Multiple Choice Questions

Parenteral nutrition in critical care (d) NICE and ESPEN recommend calculating nutritional require-
ments based on grams of protein per kg body weight per day.
1. Refeeding syndrome:
(e) Once established on parenteral nutrition in hospital, patient
monitoring and assessment is most likely to be performed
(a) Is characterized by rapid weight gain after initiation of
once per week.
nutrition.
(b) Is likely to occur when nutrition is commenced after at least
5 days of starvation. Practical aspects of long-term venous
(c) Has been reported to present with sudden cardiac death. access
(d) Occurs as a result of rapid weight loss when nutrition 5. In a 60-yr-old man who has a port for 6 months:
is restarted.
(e) Would be an indication to discontinue parenteral nutrition.
(a) Magnetic resonance imaging (MRI) is contraindicated.
2. Formulations of parenteral nutrition (PN) are likely to: (b) The catheter is likely to be flushed at least once per week.
(c) There are likely to be 1 or 2 lumens.
(a) Contain different quantities of carbohydrate, lipid, and (d) Swimming is possible without special precautions.
protein. (e) Access is obtained using a specialized Huber needle.
(b) Require further individualization for patients. 6. In a 70-yr-old man who has congestive cardiac failure with
(c) Contain linoleic acid and alpha linoleic acid. orthopnoea, a peripherally inserted central venous catheter
(d) Have a standard 2000 ml volume when administered centrally.
(PICC line) is likely to:
(e) Be adjusted to meet a patient’s electrolyte requirements.

3. Appropriate statements regarding parenteral nutrition (PN) (a) Be difficult to insert owing to the inability to place him in
include: the Trendelenberg position.
(b) Be removed if the initial chest radiograph shows that it
(a) Line asepsis is required. terminates in the right internal jugular vein rather than the
(b) ESPEN (European Society of Parenteral and Enteral superior vena cava.
Nutrition) recommends PN when there has been inadequate (c) Be inserted in theatre under X-ray guidance.
enteral nutrition for more than 48 h. (d) Be secured in position by tissue in-growth.
(c) PN is not too important if the patient is likely to be (e) Cause phlebitis in ,1 in 30 cases.
commenced on oral nutrition within 72 h. 7. A dual-lumen, tunnelled, central-venous access device was
(d) PN is most likely to be avoided in patients with sepsis. inserted into the right subclavian vein of a 30-yr-old man, 6 weeks
(e) PN is mostly likely to be discontinued as soon as enteral
ago. The catheter does not flush easily. Appropriate statements
feeding is commenced. regarding attempts to relieve the obstruction include:
4. The most appropriate statements regarding guidelines for nutrition
include: (a) Fracture of the catheter is likely to occur over time if the
moving of the patient’s right arm repeatedly relieves the
(a) NICE (National Institute for Health and Clinical obstruction.
Excellence) guidance is preferential to ESPEN (European (b) Intraluminal thrombolytic agents are useful provided the
Society of Parenteral and Enteral Nutrition) guidance. catheter can be flushed initially with normal saline.
(b) Both ESPEN and NICE recommend nutritional (c) Leakage of fluid from the exit site in the skin indicates that
support for patients who have had little or no nutrition the catheter has become misplaced.
for 7 days. (d) Normal saline contained in a 2 ml syringe should be used to
(c) NICE and ESPEN recommend calculating nutritional flush the catheter to maximize the probability of clearing
requirements based on kcal kg21 day21 for calories. the obstruction.
doi:10.1093/bjaceaccp/mks075 35
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Multiple Choice Questions

(e) If the right arm appears swollen, then the patient should be (d) Has three parallel test channels; each test cell has one pair
anti-coagulated systemically, after removal of the catheter. of silver coated wires.
(e) Shows good correlation with the gold standard of light
8. Appropriate statements regarding removal of a tunnelled cuffed
transmission aggregometry.
catheter include:
12. Appropriate statements regarding point-of-care coagulation
(a) It is generally best to perform the procedure under general testing include:
anaesthesia as it requires surgical removal.
(b) The venous end of the catheter should be removed before (a) Point-of-care coagulation testing has replaced conventional
the end that terminates at the external hub. laboratory testing in the perioperative period.
(c) Pulling hard is required to release a well-anchored catheter. (b) Transfusion algorithms developed for TEGw and ROTEMw
(d) The skin exit site will need to be debrided and sutured. are expected to decrease transfusion and expenditure asso-
(e) An air-occlusive dressing is likely to be applied to the site. ciated with blood product wastage.
(c) The activated clotting time (ACT) is likely to be prolonged
in the presence of haemodilution.
Point-of-care coagulation testing
(d) If the Multiplate device suggests normal platelet function
9. A 72-yr-old man taking aspirin and clopidogrel for unstable in patients on clopidogrel, then delay in timing of
angina requires coronary arterial revascularization. Appropriate elective open gastrointestinal surgery is likely to be
statements regarding this situation include: prevented.
(e) Point-of-care coagulation test devices are simple to use and
(a) Excessive postoperative haemorrhage is likely to be pre- include integrated systems of quality assurance that obviate
dicted by preoperative viscoelastic testing. additional external surveillance.
(b) Postoperative viscoelastic testing using heparinase-containing
cuvette cups is likely to detect residual circulating heparin.
(c) The reaction time (R) (TEGw) or the clotting time (CT)
Humans at altitude: physiology
and pathophysiology
(ROTEMw) is likely to guide administration of fresh frozen
plasma (FFP). 13. As a climber ascends to altitude, which of the following
(d) A normal maximum amplitude (MA) (TEGw) or maximum decreases?
clot firmness (MCF) (ROTEMw) confirms that, despite
taking aspirin and clopidogrel, his platelet function is likely (a) Barometric pressure.
to be normal. (b) Saturated vapour pressure of water.
(e) Viscoelastic testing is likely to demonstrate the contribution (c) Percentage of atmospheric oxygen.
of hypothermia to coagulopathy. (d) Alveolar ventilation.
(e) Arterial partial pressure of carbon dioxide (PaCO2).
10. Appropriate statements regarding the Platelet function analyzer
(PFA)-100 include: 14. Physiological changes of advantage to a trekker hiking from
Lukla airport (2860 m) to Everest Basecamp, Nepal (5364 m) are
(a) Inhibition of platelets by clopidogrel is demonstrated expected to include:
by a prolonged adenosine diphosphate (ADP) closure time.
(b) Inhibition of platelets by aspirin is demonstrated (a) An increase in alveolar ventilation.
by a prolonged epinephrine closure time. (b) A reduction in humidification of inhaled gases in the upper
(c) Qualitative and quantitative abnormalities in von Willebrand airways.
factor are detectable. (c) An increase in renal retention of bicarbonate.
(d) It is not sensitive enough to allow monitoring (d) An increase in erythropoietin production.
of glycoprotein (GP) IIb/IIIa antagonists. (e) An increase in pulmonary artery pressure.
(e) Platelet rich plasma is required to assess platelet function.
15. During physiological investigation, the following parameters
11. The Multiplate device: are required to calculate oxygen delivery (DO2):

