : Glucose is produced in increased amounts to

satisfy the fuel requirements of the healing wound. In addition,
nerve tissue and the renal medulla also utilize this substrate.
Skeletal muscle primarily utilizes fatty acids, and bone utilizes
mineral substrate.

4. Cytokines are endogenous signals that stimulate:

A. Local cell proliferation within the wound.
B. The central nervous system to initiate fever.
C. The production of “acute-phase proteins.”
D. Hypoferremia.
E. Septic shock.
Answer:ABCD

D I S C U S S I O N : Although cytokines exert primarily autocrine and

paracrine effects, they may also cause systemic effects.

5. The characteristic changes that follow a major operation or

moderate to severe injury do not include the following:
A. Hypermetabolism.
B. Fever.
C. Tachypnea.
D. Hyperphagia.
E. Negative nitrogen balance.
Answer: D

D I S C U S S I O N : The characteristic metabolic response to injury

includes hypermetabolism, fever, accelerated gluconeogenesis,
and increased proteolysis (creating a negative nitrogen
balance). Food intake is generally impossible because of
abdominal injury or ileus. With time, food intake increases, but
the patient generally experiences anorexia, not hyperphagia.

6. Shock can best be defined as:

A. Hypotension.
B. Hypoperfusion of tissues.
C. Hypoxemia.
D. All of the above.
Answer: B

D I S C U S S I O N : Shock, no matter what the cause, is a syndrome

associated with tissue hypoperfusion. Tissue hypoperfusion
leads to tissue hypoxia, which may or may not be due to
hypoxemia. Hypotension is a late sign of shock and, therefore,
is not a good clinical indicator of the presence of tissue
hypoperfusion.

7. Which of the following statements about continuous cardiac

output monitoring are true?
A. Continuous cardiac output monitoring may unmask events
not detected by intermittent cardiac output measurements.
B. Continuous cardiac output monitoring by the thermodilution
method requires continuous infusion of fluid injectate at a
constant rate and temperature.
C. The major advantage of the Fick method over the
thermodilution method of calculating cardiac output is that it is
noninvasive, requiring only the determination of oxygen
consumption by respiratory gas analysis.
D. The technique of thoracic electrical bioimpedance utilizes
sensors to determine stroke volume by detecting changes in
resistance to a small, applied alternating current.
Answer: AD

D I S C U S S I O N : Various techniques are available to measure

cardiac output continuously. The advantages of continuous
cardiac output monitoring, as compared with intermittent
methods, are (1) previously undetected events may be
unmasked; (2) more prompt recognition of adverse events may
be achieved; and (3) earlier therapeutic intervention may be
possible. Continuous cardiac output monitoring using the
thermodilution method appears to be as accurate as the
“standard” intermittent bolus method, but it does not require
fluid injectates. In this method, a modified pulmonary artery
catheter incorporating a thermal filament heats blood in the
right ventricle at pulsed intervals, and a distal thermistor
detects the temperature change, which can be related
mathematically to cardiac output. The Fick method combines
respiratory gas analysis with oximetery to determine oxygen
consumption (V(overdot)O 2) and to estimate mixed venous and
arterial oxygen content differences, respectively. Cardiac output
(CO) is then determined from the formula: CO = V(overdot)O 2/
{C(a-v)O 2 × 10} @ V(overdot)O 2/ {SaO 2 - SvO 2) × (Hb) ×
(1.39) × 10}. Thoracic electrical bioimpedance is a technique by
which the resistance to a small-amplitude alternating current
(i.e., the impedance) is measured using various electrodes. The
impedance change induced by each cardiac ejection is a function
of the stroke volume, which then can be used to calculate the
cardiac output.

8. 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.
Answer: C

D I S C U S S I O N : 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 include
the interleukins, tumor necrosis factor, colony-stimulating
factors, and the interferons, comprise only one category of
inflammatory mediators involved in the host response.
Endotoxin, complement fragments, eicosanoids, kinins, nitric
oxide, oxidants, and PAF are noncytokine mediators that also
have important roles in the systemic inflammatory response.
IL-1 and TNF-a, like other cytokines, have multiple effects on
target cells and potentiate the actions of other mediators to
produce an amplified inflammatory response. TNF-a is thought
to play a central role in the stress response, particularly in
response to endotoxemia.

9. True statements concerning hypoadrenal shock include which

of the following?
A. Adrenocortical insufficiency may manifest itself as severe
shock refractory to volume and pressor therapy.
B. The presence of hyperglycemia and hypotension may
suggest the diagnosis of shock due to adrenocortical
insufficiency.
C. Hydrocortisone does not interfere with the serum cortisol
assay and should be given to hemodynamically unstable
patients suspected of having hypoadrenal shock.
D. The rapid adrenocorticotropic hormone (ACTH) stimulation
test should be performed to help establish the diagnosis of acute
adrenocortical insufficiency.
Answer: AD

D I S C U S S I O N : Shock due to acute adrenocortical insufficiency is

relatively uncommon but must be considered when shock
refractory to volume replacement and pressor therapy is
present. Hypoglycemia may be present. Patients with high
metabolic stress may exhibit adrenal insufficiency only under
conditions of severe stress; thus, a history of adrenal
insufficiency or steroid dependency need not be elicited. When
adrenocortical insufficiency is suspected, the rapid ACTH
(cosyntropin) stimulation test should be performed. Serum
cortisol levels should be drawn before intravenous
administration of 250 mg. of cosyntropin, and 30 and 60
minutes afterward. A peak cortisol level of less than 20 mg./100
ml. suggests abnormal adrenal function. In a hemodynamically
unstable patient therapy should be instituted before the test
results become available. Dexamethasone does not interfere
with the cortisol assay, and it is the corticosteroid of choice
while the ACTH stimulation test is being performed.

10. 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.
Answer: C
D I S C U S S I O N : Neurogenic shock occurs when severe head
injury, spinal cord injury, or pharmacologic sympathetic
blockade leads to sympathetic denervation and loss of
vasomotor tone. Both arteriolar and venous vessels dilate,
causing reduced systemic vascular resistance and a great
increase in venous capacitance. The patient's extremities appear
warm and dry, in contrast to those of a patient in cardiogenic or
hypovolemic shock. Tachycardia is frequently observed, though
the classic description of neurogenic shock includes bradycardia
and hypotension. Volume administration to fill the expanded
intravascular compartment is the mainstay of treatment. The
use of alpha-adrenergic agonist is infrequently necessary to
treat neurogenic shock.

