1.
Which of the following statements regarding nutritional needs in infants
and children is inaccurate:
A. Storage of fat may constitute as much as 20% of gross body weight in
normal infants
B.
There are two essential fats: linoleic
and linolenic acid
C.
Daily normal nitrogen losses include 2 mg of nitrogen per basal Kcal, 20%
in feces, and 10mg/kg body weight from skin
D.
Protein requirement in infants/children is approximately 2.0 g/kg/day
E.
Fat requirement in infants is approximately 1 g/kg/day
Click here for answer
2.
All of the following statements regarding starvation are true except:
A.
Only glycogen which is stored in the liver is available for transport to
the central nervous system
B. As glucose levels fall, insulin levels decrease
C.
Ketonemia inhibits pyruvate dehydrogenase and thus blocks glucose-derived
substrate from entering the Krebs cycle
D.
The ebb phase followed by the flow phase are characteristic features
Click here for answer
3.
Which of the following statements are true regarding stressed starvation
or hypermetabolism?
A.
Ebb phase is associated with an increase in metabolic rate
B.
Flow phase corresponds to the period of hypermetabolism
C.
Hypoglycemia is the hallmark of stressed metabolism
D.
Peripheral oxidation of lipids is decreased
E.
Enhanced and increased sensitivity to the effect of insulin on glucose
uptake is noted
Click here for answer
4.
After several days of starvation, the levels of which of the following
continue to rise:
A.
Serum insulin
B.
Serum ketones
C.
Serum glucose
D.
Urinary nitrogen excretion
Click here for answer
5.
Match the following metabolic fuel with its respiratory quotient:
A.
Carbohydrate
B.
Fat
C.
Protein
____
0.7
____
0.8
____
1.0
Click here for answer
6.
Preventive measures against stress ulceration in the intensive care unit
does not include which of the following:
A.
Enteral feeding of an elemental diet
B. H2-blockers administration by continuous infusion
C.
Hourly anti-acid administration enterally
D.
Administration of sucralfate enterally
E. Administration of gastrin
Click here for answer
7.
An elemental diet has been utilized in the prevention of stress
ulceration in the intensive care unit. Which
one of the following statements is not a proposed mechanism by which enteral
feeding protects against stress ulceration:
A.
Accelerating turnover of gastric mucosal cells
B.
Releasing the hormone Gastrin
C.
Buffering gastric acid and maintaining a gastric pH > 4
D.
Releasing cholecystokinin and catecholamines such as norepinephrine
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8.
A 9-year-old boy, a victim of a motor vehicle accident with a closed head
injury, is in the Pediatric ICU. Brisk
fresh blood along with some coffee ground material is retrieved from the
nasogastric tube. The procedure
that is least helpful in the management of this patient is:
A.
Gastric lavage
B.
Endoscopy
C.
Arteriography
D.
Upper gastrointestinal series
Click here for answer
9. Endoscopy in the above patient revealed diffuse gastritis diagnosed as
“stress gastritis.” Which of
the following statements most accurately describes the clinical course and
management of this patient:
A.
A satisfactory clinical response to gastric lavage and hemodynamic
support
B.
H2-blockers stop bleeding faster than lavage alone
C.
Anti-acids stop bleeding faster than lavage alone
D.
Prostaglandin analogs such as Enprustil has been shown to be superior to
all other traditional measures combined
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10.
Paralytic ileus is a common problem after laparotomy.
Which of the following statements pertaining to this phenomenon is least
accurate:
A.
Vasopressin is released during laparotomy and contributes to decreased
small bowel contractility
B.
Hypokalemia appears to exert its effects by interfering with the release
of acetylcholine from the presynaptic area when serum K+ is < 2.5 mEq/l
C.
The colon is the portion of the gut most sensitive to anesthesia induced
inhibition of motility, because it is most dependent on neural controls to
achieve motility
D.
The role that handling or direct manipulation of the gut plays in the
development of ileus is very well established
Click here for answer
11.
Ogilvies Syndrome (localized ileus or pseudo-obstruction) is associated
with all of the following conditions except:
A. Cholecystitis
B. Pancreatitis
C.
Intra-abdominal abscess
D.
Lower lobe pneumonia
E.
Torus fracture
Click here for answer
12.
Post-operative intussusception is a problem that is sometimes overlooked
in the post-operative period in patients with evidence of gastrointestinal
obstruction. True statements
pertaining to this entity include all of the following except:
A.
A granulocytic leukocytosis of major proportions may be seen
B. Usually appears within the first post-operative week
C.
