Bailey & Love
COMPANION GUIDE
MCQs & EMQs
in Surgery
, The metabolic response to
injury
Multiple choice questions
➜ Homeostasis B Every endocrine gland plays an equal
1. Which of the following statements part.
about homeostasis are false? C They produce a model of several phases.
A It is defined as a stable state of the D The phases occur over several days.
normal body. E They help in the process of repair.
B The central nervous system, heart, lungs,
kidneys and spleen are the essential ➜ The recovery process
organs that maintain homeostasis at a 4. With regard to the recovery process,
normal level. identify the statements that are true.
C Elective surgery should cause little A All tissues are catabolic, resulting in repair
disturbance to homeostasis. at an equal pace.
D Emergency surgery should cause little B Catabolism results in muscle wasting.
disturbance to homeostasis. C There is alteration in muscle protein
E Return to normal homeostasis after breakdown.
an operation would depend upon the D Hyperalimentation helps in recovery.
presence of co-morbid conditions. E There is insulin resistance.
➜ Stress response ➜ Optimal perioperative care
2. In stress response, which of the 5. Which of the following statements are
following statements are false? true for optimal perioperative care?
A It is graded. A Volume loss should be promptly treated
B Metabolism and nitrogen excretion are by large intravenous (IV) infusions of
related to the degree of stress. fluid.
C In such a situation there are B Hypothermia and pain are to be avoided.
physiological, metabolic and C Starvation needs to be combated.
immunological changes. D Avoid immobility.
D The changes cannot be modified. E Helpful measures can be taken.
E The mediators to the integrated response
are initiated by the pituitary.
➜ Mediators
3. Which of the following statements
about mediators are true?
A They are neural, endocrine and
inflammatory.
3
, Answers: Multiple choice questions
PRINCIPLES
➜ Homeostasis
1. D
The normal physiological state of the human body is referred to as homeostasis – a normal
internal environment (the milieu intérieur of Claude Bernard). All the vital organs – the
brain, heart, lungs, kidneys and, to a lesser extent, the spleen – play an important role in its
maintenance. These organs are interdependent and thus help to maintain a normal fluid and
acid–base balance.
In the elective situation, the patient is always optimised prior to any operation, thereby
minimising the homeostatic disturbance. The extent of surgery also plays a part. Disturbance in
the homeostasis to some degree occurs in emergency surgery; this depends upon the extent
of injury, presence of sepsis and any ongoing insults. If the patient has co-morbid conditions,
postoperatively the return to normal homeostasis would take longer than in those with no
co-morbidity. In such cases, care in a high-dependency or intensive care unit (ICU) is essential.
➜ Stress response
2. D
The stress response is graded according to the injury inflicted. An elective operation in a fit patient,
such as a laparoscopic cholecystectomy in a 30-year-old female, will elicit a minor transient
stress response from which the patient recovers quite quickly. On the other hand, a severely
injured patient of 70 will elicit a major response, requiring care in the ICU (see Fig. 1.1). There
is an increase in metabolism and nitrogen excretion in direct proportion to the injury. There are
immunological and metabolic changes which are reflected in the physiology – pyrexia, tachycardia
and tachypnoea. The body’s innate defence mechanisms can combat mild stress, and return to
normal physiology occurs very soon.
Stress response depends upon
Severity of injury Type of injury
To get speedy resolution avoid (‘SO’)
Secondary insults – 3 Is: Ischaemia
Infection
Inadequate oxygenation (hypoxia)
Ongoing trauma, e.g. compartment syndrome (abdominal/limb)
Figure 1.1 Metabolic response to severe trauma.
In severe injury, the stress response can be modified by anticipating complications and
preventing them by judicious management in an ICU, i.e. attention to nutrition and anticipation
and prevention of secondary insults such as ischaemia, infection, hypoxia and compartment
syndrome.
4
, The pituitary gland, rightly referred to as ‘the leader in the endocrine orchestra’ (Sir Walter
1: THE METABOLIC RESPONSE TO INJURY
Langdon-Brown, 1931), sets in motion the entire synchronous response. The body will bring into
play neural, endocrine and inflammatory responses. The neural response that initiates and acts in
concert with the endocrines is referred to as the neuroendocrine response to trauma.
