Nutritional Strategies — MCQs

10 questions

A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

Ramesh met an accident with a car and has been in deep coma for the last 15 days. The most suitable route for the administration of protein and calories is by :

Optimum urine output in post-operative patient:

Postoperative third-space accumulation should be managed by intravenous fluid with

Which of the following is not a prokinetic?

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

As per the latest NRP guidelines, what is the target preductal saturation after birth at 5 minutes?

Which of the following anaesthetic agent lacks analgesic effect? A) N2O B) Thiopentone C) Methohexitone D) Ketamine E) Fentanyl

Which of the following is the induction anesthesia of choice in the pediatric age group?

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?

Nutritional Strategies Indian Medical PG Practice Questions and MCQs

Question 1: A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

A. Postoperative administration for 5 to 7 days of parenteral antibiotics effective against aerobes and anaerobes
B. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes may provide initial coverage. (Correct Answer)
C. Postoperative administration for 2 to 4 days of parenteral antibiotics effective against aerobes and anaerobes
D. Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile

Explanation: ***Single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes*** - For **elective colorectal surgery**, a single dose of a **broad-spectrum parenteral antibiotic** administered within 60 minutes prior to incision is the standard of care to reduce surgical site infections. - This approach ensures adequate drug levels in the tissues during the period of potential bacterial contamination and is a cornerstone of modern surgical prophylaxis. - Current guidelines (WHO, SCIP) recommend a single preoperative dose, which may be redosed intraoperatively if the procedure is prolonged beyond 3-4 hours. *Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile* - This is **incorrect**. **Oral antibiotics** (such as neomycin and metronidazole) are routinely used preoperatively in conjunction with mechanical bowel preparation for colorectal surgery to reduce intraluminal bacterial load. - The concern for *Clostridioides difficile* infection is generally low with short-term, targeted prophylactic antibiotic regimens compared to broad-spectrum, prolonged use. - The combination of oral and parenteral antibiotics has been shown to further reduce surgical site infections. *Postoperative administration for 5 to 7 days of parenteral antibiotics* - **Prolonged postoperative antibiotic administration** beyond 24 hours in uncomplicated cases is not recommended as it increases the risk of **antibiotic resistance**, *C. difficile* infection, and adverse drug reactions without additional benefit. - The goal of prophylactic antibiotics is to cover the period of contamination during surgery, not to treat presumed ongoing infection postoperatively. *Postoperative administration for 2 to 4 days of parenteral antibiotics* - While administration for up to 24 hours post-operatively may be considered in some high-risk cases, routine **prolonged postoperative antibiotics** (2-4 days) are unnecessary for most elective colorectal resections. - Evidence suggests that continuing antibiotics beyond the immediate perioperative period does not further reduce the incidence of **surgical site infections** in clean-contaminated surgeries.

Question 2: Ramesh met an accident with a car and has been in deep coma for the last 15 days. The most suitable route for the administration of protein and calories is by :

A. Central venous hyperalimentation
B. Nasogastric tube feeding
C. Jejunostomy tube feeding (Correct Answer)
D. Gastrostomy tube feeding

Explanation: ***Jejunostomy tube feeding*** - For patients in a **deep coma** who need long-term nutritional support, **enteral feeding** is preferred over parenteral if the gut is functional [1]. - A **jejunostomy tube** is suitable when there is a risk of **gastric reflux** and aspiration, which is common in comatose patients, as feeding directly into the jejunum bypasses the stomach. *Central venous hyperalimentation* - This is **parenteral nutrition**, which is generally reserved for patients where the **gastrointestinal tract is not functional** or cannot safely be used [1]. - It carries higher risks of **infection**, **metabolic complications**, and is more expensive than enteral feeding. *Nasogastric tube feeding* - While a common route for short-term enteral feeding, **nasogastric tubes** have a higher risk of **aspiration pneumonia** in patients with an impaired gag reflex or altered consciousness, like those in a deep coma. - Long-term use can also lead to **nasal irritation**, **sinusitis**, or **esophageal erosion**. *Gastrostomy tube feeding* - A **gastrostomy tube** delivers feed directly into the stomach, which can still pose a significant risk of **gastroesophageal reflux** and subsequent **aspiration** in a comatose patient [1]. - This route is typically considered when the patient has intact gastric emptying and a low risk of aspiration [1].