Requires surgical correction
D.
Is usually ileocecal
E.
Is difficult to diagnose because symptoms are masked by nasogastric
suctioning and use of post-operative pain medications
Click here for answer
13. Which part of the gastrointestinal tract is most sensitive to inhibition
of motility by anesthesia, with consequent development of ileus in the
post-operative period:
A.
Stomach
B.
Duodenum
C.
Jejunum
D.
Ileum
E. Colon
Click
here for answer
14.
Regarding management of post-operative ileus, which of the following
statements is least accurate:
A.
If the cecum is dilated to greater than 12 cm in diameter, a definite
risk of perforation exists even in the absence of mechanical obstruction
B. Nasointestinal intubation with decompression remains the only effective
proven therapy
C.
Passage of flatus and/or a bowel movement herald the end of the ileus
D.
Neostigmine is a very effective and safe therapeutic intervention without
any recognized side effects
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15. Inadequate blood flow and impaired oxygenation have deleterious effects
on the bowel. True statements regarding these physiologic derangements
include:
A.
In the small bowel, O2 delivery is least to the tip of the
villi
B. Inability to absorb glucose has been reported for several months in
infants who have sustained severe anoxia at birth
C.
Impaired blood flow with subsequent dilatation of bowel loops is
associated with bacterial overgrowth which is known to lead to fat malabsorption
D. All of the above
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16.
A 5-year-old boy who was admitted to the Pediatric ICU over one week ago
is recovering from multiple organ dysfunction syndrome.
He has had frequent diarrheal stools throughout the day.
From a therapeutic standpoint, which of the following would be the most
appropriate initial diagnostic test:
A.
Stool culture for corona virus
B.
Eliza test for rotavirus
C.
C. difficile toxin assay
D.
Small bowel radiographic imaging series
E.
Sigmoido-colonoscopy with biopsy
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17.
Which of the following most accurately describes the laboratory findings
in acute pancreatitis:
A.
The degree of elevation of serum amylase closely correlates with the
severity of acute pancreatitis
B.
Serum lipase levels tend to be elevated for a shorter period than serum
amylase levels
C.
Pancreatic trypsinogen serum levels rise early in the course of
pancreatitis and remain elevated for up to five days
D.
One of the ominous prognostic signs is hypercarbia
E.
All of the above
Click here for answer
18.
Which of the following symptoms is least likely to be associated with
Reye’s Syndrome:
A.
Bleeding
B. Cerebral edema
C.
Coma
D.
Jaundice
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19.
Patients who develop fulminant hepatic failure as a result of Hepatitis B
infection when compared to patients who do not develop hepatic failure have
which of the following serologic characteristics:
A.
Later appearance of antibodies to the Hepatitis B surface antigen
B.
Later appearance of antibodies to the Hepatitis e antigen
C.
More rapid clearance of Hepatitis B antigen
D.
All of the above
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20.
With regard to management of fulminant hepatic failure with coma, all of
the following statements describe the appropriate clinical picture and
management except:
A.
A single toxicology screening test on admission should be obtained to
rule out other treatable causes of encephalopathy with coma
B.
Hyponatremia due to an ADH-like effect and hypokalemia due to
hyperaldosteronism are recognized electrolyte abnormalities that require
meticulous correction
C.
Arterial ammonia levels are useful in confirming a hepatic origin to the
coma
D.
Fatty acid emulsion should be used liberally to provide calories and help
clear the encephalopathy
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QUESTIONS
21-23: A 3-year-old boy with
history of biliary atresia and Kassai procedure is admitted to the Pediatric ICU
with vomiting of fresh blood of 20 minutes duration.
Examination reveals a diaphoretic child with tachycardia.
He has vomited several ounces of fresh blood during the period of time
that he was being admitted to the Pediatric ICU.
21.
Appropriate therapeutic interventions for this patient include all of the
following except:
A.
Saline gastric lavage
B.
Fresh frozen plasma
C. Volume expanders
D. Because sodium retention may lead to
anasarca, saline administration
should be withheld in these patients in spite of marginal blood pressure
Click here for answer
22.
If the bleeding in this patient persists, the next step in the management
process would be:
A.
Portosystemic anastomosis
B. Variceal banding
C.
Endoscopy
D.
Vagotomy
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23.
The above patient underwent sclerotherapy.
Potential complications include:
A.
Re-bleeding due to gastric varices
B. Fever
C.
Ulceration
D.
Stricture
E. All of the above
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24.
Hypoxia is observed in up to 40% of patients with hepatic failure.
