Nutrition in Critical Illness — MCQs

10 questions

Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

A patient on total parenteral nutrition for 20 days presents with weakness, vertigo and convulsions. Diagnosis is

Nil per oral orders for an 8-year-old child posted for elective nasal polyp surgery at 8 AM include all of the following EXCEPT:

Which of the following is the preferred cannulation site for total parenteral nutrition?

In pregnancies complicated by intrauterine growth restriction (IUGR) with otherwise reassuring fetal surveillance, what is the recommended gestational age for planned delivery to optimize neonatal outcomes?

Stress induced hyperglycemia is mediated through which hormone:

In surgical stress all hormones are increased except:

A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

Propofol infusion syndrome all except?

Q10

Which of the following are components of SOFA scoring system? I. PaO_2 / FiO_2 ratio II. Mean arterial pressure III. Glasgow coma scale IV. Prothrombin Time with INR Select the correct answer using the code given below :

Nutrition in Critical Illness Indian Medical PG Practice Questions and MCQs

Question 1: Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

A. Normal saline
B. Ringer lactate
C. 10% dextrose
D. Ringer lactate + 5% dextrose (Correct Answer)

Explanation: ***Ringer lactate + 5% dextrose*** - This combination provides both **electrolytes** (from Ringer lactate) to help correct **shock** and **glucose** (from 5% dextrose) to address **hypoglycemia** in a child with severe acute malnutrition (SAM). - Patients with SAM are at a high risk of **hypoglycemia** during shock, making glucose supplementation crucial. *Normal saline* - While suitable for initial fluid resuscitation in shock, it does **not contain glucose** and would not address the concomitant hypoglycemia. - Excessive use of normal saline can also lead to **hyperchloremic metabolic acidosis**, which is undesirable in already compromised patients. *Ringer lactate* - Ringer lactate provides **electrolytes** and is a good crystalloid for shock resuscitation, but it **lacks glucose** to correct hypoglycemia. - In SAM patients, where energy stores are depleted, simply providing Ringer lactate might not be sufficient to prevent or treat hypoglycemia. *10% dextrose* - 10% dextrose would effectively treat **hypoglycemia** but is not an appropriate fluid for fluid resuscitation in **shock**. - It would not adequately expand the intravascular volume or provide the necessary electrolytes for managing shock alone.

Question 2: A patient on total parenteral nutrition for 20 days presents with weakness, vertigo and convulsions. Diagnosis is

A. Hypomagnesemia (Correct Answer)
B. Hypercalcemia
C. Hypermagnesemia
D. Hypocalcemia

Explanation: Hypomagnesemia - **Weakness, vertigo, and convulsions** in a patient on **total parenteral nutrition (TPN)** for 20 days are classic signs of magnesium deficiency. - TPN without adequate magnesium supplementation can lead to this condition, as magnesium is crucial for **neuromuscular function**. *Hypercalcemia* - Symptoms of hypercalcemia typically include **bone pain, kidney stones (nephrolithiasis) [1], abdominal groans (constipation, nausea, vomiting)**, and **psychiatric overtones (depression, lethargy)**. - It does not typically cause vertigo or convulsions as primary symptoms, especially not after TPN. *Hypermagnesemia* - Hypermagnesemia is usually associated with **renal failure** or excessive magnesium intake (e.g., antacids, laxatives). - Symptoms often include **hypotension, bradycardia, respiratory depression**, and **loss of deep tendon reflexes**, which are not described here. *Hypocalcemia* - Hypocalcemia can cause neuromuscular irritability, leading to **tetany, muscle cramps**, and **paresthesias**. - While it can manifest with seizures, the combination of **vertigo** and the context of TPN makes hypomagnesemia a more direct and often co-occurring cause.

