Nutrition in Surgical Patients — MCQs
Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia
What is the most definitive indication for surgery in necrotizing enterocolitis?
What is the most frequent complication of Total Parenteral Nutrition (TPN)?
A patient presents in coma for 20 days, what will be the best way to give him nutrition?
A young man weighing 65 kg was admitted to the hospital with severe burns in a severe catabolic state. An individual in this state requires 40 kcal per kg body weight per day and 2 gms of protein/kg body weight/day. This young man was given a solution containing 20% glucose and 4.25% protein. If 3000 ml of solution is infused per day, which of the following statements is most accurate regarding the nutritional provision?
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:
In trauma, which of the following hormones is/are increased? a) Epinephrine b) ACTH c) Glucagon d) Parathormone
Biological value is used for the assessment of?
A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the
Nutrition in Surgical Patients 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: What is the most definitive indication for surgery in necrotizing enterocolitis?
- A. Pneumatosis intestinalis- Stage IIA of NEC
- B. Pneumoperitoneum- Stage IIIB of NEC (Correct Answer)
- C. Peritonitis- Stage IIIA of NEC
- D. Portal Vein gas- Stage IIB of NEC
Explanation: ***Pneumoperitoneum- Stage IIIB of NEC*** - **Pneumoperitoneum** (free air in the peritoneal cavity) is the **most definitive indication** for immediate surgical intervention in necrotizing enterocolitis (NEC), as it provides radiological proof of bowel perforation. - This finding represents advanced disease (**Stage IIIB** according to the **modified Bell's staging criteria**) and is an **absolute indication for surgery**. - Pneumoperitoneum is detected on plain abdominal radiographs or cross-table lateral films and indicates full-thickness bowel necrosis with perforation. *Pneumatosis intestinalis- Stage IIA of NEC* - **Pneumatosis intestinalis** (intramural gas in the bowel wall) is a hallmark radiological sign of NEC but does **not** warrant surgery in Stage IIA. - Stage IIA is managed with **medical therapy** including NPO (nil per oral), nasogastric decompression, broad-spectrum antibiotics, and supportive care unless there are signs of clinical deterioration or progression to advanced stages. *Portal Vein gas- Stage IIB of NEC* - **Portal vein gas** indicates severe bowel ischemia and necrosis and is a concerning prognostic sign associated with advanced NEC (Stage IIB). - While it signifies severe disease, portal vein gas is **not an absolute indication for surgery** by itself; surgical intervention is based on overall clinical status, presence of peritonitis, or pneumoperitoneum. *Peritonitis- Stage IIIA of NEC* - Clinical signs of **peritonitis** (abdominal wall erythema, edema, tenderness, guarding, rigidity) indicate Stage IIIA NEC and **are also an indication for surgery**. - However, **pneumoperitoneum** is considered the **most definitive** indication as it provides objective radiological evidence of perforation, whereas peritonitis is based on clinical examination which can be challenging in premature neonates.
Question 3: What is the most frequent complication of Total Parenteral Nutrition (TPN)?
- A. Hyperglycemia (Correct Answer)
- B. Rebound hyperglycemia
- C. Hypoglycemia
- D. Hypertriglyceridemia
Explanation: ***Hyperglycemia*** - **Hyperglycemia** is the most common metabolic complication of TPN due to the high dextrose content, especially in patients with pre-existing glucose intolerance or stress. - Close monitoring of blood glucose and insulin administration are often necessary to manage this complication. *Rebound hyperglycemia* - **Rebound hyperglycemia** typically refers to a surge in blood glucose levels following a period of hypoglycemia, or in response to a sudden cessation of insulin, neither of which is the most frequent primary complication of TPN initiation. - While TPN can cause hyperglycemia, the term "rebound hyperglycemia" is not the most accurate description for the initial and most frequent TPN-associated glucose abnormality. *Hypoglycemia* - **Hypoglycemia** is less common during continuous TPN infusion but can occur if TPN is abruptly discontinued, or if excessive insulin is administered. - It is not the most frequent complication observed during steady-state TPN administration. *Hypertriglyceridemia* - **Hypertriglyceridemia** can occur with TPN, particularly with excessive lipid emulsion administration or in patients with impaired lipid metabolism. - Although a potential complication, it is not as frequent as hyperglycemia.
Question 4: 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 5: A young man weighing 65 kg was admitted to the hospital with severe burns in a severe catabolic state. An individual in this state requires 40 kcal per kg body weight per day and 2 gms of protein/kg body weight/day. This young man was given a solution containing 20% glucose and 4.25% protein. If 3000 ml of solution is infused per day, which of the following statements is most accurate regarding the nutritional provision?
