A Bailey & Love
REVISION GUIDE
MCQs and EMQs
in Surgery
SECON D EDITION
Edited by
Pradip K Datta, Christopher J K Bulstrode, Iain J Nixon
12/9/14 10:55 AM
, 1 Metabolic response
to trauma
Pradip K Datta
Multiple choice questions
➜➜ Homeostasis ➜➜ Mediators
1. Which one of the following statements 4. Which of the following statements
about homeostasis is false? about mediators are true?
A It is defined as a stable state of the A They consist of neural, endocrine and
normal body. inflammatory.
B The central nervous system, heart, lungs, B Every endocrine gland plays a part.
kidneys and spleen are the essential C They play an important role in the flow
organs that maintain normal homeostasis. phase.
C Elective surgery should cause little D These mediators are released over
disturbance to homeostasis. several days.
D Emergency surgery should cause little E They play an important role in the
disturbance to homeostasis. recovery process.
E Return to normal homeostasis after an ➜➜ Optimal perioperative care
insult (operation, injury, infection) would
5. Which of the following statements are
depend upon the presence of comorbid
true of optimal perioperative care?
conditions.
A Surgery should be carried out by the use
➜➜ Stress response of adequate large incisions to give good
exposure.
2. Neuroendocrine pathways of the
stress response consist of the follow-
B Adequate pain relief is essential.
ing except: C Early mobilisation.
A Spinal cord D Avoid ongoing insults and secondary
B Thalamus trauma.
C Hypothalamus E Maintain good fluid load with several
D Pituitary litres of normal saline.
E Thyroid 6. The following statements are true
regarding Enhanced Recovery After
➜➜ Body metabolism Surgery (ERAS) programmes except:
A It optimises rehabilitation following
3. Changes in body metabolism that
major surgery.
occur in response to trauma are the
following except: B It reduces hospital stay.
A Lipolysis C Patient engagement is an integral part.
B Gluconeogenesis D It is only used in colorectal surgery.
C Protein breakdown E Blocking afferent painful stimuli is
D Hypoglycaemia important in reducing stress response.
E Hypermetabolism
3
K23682_Book.indb 3 20/12/14 3:35 AM
, MCQs and EMQs in Surgery
Answers to multiple choice questions
➜➜ Homeostasis
1. D
Emergency surgery causes a marked disturbance in homeostasis. This disturbance is directly
proportional to the degree of injury and inversely proportional to the fitness of the patient
prior to the event. The greater the injury the more pronounced is the physiological, metabolic
and immunological changes, all of which are graded according to the magnitude of the initial
insult. Elective surgery causes minimal disturbance because the patient is optimised and
precautions taken against comorbid conditions prior to an operation.
Homeostasis is the normal physiological state of the human body – the milieu intérieur, a
term coined by Claude Bernard. The vital organs – the brain, heart, lungs and kidneys, and,
to a lesser extent, the spleen – play an essential part in its maintenance. The brain, heart and
kidneys by their specific ability of autoregulation play an added role in response to trauma.
Fluid and electrolyte conservation is the vital first stage (Figure 1.1). A return to normal
physiology is always affected by the presence of ongoing complications or secondary insults,
such as ischaemia from hypotension, inadequate oxygenation from hypoxia, or infection and
complications such as compartment syndrome or deep venous thrombosis (see Figure 1.2).
➜➜ Stress response
2. E
The thyroid does not form a part of the neuroendocrine pathway to the stress response.
Following any form of injury, the afferent nociceptive pathways consist of the spinal cord,
thalamus, hypothalamus and the pituitary. The hypothalamus secretes corticotrophin-
releasing factor (CRF), which acts on the anterior pituitary to secrete adrenocorticotrophic
hormone (ACTH), which, in turn, acts on the adrenal glands to release cortisol (Figure 1.3).
Classically it has been described as the ‘fight or flight’ response. This occurs as a result of a
concerted interplay between neural, endocrine and inflammatory factors (Figure 1.4).
The stress response is graded. For instance, a 30-year-old fit woman undergoing an
elective laparoscopic cholecystectomy will elicit a minor transient stress response compared
to a 70-year-old involved in a road traffic accident who has to undergo major orthopaedic
Fluid and electrolyte conservation
Hypovolaemia from haemorrhage
(‘The ‘3-line whip’)
CNS (hypothalamus) Aortic and carotid body Renin-angiotensin
pressure receptors system
Atrial stretch receptors
Posterior pituitary Atrial natriuretic peptide Aldosterone
ADH (ANP)
Conservation of sodium and water at renal tubule
Figure 1.1 Fluid and water conservation.
4
K23682_Book.indb 4 20/12/14 3:35 AM
, Stress response depends upon
1: Metabolic response to trauma
Severity of injury Type of injury
To get speedy resolution avoid (‘SO’)
Secondary insults – 3 ‘I’s: Ischaemia
Infection
Inadequate oxygenation (hypoxia)
Ongoing trauma – e.g., compartment syndrome (abdominal/limb)
deep vein thrombosis
Figure 1.2 Ongoing complications and secondary insults affecting recovery.
Trauma
Sepsis Hypothalamus CRF Anterior pituitary
Major operation
ACTH
Adrenals
Cortisol
Figure 1.3 The release of cortisol.
Catecholamine-mediated Cytokines
‘fight or flight’ response
Adrenal medulla Hypothalamus Inflammatory
response
Nor adrenaline Cortisol-releasing
Adrenaline from peripheral hormone (CRH)
nerves
Anterior pituitary
ACTH
Neurohormonal
response
Cortisol and glucocorticoids
Stress response to injury
Figure 1.4 Interplay of neural, endocrine and inflammatory factors.