Question 3: Nil per oral orders for an 8-year-old child posted for elective nasal polyp surgery at 8 AM include all of the following EXCEPT:

A. Apple juice can be taken at 10 PM previous night
B. Milk can be taken at 7 AM in morning (Correct Answer)
C. Can take sips of water up to 6 AM in morning
D. Rice can be consumed at 11 PM previous night

Explanation: **Milk can be taken at 7 AM in morning** - For an 8-year-old undergoing elective surgery at 8 AM, **milk is considered a solid or heavy fluid** and should be stopped at least **6 hours pre-operatively**. - Taking milk at 7 AM, just one hour before surgery, significantly increases the risk of **pulmonary aspiration** during anesthesia. *Apple juice can be taken at 10 PM previous night* - **Clear liquids**, such as apple juice, can generally be consumed up to **2 hours before surgery** in children. - Taking apple juice at 10 PM the night before for an 8 AM surgery falls well within the safe fasting window for clear liquids. *Can take sips of water up to 6 AM in morning* - **Sips of water** are considered a clear liquid and can be consumed up to **2 hours before surgery** in children. - Allowing water until 6 AM for an 8 AM surgery is appropriate and helps prevent dehydration without increasing aspiration risk. *Rice can be consumed at 11 PM previous night* - **Solid foods**, like rice, require a longer fasting period, typically at least **6-8 hours before surgery**. - Consuming rice at 11 PM the night before, for an 8 AM surgery, allows for sufficient gastric emptying and is generally safe.

Question 4: Which of the following is the preferred cannulation site for total parenteral nutrition?

A. Subclavian vein (Correct Answer)
B. Great Saphenous vein
C. Median cubital vein
D. External jugular vein

Explanation: ***Subclavian vein*** - The **subclavian vein** is the preferred site for total parenteral nutrition (TPN) due to its **high blood flow**, which helps to rapidly dilute the hyperosmolar TPN solution, reducing the risk of thrombophlebitis. - Its relatively stable anatomical position also allows for long-term catheter placement with a **lower risk of dislodgement and infection**. *Great Saphenous vein* - The **great saphenous vein** is a peripheral vein with a **smaller diameter** and **lower blood flow** compared to central veins. - It is unsuitable for TPN due to the high risk of **thrombophlebitis** and **catheter-related infections** from the hyperosmolar solution. *Median cubital vein* - The **median cubital vein** is a peripheral vein commonly used for routine intravenous access but is not suitable for TPN. - Its **smaller caliber** and **peripheral location** would lead to a high incidence of phlebitis and pain with the continuous infusion of highly concentrated TPN solutions. *External jugular vein* - While the **external jugular vein** is a central vein, it is generally considered **less desirable** for long-term TPN compared to the subclavian vein. - Catheter placement in the external jugular vein can be associated with a **higher risk of patient discomfort** and potential for **catheter dislodgement** due to neck movement.

Question 5: In pregnancies complicated by intrauterine growth restriction (IUGR) with otherwise reassuring fetal surveillance, what is the recommended gestational age for planned delivery to optimize neonatal outcomes?

A. 39 weeks
B. 37 weeks
C. 40 weeks
D. 38 weeks (Correct Answer)

Explanation: ***38 weeks*** - For pregnancies complicated by **IUGR (Intrauterine Growth Restriction)** with reassuring fetal surveillance, planned delivery at **38-39 weeks** is recommended by **ACOG guidelines** to optimize neonatal outcomes. - Among the given options, **38 weeks** represents the earliest point in this recommended range, balancing the risks of continued intrauterine compromise with the risks of **prematurity** such as **respiratory distress syndrome**. - This timing is appropriate for **mild to moderate IUGR** without concerning Doppler findings or other complications. *39 weeks* - **39 weeks** is actually within the acceptable range (38-39 weeks) for IUGR delivery per current guidelines. - However, many obstetricians prefer **38 weeks** to minimize the risk of continued **fetal compromise** from **placental insufficiency**, making 38 weeks the more commonly cited benchmark. - The distinction between 38 and 39 weeks is nuanced and depends on individual case factors and surveillance findings. *37 weeks* - Delivery at **37 weeks** is considered **early term** and carries higher risk of **neonatal morbidities**, particularly **respiratory complications** and **hypoglycemia**. - This timing may be appropriate for **severe IUGR** with abnormal **umbilical artery Doppler** findings, **absent or reversed end-diastolic flow**, or other concerning features, but not for routine IUGR with reassuring surveillance. - It is not the standard recommendation for uncomplicated IUGR to optimize outcomes. *40 weeks* - Delivering at **40 weeks** in an IUGR pregnancy is **not recommended** due to increased risk of **stillbirth** and complications from ongoing **placental insufficiency**. - The risks of adverse outcomes escalate with expectant management beyond 38-39 weeks in IUGR pregnancies. - Minimal additional fetal growth occurs beyond this point while risks continue to increase.

