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

A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

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 patient presents in coma for 20 days, what will be the best way to give him nutrition?

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 :

The following are true of Mendelson's syndrome –

The treatment of choice for a mucocele of the gallbladder is:

Propofol infusion syndrome all except?

Q10

A 50 kg patient has 40 % burn of the body surface area. Calculate the ringer lactate solution to be given for first 8 hours of fluid:

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: A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

A. RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours
B. RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours
C. RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours
D. RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours (Correct Answer)

Explanation: ***RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours*** - The child shows signs of **some dehydration** (sunken eyes, skin pinch returning very rapidly). According to **WHO Plan B**, some dehydration requires **75 ml/kg over 6 hours** for rehydration. - For a 6 kg child: **75 × 6 = 450 ml total** - **Distribution:** 30 ml/kg in first hour (180 ml) + 45 ml/kg over next 5 hours (270 ml) - This option provides exactly **450 ml (180 + 270)**, perfectly matching WHO guidelines for some dehydration *RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours* - First hour: 120 ml = only **20 ml/kg**, which is **below the recommended 30 ml/kg** initial bolus for some dehydration - Total volume: **480 ml** exceeds the required **450 ml** for a 6 kg child - Incorrect fluid distribution pattern for WHO Plan B *RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours* - First hour volume is correct at **30 ml/kg (180 ml)** - However, next 5 hours: **480 ml = 80 ml/kg**, far exceeding the recommended **45 ml/kg** - Total: **660 ml** significantly exceeds **450 ml**, risking **fluid overload** in a small child *RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours* - Initial rate: **240 ml = 40 ml/kg** is appropriate for **severe dehydration (WHO Plan C)**, not some dehydration - This child shows **some dehydration** signs, not severe (no lethargy, unconsciousness, or very slow skin pinch) - Total: **600 ml** exceeds the **450 ml** requirement, indicating overtreatment for this clinical scenario

Question 4: 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 5: A patient presents in coma for 20 days, what will be the best way to give him nutrition?

A. Ryle's tube feeding (Correct Answer)
B. Feeding via jejunostomy
C. Parenteral nutrition
D. Oral feeding

Explanation: ***Ryle's tube feeding*** - A **Ryle's tube (nasogastric tube)** is the most appropriate method for enteral feeding in a patient who has been in coma for **20 days (~3 weeks)**. - **Current guidelines** recommend NG tube feeding for durations up to **4-6 weeks**, making it suitable for this patient's timeline. - NG tube placement is **non-invasive, quick to establish**, and provides effective enteral nutrition while the patient's neurological status is being assessed and managed. - The gastrointestinal tract is functioning (no contraindication mentioned), making enteral feeding via NG tube the preferred route following the principle: **"If the gut works, use it."** - Proper positioning (head elevation 30-45°) and monitoring can minimize aspiration risk in comatose patients. *Feeding via jejunostomy* - **Jejunostomy** or PEG tube placement is considered for **long-term feeding beyond 4-6 weeks**. - At 20 days, it is **premature** to proceed with a surgical/endoscopic procedure for feeding access unless there are specific indications (recurrent aspiration despite NG feeding, NG tube intolerance, anticipated prolonged need beyond 6 weeks). - Jejunostomy requires a surgical procedure with associated risks and is reserved for patients clearly requiring extended nutritional support. *Parenteral nutrition* - **Parenteral nutrition** (intravenous feeding) is indicated when the gastrointestinal tract is **non-functional** or enteral access is impossible. - Since the question doesn't mention GI dysfunction, enteral feeding is preferred as it maintains gut integrity, is more physiological, safer, and more cost-effective. - Parenteral nutrition carries risks of catheter-related infections, metabolic complications, and gut mucosal atrophy. *Oral feeding* - **Oral feeding** is absolutely contraindicated in a comatose patient due to absent protective airway reflexes and extremely high risk of **aspiration pneumonia**. - A patient in coma cannot safely swallow and protect their airway during oral intake.

Question 6: 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.