Factors that contribute to hypoxia include all of the following except:
A.
Neurogenic pulmonary edema
B.
An ADH-like effect leading to fluid overload
C.
Intrapulmonary shunting
D.
Patent foramen ovale
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QUESTIONS
25-27: An 8-year-old male with cirrhosis of the liver due to
congenital biliary atresia is on the waiting list for liver transplantation.
25.
Prolonged use of ibuprofen in this patient results in:
A.
Water retention
B.
Dilutional hyponatremia
C.
Ascites resistant to diuretics
D.
All of the above
Click
here for answer
26.
The patient develops oliguria with urine output decreasing to 300 ml/day.
Central venous pressure is 8 mm Hg.
BUN is 60 mg% and urinalysis does not show red blood cell or while blood
cell casts. Urine electrolytes:
Sodium level is 9 mEq/l, potassium is 5.8 mEq/l, and chloride is 10 mEq/l.
Urine osmolality is 310 mOsmol/l. The
most likely diagnosis is:
A.
Pre-renal azotemia due to hypovolemia
B.
Hepatorenal syndrome
C.
Acute tubular necrosis
D.
Acute cortical necrosis
E.
None of the above
Click here for answer
27. Preventive measures that have been shown to be helpful for the above
clinical condition include all of the following measures except:
A.
Avoiding large volume paracentesis
B. Avoiding use of potent diuretics
C.
Use of dopamine at 6 mg/kg/min
D.
In the event that this diagnosis is suspected, intravascular volume
expansion causing salt-poor albumin to raise the central venous pressure to 10 mm
Hg is a helpful preventative measure
E. Avoiding use of prostaglandin antagonists
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28.
Which of the following statements pertaining to hepatic encephalopathy is
most accurate:
A.
All patients with hepatic encephalopathy have elevated serum ammonia
levels
B.
The height of ammonia correlates with the grade of encephalopathy
C.
Arterial and venous ammonia correlate equally with the degree of
encephalopathy
D.
Plasma octopamine levels have been shown to always inversely correlate
with the degree of encephalopathy
E.
None of the above
Click here for answer
29.
A 10-month-old boy with end stage liver disease from biliary atresia
(that was not recognized in early infancy) is admitted to the Pediatric ICU with
lethargy. Appropriate intervention
that is expected to improve the clinical status of the patient include:
A.
Reduction of protein intake
B. Use of oral lactulose
C.
Use of oral neomycin
D.
Use of hypertonic glucose
E. All of the above
Click here for answer
30.
A 7-year-old with fulminant hepatic failure is admitted to the Pediatric
ICU because today he has become progressively more difficult to arouse.
Physical examination reveals a child who responds to painful stimuli by
moaning. Increased tone in the
extremities is noted and pupils are dilated and react sluggishly to light.
Correct statements pertaining to this patient include all of the
following except:
A.
Inappropriate pathologic cerebral vascular tone and altered permeability
of the blood brain barrier are contributing to this patient’s symptomatology
B.
Intracranial pressure monitoring will facilitate management of this
patient
C.
A PCO2 of > 25 torr is associated with cerebral
vasodilation and the level of consciousness correlates with the degree of
respiratory alkalosis
D.
Steroids have been shown to decrease mortality in this setting
E.
If the patient progresses to decorticate posturing and becomes ventilator
dependent, it is usually too late to initiate liver transplantation
Click here for answer
31.
Statements pertaining to patients in fulminant hepatic failure that are
true include:
A.
Rapid deterioration in the clinical course of a patient with fulminant
hepatic failure is an indication to contemplate liver transplantation
B. Patients with poor prognosis with chronic hepatitis secondary to
Hepatitis C should be considered for liver transplantation earlier
C.
Patients with acetaminophen-induced fulminant hepatic failure have a
better prognosis than fulminant hepatic failure due to viral hepatitis
D.
Hemoperfusion is known to temporarily reverse coma in these patients
E. All of the above
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32.
Match the following drug with its appropriate description:
A.
Cyclosporin
B.
Azathioprine
C.
OKT3
D.
FK506
E.
Corticosteroids
____
Inhibits purine nucleotidase
____
Selectively inhibits T-helper lymphocytes
____
A macrolide antibiotic
____
Pulmonary edema
____
Direct lymphocytotoxicity
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33.
In which of the following clinical situations is right hemidiaphragmatic
paralysis seen more often than left hemidiaphragmatic paralysis:
A.
Liver transplantation
B.
Palliative repair of congenital heart disease
C.