Question 6: Stress induced hyperglycemia is mediated through which hormone:

A. Cortisol (Correct Answer)
B. Epinephrine
C. Insulin
D. Growth hormone

Explanation: ***Cortisol*** - **Cortisol** is the **primary mediator** of stress-induced hyperglycemia among the counter-regulatory hormones - It promotes **gluconeogenesis** (formation of new glucose from amino acids and glycerol) in the liver - Stimulates **protein catabolism** in muscles, providing substrates for gluconeogenesis - Induces **insulin resistance** in peripheral tissues, reducing glucose uptake - Released as part of the **HPA axis response** to stress, with sustained elevation during prolonged stress - This is the **correct answer** for stress-induced hyperglycemia mediation *Epinephrine* - **Epinephrine** (adrenaline) is a potent hyperglycemic hormone but acts as an **acute, immediate response** to stress - Rapidly increases blood glucose through **glycogenolysis** (breakdown of glycogen) in liver and muscles - Stimulates **gluconeogenesis** and inhibits insulin secretion - Effects are **rapid but short-lived**, making it more of an emergency response rather than the sustained mediator - Works synergistically with cortisol but is not the primary sustained mediator *Growth hormone* - **Growth hormone** does contribute to hyperglycemia through **anti-insulin effects** and promoting lipolysis - Its hyperglycemic effects are **slower and less pronounced** compared to cortisol and epinephrine - Plays a role in **chronic stress** but is not the primary acute mediator - More important for **long-term metabolic adaptation** rather than immediate stress response *Insulin* - **Insulin** is a **glucose-lowering hormone** that facilitates glucose uptake into cells - During stress, insulin secretion is **suppressed** and tissues become **insulin-resistant** due to counter-regulatory hormones - It does **not mediate** stress-induced hyperglycemia; rather, its action is **opposed** by stress hormones - Decreased insulin action contributes to hyperglycemia but insulin itself is not the mediator

Question 7: In surgical stress all hormones are increased except:

A. Insulin (Correct Answer)
B. Epinephrine
C. ACTH
D. Cortisol

Explanation: ***Insulin*** - While other **stress hormones** increase, **insulin** levels typically **decrease** or remain stable due to increased **insulin resistance** during surgical stress. - This physiological response aims to maintain **blood glucose** levels for energy during heightened metabolic demands. *Epinephrine* - **Epinephrine** (adrenaline) is a key **catecholamine** released during surgical stress, leading to a "fight or flight" response. - It increases **heart rate**, **blood pressure**, and promotes **gluconeogenesis** to supply quick energy. *ACTH* - **Adrenocorticotropic hormone (ACTH)** is released from the **pituitary gland** in response to surgical stress. - **ACTH** stimulates the adrenal cortex to produce **cortisol**, a critical stress hormone. *Cortisol* - **Cortisol** levels significantly rise during surgical stress, mediated by **ACTH** release. - It plays a crucial role in **modulating inflammation**, **glucose metabolism**, and maintaining **hemodynamic stability**.