11. True statements regarding eicosanoids include which of the

following?
A. Prostaglandins and thromboxanes are synthesized via the
cyclo-oxygenase pathway.
B. The vasoconstricting, platelet-aggregating, and
bronchoconstricting effects of thromboxane A 2 are balanced by
the actions of prostacyclin, which produces the opposite effects.
C. Leukotriene synthesis is inhibited by the action of
nonsteroidal anti-inflammatory drugs (NSAIDs).
D. The principal prostaglandins have a short circulation half-life
and exert most of their effects locally.
Answer: ABD

DISCUSSION: The eicosanoids are a group of compounds arising

from the metabolism of arachidonic acid. The prostaglandins and
thromboxanes are synthesized via the cyclo-oxygenase
pathway; thus, their synthesis is blocked by NSAIDs.
Leukotrienes, on the other hand, are synthesized via the
lipoxygenase pathway. Prostacyclin, produced largely by
vascular endothelium, inhibits platelet aggregation and causes
vasodilatation as well as bronchodilatation. Its effects are
balanced by those of thromboxane A 2, which is produced by
platelets and also local actions, including platelet aggregation,
vasoconstriction, and bronchoconstriction. The leukotrienes also
have pulmonary and hemodynamic effects and may be involved
in the physiologic responses associated with anaphylactic and
septic shock.

12. 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.
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
consumption is relatively independent of oxygen delivery
because the body's cells can compensate for falls in oxygen
delivery by extracting more oxygen. In the delivery-dependent
region, if cellular hypoxia is present, the lactate-pyruvate ratio
rises, owing to the switch to anaerobic metabolism. Generally, it
is desirable to achieve delivery-independent oxygen
consumption, to avoid ongoing tissue hypoxia. There is
considerable debate, however, about the nature of the oxygen
consumption–oxygen delivery relationship in cases of
established sepsis or multiple organ dysfunction syndrome. In
such cases, D(overdot)O 2crit may be increased, although the
therapeutic benefit of trying to achieve “supranormal” oxygen
delivery has not been firmly established.

13. All of the following may be useful in the treatment of

cardiogenic shock except:
A. Dobutamine.
B. Sodium nitroprusside.
C. Pneumatic antishock garment.
D. Intra-aortic balloon pump.
Answer: C

DISCUSSION: Cardiogenic shock occurs when the heart fails to

generate adequate cardiac output to maintain tissue perfusion.
Intrinsic causes such as myocardial dysfunction secondary to
coronary artery disease, or extrinsic causes such as pulmonary
embolism, tension pneumothorax, and pericardial tamponade,
may produce cardiogenic shock. Principles of treatment of
cardiogenic shock are aimed at optimizing preload, cardiac
contractility, and afterload. Preload is usually adequate or high
in cardiogenic shock. Dobutamine is a useful inotropic agent,
particularly when filling pressures are high, because of its mild
vasodilatory effect, as well as its effect to enhance cardiac
contractility. Afterload-reducing agents, such as sodium
nitroprusside, may be beneficial in cardiogenic shock in the
setting of elevated filling pressures, low cardiac output, and
elevated systemic vascular resistance. Cardiac output may
improve with use of afterload-reducing agents by decreasing
myocardial wall tension and optimizing the myocardial oxygen
supply-demand ratio. The intra-aortic balloon pump (IABP), by
providing diastolic augmentation, reducing left ventricular
afterload, and reducing myocardial oxygen consumption, is
sometimes useful in the treatment of cardiogenic shock. The
IABP is especially useful in low–cardiac output postcardiotomy
patients, in patients awaiting revascularization, and in patients
with acute myocardial infarction complicated by mitral
insufficiency or ventricular septal defect. The pneumatic
antishock garment (PASG), which causes an increase in
systemic vascular resistance, is contraindicated in cardiogenic
shock.

14. Which of the following statements concerning monitoring

techniques in the intensive care unit are true?
A. Pulmonary artery and pulmonary capillary wedge pressure
readings should be made at end inspiration, to minimize
ventilatory artifacts.
B. Continuous SvO 2 monitoring based on the technique of
reflectance spectrophotometry has been shown to be accurate
and reliable.
C. Direct measurement of gastric intramucosal pH can be
provided by gastrointestinal tonometry.
D. Hyperlactatemia may be seen in a number of clinical
conditions not associated with tissue hypoxia, including liver
disease and hypermetabolic states.
Answer: BD

DISCUSSION: Many different monitoring techniques may be

used to assess the adequacy of therapy for shock. The
pulmonary artery catheter can provide important hemodynamic
and oxygen transport data that are very useful in directing
therapy aimed at optimizing cardiac function and oxygen
delivery. Pulmonary artery and pulmonary capillary wedge
pressure readings should be made at end-expiration to minimize
ventilatory artifacts. Continuous SvO 2 monitoring, an accurate,
reliable method that combines pulmonary artery catheterization
with the technique of reflectance spectrophotometry, may
provide early warning signs of hemodynamic compromise or
inadequate oxygen delivery. Gastrointestinal tonometry provides
information that allows one to infer the adequacy of splanchnic
tissue perfusion. In this technique, intramucosal pH is calculated
using the Henderson-Hasselbalch equation and measurements
of gut intraluminal PCO 2 and arterial bicarbonate concentration.
Serum lactate concentration may be monitored in shock to
detect metabolic acidosis associated with anaerobic metabolism;
however, mild to moderate hyperlactatemia may also be seen
with liver disease, toxin ingestion, and hypermetabolic states
not associated with shock.