Question 7: The following are true of Mendelson's syndrome –

A. Steroids have been shown to improve outcome
B. Critical volume of aspirate is 50 mls
C. Critical pH of gastric aspirate is 1.5
D. Onset of symptoms generally occurs within 30 minutes (Correct Answer)

Explanation: ***Onset of symptoms generally occurs within 30 minutes*** - Mendelson's syndrome refers to **chemical pneumonitis** resulting from pulmonary aspiration of sterile gastric contents. - Symptoms like **bronchospasm**, **dyspnea**, and **tachycardia** typically manifest rapidly, often within minutes to 30 minutes post-aspiration. *Steroids have been shown to improve outcome* - **Corticosteroids** are generally **not recommended** for the treatment of Mendelson's syndrome or chemical pneumonitis caused by gastric aspiration. - Their use can potentially increase the risk of **secondary bacterial pneumonia** due to immunosuppression, without significant clinical benefit in improving lung injury. *Critical volume of aspirate is 50 mls* - The critical volume of aspirate associated with Mendelson's syndrome is generally considered to be **25 mL** or **0.3 mL/kg** of gastric contents. - Aspiration of volumes greater than this threshold significantly increases the risk of developing **severe pneumonitis**. *Critical pH of gastric aspirate is 1.5* - The critical pH of gastric aspirate associated with Mendelson's syndrome is generally considered to be **less than 2.5**. - A pH below this value indicates highly acidic gastric contents, which cause **severe chemical burns** to the tracheobronchial tree and lung parenchyma.

Question 8: The treatment of choice for a mucocele of the gallbladder is:

A. Aspiration of mucus
B. Cholecystectomy (Correct Answer)
C. Cholecystostomy
D. Antibiotic and observation

Explanation: ***Cholecystectomy*** - **Cholecystectomy** is the definitive treatment for gallbladder mucocele because it removes the diseased organ, preventing complications such as perforation, ascending cholangitis, or conversion to empyema. - A mucocele is typically caused by **chronic obstruction of the cystic duct**, leading to the accumulation of sterile mucus and distension of the gallbladder, which requires removal to prevent recurrence and further issues. *Aspiration of mucus* - **Aspiration of mucus** is a temporary measure and does not address the underlying cause of the mucocele (cystic duct obstruction), leading to a high risk of reaccumulation and infection. - This procedure carries risks such as **perforation** and **bile leakage**, and is not considered a definitive treatment. *Cholecystostomy* - **Cholecystostomy** involves surgically creating an opening in the gallbladder for drainage and is generally reserved for critically ill patients who cannot tolerate a cholecystectomy. - While it can relieve distension, it does not remove the diseased gallbladder or the source of obstruction, carrying the risk of persistent or recurrent issues. *Antibiotic and observation* - A gallbladder mucocele contains **sterile mucus** and is not primarily an infectious process, therefore antibiotics are generally ineffective unless secondary infection (empyema) has occurred. - **Observation** alone is not appropriate due to the risk of significant complications such as rupture, biliary peritonitis, or conversion to hydrops and empyema, which can be life-threatening.

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: A 50 kg patient has 40 % burn of the body surface area. Calculate the ringer lactate solution to be given for first 8 hours of fluid:

A. 8 Litres
B. 2 Litres
C. 4 Litres (Correct Answer)
D. 1 Litre

Explanation: ***4 Litres*** - The **Parkland formula** for fluid resuscitation in burn patients is **4 mL x body weight (kg) x % total body surface area (TBSA) burned**. - For this patient: 4 mL x 50 kg x 40% = 8000 mL or **8 Litres** of Ringer's Lactate in the first 24 hours. Half of this volume ([8 Litres / 2] = **4 Litres**) is given in the first 8 hours. *8 Litres* - This amount represents the **total fluid requirement** for the entire first 24 hours, not just the first 8 hours. - Only **half of the total calculated fluid** is administered in the initial 8-hour period. *2 Litres* - This volume is generally **too low** for a patient with 40% TBSA burns, which is considered a significant burn. - Insufficient fluid resuscitation can lead to **burn shock** and organ hypoperfusion. *1 Litre* - This amount is **grossly inadequate** for a patient with 40% TBSA burns. - Administering such a small volume would likely result in **severe hypovolemic shock** and clinical deterioration.

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