# Pediatric Critical Care Review Hasan Pappas

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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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)