➜ Mediators
3. A, B, E
Stress from injury travels along afferent pathways of the spinal cord to the hypothalamus
which secretes the corticotrophin-releasing factor (CRF) that acts on the pituitary to secrete
adrenocorticotrophic hormone (ACTH) and growth hormone (GH). This creates the ‘flight or fight’
response. The pancreas increases glucagon secretion. Other endocrines, thyroid and gonads play a
minor role. This concerted neuroendocrine response results in lipolysis, hepatic gluconeogenesis,
protein breakdown, pyrexia and hypermetabolism. Cytokines, interleukins (IL-1, IL-6) and tumour
necrosis factor-alpha (TNFα) are simultaneously released (see Fig. 1.2).
Catecholamine-mediated Cytokines
‘fight or flight’ response
Adrenal medulla Hypothalamus Inflammatory
response
Adrenaline Noradrenaline Cortisol-releasing
from peripheral hormone (CRH)
nerves
Anterior pituitary
Adrenocorticotrophic hormone
Neurohormonal
response Cortisol and glucocorticoids
Stress response to injury
Figure 1.2 Neuroendocrine response to trauma.
A model of two phases, ‘ebb and flow’, is created. The term was coined by Sir David
Cuthbertson in 1930. The ebb, or early, phase helps initiate a ‘holding pattern’ within the first
12 hours (clinically manifesting as shock). The flow phase lasts much longer depending upon
the extent of damage. It can be divided into a catabolic phase lasting several days, followed by
a recovery and repair phase lasting several weeks. The time factor depends upon the extent of
initial injury and any ongoing insults. The mediators do help in the repair process by endogenous
cytokine antagonists, which controls the proinflammatory response, commonly called the systemic
inflammatory response syndrome (SIRS). If the response to SIRS is inadequate, multiple organ
dysfunction syndrome occurs (MODS), which is just a step away from death.
5
COMPANION GUIDE
MCQs & EMQs
in Surgery
, The metabolic response to
injury
Multiple choice questions
➜ Homeostasis B Every endocrine gland plays an equal
1. Which of the following statements part.
about homeostasis are false? C They produce a model of several phases.
A It is defined as a stable state of the D The phases occur over several days.
normal body. E They help in the process of repair.
B The central nervous system, heart, lungs,
kidneys and spleen are the essential ➜ The recovery process
organs that maintain homeostasis at a 4. With regard to the recovery process,
normal level. identify the statements that are true.
C Elective surgery should cause little A All tissues are catabolic, resulting in repair
disturbance to homeostasis. at an equal pace.
D Emergency surgery should cause little B Catabolism results in muscle wasting.
disturbance to homeostasis. C There is alteration in muscle protein
E Return to normal homeostasis after breakdown.
an operation would depend upon the D Hyperalimentation helps in recovery.
presence of co-morbid conditions. E There is insulin resistance.
➜ Stress response ➜ Optimal perioperative care
2. In stress response, which of the 5. Which of the following statements are
following statements are false? true for optimal perioperative care?
A It is graded. A Volume loss should be promptly treated
B Metabolism and nitrogen excretion are by large intravenous (IV) infusions of
related to the degree of stress. fluid.
C In such a situation there are B Hypothermia and pain are to be avoided.
physiological, metabolic and C Starvation needs to be combated.
immunological changes. D Avoid immobility.
D The changes cannot be modified. E Helpful measures can be taken.
E The mediators to the integrated response
are initiated by the pituitary.
➜ Mediators
3. Which of the following statements
about mediators are true?
A They are neural, endocrine and
inflammatory.
3
, Answers: Multiple choice questions
PRINCIPLES
➜ Homeostasis
1. D
The normal physiological state of the human body is referred to as homeostasis – a normal
internal environment (the milieu intérieur of Claude Bernard). All the vital organs – the
brain, heart, lungs, kidneys and, to a lesser extent, the spleen – play an important role in its
maintenance. These organs are interdependent and thus help to maintain a normal fluid and
acid–base balance.