15. An 18-year-old man shot once in the left chest has a blood
pressure of 80/50 mm. Hg, a heart rate of 130 beats per
minute, and distended neck veins. Immediate treatment might
include:
A. Administration of one liter of Ringer's lactate solution.
B. Subxiphoid pericardiotomy.
C. Needle decompression of the left chest in the second
intercostal space.
D. Emergency thoracotomy to cross-clamp the aorta.
Answer: AC

DISCUSSION: The finding of distended neck veins in conjunction

with hypotension should suggest tension pneumothorax or
pericardial tamponade. Absent ipsilateral breath sounds and a
trachea deviated to the contralateral side may provide additional
evidence for a tension pneumothorax, the immediate treatment
of which is needle decompression of the chest in the second or
third intercostal space in the midclavicular line. Pericardial
tamponade may initially respond to volume administration by
enhancing preload. Pericardiocentesis may need to be
performed emergently if hemodynamic instability persists after
an initial fluid bolus when signs of compressive cardiogenic
shock are present. Subxiphoid pericardiotomy should be
performed only in the operating room by experienced persons
who are trained to deal with penetrating cardiac injuries. There
is no role for aortic cross-clamping in this scenario of
cardiogenic shock.

16. 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.
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 as injury or
infection. MODS may develop as a result of the initial insult, but
more commonly, it develops following a second or subsequent
insult to the host. The two-hit theory holds that the systemic
inflammatory response is amplified following the second hit,
such as nosocomial pneumonia, leading to exaggerated,
persistent release of inflammatory mediators that contribute to
the pathogenesis of MODS. The liver appears to be a pivotal
organ in the progression and outcome of MODS, partly because
of the activation and prolonged stimulation of the Kupffer cells,
which comprise the majority of the body's macrophage
population. Macrophages are known to play a critical role in the
elaboration of numerous inflammatory mediators. Despite
advances in critical care and in the understanding of the
pathogenesis of MODS, the incidence of MODS continues to
increase without a significant improvement in outcome.

17. 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.
Answer: BC

DISCUSSION: Hemorrhagic shock is associated with a

contraction of the interstitial fluid compartment because of
precapillary vasoconstriction and reabsorption of interstitial fluid
into the vascular compartment along hydrostatic pressure
gradients. Systolic hypotension may not be evident in
hemorrhagic shock until at least 30% or more of blood volume
is exsanguinated. A decrease in the pulse pressure (the
difference between systolic and diastolic pressures) may be
observed with losses of 15% to 30% of blood volume.
Treatment of hemorrhagic shock includes intravascular fluid
administration and definitive control of the source of the
hemorrhage. Inotropic agents should not be started before
volume resuscitation but may be added to improve oxygen
delivery to hypoxic tissues if volume administration alone does
not produce resuscitative goals. Colloid or hypertonic saline
solutions are not contraindicated in the treatment of
hemorrhagic shock; however, definitive evidence that such
solutions are better than standard crystalloid solutions is
lacking.

18. Which of the following statements about septic shock are

true?
A. A circulating myocardial depressant factor may account for
the cardiac dysfunction sometimes seen with shock due to
sepsis or SIRS.
B. A cardiac index (CI) of 6 liters per minute per square meter
of body surface, a pulmonary capillary wedge pressure of 15
mm. Hg, and a systemic vascular resistance index (SVRI) of 800
dynes-sec/(cm 5-m 2) is a hemodynamic profile consistent with
septic shock.
C. An increase in SvO 2 in septic patients may be explained by
the finding of anatomic arteriovenous shunts.
D. Results of human trials employing antimediator therapy,
such as antiendotoxin antibodies, IL-1 receptor antagonist, and
tumor necrosis factor (TNF) antibodies, have confirmed animal
studies that demonstrate a significant improvement in survival
with the use of such agents.
Answer: AB

DISCUSSION: Shock due to sepsis or SIRS frequently manifests

as a hyperdynamic cardiovascular response, consisting of an
elevated CI and a decreased SVR or SVRI. Occasionally,
myocardial depression may be seen, characterized by increased
ventricular volumes and decreased ejection fractions. A
circulating myocardial depressant factor, possibly TNF, may be
responsible for the cardiac dysfunction in such instances. The
cause of the increased SvO 2 frequently observed in septic
patients is unclear, but it may be secondary to bioenergetic
failure, metabolic downregulation, or microcirculatory
maldistribution leading to physiologic shunting. True anatomic
arteriovenous shunting has not been demonstrated in humans in
septic shock. Treatment of septic shock consists of appropriate
antibiotic use and supportive therapy. Experimental
antimediator therapies have not been encouraging thus far in
human clinical trials, despite the promising results from many
animal studies.

19. Which of the following statements are true of oxidants?

A. In addition to their pathophysiologic roles in inflammation,
injury, and infection, oxidants also have physiologic roles.
B. Oxidants may be generated from activated neutrophils and
during reperfusion following a period of ischemia.
C. The deleterious effects of oxidants include lipid peroxidation
and cell membrane damage, oxidative damage to DNA, and
inhibition of adenosine triphosphate (ATP) synthesis.
D. The mechanism of ischemia-reperfusion injury involved the
catalytic production of superoxide anion (O 2•) by the enzyme
xanthine oxidase.
Answer: ABCD

DISCUSSION: Oxidants are reactive oxygen metabolites that

have both physiologic and pathophysiologic roles. As potent
oxidizing agents, oxidants are involved in cytochrome P
450–mediated oxidations, for example. In pathophysiologic
processes associated with inflammation, injury, and infection,
oxidants may be generated by activated neutrophils and in
ischemia-reperfusion injury. During ischemia, the enzyme
xanthine oxidase accumulates. When oxygen availability
increases during reperfusion, O 2• is formed in a reaction
catalyzed by xanthine oxidase. Further oxidant formation
ensues, causing the production of H 2O 2 and the extremely
reactive hydroxyl ion (OH•). Oxidants may cause direct cell
damage by the mechanisms of lipid peroxidation and cell
membrane disruption, inhibition of ATP synthesis, reduction of
cellular nicotinamide adenine dinucleotide (NAD), and oxidative
damage to DNA and amino acids. In addition, oxidants may
have a chemotactic role, leading to leukocyte infiltration and
activation, causing further tissue damage by the release of
cytotoxic proteases.

