Surgical Sepsis — MCQs
Refractory Septic shock is defined as?
For shock patient, best guideline to check for adequacy of fluid replacement therapy:
Which one of the following is not a component of THORACOSCORE?
What is the term for bacteria that are actively dividing and have invaded the wound surface in the context of surgical site infection?
A patient develops sepsis following the use of a central venous catheter. Which organism is most commonly associated with this condition?
What is the main goal of fluid resuscitation in a child with septic shock?
A 17-year-old girl presents to the emergency department with a stab wound to the abdomen in the anterior axillary line at the right costal margin. Her blood pressure is 80/50 mmHg, pulse rate is 120 beats per minute, and respiratory rate is 28 breaths per minute. Two large-bore intravenous lines, a nasogastric tube, and a Foley's catheter have been inserted. Her blood pressure rises to 90/60 mmHg after administration of 2 liters of Ringer's lactate. The appropriate management is which of the following?
In sepsis due to cholecystitis, which is the initial anatomical structure typically involved?
Not true about gas gangrene:
A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?
Surgical Sepsis Indian Medical PG Practice Questions and MCQs
Question 1: Refractory Septic shock is defined as?
- A. Shock requiring mechanical ventilation and inotropic support
- B. Shock with lactate levels >4 mmol/L despite treatment
- C. Shock that does not respond to initial fluid bolus within 1 hour
- D. Shock persisting despite adequate fluid resuscitation and vasopressor support (Correct Answer)
Explanation: ***Shock persisting despite adequate fluid resuscitation and vasopressor support*** - This is the **standard definition** of refractory septic shock according to current **Surviving Sepsis Campaign Guidelines** and critical care literature. - It specifically refers to the failure of **both fluid resuscitation and vasopressor therapy** to restore adequate mean arterial pressure and tissue perfusion. *Shock that does not respond to initial fluid bolus within 1 hour* - This describes **early non-response** to fluid therapy, which is concerning but not the complete definition of refractory shock. - Refractory shock requires failure of **comprehensive standard therapy** (fluids AND vasopressors), not just initial fluid bolus failure. *Shock requiring mechanical ventilation and inotropic support* - This describes a patient in **severe septic shock** with multi-organ support but does not define its **refractory nature**. - The need for these interventions indicates **organ dysfunction** and severity, not necessarily refractoriness to standard resuscitation efforts. *Shock with lactate levels >4 mmol/L despite treatment* - **Elevated lactate** indicates tissue hypoperfusion and ongoing shock, but it is a **severity marker**, not the definition of refractoriness. - High lactate levels can occur even in shock that is **responsive to standard therapy** and doesn't specifically indicate failure of resuscitation efforts.
Question 2: For shock patient, best guideline to check for adequacy of fluid replacement therapy:
- A. Central Venous Pressure
- B. Urine output (Correct Answer)
- C. Hemoglobin
- D. Blood pressure and pulse
Explanation: Detailed assessment of a shock patient involves monitoring multiple parameters to guide fluid therapy. ***Urine output*** is a sensitive indicator of **renal perfusion** and overall tissue perfusion, reflecting the adequacy of fluid resuscitation [1]. A target urine output of **0.5-1 mL/kg/hour** is generally used in shock patients to ensure sufficient organ perfusion. *Central Venous Pressure* - **Central Venous Pressure (CVP)** can be a misleading indicator of fluid status, as it reflects right atrial pressure and not necessarily ventricular preload or cardiac output [1]. - While it provides some information, it has limitations as a sole measure for guiding fluid resuscitation due to its poor correlation with **volume responsiveness**, and certain conditions like pulmonary hypertension may raise CVP even in hypovolemia [1]. *Hemoglobin* - **Hemoglobin** levels primarily reflect the oxygen-carrying capacity of the blood and are crucial for diagnosing **anemia** or assessing **blood loss**. - It does not directly indicate the adequacy of fluid volume or tissue perfusion, especially in cases of distributive or cardiogenic shock without significant hemorrhage. *Blood pressure and pulse* - **Blood pressure** and **pulse rate** are important vital signs for assessing the initial response to fluid resuscitation and the presence of shock [1]. - However, they can be maintained within normal limits by compensatory mechanisms even in ongoing hypoperfusion (**compensated shock**), making them less reliable as a sole indicator of adequate fluid replacement [1].