5
K23682_C001.indd 5 03/01/15 4:22 AM
REVISION GUIDE
MCQs and EMQs
in Surgery
SECON D EDITION
Edited by
Pradip K Datta, Christopher J K Bulstrode, Iain J Nixon
12/9/14 10:55 AM
, 1 Metabolic response
to trauma
Pradip K Datta
Multiple choice questions
➜➜ Homeostasis ➜➜ Mediators
1. Which one of the following statements 4. Which of the following statements
about homeostasis is false? about mediators are true?
A It is defined as a stable state of the A They consist of neural, endocrine and
normal body. inflammatory.
B The central nervous system, heart, lungs, B Every endocrine gland plays a part.
kidneys and spleen are the essential C They play an important role in the flow
organs that maintain normal homeostasis. phase.
C Elective surgery should cause little D These mediators are released over
disturbance to homeostasis. several days.
D Emergency surgery should cause little E They play an important role in the
disturbance to homeostasis. recovery process.
E Return to normal homeostasis after an ➜➜ Optimal perioperative care
insult (operation, injury, infection) would
5. Which of the following statements are
depend upon the presence of comorbid
true of optimal perioperative care?
conditions.
A Surgery should be carried out by the use
➜➜ Stress response of adequate large incisions to give good
exposure.
2. Neuroendocrine pathways of the
stress response consist of the follow-
B Adequate pain relief is essential.
ing except: C Early mobilisation.
A Spinal cord D Avoid ongoing insults and secondary
B Thalamus trauma.
C Hypothalamus E Maintain good fluid load with several
D Pituitary litres of normal saline.
E Thyroid 6. The following statements are true
regarding Enhanced Recovery After
➜➜ Body metabolism Surgery (ERAS) programmes except:
A It optimises rehabilitation following
3. Changes in body metabolism that
major surgery.
occur in response to trauma are the
following except: B It reduces hospital stay.
A Lipolysis C Patient engagement is an integral part.
B Gluconeogenesis D It is only used in colorectal surgery.
C Protein breakdown E Blocking afferent painful stimuli is
D Hypoglycaemia important in reducing stress response.
E Hypermetabolism
3
K23682_Book.indb 3 20/12/14 3:35 AM
, MCQs and EMQs in Surgery
Answers to multiple choice questions
➜➜ Homeostasis
1. D
Emergency surgery causes a marked disturbance in homeostasis. This disturbance is directly
proportional to the degree of injury and inversely proportional to the fitness of the patient
prior to the event. The greater the injury the more pronounced is the physiological, metabolic
and immunological changes, all of which are graded according to the magnitude of the initial
insult. Elective surgery causes minimal disturbance because the patient is optimised and
precautions taken against comorbid conditions prior to an operation.
Homeostasis is the normal physiological state of the human body – the milieu intérieur, a
term coined by Claude Bernard. The vital organs – the brain, heart, lungs and kidneys, and,
to a lesser extent, the spleen – play an essential part in its maintenance. The brain, heart and
kidneys by their specific ability of autoregulation play an added role in response to trauma.
Fluid and electrolyte conservation is the vital first stage (Figure 1.1). A return to normal
physiology is always affected by the presence of ongoing complications or secondary insults,
such as ischaemia from hypotension, inadequate oxygenation from hypoxia, or infection and
complications such as compartment syndrome or deep venous thrombosis (see Figure 1.2).
➜➜ Stress response
2. E
The thyroid does not form a part of the neuroendocrine pathway to the stress response.
Following any form of injury, the afferent nociceptive pathways consist of the spinal cord,
thalamus, hypothalamus and the pituitary. The hypothalamus secretes corticotrophin-
releasing factor (CRF), which acts on the anterior pituitary to secrete adrenocorticotrophic
hormone (ACTH), which, in turn, acts on the adrenal glands to release cortisol (Figure 1.3).
Classically it has been described as the ‘fight or flight’ response. This occurs as a result of a
concerted interplay between neural, endocrine and inflammatory factors (Figure 1.4).
The stress response is graded. For instance, a 30-year-old fit woman undergoing an
elective laparoscopic cholecystectomy will elicit a minor transient stress response compared
to a 70-year-old involved in a road traffic accident who has to undergo major orthopaedic
Fluid and electrolyte conservation
Hypovolaemia from haemorrhage
(‘The ‘3-line whip’)
CNS (hypothalamus) Aortic and carotid body Renin-angiotensin
pressure receptors system
Atrial stretch receptors
Posterior pituitary Atrial natriuretic peptide Aldosterone
ADH (ANP)
Conservation of sodium and water at renal tubule
Figure 1.1 Fluid and water conservation.
4
K23682_Book.indb 4 20/12/14 3:35 AM
, Stress response depends upon
1: Metabolic response to trauma
Severity of injury Type of injury
To get speedy resolution avoid (‘SO’)
Secondary insults – 3 ‘I’s: Ischaemia
Infection
Inadequate oxygenation (hypoxia)
Ongoing trauma – e.g., compartment syndrome (abdominal/limb)
deep vein thrombosis
Figure 1.2 Ongoing complications and secondary insults affecting recovery.
Trauma
Sepsis Hypothalamus CRF Anterior pituitary
Major operation
ACTH
Adrenals
Cortisol
Figure 1.3 The release of cortisol.
Catecholamine-mediated Cytokines
‘fight or flight’ response
Adrenal medulla Hypothalamus Inflammatory
response
Nor adrenaline Cortisol-releasing
Adrenaline from peripheral hormone (CRH)
nerves
Anterior pituitary
ACTH
Neurohormonal
response
Cortisol and glucocorticoids
Stress response to injury
Figure 1.4 Interplay of neural, endocrine and inflammatory factors.
5
K23682_C001.indd 5 03/01/15 4:22 AM