Both
D.
Neither
Click here for answer
34.
An 8-year-old boy who underwent liver transplantation last month from an
ABO-compatible, non-identical recipient is admitted to the Pediatric ICU for
right lower lobe pneumonia. His hemoglobin is 5.4 gram%, and the total bilirubin is 8mg% (from 2mg% 8 days ago).
The ALT and AST are 38 IU/l and 48 IU/l respectively.
The reticulocyte count is 5%. Correct
statements regarding this clinical situation include all of the following
except:
A.
Serial reticulocyte counts are the most useful tool in following the
progression of this patient’s hematological problem
B. Haptoglobin is a valuable and useful test for this hematologic problem
C.
The patient should receive type O blood when transfusion is contemplated
D.
This hematologic condition usually resolves spontaneously in 2-4 weeks
E.
Hemoglobinuria is a recognized feature
Click here for answer
35. Regarding hepatic clearance of medications, adjustment of drug dosage,
and liver disease, true statements include all of the following except:
A.
Liver disease is usually homogenous and affects drug metabolism equally
B. In acute hepatic disease, clearance is more likely to affect drugs that
undergo oxidation rather than those that undergo conjugation
C.
In treating patients with liver disease, preference should be given to
drugs which are metabolized through glucuronidation
D.
Changes in protein binding are not likely to be clinically important when
the boung fraction of the drug is < 80%
E.
For drugs that undergo efficient hepatic biotransformation, clearance of
the drug is proportionate to liver blood flow
Click here for answer
36.
With regard to nutritional support in children in the intensive care
unit, which of the following statements is least accurate:
A.
Hepatic cholestasis associated with parenteral nutrition responds
favorably to providing some enteral nutrition
B.
Glutamine when added to parenteral nutrition improves structure and
function of the intestine due to its trophic effects
C.
Branched chain amino acids always resolve hepatic encephalopathy
regardless of the etiology
D.
Trophamine with 100 mg/kg body weight of l-lysine allows more of the
calcium and phosphorus to be in solution which is clinically relevant
E.
Carbohydrate administration in excess of 14 mg/kg/min exacerbates hepatic
steatosis
Click here for answer
37.
Serum proteins can be used as biochemical markers for nutritional status.
Match the following markers with its approximate half-life:
A.
Albumin
B.
Prealbumin
C.
Transferrin
D.
Retinal Binding Protein
____
20 days
____
10 hours
____
8 days
____
2 days
Click here for answer
38.
The difference between medium chain triglycerides (MCT) and long chain
fat is that MCT:
A. A.
Inhibits gastric emptying more so than long chain fat
B. B.
Is absorbed at a slower rate than long chain fat
C.
C. Is converted into energy faster than long chain fat
D. D.
Is absorbed via the lymphatic lacteals
E. E.
None of the above
Click here for answer
39.
Which of the following is/are true regarding nutrition in the critically
ill child:
A. Disaccharidase activity may be
diminished after acute injury
B.
Predigested protein (hydrolysates)
formulas are the principal formulas
recommended for critically ill infants
C.
The presence of reducing
substances in the stool indicates appropriate
carbohydrate absorption
D.
Long chain triglycerides are
preferred over medium chain triglycerides
because of their faster absorption
from the intestine
E.
A and B only
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40.
Stress ulcers are usually located in:
A.
The body of the stomach
B.
The fundus of the stomach
C.
The antrum of the stomach
D.
The pylorus of the stomach
Click here for answer
41.
All of the medications listed below will decrease gastric pH and its
concentration except:
A.
Ranitidine
B.
Famotidine
C.
Sucralfate
D.
Proton pump inhibitors
Click here for answer
42.
A 15-year-old female is admitted to the Pediatric ICU with severe
hematemesis and hemodynamic instability. Immediate
management should be:
A. Intravenous normal saline followed by room temperature normal saline via
gastric lavage
B. Prompt resuscitation of circulation with normal saline followed by iced
“cold” normal saline gastric lavage
C. Prompt resuscitation of circulation with normal saline followed by
intravenous Ranitidine infusion
D. All of the above
Click here for answer
43.
The major cause of death in patients with fulminant hepatic failure is:
A.
Sepsis
B.
Variceal hemorrhage
C.
Cerebral edema
D.
The initial cause of fulminant hepatic failure
E.
None of the above
Click here for answer
44.
Complications of acute pancreatitis include all of the following except:
A.
Pancreatic necrosis
B.
Glomerulonephritis
C.