Question 3: Which one of the following is not a component of THORACOSCORE?
- A. Performance status
- B. Complication of surgery (Correct Answer)
- C. Priority of surgery
- D. ASA grading
Explanation: ***Complication of surgery*** - THORACOSCORE is a **risk prediction model** for thoracic surgery used to estimate the *probability of mortality and significant morbidity*, but it does not account for the complications of surgery itself as a component. - The score uses **pre-operative patient characteristics** and co-morbidities to predict outcomes, not post-operative events. *Performance status* - **Performance status**, such as the **ECOG scale**, is a crucial component of THORACOSCORE, reflecting the patient's general health and functional capacity prior to surgery. - A lower performance status (indicating poorer functional ability) increases the predicted risk in THORACOSCORE. *Priority of surgery* - The **priority of surgery** (e.g., elective, urgent, emergency) is an important factor in THORACOSCORE, as emergency procedures generally carry a higher risk. - This variable helps to capture the urgency and associated physiological stress on the patient at the time of presentation for surgery. *ASA grading* - The **American Society of Anesthesiologists (ASA) physical status classification system** is a component of THORACOSCORE, assessing the patient's overall health status and anesthetic risk. - A higher ASA grade (indicating more severe systemic disease) contributes to a higher predicted risk in the THORACOSCORE model.
Question 4: What is the term for bacteria that are actively dividing and have invaded the wound surface in the context of surgical site infection?
- A. Contamination
- B. Colonization
- C. Local infection
- D. Infection (Correct Answer)
Explanation: ***Infection*** - This term precisely describes bacteria that are **actively dividing** and have **invaded the host tissue**, causing a clinical infection with tissue damage and host immune response. - In surgical site infections, this represents the stage where microorganisms have overcome host defenses and are causing disease. - This is the standard terminology used in surgical literature to describe the progression from contamination to active disease. *Contamination* - **Contamination** refers to the presence of microorganisms on a surface or in a wound without active proliferation or host response. - It's an early stage where bacteria are present but not yet multiplying or causing disease. *Colonization* - **Colonization** indicates that microorganisms are replicating on the host surface or in a wound without tissue invasion or causing an immune response. - Unlike infection, colonization does not involve invasion of tissue or clinical signs of disease. *Local infection* - While this describes an infection confined to a particular anatomical area, it is a descriptor of the **location** rather than the **process** described in the question. - The question asks specifically about the term for dividing and invading bacteria, which is simply "infection" - the word "local" adds information about location but doesn't define the fundamental process.
Question 5: A patient develops sepsis following the use of a central venous catheter. Which organism is most commonly associated with this condition?
- A. Candida spp.
- B. Staphylococcus epidermidis (Correct Answer)
- C. Escherichia coli (E. coli)
- D. Pseudomonas species
Explanation: ***Staphylococcus epidermidis*** - This organism is a common commensal on the skin and the most frequent cause of **catheter-related bloodstream infections (CRBSI)** due to its ability to form **biofilms** on medical devices. - Its presence on the skin makes it an opportunistic pathogen that can easily contaminate and colonize the surface of central venous catheters, leading to systemic infection. *Candida spp.* - While fungal infections can occur with central venous catheters, especially in immunocompromised patients or those on prolonged antibiotics, **Candida** is less common than bacterial causes like *Staphylococcus epidermidis* in general sepsis cases. - **Candidemia** in the setting of CVCs is often associated with total parenteral nutrition, abdominal surgery, or broad-spectrum antibiotic use. *Escherichia coli (E. coli)* - **E. coli** is a common cause of sepsis, particularly from **urinary tract infections (UTIs)** or intra-abdominal infections, but it is not the most common organism associated "directly" with central venous catheter-related sepsis. - While *E. coli* can cause CRBSIs, it typically indicates a source other than simple skin colonization of the catheter, often due to translocation from the gut. *Pseudomonas species* - **Pseudomonas** species, notably *P. aeruginosa*, are typically associated with catheter-related infections in specific contexts, such as in neutropenic patients, those with significant underlying lung disease (e.g., cystic fibrosis), or those in critical care settings. - While it can cause severe CRBSIs, it is not the *most common* overall pathogen compared to coagulase-negative staphylococci like *S. epidermidis*.
Question 6: What is the main goal of fluid resuscitation in a child with septic shock?