20. 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.
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
ischemia may occur early in the various shock syndromes. Gut
injury, as a result of ischemia or reperfusion injury, leads to
disruption in the intestinal mucosal barrier and increased gut
permeability. Translocation of enteric flora or bacterial toxins
across the gut wall may then occur, resulting in amplification of
the systemic inflammatory response and the development of
multiple organ dysfunction. Gut dysfunction, therefore, may
perpetuate the inflammatory process. Various methods have
been tried to modulate the deleterious effects of gut
dysfunction. Selective decontamination of the digestive tract by
oral antibiotics has been shown to reduce the incidence of
nosocomial pneumonias, but no improvement in mortality has
been demonstrated thus far with this controversial technique.
Early enteral nutrition probably has the biggest impact on the
preservation of gut architecture and function. When compared
to parenteral nutrition, enteral feeding is more cost effective
and is associated with a lower rate of septic morbidity.

21. Which of the following statements about head injury and

concomitant hyponatremia are true?
A. There are no primary alterations in cardiovascular signs.
B. Signs of increased intracranial pressure may be masked by
the hyponatremia.
C. Oliguric renal failure is an unlikely complication.
D. Rapid correction of the hyponatremia may prevent central
pontine injury.
E. This patient is best treated by restriction of water intake.
Answer: A

DISCUSSION: Acute symptomatic hyponatremia is characterized

by central nervous system signs of increased intracranial
pressure. Changes in blood pressure and pulse are secondary to
increased intracranial pressure. In the absence of hypovolemia,
asymptomatic patients may be treated by restriction of water
intake; however, in such patients, hyponatremia should be
partially corrected by parenteral sodium administration. Rapid
correction, particularly to hypernatremia, may lead to central
pontine myelinolysis. Oliguric renal failure may rapidly develop
in severe hyponatremia.

22. Which of the following statements about total body water

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

DISCUSSION: Since fat contains little water, lean persons with a

proportionately greater muscle mass have a greater than
expected volume of total body water. Likewise, the female body
habitus and obesity contribute to decreased total body water
percentage. The highest proportion of total body water is found
in newborn infants, and total body water decreases steadily and
significantly with age. The actual figure for a healthy person is
remarkably constant.

23. Which of the following statements about extracellular fluid

are true?
A. The total extracellular fluid volume represents 40% of the
body weight.
B. The plasma volume constitutes one fourth of the total
extracellular fluid volume.
C. Potassium is the principal cation in extracellular fluid.
D. The protein content of the plasma produces a lower
concentration of cations than in the interstitial fluid.
E. The interstitial fluid equilibrates slowly with the other body
compartments.
Answer: B

DISCUSSION: The total extracellular fluid volume represents

20% of body weight. The plasma volume is approximately 5% of
body weight. Sodium is the principal cation. The Gibbs-Donan
equilibrium equation explains the higher total concentration of
cations in plasma. Except for joint fluid and cerebrospinal fluid,
the majority of the interstitial fluid exists as a rapidly
equilibrating component.

24. 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.
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 acts as an
osmotic diuretic, producing increased urine flow, which can lead
to volume depletion. Insulin therapy and the correction of the
patient's associated acidosis produce movement of potassium
ions into the intracellular compartment.

25. 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.
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, ammonia formation, and shift of chloride into red
cells combine to increase the ratio of bicarbonate to carbonic
acid to 20:1.
26. 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.
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 lactic
acidosis from hypovolemia, as lactate is converted to
bicarbonate with hepatic reperfusion. Bicarbonate loss from
diarrhea and “dilutional acidosis” are non–anion gap types of
metabolic acidosis.

27. 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.
Answer: DE

DISCUSSION: Gastric secretions are relatively high in chloride

and potassium. Other than an isolated pancreatic fistula,
gastrointestinal tract losses below the pylorus are best replaced
by a balanced salt solution. Although potassium concentrations
are low, copious losses require potassium supplementation to
prevent hypokalemia.

28. Which of the following statements regarding hypercalcemia

are true?
A. The symptoms of hypercalcemia may mimic some symptoms
of hyperglycemia.
B. Metastatic breast cancer is an unusual cause of
hypercalcemia.
C. Calcitonin is a satisfactory long-term therapy for
hypercalcemia.
D. Severely hypercalcemic patients exhibit the signs of
extracellular fluid volume deficit.
E. Urinary calcium excretion may be increased by vigorous
volume repletion.
Answer: ADE

DISCUSSION: Markedly elevated serum calcium levels produce

polydipsia, polyuria, and thirst. Vigorous volume repletion and
saline diuresis correct the extracellular fluid volume deficit and
promote the urinary excretion of calcium. Metastatic breast
cancer is the most common cause of hypercalcemia, from bony
metastasis. The calcitonin effect on calcium is diminished with
repeat administrations.

29. Which of the following statements about normal salt and

water balance are true?
A. The products of catabolism may be excreted by as little as
300 ml. of urine per day.
B. The lungs represent the primary source of insensible water
loss.
C. The normal daily insensible water loss is 600 to 900 ml.
D. Excessive cell catabolism causes significant loss of total body
water.
E. In normal humans, urine represents the greatest source of
daily water loss.
Answer: CE

DISCUSSION: The skin is the primary source of insensible water

loss. Including losses from the lungs, this averages 600 to 900
ml. per day. Catabolism liberates “water of solution.” In normal
humans, urine represents the greatest source of water loss. The
patient deprived of external access to water must still excrete a
minimum of 500 to 800 ml. of urine per day to expel the
products of catabolism.

30. Which of the following is/are not associated with increased

likelihood of infection after major elective surgery?
A. Age over 70 years.
B. Chronic malnutrition.
C. Controlled diabetes mellitus.
D. Long-term steroid use.
E. Infection at a remote body site.
Answer: C

DISCUSSION: Controlled diabetes mellitus has been shown

repeatedly not to be associated with increased likelihood of
incisional infection provided one avoids operations on body parts
that may be ischemic or neuropathic. Uncontrolled diabetes
mellitus, such as ketoacidosis, is associated with a dramatic
increase in surgical infection. The other parameters noted—age
over 70, chronic malnutrition, regular steroid use, and an
infection at a remote body site—are well-recognized adverse
predictive factors and are identified in tables within the chapter.