Adult Respiratory Distress Syndrome (ARDS)
D.
Pancreatic pseudocyst
Click here for answer
45.
Toxic megacolon is most likely a complication of:
A.
Crohn Colitis
B.
Pseudomembranous enterocolitis
C.
Ischemic colitis
D.
Ulcerative colitis
Click here for answer
46.
A 15-year-old male with a known diagnosis of HIV is admitted to the
Pediatric ICU with severe abdominal pain, bloating sensation, fever, neutropenia
and thrombocytopenia. Radiographic analysis shows a dilated cecum.
Immediate medical treatment includes all of the following except:
A.
NPO
B.
Aggressive fluid management followed by total parenteral nutrition
C.
Antibiotics
D.
Colonoscopy
Click here for answer
Answers
1.
E
The fat requirement in infants is
4 g/kg/day. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1142-1145)
2.
D
The ebb phase and the flow phase
are characteristic features of hypermetabolism and not features of a starvation
syndrome. The ebb phase is similar
to a shock stage during which the metabolic rate is slow. The flow phase is characterized by increased metabolism.
Normally with aerobic glycolysis, the end product is pyruvate.
Subsequently the end products enter the tricarboxylic acid cycle (kreb
cycle) for production of the high energy ATP.
With substantial ketonemia, this process is inhibited, and therefore,
utilization of glucose is impaired. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1145-1148)
3.
B
During hypermetabolism, which is
characterized by an initial ebb phase followed by a flow phase, there is usually
an associated hyperglycemia due to decreased sensitivity to the effect of
insulin even though the level of insulin may actually be higher than usual.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1145-1148)
4.
B
After several days of starvation,
the serum glucose and insulin levels gradually decrease but eventually a plateau
is reached. Levels of ketones,
however, continue to rise along with an increase in the level of glucagon.
With continuation of starvation, nitrogen excretion falls.
There is adaptation of the brain to use ketones which is usually
available because the level of ketones continue to rise.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1145-1148)
5.
B, C, A These are the respiratory
quotients for the various fuels. The
respiratory quotient is highest for carbohydrate, and therefore, with patients
who have a problem with elimination of carbon dioxide, the administration of
carbohydrate should be lowered in order to minimize carbon dioxide production.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1150-1151)
6.
E
Preventive measures that are used
for stress ulceration in the intensive care unit include feeding, which by
itself, acts as a protective barrier for the gastric mucosa, or the
administration of H2 blockers which may be administered by continuous
infusion. These would include
ranitidine or famotidine. Administration
of antacids has been shown to be as effective as H2 blockers.
Alternatives include administration of sucralfate which has been shown to
be comparable to H2 blockers. Enteral
feedings seem to stimulate release of the hormone gastrin.
Administration of gastrin, itself, is not one of the measures that is
clinically used in an intensive care unit as a preventative measure against
stress ulceration. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; pp 1167-1168)
7.
D
Administration of an elemental
diet has been associated with an increased release of the hormone, gastrin,
which seems to be trophic for the gastric mucosa.
(Choctaw W, et al. Prevention
of Upper GI Bleeding in Burn Patients. Arch
Surg, 1980; Vol. 115:1073)
8-9.
D, A
With gastric lavage and
hemodynamic support, usually most patients with gastritis and bleeding will
respond. H2 blockers have not been
shown to stop gastric bleeding faster than lavage.
Endoscopy should be performed to identify the site of bleeding, which if
found, endoscopic therapy with electrical or laser cautery may be indicated and
helpful. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1167-1168)
10.
D
Vasopressin, an anti-diuretic
hormone, appears to be released during laparotomy and contributes to the
decreased motility of the small bowel. Other
contributing factors are hypokalemia, particularly with potassium levels of less
than 2.5 mEq/l. The colon is the
portion of the bowel most dependent on neural control to achieve motility.
This is the portion of the bowel that is most sensitive to
anesthesia-induced inhibition of motility, and the last to recover.
The role that handling or direct manipulation of the gut plays in the
development of ileus is not very clear. (Livingston
E, Passaro E. Post-Operative Ileus.
Dig Dis Sci, 1990; Vol. 35(1):121)
11.
E
Ogilvies syndrome, which is a
localized ileus of the bowel leading to pseudo-obstruction, is associated with
inflammatory conditions, in the intra-abdominal or para-abdominal regions.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1168-1169)
12.
D
Post operative intussusception
that is usually ileoileal rather than ileocecal (which is seen in late infancy)
is a problem that can be overlooked in the post-operative patient, particularly
in patients who are receiving analgesia for post-operative care along with
nasogastric suctioning to decompress the bowel.
