Critical Care Practice Questions

Q: In a septic shock patient who remains hypotensive despite adequate fluid resuscitation, what would be the next drug of choice?

Noradrenaline. ***Noradrenaline*** - **Noradrenaline (Norepinephrine)** is the preferred first-line vasopressor for septic shock, recommended to target a mean arterial pressure (MAP) of at least **65 mmHg** [1]. - It is the vasoconstrictor with the most potent **alpha-1 adrenergic agonist effects**, effectively raising systemic vascular resistance (SVR) and blood pressure while having less tachycardia compared to adrenaline. ***Adrenaline*** - **Adrenaline (Epinephrine)** is typically a second-line agent, added when noradrenaline alone is insufficient, due to its mixed alpha and potent **beta-1 effects** (which can increase heart rate and the risk of arrhythmias). - Its use as a first-line agent is generally reserved for situations like **anaphylactic shock** or severe cardiogenic shock, not routine septic shock management. ***Dopamine*** - **Dopamine** is no longer recommended as the primary vasopressor in septic shock because it is associated with a higher incidence of **tachyarrhythmias** compared to noradrenaline. - It may be considered only in highly selected patients with a low risk of tachyarrhythmias and **absolute or relative bradycardia**. ***Hydrocortisone*** - **Hydrocortisone** (low-dose corticosteroids) is indicated only if the patient remains hypotensive despite adequate fluid resuscitation and **high-dose vasopressor therapy** (e.g., noradrenaline and likely a second agent like vasopressin or adrenaline). - This treatment addresses potential **critical illness-related corticosteroid insufficiency (CIRCI)**, but it is not the immediate next step after initial fluid failure.

Q: A 65-year-old alcoholic is admitted to the ICU with diagnosis of acute pancreatitis. After 48 hours he is unconscious and has the following findings: $\mathrm{sPO}_{2}=$ $60 \%, \mathrm{pO}_{2}=60 \mathrm{~mm} \mathrm{Hg}, \mathrm{pCO}_{2}=30 \mathrm{~mm} \mathrm{Hg}$ and $\mathrm{HR}=$ 120 bpm . CXR was performed. Diagnosis is?

Shock lung. ***Shock lung*** - The rapid progression to severe hypoxemia (sPO2 60%, pO2 60 mmHg), tachycardia, and the CXR findings of **bilateral diffuse infiltrates** in a patient with severe pancreatitis is highly suggestive of **Acute Respiratory Distress Syndrome (ARDS)**, which is colloquially known as "shock lung". - **Acute pancreatitis** is a common cause of ARDS due to the systemic inflammatory response leading to increased pulmonary vascular permeability and non-cardiogenic pulmonary edema. *Mendelson syndrome* - This syndrome refers to **chemical pneumonitis** caused by aspiration of gastric contents, typically during anesthesia or in patients with impaired consciousness. - While aspiration is a concern in an unconscious patient, the diffuse, widespread infiltrates seen on CXR and the context of severe pancreatitis point more strongly to ARDS. *Nosocomial pneumonia* - Nosocomial pneumonia is an infection acquired in a hospital setting, often characterized by **new onset fever, purulent sputum, and new infiltrate on chest X-ray**. - While possible in an ICU patient, the rapid deterioration, severe hypoxemia, and acute onset after 48 hours of admission with acute pancreatitis are more classic for ARDS than typical nosocomial pneumonia. *Sympathetic pleural effusion* - **Sympathetic pleural effusions** can occur in acute pancreatitis, particularly on the left side, due to localized inflammation. - However, the chest X-ray shows **diffuse bilateral parenchymal infiltrates** rather than predominant pleural fluid, and the severe hypoxemia is indicative of significant lung tissue involvement, not just an effusion.

Q: 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 :

I, III and IV. ***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.

Q: Which of the following are correct in respect of Systemic Inflammatory Response Syndrome (SIRS)? 1. It is caused by the release of lipopolysaccharide endotoxin from dying E. coli bacteria. 2. It is same as bacteraemia. 3. It results in Multiple Organ Dysfunction Syndrome (MODS). 4. White cell counts of more than 12 × 10^9/litre are present. Select the answer using the code given below.