31. Which of the following are not determinants of a

postoperative cardiac complication?
A. Myocardial infarct 4 months previously.
B. Clinical evidence of congestive heart failure in a patient with
8.5 gm. per dl. hemoglobin.
C. Premature atrial or ventricular contractions on
electrocardiogram.
D. A harsh aortic systolic murmur.
E. Age over 70 years.
Answer: B

DISCUSSION: Clinical evidence of congestive heart failure in a

patient with 8.5 gm. per dl. hemoglobin concentration is a
misleading sign. Evidence of congestive failure is ordinarily a
major risk factor, but in this particular patient the anemia lends
itself to correction by preoperative transfusion with packed red
blood cells, and often it is found that congestive failure and the
associated increased risks disappear when the hemoglobin
concentration is returned to the 12 gm. per dl. or higher ratio.
All other factors are overt signs of increased likelihood of a
postoperative cardiac event, the most ominous being a
myocardial infarction 4 months preoperatively or the presence
of a harsh aortic systolic murmur suggesting the presence of
aortic stenosis. Age over 70 years and the presence of
premature atrial or ventricular contractions on the
electrocardiogram are less strong determinants of a
postoperative cardiac complication.

32. Rank the clinical scenarios in order of greatest likelihood of

serious postoperative pulmonary complications.
A. Transabdominal hysterectomy in an obese woman that
requires 3 hours of anesthesia time.
B. Right middle lobectomy for bronchogenic cancer in a
65-year-old smoker.
C. Vagotomy and pyloroplasty for chronic duodenal ulcer
disease in a 50-year-old who had chest film findings of old,
healed tuberculosis.
D. Right hemicolectomy in an obese 60-year-old smoker.
E. Modified radical mastectomy in a 58-year-old woman who is
obese.
Answer: BDCAE

DISCUSSION: If one considers the constellation of risk factors

for pulmonary complications that is provided in tabular form in
the accompanying chapter, one should readily recognize B, right
middle lobectomy for bronchogenic cancer in a 65-year-old
smoker, as the highest risk of a clinical situation for the
likelihood of serious pulmonary complications. The next in rank
may be properly debated between answer D and answer C. D,
right hemicolectomy, is judged to have somewhat greater
likelihood of complications since the patient is older, smokes,
and is obese, although the procedure may be done through a
transverse or lower abdominal incision. C, vagotomy and
pyloroplasty, is viewed as being somewhat less serious since it
is an upper abdominal operation on an elective basis in a
50-year-old whose only abnormalities include old, healed
tuberculosis on a chest film. A very low risk of pulmonary
complication should follow a transabdominal hysterectomy done
through a lower abdominal incision in a woman whose only risk
factors are obesity and a 3-hour anesthesia time. The lowest
risk probably resides with the younger patient undergoing
modified radical mastectomy, whose only risk factor is obesity.
This is particularly true since this operation is conducted on the
surface of the body, is associated with relatively little
postoperative pain, and provides free and unrestricted
respiratory function.

33. Rank the following laboratory tests and procedures in terms

of their relative value to a 65-year-old woman who is to undergo
elective resection of a sigmoid cancer.
A. Carcinoembryonic antigen (CEA).
B. Blood urea nitrogen (BUN).
C. Electrocardiogram (ECG).
D. Hemoglobin concentration (Hgb).
E. Serum creatinine (Cr).
F. Arterial blood oxygen tension (PaO 2) on room air.
G. Serum sodium concentration (Na+).
Answer: CDFEBAG

DISCUSSION: The most important test by far is the

electrocardiogram, with its capacity to indicate signs of occult
heart disease. The second most important evaluation is the
hemoglobin concentration, which in this patient may show an
anemia related to chronic alimentary tract blood loss that would
require correction prior to safe induction of a general anesthetic.
Arterial blood gases vary from individual to individual depending
primarily on smoking habits and age. Accordingly, each older
person should have a resting baseline determination prior to
operation. Serum creatinine may show evidence of occult renal
disease and is substantially more useful than blood urea
nitrogen, which is more vulnerable to transient volume changes.
Carcinoembryonic antigen is important to know in many patients
with cancer with respect to postoperative follow-up since in
some cases it may be an early herald of recurrent disease.
However, it has little to do with the patient's preoperative
assessment in terms of risk and preparation for an elective
operation. The presence of liver metastases, for example, can
be discovered with significant accuracy by palpation at the time
of operation, and an elevated carcinoembryonic antigen in no
set of circumstances would lead one to withhold colon resection
with its relief of potential obstruction and bleeding. Finally,
serum sodium concentration in a 65-year-old woman who is
admitted electively for resection of the colon is always normal
and would be of least value among these tests.

34. Which of the following statements regarding whole blood

transfusion is/are correct?
A. Whole blood is the most commonly used red cell preparation
for transfusion in the United States.
B. Whole blood is effective in the replacement of acute blood
loss.
C. Most blood banks in the United States have large supplies of
whole blood available.
D. The use of whole blood produces higher rates of disease
transmission than the use of individual component therapies.
Answer: B

DISCUSSION: Whole blood is effective as a replacement fluid for

acute blood loss because it provides both volume and oxygen-
carrying capacity (red blood cells). It is rarely used in the United
States nowadays, and most blood banks do not provide whole
blood transfusions. It is significantly more efficient to separate
donated blood into its components. In this manner, the red
blood cell mass can be used to provide oxygen-carrying
capacity, the plasma can be used for factor replacement, and
the platelets and white cells can be used for patients deficient in
these components. The use of whole blood to replace acute
blood loss is associated with lower disease transmission rates
than the use of packed red blood cells, fresh frozen plasma, and
platelets, each from a different donor.

35. Which of the following statements about the preparation and

storage of blood components is/are true?
A. Solutions containing citrate prevent coagulation by binding
calcium.
B. The shelf life of packed red blood cells preserved with
CPDA-1 is approximately 35 days at 1‫ ؛‬to 6‫ ؛‬C.
C. There are normal numbers of platelets in packed red blood
cells stored at 1‫ ؛‬to 6‫ ؛‬C for more than 2 days.
D. The storage lesion affecting refrigerated packed red blood
cells includes development of acidosis, hyperkalemia, and
decreased intracellular 2,3DPG (diphosphoglycerate).
Answer: ABD

DISCUSSION: After blood has been collected from a donor, it is

anticoagulated with a solution containing citrate, which acts by
binding calcium. Blood is then separated into its components.
Packed red blood cells stored at 1‫ ؛‬to 6‫ ؛‬C using CPDA-1
preservative have a shelf life of 35 days. There are essentially
no functional platelets in refrigerated blood stored at 1‫ ؛‬to 6‫ ؛‬C
after approximately 48 hours in storage. Refrigerated packed
red blood cells undergo progressive changes termed a storage
lesion. Such changes include acidosis, hyperkalemia, and
decreased levels of 2,3-DPG, which are reversed after
transfusion or produce effects other than those predicted based
on the content of the unit of blood.