However, this is important to recognize to avoid morbidity and mortality.
(Ein H, Ferguson J. Intussusception
– The Forgotten Post-Operative Obstruction.
J Pediatr Surg, 1971; Vol. 6:16)
13.
E
(See answer to Question #10)
14.
D In the setting of post-operative ileus, if the cecum is very dilated,
particularly if the diameter is greater than 12 cm, there is a very high risk of
perforation even in the absence of mechanical obstruction.
The only effective treatment for post-operative ileus is nasointestinal
intubation to decompress the bowel and supportive measures.
Neostigmine has not been shown to be a safe therapeutic intervention, and
is associated with significant side effects.
(Adams J. A dynamic ileus of
colon. Arch Surg, 1974; Vol.
109:513. Livingston E. Post-operative ileus. Dig
Dis Sci, 1990; Vol. 35(1):121)
15.
D
Because of the counter current
mechanism, the oxygen delivery is least to the tip of the villi. Impaired blood flow to the bowel leads to dilation of the
bowel which leads to overgrowth of bacteria, and this can lead to malabsorption,
including fat malabsorption. (Perman
PA. Contaminated small bowel
syndrome. Hokelman RA. Princ9iples of Pediatrics, New York; McGraw Hill, 1978; p
808)
16.
C.
Clostridium difficile is an
important infection to recognize in the intensive care unit, particularly where
broad-spectrum antibiotics have been utilized.
It presents with diarrhea, which can be bloody in nature and associated
with significant volume loss. When
this is diagnosed, usually by obtaining a toxin assay, oral vancomycin or
intravenous metronidazole are usually effective.
Stool culture for corona virus and rotavirus are important for
epidemiologic studies, but will not contribute to a patient’s therapeutic
intervention, nor do small bowel radiography or colonoscopy.
(Viscidi RP. Pediatrics,
1981; Vol. 67:381)
17.
C
Acute pancreatitis is a medical
condition characterized by inflammation of the pancreas with subsequent release
of the enzymes amylase and lipase. The
degree of serum amylase does not seem to be proportional to the severity of
acute pancreatitis. Serum lipase
levels seem to be elevated for a longer period of time than serum amylase.
Pancreatic trypsinogen serum levels seem to rise early in the course of
pancreatitis and remain elevated for up to five days.
In a clinical situation where amylase and lipase are normal and there is
a high suspicion of pancreatitis, one could look at the level of trypsinogen.
Some of the bad prognostic signs of acute pancreatitis include,
hyperglycemia, leukocytosis, hypocalcemia, and azatemia.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1175-1178)
18.
D
Reye’s Syndrome which has
practically vanished and is very infrequently seen today, is characterized by
alteration of mental status which can progress to coma in association with
derangement of the liver enzymes and alteration in the coagulation profile. However, an increased level of bilirubin or jaundice is not a
recognized feature of this condition. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1178-1180)
19.
C
Patients who develop fulminant
hepatic failure as a result of hepatitis B virus infection (when compared to
patients who do not progress to hepatic failure), tend to have earlier
appearance of antibodies against hepatitis B surface antigen.
Also, they have earlier appearance of antibodies against hepatitis B,
e-antigen and more rapid clearance of the hepatitis B surface antigen.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1179-1181)
20.
D
Intravenous fat emulsions may not
be tolerated well in patients with significant hepatic disease, as it may not be
metabolized by these patients. Accumulation
of fatty acids intrahepatically may further compromise the hepatic function.
Furthermore, non-esterified fatty acids may compete with tryptophan for
binding to albumin. This may increase the risk of encephalopathy.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1178-1187)
21-23.
D, C, E The initial intervention for
an upper gastrointestinal hemorrhage is gastric lavage and supportive measures
which would include correction of any coagulopathy and use of volume expanders,
either crystalloids or colloids. In
patients who are hemodynamically unstable due to upper gastrointestinal
hemorrhage, adequate volume expansion is crucial and this should not be
withheld, even in patients who have evidence of edema.
If the patient does not respond to initial intervention, an endoscopy
should be performed, and if any localized area of bleeding is identified, this
can be treated through endoscopy with electrical or laser cautery, or with the
application of topical coagulants as indicated.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1181-1182)
24.
D
Patent foramen ovale is not a
recognized cause or a contributing factor to hypoxia in patients with hepatic
failure. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
p 1182)
25.
