Answers to Self-Assessment Questions - ACCP

in this patient population because there is no evidence that
they improve outcomes.
1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J,
Champoux J, et al. Decreased mortality and infectious
morbidity in adult burn patients given enteral glutamine
supplements: a prospective, controlled, randomized clinical
trial. Crit Care Med 2003;31:2444–9.
2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for
nutritional management of burn injury and recovery. Burns
2007;33:14–24.
47. Answer: D
The medical resident would like to discuss changing
R.R. to an immune-enhancing EN formulation with
omega-3 PUFAs and antioxidants. The correct response to
this suggestion would highlight that immune-enhancing
EN formulations shown to be beneficial in a specific
patient population may not be associated with the same
improvements in outcomes in other patient populations.
The correct response is that the suggested change should
not be made because an immune-enhancing EN formulation
with omega-3 PUFAs 8.6 g/L and antioxidants is associated
with increased survival in patients with sepsis and ARDS
but has not been evaluated in patients with burns (Answer
D). An immune-enhancing EN formulation with omega-3
PUFAs 8.6 g/L and antioxidants has not been shown to
alter oxygenation in patients with burns (Answer B) or
to increase survival in a nonseptic mixed medical ICU
population (Answer C). Because an immune-enhancing EN
formulation has not been evaluated in patients with burns,
switching to an immune-enhancing product (Answer A) is
incorrect.
1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J,
Champoux J, et al. Decreased mortality and infectious
morbidity in adult burn patients given enteral glutamine
supplements: a prospective, controlled, randomized clinical
trial. Crit Care Med 2003;31:2444–9.
2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for
nutritional management of burn injury and recovery. Burns
2007;33:14–24.
48. Answer: D
The length of time that RR receives immunonutrition
should be evidence-based. In one study that evaluated
immunonutrition in patients with burns and demonstrated
improved patient survival with enteral glutamine
supplementation, immunonutrition was continued until
complete wound healing was achieved (Answer D), making
Answer D the correct answer. The other durations, until
extubation (Answer C), 96 hours (Answer B), or 48 hours
(Answer A), have been used as minimum therapy goals in
other trials of immune-enhancing nutrients. However, in
patients with burns, extending the duration of therapy until
complete would healing occurs is more likely to result in
additional benefit.
1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J,
Champoux J, et al. Decreased mortality and infectious
morbidity in adult burn patients given enteral glutamine
supplements: a prospective, controlled, randomized clinical
trial. Crit Care Med 2003;31:2444–9.
2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for
nutritional management of burn injury and recovery. Burns
2007;33:14–24.
49. Answer: C
Clinicians should be aware that harm might result from
the use of immune-enhancing EN formulations in certain
patient populations. Some evidence indicates that argininecontaining
immune-enhancing diets may be harmful in
critically ill patients with severe sepsis. Therefore, the
62-year-old man with severe sepsis and an APACHE II score
of 26 (Answer C) may be harmed by an arginine-containing
immune-enhancing EN formulation, making Answer C the
best answer. The 32-year-old patient with a urinary tract
infection after severe trauma (Answer A) is likely to benefit
from an arginine-containing immune-enhancing diet, as is
the 59-year-old man with gastrointestinal (GI) cancer after
colonic resection (Answer B); thus Answer A and Answer
B are incorrect. The 48-year-old man in the medical ICU
with an APACHE II score of 12 (Answer D) is less likely
to benefit from an immune-enhancing diet, but he is not
in a patient population in which additional harm has been
suggested.
1. Bertolini G, Iapichino G, Radrizzani D, Facchini R, Simini
B, Bruzzone P, et al. Early enteral immunonutrition in
patients with severe sepsis: results of an interim analysis of
a randomized multicentre clinical trial. Intensive Care Med
2003;29:834–40.
2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet
P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition:
intensive care. Clin Nutr 2006;25:210–23.
50. Answer: C
Glutamine is a major energy source for enterocytes and is
associated with enhanced luminal barrier function (Answer
A), but this effect is not a potential advantage of parenteral
glutamine compared with enteral glutamine because this
effect should occur regardless of the route of administration,
so Answer A is incorrect. Arginine, not glutamine, increases
the production of inducible nitric oxide (NO) (Answer B);
thus, neither route of glutamine administration would be
expected to produce this effect, and Answer B is incorrect.
Increasing the production of heat shock proteins (Answer
C) is an advantage of parenteral compared with enteral
glutamine administration because this effect has been
more strongly associated with parenteral supplementation
than enteral supplementation, making Answer C correct.
Glutamine by either route would be expected to increase
T-helper lymphocytes, rather than decrease them as stated
in Answer D; thus, Answer D is incorrect.
1. Tjader I, Berg A, Wernerman J. Exogenous glutamine—
compensating a shortage? Crit Care Med 2007;35(suppl):S553–
S556.
2. Suchner U, Kuhn KS, Furst P. The scientific basis of
immunonutrition. Proc Nutr Soc 2000;59:553–63.
51. Answer: D
The use of PN is often necessary because of GI
intolerance or other complications of EN or because of the
presence of a contraindication to EN. The use of immuneenhancing
EN is often limited by the ability of the patient to
tolerate an adequate volume enterally, so feeding intolerance
Gastroenterology and Nutrition Answers
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Pharmacotherapy Self-Assessment Program, 6th Edition