36. Which of the following is/are acceptable reasons for the

transfusion of red blood cells based on currently available data?
A. Rapid, acute blood loss with unstable vital signs but no
available hematocrit or hemoglobin determination.
B. Symptomatic anemia: orthostatic hypotension, severe
tachycardia (greater than 120 beats per minute), evidence of
myocardial ischemia, including angina.
C. To increase wound healing.
D. A hematocrit of 26% in an otherwise stable, asymptomatic
patient.
Answer: AB
DISCUSSION: Currently accepted guidelines for the transfusion
of packed red blood cells include acute ongoing blood loss, as
might occur in an injured patient, and the development of
symptomatic anemia with manifestations of decreased tissue
perfusion related to decreased oxygen-carrying capacity of the
blood. This includes situations in which the patient is unable to
compensate for a decreased oxygen-carrying capacity by the
usual mechanisms, such as increased cardiac output. Such
patients develop myocardial dysfunction if an excessive demand
is placed on the heart. The patient should be transfused with
packed red blood cells, which afford added oxygen-carrying
capacity. This decreases the workload on the myocardium while
providing the necessary oxygen-delivery capability. The use of
packed red blood cells to improve wound healing or to improve
the patient's sense of well-being is highly questionable. No data
support such a practice. In general, the use of a transfusion
trigger such as a hematocrit of 30% or hemoglobin of 10 gm.
per dl. constitutes a questionable indication for transfusion. If a
patient is asymptomatic and stable and has no risk of
myocardial ischemia, packed red blood cell transfusion should
not be given based solely or predominantly on a numerical value
such as a hematocrit of 28%.

37. The transfusion of fresh frozen plasma (FFP) is indicated for

which of the following reasons?
A. Volume replacement.
B. As a nutritional supplement.
C. Specific coagulation factor deficiency with an abnormal
prothrombin time (PT) and/or an abnormal activated partial
thromboplastin time (APTT).
D. For the correction of abnormal PT secondary to warfarin
therapy, vitamin K deficiency, or liver disease.
Answer: CD

DISCUSSION: The use of FFP as a volume expander is not

indicated. There are currently several preparations (both
crystalloid and colloid) that are equally effective and do not
carry the infectious and other risks associated with the use of
FFP. The use of FFP as a “nutritional” supplement is to be
condemned. Patients with specific deficiencies of coagulation
factors generally benefit greatly from the infusion of FFP. In
cases of specific factor deficiency, other preparations may be
more appropriate, but FFP is generally immediately available
and is effective in most patients. Patients receiving warfarin
therapy, those who have vitamin K deficiency, and those with
liver dysfunction have abnormalities of the vitamin K–dependent
factors II, VII, IX, and X, as well as protein C and protein S.

38. 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.
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 of crystalloid solution is inadequate to restore
intravascular volume status, packed red blood cells should be
infused as soon as possible. There is no role for “prophylactic
infusion” of FFP, platelets, bicarbonate, or calcium to patients
receiving massive blood transfusion. If specific indications exist
patients should receive these supplemental components. In
particular, patients who have abnormal coagulation tests and
have ongoing bleeding should receive FFP. Patients who have
depressed platelet counts along with clinical evidence of oozing
(microvascular bleeding) benefit from platelet infusion. Sodium
bicarbonate is not necessary, since most patients who receive
blood transfusion ultimately develop alkalosis from the citrate
contained in stored red blood cells. The use of calcium chloride
is usually unnecessary unless the patient has depressed liver
function, ongoing prolonged shock associated with hypothermia,
or, rarely, when the infusion of blood proceeds at a rate
exceeding 1 to 2 units every 5 minutes.

39. Hemostasis and the cessation of bleeding require which of

the following processes?
A. Adherence of platelets to exposed subendothelial
glycoproteins and collagen with subsequent aggregation of
platelets and formation of a hemostatic plug.
B. Interaction of tissue factor with factor VII circulating in the
plasma.
C. The production of thrombin via the coagulation cascade with
conversion of fibrinogen to fibrin.
D. Cross-linking of fibrin by factor XIII.
Answer: ABCD

DISCUSSION: Hemostasis requires the interaction of platelets

with the exposed subendothelial structures at the site of injury
followed by aggregation of more platelets in that area.
Interactions between endothelial cell and subendothelial tissue
factor with factor VII activate the coagulation cascade. The end
product is large amounts of thrombin that catalyze the
conversion of fibrinogen into fibrin. Fibrin thus formed is cross-
linked by factor XIII to form a stable clot that incorporates the
platelet plug and fibrin thrombus into a stable clot.

40. Which of the statements listed below about bleeding

disorders is/are correct?
A. Acquired bleeding disorders are more common than
congenital defects.
B. Deficiencies of vitamin K decrease production of factors II,
VII, IX, and X, protein C, and protein S.
C. Hypothermia below 32‫؛‬C rarely causes a bleeding disorder.
D. Von Willebrand's disease is a very uncommon congenital
bleeding disorder.
Answer: AB

DISCUSSION: Acquired bleeding disorders are significantly more

common than congenital bleeding defects. Vitamin K deficiency
may be related to malnutrition or competitive inhibition of the
production of the vitamin K–dependent factors II, VII, IX, X,
protein C, and protein S by warfarin (Coumadin). Hypothermia
causes significant platelet dysfunction with a significant bleeding
disorder in many patients. It is among the least recognized
causes of altered coagulation in surgical patients. Von
Willebrand's disease is a relatively common disorder of bleeding
and is generally undetectable by routine screening methods.