D
Ibuprofen, a non-steroidal
anti-inflammatory medication, can reduce renal plasma flow as well as glomerular
filtration rate. This would result
in water retention, dilutional hyponatremia, and ascites which might be
resistant to diuretic therapy. It
appears that prostaglandins are important in renal vasodilation and ibuprofen
may compromise this physiologically important parameter that maintains renal
blood flow in patients in hepatic failure.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1183)
26.
B
Hepatorenal syndrome is
characterized by low urine sodium due to the hyperaldosteronism.
The associated high anti-diuretic hormone levels lead to urine osmolality
which is generally greater than the serum osmolality. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
p 1183)
27.
C
Hepatorenal syndrome can develop
in a setting of isovolemia. However,
preventive measures which have been shown to be helpful for this clinical
condition include avoiding large volume paracentesis in order to avoid
intravascular volume depletion, as well as use of potent diuretics which can
also lead to intravascular volume depletion.
Use of dopamine has not been shown to be effective for this clinical
condition. In the early stages when
this condition is suspected, expansion of intravascular volume with salt-poor
albumin to raise the central venous pressure to the upper limits of normal is a
helpful preventive measure. Other
preventive measures include avoidance of prostaglandin antagonists such as
ibuprofen. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
p 1183)
28.
E
Arterial ammonia is preferred to
venous ammonia, however, there is no positive correlation between the grade of
encephalopathy and the height of the ammonia.
Not all patients with hepatic encephalopathy have elevated ammonia
levels. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1183)
29.
E
Measures to decrease protein
intake as well as elimination of colonic bacteria by use of oral lactulose, oral
antibiotics such as neomycin have been shown to be effective for hepatic
encephalopathy. Use of hypertonic
glucose to provide calories is also an important measure in the management of
these patients. (Butterworth RF. Pathogenesis and treatment of portal systemic encephalopathy:
an update. Dig Dis Sci,
1992; Vol. 37, 321-327)
30-31.
D, E
In a patient with hepatic
encephalopathy, there is inappropriate pathologic cerebrovascular tone along
with altered permeability of the blood brain barrier which contribute to their
symptomatology. In these patients,
intracranial pressure monitoring along with hyperventilation to lower the PCO2
will facilitate management. Steroids
have not been shown to decrease mortality in these settings.
These patients should be considered for hepatic transplantation and
evaluated for this procedure in the initial stages of ICU admission because it
has been shown that if the patient progresses to decorticate posturing and
becomes ventilator dependent, it usually too late to initiate liver
transplantation. (Zaki AEO, et al.
Potential toxins of acute liver failure and their affects on blood brain
barrier permeability. Experientia,
1983; Vol. 39:988. Rogers MC, et
al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1193-1195)
32.
B, A, D, C, E
Pulmonary edema is
rarely associated with administration of OKT3. Therefore, patients who are receiving OKT3,
usually in the post-operative period, are monitored in the intensive care
setting. Their fluids and
electrolytes are adjusted very carefully to prevent pulmonary edema.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1202-1204)
33.
A (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp
1197-1199)
34.
B
This form of hemolytic anemia is
usually self-limited and resolves spontaneously within 2-4 weeks.
During this period, a serial reticulocyte count is often helpful in
monitoring the progression or regression of this hematologic problem.
Haptoglobin may not be useful in this setting because the level of
haptoglobin may be decreased due to underlying liver disease.
(Ramsey G, et al. N Engl J
Med, 1984; Vol. 311:1167)
35.
A
Liver disease is usually not
homogenous, and therefore, drug metabolism is affected to a variable degree
depending on the type of medication. It
seems that the process of glucuronidation is more resistant to abnormalities in
function than the process of oxidation,
and therefore, in treating a patient with liver disease, preference should be
given to drugs that are metabolized through this pathway. For drugs that undergo significant hepatic biotransformation
clearance of these drugs tends to be proportionate to the degree of liver blood
flow. (Bass NM, Williams RL.
Guide to drug dosage in hepatic disease.
Clin Pharmacokinetics, 1988; Vol. 6:396)
36.
C
Branched chain amino acids have
been shown to be of some use in chronic liver disease, however, they do not
resolve hepatic encephalopathy on a consistent basis.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1184-1186)
37.
A, D, C, B
These are the half lives
of various proteins which can be used to evaluate the nutritional status of
patients. Albumin has the longest
half-life of 20-21 days. On the
other hand, pre-albumin has a half-life of 2 days, and transferrin has a
half-life of 8 days. Retinol-
binding protein has a very short half-life of only 10 hours, and therefore, can
be evaluated in patients who are suspected of having a recent onset of their
nutritional deficiency. (Rogers MC,
et al. Textbook of Pediatric
Intensive Care, 3rd Edition; p 1149)
38.