- A. Increase urine output
- B. Reduce heart rate
- C. Decrease fever
- D. Restore blood pressure (Correct Answer)
Explanation: ***Restore blood pressure*** - In septic shock, **vasodilation** and extravasation of fluids lead to decreased **effective circulating volume** and profound **hypotension**. - Aggressive fluid resuscitation is critical to restore adequate **mean arterial pressure** and improve **organ perfusion**. *Increase urine output* - While increased urine output is a positive sign of improved renal perfusion, it is a **consequence** of successful resuscitation rather than the primary goal. - The main focus is on addressing the circulatory dysfunction that leads to **oliguria** in the first place. *Reduce heart rate* - A **high heart rate** (tachycardia) in septic shock is a compensatory mechanism to maintain **cardiac output** in the face of reduced preload and systemic vascular resistance. - Reducing heart rate directly is not the primary goal of fluid resuscitation and may even be harmful if **cardiac output** is already compromised. *Decrease fever* - Fever is a systemic inflammatory response to infection and is typically managed with **antipyretics**, not primarily with fluid resuscitation. - While fluids can help prevent complications of hyperthermia like dehydration, the main goal in shock is **hemodynamic stabilization**.
Question 7: A 17-year-old girl presents to the emergency department with a stab wound to the abdomen in the anterior axillary line at the right costal margin. Her blood pressure is 80/50 mmHg, pulse rate is 120 beats per minute, and respiratory rate is 28 breaths per minute. Two large-bore intravenous lines, a nasogastric tube, and a Foley's catheter have been inserted. Her blood pressure rises to 90/60 mmHg after administration of 2 liters of Ringer's lactate. The appropriate management is which of the following?
- A. Exploratory laparotomy (Correct Answer)
- B. Peritoneal lavage
- C. Abdominal ultrasound (FAST exam)
- D. Laparoscopic exploration
Explanation: ***Exploratory laparotomy*** - The patient presents with a **penetrating abdominal stab wound** near the **costal margin** with significant **hemodynamic instability** despite fluid resuscitation (transient responder - BP rose from 80/50 to only 90/60 after 2 liters). These are absolute indications for immediate **exploratory laparotomy** per ATLS guidelines. - The location of the wound near the right costal margin suggests potential injury to the **liver**, **diaphragm**, **right kidney**, or adjacent structures, all of which require prompt surgical assessment given the patient's unstable hemodynamic status. - In penetrating abdominal trauma with hemodynamic instability (transient or non-responder to resuscitation), immediate surgical exploration is mandatory to control hemorrhage and repair injuries. *Peritoneal lavage* - While **diagnostic peritoneal lavage (DPL)** can detect intra-abdominal bleeding, it is not appropriate for a hemodynamically unstable patient with a clear indication for surgery, as it delays definitive treatment. - DPL is more often used when the clinical picture is equivocal in hemodynamically stable patients, not in cases of ongoing shock from penetrating injury requiring immediate operative intervention. *Abdominal ultrasound (FAST exam)* - A **Focused Assessment with Sonography for Trauma (FAST) exam** can rapidly detect free fluid (blood) in the abdomen and is useful in the trauma bay for stable patients. - However, for a patient with **persistent hemodynamic instability** after initial resuscitation and **penetrating abdominal trauma**, diagnostic imaging would delay necessary surgery. The combination of mechanism (penetrating injury) and physiology (unstable vital signs) already mandates laparotomy regardless of FAST findings. *Laparoscopic exploration* - **Laparoscopic exploration** may be used for selected abdominal trauma cases in **hemodynamically stable patients** to assess for peritoneal violation, diaphragm injury, or minor organ damage. - It is contraindicated in **hemodynamically unstable patients** due to the need for pneumoperitoneum (which can compromise venous return and cardiovascular stability), risk of gas embolism, and prolonged operative time. Immediate open laparotomy is required for unstable penetrating trauma patients.
Question 8: In sepsis due to cholecystitis, which is the initial anatomical structure typically involved?