41. The evaluation of a patient scheduled for elective surgery

should always include the following as tests of hemostasis and
coagulation:
A. History and physical examination.
B. Complete blood count (CBC), including platelet count.
C. Prothrombin time (PT) and activated partial thromboplastin
time (APTT).
D. Studies of platelet aggregation with adenosine diphosphate
(ADP) and epinephrine.
Answer: A

DISCUSSION: The evaluation of most patients scheduled for

elective surgery who do not have a history of significant
bleeding disorders is somewhat controversial. An adequate
history and physical examination screen out most patients with
bleeding problems. For patients who are scheduled to undergo a
major surgical procedure, it is advisable to obtain a CBC and
platelet count, as well as a PT and APTT level. This detects a
large number of bleeding disorders but does not rule out all
possible causes of perioperative bleeding. Studies of platelet
aggregation are indicated only for patients who are suspected of
having qualitative defects of platelet function (e.g., von
Willebrand's disease).

42. Which of the following statements regarding the

transmission of infectious agents through blood transfusions
is/are true?
A. The transmission rates for human immunodeficiency virus
(HIV) have been decreasing progressively since the early 1980s.
B. The transmission rates of hepatitis have been decreasing
steadily since the 1980s.
C. Cytomegalovirus (CMV) is the infectious agent most
commonly transmitted in blood.
D. Severely immunocompromised patients (such as patients
undergoing transplantation) should receive specially screened
blood products.
Answer: ABCD

DISCUSSION: The incidence of both HIV and hepatitis

transmitted via blood transfusions has been steadily decreasing
since the 1980s. This is related to improved methods for
detection and increased awareness of surrogate markers of
disease. The currently available techniques for the detection of
HIV are highly effective, provided the donor is not in the
“window” before the formation of specific antibody. The
surrogate markers for hepatitis C, as well as the specific assays
for the organism, are now sufficiently refined to allow the
detection of a large percentage of hepatitis C infection in
donated blood. Screening for hepatitis B surface antigen has
effectively eliminated the transmission of hepatitis B through
blood products in most cases. CMV is the most commonly
transmitted infectious agent in blood. Since a large percentage
of the population carry the virus, routine screening is not
performed for this organism; however, severely compromised
patients such as those undergoing transplantation should
receive CMV-negative blood products.

43. The most common cause of fatal transfusion reactions is:

A. An allergic reaction.
B. An anaphylactoid reaction.
C. A clerical error.
D. An acute bacterial infection transmitted in blood.
Answer: C

DISCUSSION: The most common cause of fatalities related to

transfusion reactions result from ABO-incompatible transfusion
related to clerical error. Most such reactions occur if a type O
person receives type A red cells owing to a clerical error that
occurs either at the time the blood sample was drawn, during
processing in the laboratory, or at the time a unit is
administered. The importance of extremely careful labeling,
transfer, and handling of specimens and of cross-matched blood
products cannot be overemphasized. Allergic and other reactions
are common but rarely fatal. The transmission of bacterial
organisms (e.g., Staphylococcus aureus) has been reported
especially with platelet concentrates maintained at or near room
temperature. Fortunately, such reactions are rare.

44. Which of the following statements about the coagulation

cascade is/are true?
A. The intrinsic pathway of coagulation is the predominant
pathway in vivo for hemostasis and coagulation.
B. The intrinsic pathway beginning with the activation of factor
XII is the predominant in vivo mechanism for activation of the
coagulation cascade.
C. Deficiencies of factor VIII and IX cause highly significant
coagulation abnormalities.
D. Deficiencies of factor XII cause severe clinical bleeding
syndromes.
Answer: AC

DISCUSSION: Although it was previously held that two

somewhat distinct pathways existed for the activation of the
coagulation cascade, it is now recognized that the predominant
mechanism for coagulation in vivo is the “extrinsic pathway.”
Tissue factor is exposed in the subendothelial tissues when
endothelial cell injury occurs. Tissue factor then tightly binds
factor VII circulating in the plasma and activates the coagulation
cascade. Factor VIII and factor IX deficiency cause the clinical
syndromes of hemophilia A and hemophilia B, respectively. Both
of these disorders involve very severe clinical bleeding
disorders, whereas deficiencies of factor XII do not generally
cause clinically significant bleeding. This further emphasizes the
secondary role that the “intrinsic pathway” plays in coagulation.

45. A major problem in nutritional support is identifying

patients at risk. Recent studies suggest that these patients can
be identified. Which of the following findings identify the patient
at risk?
A. Weight loss of greater than 10% over 2 to 4 months.
B. Serum albumin of less than 3 gm. per 100 ml. in the
hydrated state.
C. Malnutrition as identified by global assessment.
D. Serum transferrin of less than 220 mg. per 100 ml.
E. Functional impairment by history.
Answer: ABCDE

DISCUSSION: All of these are at least partially correct. It is not

clear whether weight loss of 10% or 15% is the required
threshold, but it certainly is close. Serum albumin of less than 3
gm per 100 ml. remains the most constant identifier of patients
at risk in the literature and has been so for years. Global
assessment in the hands of an experienced investigator is quite
efficacious at identifying persons at risk. Serum transferrin is
certainly a confirmatory identifier of patients with
malnutrition—and may be even a primary one. Graham Hill and
his co-workers have pioneered the concept of global assessment
using functional parameters, and in the hands of an experienced
observer is quite a reasonable way of approaching and
identifying patients at risk.

46. 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.
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 arachidonic acid
in plasma and the appearance of the abnormal eicosatrienoic
acid may yield the earliest indication of prostaglandin deficiency;
it is not absolute. Decreased intraocular pressure, another early
indication of prostaglandin deficiency, may appear as soon as 7
days following initiation of fat-free parenteral nutrition. While
my current practice is to give at least 500 ml. of 10% lipid
emulsion daily to provide 20% to 25% of total calories to
support hepatic protein synthesis, as little as 4% to 6% of total
daily calories as fat prevents essential fatty acid deficiency.
Practically, this may be undertaken by the administration of 500
ml. of 10% lipid three times weekly. The appearance of
eicosatrienoic acid and a decrease in arachidonic acid, and a
change in ratio, is not essential to the diagnosis of essential
fatty acid deficiency, but this plasma abnormality is often
present.