1, 3 and 4. ***1, 3 and 4*** - **SIRS** can be caused by the release of **lipopolysaccharide endotoxin** from the cell wall of dying **Gram-negative bacteria** like *E. coli*, triggering a systemic inflammatory response [1]. - One of the major complications of **SIRS** is the progression to **Multiple Organ Dysfunction Syndrome (MODS)**, where organs begin to fail due to uncontrolled inflammation [1]. - A component of the **SIRS criteria** is a white blood cell count greater than 12 x 10^9/L or less than 4 x 10^9/L, or the presence of more than 10% immature band forms [1]. *2, 3 and 4* - **Bacteremia** refers specifically to the presence of **viable bacteria** in the bloodstream, while **SIRS** is a broader inflammatory response that can be triggered by various causes (infectious or non-infectious). - While bacteremia can lead to SIRS, SIRS can also occur without bacteremia (e.g., pancreatitis, trauma). *1, 2 and 3* - **Bacteremia** is not the same as SIRS; bacteremia is a potential cause of SIRS, but SIRS can arise from non-infectious conditions as well. - The presence of bacteria in the blood (bacteremia) is a specific finding, whereas SIRS describes a *syndrome* of systemic inflammation. *1, 2 and 4* - This option incorrectly states that **SIRS is the same as bacteremia**, which it is not. - Also, while bacteremia can lead to SIRS, **MODS** is a crucial and often fatal consequence of advanced SIRS, which is omitted in this option.

Q: Consider the following statements : Systemic Inflammatory Response Syndrome is characterised by 1. Temperature either above 38°C or below 36°C. 2. Heart rate less than 80/minute. 3. Tachypnoea > 20/min. 4. Leucocyte count > 4 x 109/L. Which of the statements given above are correct ?

3, 4 and 1. ***3, 4 and 1*** - **SIRS criteria** include a temperature above 38°C or below 36°C [1], and tachypnea with a respiratory rate greater than 20 breaths/minute. - Additionally, a white blood cell count greater than 12,000 cells/mm³ (12 x 10⁹/L) or less than 4,000 cells/mm³ (4 x 10⁹/L), or the presence of more than 10% immature band forms, are part of the criteria. *1 and 3* - This option correctly identifies **temperature** [1] and **tachypnea** as SIRS criteria but omits the leukocyte count, which is also a key component. - It is an incomplete set of correct criteria, missing one crucial element. *1, 4, 3 and 2* - This option incorrectly states a heart rate **less than 80/minute** as a SIRS criterion; the correct criterion for SIRS is a heart rate **greater than 90/minute**. - While it includes other correct criteria, the inclusion of an incorrect heart rate makes this option wrong. *2, 4 and 3* - This option incorrectly states a heart rate **less than 80/minute** as a SIRS criterion. The correct criterion for SIRS is a heart rate **greater than 90/minute**. - It also misses the **temperature** criterion, which is a fundamental component of SIRS [1].

Q: Systemic Inflammatory Response Syndrome (SIRS) diagnostic criteria include the following except

White cell count 12,000/mm³ or 10% **immature (band) forms**. [2] - This option correctly states a **WBC count below 4000/mm³**, which is indeed a criterion for SIRS. *Temperature > 38°C or < 36°C* - This is a correct criterion for SIRS, indicating a significant deviation from normal body temperature. [1] - Both **fever (hyperthermia)** and **hypothermia** are signs of systemic inflammation. *Tachycardia with a heart rate of more than 90/min.* - This is a correct criterion for SIRS, reflecting the increased metabolic demand and sympathetic activation during systemic inflammation. [2] - A persistent **heart rate above 90 bpm** is considered indicative of such stress. *Tachypnoea with a respiratory rate of > 20/min.* - This is a correct criterion for SIRS, showing the body's attempt to compensate for metabolic disturbances or increased oxygen demand. [2] - A **respiratory rate greater than 20 breaths per minute** or a PaCO2 less than 32 mmHg are both SIRS criteria.

Q: Which of the following is NOT a feature of Systemic Inflammatory Response Syndrome?