In the elective situation, the patient is always optimised prior to any operation, thereby
minimising the homeostatic disturbance. The extent of surgery also plays a part. Disturbance in
the homeostasis to some degree occurs in emergency surgery; this depends upon the extent
of injury, presence of sepsis and any ongoing insults. If the patient has co-morbid conditions,
postoperatively the return to normal homeostasis would take longer than in those with no
co-morbidity. In such cases, care in a high-dependency or intensive care unit (ICU) is essential.
➜ Stress response
2. D
The stress response is graded according to the injury inflicted. An elective operation in a fit patient,
such as a laparoscopic cholecystectomy in a 30-year-old female, will elicit a minor transient
stress response from which the patient recovers quite quickly. On the other hand, a severely
injured patient of 70 will elicit a major response, requiring care in the ICU (see Fig. 1.1). There
is an increase in metabolism and nitrogen excretion in direct proportion to the injury. There are
immunological and metabolic changes which are reflected in the physiology – pyrexia, tachycardia
and tachypnoea. The body’s innate defence mechanisms can combat mild stress, and return to
normal physiology occurs very soon.
Stress response depends upon
Severity of injury Type of injury
To get speedy resolution avoid (‘SO’)
Secondary insults – 3 Is: Ischaemia
Infection
Inadequate oxygenation (hypoxia)
Ongoing trauma, e.g. compartment syndrome (abdominal/limb)
Figure 1.1 Metabolic response to severe trauma.
In severe injury, the stress response can be modified by anticipating complications and
preventing them by judicious management in an ICU, i.e. attention to nutrition and anticipation
and prevention of secondary insults such as ischaemia, infection, hypoxia and compartment
syndrome.
4
, The pituitary gland, rightly referred to as ‘the leader in the endocrine orchestra’ (Sir Walter
1: THE METABOLIC RESPONSE TO INJURY
Langdon-Brown, 1931), sets in motion the entire synchronous response. The body will bring into
play neural, endocrine and inflammatory responses. The neural response that initiates and acts in
concert with the endocrines is referred to as the neuroendocrine response to trauma.
➜ Mediators
3. A, B, E
Stress from injury travels along afferent pathways of the spinal cord to the hypothalamus
which secretes the corticotrophin-releasing factor (CRF) that acts on the pituitary to secrete
adrenocorticotrophic hormone (ACTH) and growth hormone (GH). This creates the ‘flight or fight’
response. The pancreas increases glucagon secretion. Other endocrines, thyroid and gonads play a
minor role. This concerted neuroendocrine response results in lipolysis, hepatic gluconeogenesis,
protein breakdown, pyrexia and hypermetabolism. Cytokines, interleukins (IL-1, IL-6) and tumour
necrosis factor-alpha (TNFα) are simultaneously released (see Fig. 1.2).
Catecholamine-mediated Cytokines
‘fight or flight’ response
Adrenal medulla Hypothalamus Inflammatory
response
Adrenaline Noradrenaline Cortisol-releasing
from peripheral hormone (CRH)
nerves
Anterior pituitary
Adrenocorticotrophic hormone
Neurohormonal
response Cortisol and glucocorticoids
Stress response to injury
Figure 1.2 Neuroendocrine response to trauma.
A model of two phases, ‘ebb and flow’, is created. The term was coined by Sir David
Cuthbertson in 1930. The ebb, or early, phase helps initiate a ‘holding pattern’ within the first
12 hours (clinically manifesting as shock). The flow phase lasts much longer depending upon
the extent of damage. It can be divided into a catabolic phase lasting several days, followed by
a recovery and repair phase lasting several weeks. The time factor depends upon the extent of
initial injury and any ongoing insults. The mediators do help in the repair process by endogenous
cytokine antagonists, which controls the proinflammatory response, commonly called the systemic
inflammatory response syndrome (SIRS). If the response to SIRS is inadequate, multiple organ
dysfunction syndrome occurs (MODS), which is just a step away from death.
5
