Carbohydrate Loading — MCQs

10 questions

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

Protein metabolism after trauma is characterized by the following except:

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:

In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?

Among the following conditions, laparoscopy carries the highest risk in patients with:

A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting

In surgical stress all hormones are increased except:

Gastric lavage is contraindicated in the following:

All of the following are increased in Acute stress except

Q10

A meta-analysis comparing ERAS versus traditional perioperative care shows 30% reduction in length of stay and 50% reduction in complications without increase in readmission rates. However, implementation costs are 20% higher initially. As a department head, how should you evaluate the adoption of ERAS protocol?

Carbohydrate Loading 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: Protein metabolism after trauma is characterized by the following except:

A. Increased liver gluconeogenesis
B. Increased urinary nitrogen loss
C. Hepatic synthesis of acute phase reactants
D. Inhibition of skeletal muscle breakdown by interleukin 1 and tumour necrosis factor (Correct Answer)

Explanation: ***Inhibition of skeletal muscle breakdown by interleukin 1 and tumour necrosis factor*** - After trauma, **interleukin 1 (IL-1)** and **tumor necrosis factor (TNF)** actually **promote** skeletal muscle breakdown (catabolism) to provide amino acids for gluconeogenesis and acute phase protein synthesis. - This statement is incorrect because these cytokines are **pro-catabolic**, not inhibitory, in their effect on muscle protein. *Increased liver gluconeogenesis* - Trauma leads to a significant increase in **liver gluconeogenesis**, primarily to maintain glucose supply for **immune cells** and wound healing, which rely heavily on glucose. - This process utilizes amino acids obtained from muscle breakdown as substrates. *Increased urinary nitrogen loss* - The breakdown of muscle protein releases amino acids, which are then deaminated. The nitrogen waste product, **urea**, is excreted in the urine, leading to **increased urinary nitrogen loss**. - This is a direct consequence of the catabolic state. *Hepatic synthesis of acute phase reactants* - The liver increases the synthesis of **acute phase reactants** (e.g., C-reactive protein, fibrinogen, haptoglobin) in response to inflammatory cytokines like IL-1, **IL-6**, and TNF. - These proteins play a crucial role in the inflammatory response and tissue repair.

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: In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?

A. 2000 ml Ringer's lactate bolus
B. 1000 ml Ringer's lactate bolus, then regulated by clinical indicators (Correct Answer)
C. 250 ml Ringer's lactate bolus
D. 500 ml Ringer's lactate bolus, then regulated by clinical indicators

Explanation: ***1000 ml Ringer's lactate bolus, then regulated by clinical indicators*** - For **hemodynamically unstable** polytrauma patients, the initial recommended crystalloid bolus is typically **1 liter (1000 mL)** of Ringer's lactate. - This initial bolus allows for rapid assessment of the patient's response and guides subsequent fluid management based on **clinical indicators** such as blood pressure, heart rate, and urine output, avoiding over-resuscitation. *2000 ml Ringer's lactate bolus* - A **2000 ml bolus** is generally considered too large for an initial dose in trauma, as it can lead to **dilutional coagulopathy**, worsening hemorrhage, and **abnormal fluid shifts**, especially in cases where definitive hemorrhage control is not yet achieved. - Excessive fluid administration can lead to complications such as **abdominal compartment syndrome** and **acute respiratory distress syndrome (ARDS)**. *250 ml Ringer's lactate bolus* - A **250 ml bolus** is generally too small to effectively address **hemodynamic instability** in a polytrauma patient, offering insufficient volume to significantly improve circulation or organ perfusion. - While small boluses might be used in specific situations (e.g., small children or patients with cardiac comorbidities), this dose is not adequate for initial resuscitation in a severely unstable adult trauma patient. *500 ml Ringer's lactate bolus, then regulated by clinical indicators* - While **500 mL** is a common bolus size in other medical settings, it may be insufficient for the initial resuscitation of a **hemodynamically unstable adult polytrauma patient**. - Current trauma guidelines often recommend a larger initial bolus (e.g., 1000 mL) to gain a more immediate and measurable hemodynamic response for assessment.

Question 5: Among the following conditions, laparoscopy carries the highest risk in patients with:

A. COPD (Correct Answer)
B. Diabetes
C. Hypertension
D. Obesity

Explanation: ***COPD*** - **COPD** patients have severely compromised respiratory function, and the **pneumoperitoneum** from CO2 insufflation causes **diaphragmatic splinting** and reduced lung compliance, leading to dangerous **CO2 retention** and respiratory failure. - The increased **intra-abdominal pressure** significantly impairs ventilation in patients who already have limited respiratory reserve, making laparoscopy extremely high-risk. *Diabetes* - While diabetes increases risks of **poor wound healing** and **infection**, these complications are not specifically worse with laparoscopy compared to open surgery. - **Perioperative glucose management** can effectively control diabetes-related risks, and laparoscopy may actually offer benefits like smaller incisions. *Hypertension* - **Hypertension** requires careful **blood pressure monitoring** during surgery but doesn't pose risks unique to laparoscopic procedures. - Well-controlled hypertension with appropriate **antihypertensive medications** allows for safe laparoscopic surgery. *Obesity* - **Obesity** makes laparoscopy technically challenging due to **thick abdominal walls** and need for higher insufflation pressures. - However, laparoscopy is often **preferred over open surgery** in obese patients due to reduced wound complications and faster recovery.