Question 3: Optimum urine output in post-operative patient:

A. 2 ml/kg/hr
B. 1 ml/kg/hr (Correct Answer)
C. 3 ml/kg/hr
D. 4 ml/kg/hr

Explanation: ***1 ml/kg/hr*** - This is the **optimal urine output** for routine post-operative monitoring, indicating adequate renal perfusion and hydration status. - The **minimum acceptable** urine output is **0.5 ml/kg/hr**, but aiming for 1 ml/kg/hr ensures a comfortable margin above the critical threshold. - This target helps prevent **acute kidney injury** and ensures proper waste excretion without requiring excessive fluid administration. *2 ml/kg/hr* - While this is a **perfectly acceptable** urine output indicating good hydration, it exceeds the standard **optimal target** for routine post-operative monitoring. - It may be appropriate in specific contexts (e.g., young patients, high fluid intake), but is higher than the general recommended target. - This output does not necessarily indicate overhydration in most post-operative patients. *3 ml/kg/hr* - This higher output is generally above routine targets and may indicate **increased fluid administration** or diuresis. - While not necessarily harmful, it's not the standard optimal target for typical post-operative care. - May be intentionally targeted in specific conditions like rhabdomyolysis or tumor lysis syndrome. *4 ml/kg/hr* - This significantly elevated output is well above standard monitoring targets for routine post-operative care. - While it could occur with aggressive hydration or diuretic use, it's not considered the optimal baseline target. - Such outputs require assessment of fluid balance and potential causes of polyuria.

Question 4: Postoperative third-space accumulation should be managed by intravenous fluid with

A. Albumin
B. Normal saline (Correct Answer)
C. Fluid restriction
D. Dextrose in water

Explanation: ***Normal saline*** - **Third-space accumulation** leads to fluid shifts from the intravascular space to the interstitial space, commonly seen after trauma or surgery, resulting in **hypovolemia**. - **Isotonic solutions** like normal saline help replenish the lost intravascular volume and maintain blood pressure without shifting more fluid into the third space. *Albumin* - While albumin can increase oncotic pressure and draw fluid back into the intravascular space, it is typically reserved for cases of **severe hypoalbuminemia** or when crystalloids alone are insufficient. - Using albumin in the setting of acute third-space loss without clear indications of hypoalbuminemia may not be the initial or most appropriate intervention. *Fluid restriction* - **Fluid restriction** would worsen the patient's hypovolemia as third-space losses deplete the effective circulating volume of the patient. - This approach is appropriate for conditions like **heart failure** or **SIADH**, where there is true fluid excess or impaired excretion, not for hypovolemic states due to fluid shifts. *Dextrose in water* - Dextrose in water is a **hypotonic solution** that would rapidly distribute into the intracellular and interstitial compartments and may contribute to worsening edema in the third space. - It does not effectively expand intravascular volume and can lead to **hyponatremia** if administered in large quantities.

Question 5: Which of the following is not a prokinetic?

A. Macrolides
B. D2 blocker
C. 5HT4 agonist
D. Loperamide derivative (Correct Answer)

Explanation: **Loperamide derivative** - **Loperamide** is an **opioid receptor agonist** that acts on the mu-opioid receptors in the gut, primarily to **decrease gastrointestinal motility** and treat diarrhea. - Its mechanism of action directly opposes that of prokinetic agents, which aim to increase GI motility. *Macrolides* - Certain macrolide antibiotics, particularly **erythromycin**, act as **motilin receptor agonists** at low doses. - This agonism leads to increased gastric motility and can be used as a prokinetic in conditions like gastroparesis. *D2 blocker* - **Dopamine D2 receptor antagonists** (e.g., **metoclopramide**, **domperidone**) block the inhibitory effect of dopamine on cholinergic smooth muscle. - This blockade enhances acetylcholine release, leading to increased gastrointestinal motility and prokinetic effects. *5HT4 agonist* - **Serotonin 5-HT4 receptor agonists** (e.g., **cisapride**, **prucalopride**) stimulate the release of acetylcholine and other excitatory neurotransmitters in the enteric nervous system. - This action promotes increased gastrointestinal motility, making them effective prokinetic agents.