Bradycardia. ***Bradycardia*** - **Bradycardia** (a slow heart rate) is **not** a typical diagnostic criterion for **Systemic Inflammatory Response Syndrome (SIRS)**. - SIRS is usually associated with **tachycardia** (heart rate >90 beats/min) due to the body's increased metabolic demand and stress response [2]. *Hypothermia (less than 36°C)* - **Hypothermia** ( 38°C) is a common and primary diagnostic criterion for **SIRS**, reflecting the body's inflammatory response to infection or injury [2], [3]. - This elevated core temperature is part of the systemic response to pathogens or tissue damage. *Leucocytosis* - **Leucocytosis** (white blood cell count >12,000 cells/mm³) is a key diagnostic criterion for **SIRS**, indicating a robust innate immune response [1], [2]. - A WBC count 10% immature neutrophils ("bands") also fulfills this criterion.

Q: A 25 year old lady underwent exploratory laparotomy for bowel injury which happened while she underwent medical termination of pregnancy 2 days back. 24 hours after exploratory laparotomy her pulse is 106/m, respiratory rate 26/m, total leucocyte count 14000/cumm with blood urea 84 mg% and serum creatinine 2.0 mg/dL. The lady is having:

Systemic inflammatory response syndrome. ***Systemic inflammatory response syndrome*** - The patient's presentation with **tachycardia** (pulse 106/min), **tachypnea** (respiratory rate 26/min), and **leukocytosis** (TLC 14000/µL) meets at least two criteria for **Systemic Inflammatory Response Syndrome (SIRS)** following a significant surgical stressor. - SIRS is a generalized inflammatory response to various insults, including major surgery, trauma, and infection, occurring in the absence of a confirmed infection. *Sepsis syndrome* - **Sepsis syndrome** is defined as SIRS with a **confirmed or suspected infectious source**. While the patient had a bowel injury, there is no definitive evidence of active infection provided (e.g., positive cultures, purulent discharge). - Although the bowel injury could lead to infection, the current information only confirms a systemic inflammatory response, not necessarily a microbial cause. *Multisystem organ failure (MSOF)* - **Multisystem organ failure (MSOF)** involves the failure of two or more organ systems. While the patient has elevated **BUN** and **creatinine**, indicating **acute kidney injury**, there's no evidence of failure in other systems required to diagnose MSOF. - MSOF is a more severe progression of SIRS or sepsis, characterized by severe organ dysfunction, which is not fully met by the current presentation. *Wound infection* - **Wound infection** is a localized infection and would typically present with signs like **erythema**, **purulent discharge**, **tenderness**, or **warmth** at the surgical site. None of these specific local signs are mentioned. - While a wound infection could be a potential source of SIRS or sepsis, the clinical picture provided describes a systemic response rather than a localized one.

Q: Systemic Inflammatory Response Syndrome (SIRS) is characterized by all of the following EXCEPT:

Platelet count ( 38˚C)* - **Fever** is a classic sign of inflammation and infection, and a temperature greater than 38°C is one of the key diagnostic criteria for SIRS. [2] - This indicates the body's systemic inflammatory response to a perceived insult. [3] *Tachypnoea (>20/min)* - An increased **respiratory rate**, or **tachypnea**, is another important criterion for SIRS, reflecting increased metabolic demand or respiratory compensation. - This criterion helps identify patients with a significant physiological response to inflammation. *Hypothermia (<36˚C)* - While less common than fever, **hypothermia** (temperature less than 36°C) can also be a sign of a severe systemic inflammatory response, particularly in immunocompromised or severely ill patients. - It signifies a dysregulated thermoregulatory response in SIRS.

Q: All the following are criteria for SIRS, except

Systolic blood pressure 90/min* - An elevated **heart rate** (tachycardia) is a common physiological response to systemic stress and inflammation. - This criterion fulfills one of the four clinical parameters to diagnose **SIRS**. *Respiratory rate >20 bpm* - An increased **respiratory rate** (tachypnea) reflects the body's attempt to compensate for metabolic acidosis or increased oxygen demand during a systemic inflammatory response. - This criterion is one of the four clinical parameters used to diagnose **SIRS**. *Temperature >38 degree Celsius or 38°C) and **hypothermia** (<36°C) are indicators of a systemic inflammatory response, as the body's thermoregulation is affected [1]. - This criterion is one of the four principal parameters used to diagnose **SIRS** [1].