(a) Uses the principle of impedance aggregometry. (a) Partial pressure of alveolar oxygen (PAO2).
(b) Tests the antiplatelet effects of glycoprotein (GP) IIb/IIIa (b) Arterial oxygen saturation (SaO2).
inhibitors. (c) Partial pressure of arterial oxygen (PaO2).
(c) Detects platelet inhibition in patients who have been (d) Partial pressure of inspired oxygen (PiO2).
on both aspirin and clopidogrel. (e) Stroke volume (SV).

36 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 1 2013
 Multiple Choice Questions

16. High altitude pulmonary oedema: (b) Glucose.

(c) Interleukin 6 (IL-6).
(a) Is responsible for the majority of deaths from high altitude (d) Growth hormone.
illness. (e) Tumour necrosis factor (TNF).
(b) Is unlikely to occur with high altitude cerebral oedema.
(c) Has an increased incidence after a recent history of respira-
tory infection. Nausea and vomiting after surgery
(d) Is often associated with pyrexia.
(e) Is unlikely to recur on returning to altitude after a further 21. The vomiting centre is likely to:
period of acclimatization.
(a) Be an anatomically defined structure.
(b) Include the area postrema and nucleus tractus solitaries.
Humans at altitude: research and critical (c) Receive afferents from the cerebellum, higher cerebral
care centres and limbic system.
17. Oxygen utilization (VO2) is likely to be: (d) Detect emetogenic substances in the blood and cerebro-
spinal fluid.
(a) Proportional to oxygen delivery (DO2) in an individual who (e) Contain neurokinin-1 receptors.
takes a plane journey from an airport at sea level to El Alto 22. Major risk factors for postoperative nausea and vomiting are
International Airport, Bolivia, an airport at high altitude. most likely to:
(b) Increased at altitude in acclimatized individuals.
(c) Used as a surrogate for mitochondrial function. (a) Be surgery-related.
(d) Reduced owing to alterations of flow in the (b) Be dependent on confounding factors.
microcirculation. (c) Include female gender and non-smoking status.
(e) Therapeutically reduced in critically ill patients. (d) Include type of volatile anaesthetics.
18. Mitochondria: (e) Include body mass index and anaesthesia with propofol.
23. Antagonists at the 5-hydroxytryptamine-3 receptors:
(a) Are the primary site for anaerobic metabolism.
(b) Are likely to increase in number during a climbing exped- (a) Block serotonin from binding to receptors primarily in the
ition at over 4000 m. area postrema.
(c) Are responsible for up to 60% of total oxygen utilization (b) Are more effective against vomiting than dexamethasone.
(VO2). (c) Do not affect the QTc interval on the electrocardiogram.
(d) Activity is indirectly influenced by endocrine changes. (d) Act synergistically with droperidol and dexamethasone as
(e) Activity is inhibited by presence of inflammatory mediators. prophylaxis.
19. Hypoxia-inducible factor (HIF-1) is likely to: (e) Have duration of action up to 72 h.
24. Prophylactic and treatment strategies for postoperative nausea
(a) Be produced in the setting of hypoxia. and vomiting are most likely to include:
(b) Rely on cellular transcription to produce its effect.
(c) Increase expression of a single gene. (a) Preoperative assessment of the patient’s baseline risk.
(d) Be implicated in the pathophysiology of neoplastic disease. (b) Use of total intravenous anaesthesia.
(e) Influence nitric oxide (NO) and erythropoietin production. (c) Limitation of administration of opioids.
20. As a climber ascends from sea level to 8000 m, there is likely (d) A combination of two antiemetic drugs in a 40-yr-old male
to be an increase in plasma levels of: smoker who is listed for excision of a sebaceous cyst under
local anaesthesia.
(a) Vasopressin. (e) Metoclopramide as a first-line rescue treatment.

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