Question 8: A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

A. Hypophosphatemia (Correct Answer)
B. Hypoglycemia
C. Hyperkalemia
D. Hypermagnesemia

Explanation: ***Hypophosphatemia*** * This patient with severe malnutrition (albumin <1, 60lb weight loss) is at high risk for **refeeding syndrome** when TPN is initiated [1]. * Upon refeeding, **insulin release** causes intracellular shifts of electrolytes, particularly phosphate, leading to severe hypophosphatemia [1]. * *Hypoglycemia* * TPN contains dextrose, which typically causes **hyperglycemia**, not hypoglycemia, especially given its continuous infusion. * Hypoglycemia would be more likely if TPN was abruptly discontinued, causing a rapid drop in glucose levels as basal insulin continues to be secreted. * *Hyperkalemia* * Refeeding syndrome typically causes a rapid **intracellular shift of potassium**, leading to **hypokalemia**, not hyperkalemia [1]. * Hyperkalemia would be a concern in patients with renal insufficiency or those receiving potassium-sparing diuretics. * *Hypermagnesemia* * Similar to potassium and phosphate, refeeding syndrome usually causes an **intracellular shift of magnesium**, leading to **hypomagnesemia** [1]. * Hypermagnesemia is rare and typically seen in patients with severe renal failure or excessive exogenous magnesium intake (e.g., antacids).

Question 9: Propofol infusion syndrome all except?

A. Occurs with infusion of propofol for 48 hours or longer
B. Occurs in critically ill patients
C. Features are cardiomyopathy, hepatomegaly
D. Features are nausea and vomiting (Correct Answer)

Explanation: ***Features are nausea and vomiting*** - **Nausea and vomiting** are generally not primary defining features of **Propofol Infusion Syndrome (PRIS)**. - While patients receiving propofol may experience these symptoms due to other causes or medication side effects, they are not part of the core diagnostic criteria for PRIS. *Occurs with infusion of propofol for 48 hours or longer* - **PRIS** is more common with **prolonged infusions**, typically exceeding **48 hours**, as a higher cumulative dose increases risk. - However, it can also manifest with shorter infusions or higher doses, though this is less common. *Occurs in critically ill patients* - **Critically ill patients**, especially those with **sepsis**, **trauma**, or **neurological injury**, are at higher risk due to compromised metabolic states and the need for high-dose, prolonged sedation. - This vulnerability is linked to the increased metabolic demands and potential for **lipid overload** or **mitochondrial dysfunction**. *Features are cardiomyopathy, hepatomegaly* - **Cardiomyopathy** and subsequent **cardiac failure** are severe and common features of PRIS, often presenting as **bradycardia** and **arrhythmias**. - **Hepatomegaly** indicates liver dysfunction, which, along with **rhabdomyolysis**, **metabolic acidosis**, and **renal failure**, are characteristic manifestations of PRIS.

Question 10: Which of the following are components of SOFA scoring system? I. PaO_2 / FiO_2 ratio II. Mean arterial pressure III. Glasgow coma scale IV. Prothrombin Time with INR Select the correct answer using the code given below :

A. I, II and IV
B. II, III and IV
C. I, III and IV (Correct Answer)
D. I, II and III

Explanation: ***I, III and IV*** - The **Sequential Organ Failure Assessment (SOFA) score** evaluates organ dysfunction based on six systems: respiration, coagulation, liver, cardiovascular, central nervous system, and renal. - **PaO2/FiO2 ratio** assesses respiratory function, **Glasgow Coma Scale (GCS)** assesses central nervous system function [1], [3], and **Prothrombin Time with INR** assesses coagulation function, all of which are included in the SOFA score calculation. *I, II and IV* - This option incorrectly includes **Mean Arterial Pressure** as a primary component for calculating the cardiovascular SOFA score, though it is indirectly considered when evaluating the use of vasopressors [2]. - The SOFA cardiovascular component primarily relies on **vasopressor dosage** required to maintain blood pressure, rather than absolute mean arterial pressure alone. *II, III and IV* - This option omits the **PaO2/FiO2 ratio**, which is a crucial parameter for assessing respiratory organ dysfunction within the SOFA scoring system. - It incorrectly focuses on **Mean Arterial Pressure** as a direct component instead of the vasopressor requirement. *I, II and III* - This choice omits **Prothrombin Time (PT) with INR**, which is a vital indicator for assessing the **coagulation system** within the SOFA score. - It incorrectly includes **Mean Arterial Pressure** as a direct, standalone component rather than vasopressor support for the cardiovascular system.

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