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: As per the latest NRP guidelines, what is the target preductal saturation after birth at 5 minutes?

A. 65% - 70%
B. 75% - 85%
C. 85% - 95%
D. 80% - 85% (Correct Answer)

Explanation: ***80% - 85%*** - The Neonatal Resuscitation Program (NRP) guidelines recommend target pulse oximetry readings for **preductal oxygen saturation** in newborns. - At **5 minutes after birth**, the expected preductal saturation range is **80% - 85%**. - This represents the specific target for the 5-minute mark according to current NRP guidelines. *65% - 70%* - This range is the target for **2 minutes after birth**, reflecting the early transition from fetal circulation. - It is **too low** for the target saturation at 5 minutes post-delivery according to NRP. *75% - 85%* - This range is **too broad** and spans multiple time points (3-5 minutes). - The lower end (75%) represents the target at **3 minutes**, while 80-85% is specifically for **5 minutes**. - NRP guidelines specify **80-85%** as the precise target range for 5 minutes, not 75-85%. - This option is incorrect because it does not reflect the **specific** 5-minute target. *85% - 95%* - This higher range is the target for **10 minutes after birth**, indicating the near-complete transition to extrauterine circulation. - It is **too high** for the expected preductal saturation at 5 minutes according to current NRP guidelines.

Question 8: Which of the following anaesthetic agent lacks analgesic effect? A) N2O B) Thiopentone C) Methohexitone D) Ketamine E) Fentanyl

A. N2O
B. Methohexitone
C. Ketamine
D. Fentanyl
E. Thiopentone (Correct Answer)

Explanation: ***Thiopentone*** - Thiopentone is a **barbiturate** anesthetic primarily used for inducing anesthesia. - It provides significant **hypnosis** and sedation but lacks intrinsic **analgesic properties**, meaning it does not relieve pain. *N2O* - **Nitrous oxide** (N2O) is an inhalation anesthetic that provides good **analgesia** at sub-anesthetic concentrations. - It is often used as an adjunct to other anesthetic agents to enhance pain relief during procedures. *Methohexitone* - Methohexitone is another **barbiturate** similar to thiopentone, used for induction of anesthesia. - While it provides rapid **hypnosis**, it also lacks significant **analgesic effects**. *Ketamine* - Ketamine is a **dissociative anesthetic** known for its potent **analgesic properties**. - It works by blocking **NMDA receptors**, providing pain relief even at sub-anesthetic doses. *Fentanyl* - Fentanyl is a powerful **opioid analgesic** that is commonly used in anesthesia for its strong pain-relieving effects. - It acts on **opioid receptors** in the central nervous system to reduce pain perception.

Question 9: Which of the following is the induction anesthesia of choice in the pediatric age group?

A. A. Sevoflurane (Correct Answer)
B. B. Desflurane
C. C. Halothane
D. D. Isoflurane

Explanation: ***A. Sevoflurane*** - **Sevoflurane** is an inhalation anesthetic widely preferred for **pediatric induction** due to its rapid onset and non-pungent odor, which makes it well-tolerated by children. - Its low blood-gas partition coefficient allows for swift changes in anesthetic depth and rapid emergence. *B. Desflurane* - **Desflurane** has a **pungent odor** and is known to cause airway irritation, making it unsuitable for inhalational induction in children. - Its rapid onset and offset are beneficial, but its irritant properties limit its use for induction, especially in younger patients. *C. Halothane* - **Halothane** was previously used for pediatric induction but has largely been replaced due to its association with **hepatotoxicity** and cardiac arrhythmias. - It also has a slower onset and offset compared to newer agents like sevoflurane. *D. Isoflurane* - **Isoflurane** has a **pungent odor** and can cause airway irritation, making it less suitable for inhalational induction in children compared to sevoflurane. - While effective for maintenance, its irritant properties make for a less smooth and potentially distressing induction experience for pediatric patients.

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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