C
Medium chain triglycerides (C6
to C12) inhibit gastric emptying less than long chain fatty acids,
and are absorbed from the gastrointestinal tract faster than long chain fatty
acids. Consequently, they convert
into energy more rapidly than the long chain fatty acids, or long chain
triglycerides. Medium chain
triglycerides are absorbed directly into the systemic circulation through the
portal venous system, instead of being absorbed through the lymphatic lacteals
and subsequently into the thoracic duct. (Fuhrman
BP. Pediatric Critical Care, 2nd
Edition; p 907)
39.
E
The presence of reducing
substances in stool suggest carbohydrate malabsorption.
Disaccharides, which are located on the brush border may be diminished
following acute injury and contribute to malabsorption of carbohydrates.
Protein hydrolysate formulas, such as Alimentum, Nutramagen, and
Progestimil are predigested for ease of nutrient absorption and are suitable to
critically ill infants. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1152-1153)
40.
B
Stress ulcers are a recognized complication in critically ill children
and are usually located high in the fundus of the stomach.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition, 1996; pp 1165-1167.
Menguy R, Master YF. Mechanism
of stress ulcers. Gastroenterology,
1974; Vol. 66, p 1172)
41.
C
Ranitidine (Zantac), Famotidine and proton pump inhibitors decrease
gastric concentration. Sucralfate
does not affect gastric pH or its concentration.
(Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1165-1168.
Furhman BP, et al. Pediatric Critical Care, 2nd Edition; pp
919-932)
42.
A
Iced saline lavage offers no advantages over room temperature saline
lavage. A significant reduction in
core body temperature is a potential complication of iced saline gastric lavage
in young children. (Furhman B.P, et
al. Pediatric Critical Care,
2nd Edition; pp 919-932. Levin
D, et al. Essentials of
Pediatric Intensive Care, 1990; pp 565-572)
43.
C
The majority of patients who die due to fulminant hepatic failure are
found to have cerebral edema. Many
of these patients have evidence of transtentorial herniation. Infection and
sepsis are common but usually do not cause death.
Gastrointestinal hemorrhage is also common, and is usually related to
gastritis or ulceration. (Ware
AJ. “Cerebral edema: a major
complication of massive hepatic necrosis.”
Gastroenterology, 1971; Vol 61, p 877.
Canalese J. “Controlled
trial of dexamethasone and mannitol for cerebral edema of fulminant hepatic
failure.” Gastroenterology, 1982;
Vol 23, p 625)
44.
B
Local complications of pancreatitis include pancreatic necrosis,
pancreatic abscess, and pseudocyst formation.
ARDS may occur with pancreatitis. Renal
dysfunction is seen frequently in the setting of acute pancreatitis, and is
related to hypoperfusion, hypotension, and volume loss.
Specific renal injury such as glomerulonephritis has not been noted with
acute pancreatitis. (Lenner A.
“Pancreatic diseases in children.”
Pediatric Clinics of North America; Feb 1996, Vol 43:1, pp 125-157.
Frey CF, Bradley EL. “Progress
in acute pancreatitis.” Surg
Gynecol Obs, 1988; Vol 167, p 282)
45.
D
Toxic megacolon is usually a complication of ulcerative colitis but is
rarely involved in patients with pseudomembranous enterocolitis, Crohn’s
disease or ischemic colitis. Factors
involved in precipitation of toxic megacolon include barium enema, opiates,
anticholinergics, antidiarrheal agents and electrolyte derangements.
(Acute colonic pseudo-obstruction. British
J Surg, 1992; Vol 79, pp 99-103. Ulshen
M. Nelson’s Textbook of
Pediatrics, 15th Edition, pp 1080-1087)
46.
D
This patient has typhlitis which is a necrotizing colitis involving the
cecum. This is common among
patients with immune deficiency. Typhlitis
is a life-threatening condition that causes severe abdominal pain,
gastrointestinal bleeding, and fever. Medical
management includes discontinuing oral intake, aggressive fluid management
followed by total parenteral nutrition, antibiotics and fresh frozen plasma to
maintain adequate coagulation status.
Colonoscopy would be contraindicated due to risk of perforation.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1174-1175. Katz JA,
Wagner ML. Typhlitis – 18 years
experience and postmortem review. Cancer,
1990, Vol. 65; pp 1041-1047)