- A. The protein provided exceeds the patient's requirement
- B. The protein provided is insufficient for the patient's requirement
- C. The calories provided are insufficient for the patient's needs (Correct Answer)
- D. The solution provides adequate protein and calories for the patient
Explanation: ***The calories provided are insufficient for the patient's needs*** - The patient requires 40 kcal/kg/day × 65 kg = **2600 kcal/day** - The solution provides (200 g glucose/L × 4 kcal/g) × 3 L = **2400 kcal/day**, which is 200 kcal less than required (92.3% of requirement) - This represents a **7.7% caloric deficit**, which in a severe catabolic state with burns is clinically significant *The protein provided exceeds the patient's requirement* - The patient requires 2 g/kg/day × 65 kg = **130 g protein/day** - The solution provides (42.5 g protein/L) × 3 L = **127.5 g protein/day**, which is slightly below, not exceeding, the requirement *The protein provided is insufficient for the patient's requirement* - The patient requires **130 g protein/day** - The solution provides **127.5 g protein/day** (98% of requirement) - While technically 2.5 g short, this is nearly adequate, but the more critical issue is the caloric deficit *The solution provides adequate protein and calories for the patient* - The provided calories (2400 kcal) are **insufficient** for the patient's needs (2600 kcal) - The protein (127.5 g) is very close to the requirement (130 g) at 98% adequacy - In severe catabolic states, even modest deficits can impair recovery, making this provision inadequate
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: In trauma, which of the following hormones is/are increased? a) Epinephrine b) ACTH c) Glucagon d) Parathormone
- A. bc
- B. acd
- C. bcd
- D. abc (Correct Answer)
Explanation: ***abc*** - Trauma is a significant stressor that triggers the release of **epinephrine** (a), **ACTH** (b), and **glucagon** (c) as part of the body's **fight-or-flight response** and metabolic adaptation. - **Epinephrine** increases heart rate, blood pressure, and mobilizes energy stores; **ACTH** stimulates cortisol release to manage stress and inflammation; **glucagon** mobilizes glucose to provide energy for tissues. - **Parathormone** (d) is NOT significantly increased in acute trauma as it primarily regulates calcium homeostasis, not the acute stress response. *bc* - This option is incomplete as **epinephrine** (a) is also significantly increased during trauma due to the activation of the sympathetic nervous system. - While **ACTH** and **glucagon** are elevated, failing to include epinephrine underestimates the full hormonal response to trauma. *acd* - This option incorrectly includes **parathormone** (d) as a primary hormone elevated in acute trauma. While calcium regulation is important, parathormone's immediate increase is not a hallmark of the acute stress response. - It also omits **ACTH** (b), which is a key hormone in the stress axis response. *bcd* - This option incorrectly includes **parathormone** (d) which does not typically show a significant immediate increase during acute trauma. - It also omits **epinephrine** (a), a crucial component of the acute stress response mediated by sympathetic activation.
Question 9: Biological value is used for the assessment of?
- A. Fat quality
- B. Protein quality (Correct Answer)
- C. Carbohydrate quality
- D. None of the options
Explanation: ***Protein quality*** - **Biological value (BV)** is a measure of the proportion of absorbed protein from a food that is incorporated into the body's proteins. - It specifically assesses the amount and **proportions of essential amino acids** available for protein synthesis. *Fat quality* - Fat quality is typically assessed by its **fatty acid profile** (e.g., saturated, unsaturated, trans fats) and its impact on cardiovascular health. - BV is not used to evaluate the nutritional quality or absorption of lipids. *Carbohydrate quality* - Carbohydrate quality is generally determined by factors like **fiber content**, **glycemic index**, and presence of complex vs. simple sugars. - BV does not provide information about the carbohydrate composition or metabolic effects of foods. *None of the options* - This option is incorrect because biological value is a well-established method for assessing protein quality.
Question 10: A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the
- A. nurses safety checklist
- B. WHO surgical safety checklist (Correct Answer)
- C. universal precautions checklist
- D. MCI patient safety checklist
Explanation: **WHO surgical safety checklist** - The questions about patient identity, procedure site, and anticipated critical events are key components of the **"Sign In"** and **"Time Out"** sections of the **WHO Surgical Safety Checklist**. - This checklist is designed to improve **patient safety** by ensuring communication and adherence to essential steps before, during, and after surgery, thereby reducing surgical errors. *nurses safety checklist* - While nurses play a crucial role in patient safety, there isn't a universally recognized "nurses safety checklist" that specifically encompasses these exact comprehensive surgical verification steps. - The comprehensive framework described, with its specific questions, aligns more closely with the broader, interdisciplinary **WHO Surgical Safety Checklist**. *universal precautions checklist* - **Universal precautions** focus on preventing the transmission of bloodborne pathogens and other infectious agents by treating all bodily fluids as potentially infectious. - This checklist primarily addresses **infection control** measures and does not cover patient identification, surgical site verification, or critical event anticipation. *MCI patient safety checklist* - A "MCI patient safety checklist" is not a widely recognized or standardized medical safety protocol. - The scenario describes a standard, internationally adopted set of safety checks specifically for surgical procedures, which is the **WHO Surgical Safety Checklist**.
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