- A. Left lobe of liver
- B. Hepatic portal vein & IVC
- C. Quadrate lobe of liver (Correct Answer)
- D. Right lobe of liver
Explanation: ***Quadrate lobe of liver*** - The **gallbladder fossa** is located on the visceral surface of the liver, directly bordered by the **quadrate lobe** (Couinaud segment IV). - In cases of cholecystitis progressing to sepsis with hepatic involvement, the **quadrate lobe** is the initial anatomical structure affected due to its **direct anatomical contact** with the gallbladder. - Pericholecystic inflammation and abscess formation typically extend first into the quadrate lobe parenchyma before involving other hepatic segments. *Right lobe of liver* - While the gallbladder is anatomically related to the right lobe, the **quadrate lobe** (though functionally part of the left hepatic territory) is the structure in **immediate contact** with the gallbladder fossa. - The right lobe proper (segments V-VIII) may be involved subsequently, but it is not the **initial** site of direct inflammatory spread. *Hepatic portal vein & IVC* - The **hepatic portal vein** and **inferior vena cava (IVC)** are not in direct anatomical contact with the gallbladder. - These vascular structures may be affected in advanced stages through septic thrombophlebitis (**pylephlebitis**) or hematogenous spread, but not as the **initial** anatomical site of local extension. *Left lobe of liver* - The **left lobe** (segments II and III) is anatomically distant from the gallbladder, separated by the falciform ligament and other structures. - It would not be the initial site of direct inflammatory spread from cholecystitis.
Question 9: Not true about gas gangrene:
- A. Metronidazole is the drug of choice
- B. Cl perfringens produce heat-labile spores (Correct Answer)
- C. Most common cause is Cl perfringens
- D. Extensive necrosis of muscles
Explanation: ***Cl perfringens produce heat-labile spores*** - *Clostridium perfringens* spores are, in fact, **heat-resistant**, allowing them to survive harsh conditions and subsequently germinate into vegetative cells causing infection. - This heat resistance is a crucial factor in food poisoning outbreaks and wound infections, as spores can survive cooking temperatures. *Metronidazole is the drug of choice* - While metronidazole can be used as an adjunct, **penicillin G** is generally the primary antibiotic of choice for gas gangrene, often in combination with other agents like clindamycin. - **Surgical debridement** and **hyperbaric oxygen therapy** are also critical components of treatment, as antibiotics alone are often insufficient. *Most common cause is Cl perfringens* - **_Clostridium perfringens_** is indeed the most frequent cause of gas gangrene (clostridial myonecrosis), accounting for approximately 80-95% of cases. - This bacterium produces potent **exotoxins** that cause rapid tissue destruction and gas formation, leading to the characteristic symptoms. *Extensive necrosis of muscles* - Gas gangrene is characterized by **rapid and extensive necrosis of muscle tissue**, which is caused by the potent toxins produced by clostridial species, particularly alpha-toxin. - This muscle destruction leads to systemic toxicity, pain, and the production of gas within the tissues.
Question 10: A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?
- A. Bacterial sepsis (Correct Answer)
- B. Acute pancreatitis
- C. Ureteric stricture
- D. Splenic injury
Explanation: ***Bacterial sepsis*** - **Chills and fever** two days after a **Percutaneous Nephrolithotomy (PCNL)** are highly suggestive of a systemic infection, specifically **bacterial sepsis**, as this procedure carries a risk of introducing bacteria into the bloodstream. - Urinary tract manipulation, especially in a patient with a potentially *infected kidney stone*, can lead to bacteremia and subsequent **sepsis** if not properly managed. *Acute pancreatitis* - **Acute pancreatitis** is not a common complication of PCNL. It typically presents with severe **epigastric pain** radiating to the back, often with nausea and vomiting, and is usually associated with gallstones or alcohol abuse. - While it can cause fever, the clinical presentation and context do not strongly support **pancreatitis** as the primary issue following a PCNL. *Ureteric stricture* - A **ureteric stricture** is a *late complication* of kidney stone treatment and typically leads to symptoms of **urinary obstruction**, such as flank pain, rather than acute fever and chills two days post-procedure. - It would not cause acute systemic signs like **chills and fever** within such a short timeframe after PCNL. *Splenic injury* - **Splenic injury** is a rare but possible complication of procedures around the left kidney; however, it would typically present with **abdominal pain**, signs of **hemorrhage** (e.g., hypotension), and sometimes shoulder pain, not primarily with fever and chills as the immediate post-operative concern. - While fever can occur with internal injuries, the primary and most immediate concern with fever and chills after a urological procedure is **infection**.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free