Question 1

In a septic shock patient who remains hypotensive despite adequate fluid resuscitation, what would be the next drug of choice?

Accepted Answer

Noradrenaline

Answer

Adrenaline

Answer

Dopamine

Answer

Hydrocortisone

Question 2

A 65-year-old alcoholic is admitted to the ICU with diagnosis of acute pancreatitis. After 48 hours he is unconscious and has the following findings: $\mathrm{sPO}_{2}=$ $60 \%, \mathrm{pO}_{2}=60 \mathrm{~mm} \mathrm{Hg}, \mathrm{pCO}_{2}=30 \mathrm{~mm} \mathrm{Hg}$ and $\mathrm{HR}=$ 120 bpm . CXR was performed. Diagnosis is?

Accepted Answer

Shock lung

Answer

Mendelson syndrome

Answer

Nosocomial pneumonia

Answer

Sympathetic pleural effusion

Question 3

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 :

Accepted Answer

I, III and IV

Answer

I, II and IV

Answer

II, III and IV

Answer

I, II and III

Question 4

Which of the following are correct in respect of Systemic Inflammatory Response Syndrome (SIRS)?

1. It is caused by the release of lipopolysaccharide endotoxin from dying E. coli bacteria.
2. It is same as bacteraemia.
3. It results in Multiple Organ Dysfunction Syndrome (MODS).
4. White cell counts of more than 12 × 10^9/litre are present. Select the answer using the code given below.

Accepted Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Answer

1, 2 and 4

Question 5

Consider the following statements : Systemic Inflammatory Response Syndrome is characterised by

1. Temperature either above 38°C or below 36°C.

2. Heart rate less than 80/minute.

3. Tachypnoea > 20/min.

4. Leucocyte count > 4 x 109/L. Which of the statements given above are correct ?

Accepted Answer

3, 4 and 1

Answer

1 and 3

Answer

1, 4, 3 and 2

Answer

2, 4 and 3

Question 6

Systemic Inflammatory Response Syndrome (SIRS) diagnostic criteria include the following except

Accepted Answer

White cell count < 4000/mm³

Answer

Temperature > 38°C or < 36°C

Answer

Tachycardia with a heart rate of more than 90/min.

Answer

Tachypnoea with a respiratory rate of > 20/min.

Question 7

Which of the following is NOT a feature of Systemic Inflammatory Response Syndrome?

Accepted Answer

Bradycardia

Answer

Hypothermia (less than 36°C)

Answer

Hyperthermia (more than 38°C)

Answer

Leucocytosis

Question 8

A 25 year old lady underwent exploratory laparotomy for bowel injury which happened while she underwent medical termination of pregnancy 2 days back. 24 hours after exploratory laparotomy her pulse is 106/m, respiratory rate 26/m, total leucocyte count 14000/cumm with blood urea 84 mg% and serum creatinine 2.0 mg/dL. The lady is having:

Accepted Answer

Systemic inflammatory response syndrome

Answer

Sepsis syndrome

Answer

Multisystem organ failure (MSOF)

Answer

Wound infection

Question 9

Systemic Inflammatory Response Syndrome (SIRS) is characterized by all of the following EXCEPT:

Accepted Answer

Platelet count (<1,00,000/mm3)

Answer

Hyperthermia (>38˚C)

Answer

Tachypnoea (>20/min)

Answer

Hypothermia (<36˚C)

Question 10

All the following are criteria for SIRS, except

Accepted Answer

Systolic blood pressure <90 mmHg

Answer

Heart rate >90/min

Answer

Respiratory rate >20 bpm

Answer

Temperature >38 degree Celsius or <36 degree Celsius

Critical Care — MCQs

Critical Care — MCQs

On this page

Practice by Chapter

Want unlimited practice?