Question 6: A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting

A. Water at 12:00 PM
B. Black coffee at 5:30 AM
C. Pancakes at 10:00 AM (Correct Answer)
D. A non-clear liquid (e.g., orange juice) at 7:30 AM

Explanation: **Pancakes at 10:00 AM** - According to ASA guidelines, the fasting period for solid food is typically **6-8 hours** before surgery. Eating pancakes, which are solid food, at 10:00 AM for a 2:00 PM surgery (4-hour interval) violates this guideline. - This short fasting period for solids increases the risk of **pulmonary aspiration** during induction of anesthesia. *Water at 12:00 PM* - Water is considered a clear liquid, and ASA guidelines typically allow clear liquids until **2 hours** before surgery. Drinking water at 12:00 PM for a 2:00 PM surgery is within these guidelines. - Rapid gastric emptying of clear liquids minimizes the risk of aspiration. *Black coffee at 5:30 AM* - Black coffee is considered a clear liquid, and it is consumed well within the **2-hour** fasting window for clear liquids before a 2:00 PM surgery. - The absence of milk or cream ensures it is treated as a clear liquid, which empties quickly from the stomach. *A non-clear liquid (e.g., orange juice) at 7:30 AM* - Non-clear liquids, such as orange juice, are treated similarly to light meals and generally require a fasting period of **6 hours** before surgery. Drinking orange juice at 7:30 AM for a 2:00 PM surgery (6.5-hour interval) is compliant with these guidelines. - The protein and pulp in non-clear liquids delay gastric emptying compared to clear liquids.

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: Gastric lavage is contraindicated in the following:

A. Barbiturate poisoning
B. Paracetamol poisoning
C. Kerosene poisoning (Correct Answer)
D. Carbolic acid poisoning

Explanation: ***Kerosene poisoning*** - Gastric lavage is contraindicated in **hydrocarbon poisoning** like kerosene due to the high risk of **aspiration pneumonitis**. [1] - Aspiration of hydrocarbons can lead to severe **chemical pneumonitis**, acute respiratory distress syndrome (ARDS), and even death. *Barbiturate poisoning* - Gastric lavage can be useful in **barbiturate poisoning**, especially if presenting within 1-2 hours of ingestion, to remove unabsorbed drug. - It's part of the management strategy to reduce drug absorption and potentially speed up recovery. *Paracetamol poisoning* - **Gastric lavage** may be considered in paracetamol overdose, particularly if performed within 1-2 hours of ingestion, to remove unabsorbed drug. - However, **activated charcoal** is usually the preferred method for gastric decontamination in paracetamol overdose, followed by **N-acetylcysteine**. *Carbolic acid poisoning* - While typically considered a corrosive, gastric lavage might be cautiously used in **carbolic acid (phenol) poisoning** in specific circumstances, such as very early presentation or large ingestions, but it carries risks of esophageal injury. [2] - Dilution with milk or water is often preferred, but lavage should be avoided if there's evidence of significant caustic injury or perforation risk.

Question 9: All of the following are increased in Acute stress except

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

Explanation: ***Insulin*** - During acute stress, **insulin secretion is actively suppressed** by catecholamines (epinephrine and norepinephrine) acting on **alpha-2 adrenergic receptors** on pancreatic beta cells. - This suppression is crucial for the stress response, as it allows **unopposed action of counter-regulatory hormones** to mobilize glucose and raise blood glucose levels. - The body prioritizes **immediate energy availability** (high blood glucose) over storage, making insulin the hormone that is **decreased, not increased**, during acute stress. *Growth hormone* - **Growth hormone** is a counter-regulatory hormone that **increases during acute stress** to mobilize energy stores, particularly by promoting lipolysis and gluconeogenesis. - Its actions contribute to the stress-induced elevation of **blood glucose levels**. *Epinephrine* - **Epinephrine** (adrenaline) is a primary catecholamine released during acute stress, leading to a rapid **fight or flight response**. - It significantly **increases heart rate**, blood pressure, and **glucose mobilization** through glycogenolysis and gluconeogenesis. *Glucagon* - **Glucagon** is a key hormone involved in **maintaining glucose homeostasis** and is significantly **increased during acute stress**. - It primarily acts on the liver to **stimulate glycogenolysis** and **gluconeogenesis**, thereby raising blood glucose levels to provide energy.

Question 10: A meta-analysis comparing ERAS versus traditional perioperative care shows 30% reduction in length of stay and 50% reduction in complications without increase in readmission rates. However, implementation costs are 20% higher initially. As a department head, how should you evaluate the adoption of ERAS protocol?

A. Reject ERAS due to higher initial costs affecting hospital budget
B. Wait for more evidence before implementation
C. Adopt ERAS based on superior clinical outcomes and likely long-term cost savings from reduced complications (Correct Answer)
D. Implement ERAS only for low-risk patients to minimize costs

Explanation: ***Adopt ERAS based on superior clinical outcomes and likely long-term cost savings from reduced complications*** - Significant reductions in **length of stay (30%)** and **complications (50%)** provide strong evidence for the clinical superiority of **ERAS protocols** over traditional care. - The initial 20% cost increase is often offset by **long-term savings** gained from fewer hospital days and reduced management of postoperative complications. *Reject ERAS due to higher initial costs affecting hospital budget* - Focusing solely on **upfront costs** ignores the substantial economic benefit derived from **resource optimization** and beds being freed faster. - High-value healthcare prioritizes **outcomes per dollar spent**, and ERAS typically demonstrates a high **return on investment**. *Wait for more evidence before implementation* - Current **meta-analysis data** already provides high-level evidence regarding its efficacy in improving **surgical recovery**. - Delaying implementation based on sufficient existing evidence prevents patients from accessing safer, **evidence-based clinical pathways**. *Implement ERAS only for low-risk patients to minimize costs* - **ERAS protocols** are designed to be multi-modal and often provide the greatest absolute benefit to **high-risk patients** who are prone to complications. - Restricting the protocol limits the overall **scale of improvement** in hospital-wide metrics like **readmission rates** and total surgical volume.

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