47. It is stated that enteral nutrition is safer than parenteral

nutrition. Which of the following may be complications of enteral
nutrition?
A. Hyperosmolar, nonketotic coma.
B. Vomiting and aspiration.
C. Pneumatosis cystoides intestinalis.
D. Perforation and peritonitis.
Answer: ABCD

DISCUSSION: It is not necessarily true that enteral nutrition is

safer than parenteral nutrition, and it may in fact be associated
with a higher risk of death than parenteral nutrition. Specifically,
a well-run parenteral nutrition service should not be associated
with significant mortality, except for the occasional death due to
undetected yeast infection. On the other hand, enteral nutrition,
especially if not carried out safely, can result in significant
mortality. The most common of the severe complications of
enteral nutrition result from the gastrostomy, or tube feedings
into the stomach. Sudden changes in gastric motility, such as
those associated with sepsis, may result in aspiration.
Nasoenteric or nasoduodenal tubes help prevent this
complication, as does shutting off enteral feedings between the
hours of 11 P.M. and 7 A.M. It is also essential to keep the
patient's head elevated 30 degrees. Also necessary is the use of
extreme care when initiating enteral nutrition. If hypertonic
material is given into the stomach, one can increase osmolality
followed by an increase in volume. If, however, the material is
given into the small bowel, volume must be increased first and
then tonicity, with the expectation that osmolality greater than
400 or 500 mOsm per liter may never be achieved without
provoking severe diarrhea. If care is not taken with the initiation
of enteral nutrition, massive diarrhea may result, including fluid
loss, the absorption of enormous amounts of carbohydrate into
the circulation with inadequate fluid to support it, and the
development of hyperosmolar, nonketotic coma. Alternatively,
severe unremitting diarrhea may result in necrosis of the
intestinal wall, the appearance of pneumatosis cystoides
intestinalis, and, finally, perforation and death. All of these
complications may be prevented by judicious use of enteral
nutrition with the same care one uses for parenteral nutrition.

48. It has been suggested that enterocyte-specific fuels be

utilized for all patients receiving parenteral nutrition.
Theoretically, the benefits of such fuels include:
A. Glutamine increases gut mucosal protein content and wall
thickness.
B. Butyrate increases jejunal mucosal protein content and wall
thickness.
C. The short-chain fatty acids—butyrate, propionate, and
acetate—are useful in supporting ileal mucosal protein content
and thickness.
D. The use of glutamine-enriched solutions for parenteral
nutrition for patients with chemotherapy toxicity or radiation
enteritis is without hazards.
Answer: NONE IS ENTIRELY TRUE

DISCUSSION: The use of enterocyte-specific fuels is part of a

new and potentially exciting phase of “nutritional pharmacology”
in parenteral nutrition; however, exciting as the research may
be, the use of such fuels is by no means acceptable for
indiscriminate use at present. Though some studies have shown
that the provision of glutamine in amounts up to 2% in standard
parenteral nutrition solutions increases both jejunal and ileal
mucosal protein content, cell wall thickness, and DNA content,
this has not been the case in all studies, and this reported effect
seems very dependent on experimental design. In many of the
studies that have shown such an effect, 2% glutamine has been
used to replace virtually all nonessential amino acids, probably
initiating a deficiency state. The beneficial effects seen with
glutamine are far less impressive than those seen with
epidermal growth factor, for example, and disappear entirely
when a different experimental design is used in which 2%
glutamine is added to an adequate amino acid formulation in
which glutamine does not replace nonessential amino acids but
is added to them. Nonetheless, the use of enterocyte-specific
fuels, specifically glutamine, is potentially exciting and should be
carefully investigated. More striking are the results that follow
massive bowel resection, radiation enteritis, and chemotherapy
toxicity. Glutamine may help the small bowel regenerate more
quickly, enabling more rapid use of the small bowel for nutrition.
It should be pointed out, however, that glutamine is a fuel
utilized by many tumors and, thus, one runs the risk of
stimulating the growth of the tumor with excessive glutamine.
The short-chain fatty acids, produced from bacterial
fermentation of soluble pectin, may be useful in both the
maintenance of colonocyte-specific nutrition and, in the case of
butyrate, ileal enterocyte nutrition.

49. 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.
Answer: BC

DISCUSSION: Essential amino acids and hypertonic dextrose, as

opposed to hypertonic dextrose alone, was reported by Abel and
co-workers to be associated with a decreased mortality rate in
mostly surgical patients with acute tubular necrosis. The most
significant improvement in mortality, as compared with the
control group receiving hypertonic dextrose, was among
patients who required dialysis (i.e., the more severely affected
patients). Another group responding favorably to treatment
includes patients with nonoliguric renal failure whose need for
dialysis is not clearly established. The effect of essential amino
acids in preventing a rise in BUN, as well as its beneficial effect
in preventing hyperkalemia, may obviate dialysis in such
patients. With increasing amounts of nonessential amino acids,
BUN increases, and thus, dialysis is required. Prospective
randomized studies comparing the use of essential versus
nonessential amino acids in patients with acute renal failure
have not been carried out in sufficient numbers to yield answers
to this question.

50. 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.
Answer: D

DISCUSSION: The use of modified amino acid solutions is based

on the false neurotransmitter hypothesis of the cause of hepatic
coma. According to this hypothesis, the imbalance between
aromatic and branched-chain amino acids in the plasma results
in abnormally high levels of the toxic aromatic amino acids in
the brain, thus provoking hepatic encephalopathy. The use of
modified amino acid mixtures, with glucose as the calorie base,
has been associated in a number of studies with improvement in
encephalopathy. Meta-analysis has concluded that the use of
such solutions is indicated as therapy for hepatic
encephalopathy but has been proposed only for hepatic
encephalopathy complicating acute exacerbation of chronic liver
disease. Although there are a few anecdotal reports of beneficial
effects on hepatic encephalopathy of acute fulminant hepatitis,
the use of such a solution has not been advocated, but such a
modified solution is tolerated better than standard amino acid
mixtures in patients requiring TPN. In some studies, particularly
in complicated surgical cases, the use of a high–branched-chain,
low–aromatic amino acid solution has been associated with
lower mortality. These statements are true only for studies in
which the modified solutions are given with hypertonic glucose
as a calorie base. Studies in which lipid was the principal calorie
source have not revealed such improvements in mortality. In
recent studies, giving an aromatic amino acid–deficient,
branched-chain amino acid–enriched solution to patients about
to undergo resection of the liver has proved particularly
efficacious in a group of patients with cirrhosis, decreasing
morbidity and showing a trend toward decreased mortality.

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