Chapter 2
The perioperative assessment and management
1.
Preoperative
application of scopolamine patch to prevent postoperative nausea and vomiting
should be avoided in
A. Female, 35 years old
B. Smoker, 20 years old
C. Patient with a blood pressure of 160/96 mm Hg
D. Male, 70 years old
2.
ASA
classification for risk stratification is validated for predicting preoperative
morbidity associated with the following, except
A. General or regional anesthesia
B. Conscious sedation
C. Monitored anesthesia care
D. Surgical procedure
3.
A
healthy pregnant patient in labor has which of the following ASA
classifications?
A. I
B. II
C. III
D. IV
4.
As
per ASA classification, a controlled hypertensive patient with no target
end-organ damage scheduled for elective surgery will be classified as
A. ASA I
B. ASA II
C. ASA III
D. ASA VI
5.
A
brain-dead organ donor undergoing laparotomy for “kidney harvesting” will be classified
as an
A. ASA III
B. ASA IV
C. ASA V
D. ASA VI
6.
Which
of the following drugs antagonizes substance P in the central nervous system
and is used as premedication to prevent postoperative nausea and vomiting?
A. Palonosetron
B. Aprepitant
C. Metoclopramide
D. Prochlorperazine
7.
Which
of the following drugs is least likely to be effective for prophylaxis for
postoperative nausea and vomiting?
A. Palonosetron
B. Aprepitant
C. Metoclopramide
D. Prochlorperazine
8.
All
of the following have an antiemetic action, except
A. Promethazine
B. Propofol
C. Etomidate
D. Haloperidol
9.
Which
of the following predictors is likely to be associated with lower incidence of
perioperative nausea and vomiting?
A. Female gender
B. Use of fentanyl for pain relief
C. Patients with a history of smoking
D. Patients undergoing laparoscopic surgery
10.
For
emergent surgery, anticoagulation produced by warfarin can be reversed by using
A. Fresh-frozen plasma
(FFP)
B. Injectable vitamin K
C. Prothrombin complex concentrate
D. Factor VIII concentrate
11.
Which
of the following is the best predictor of a difficult intubation in a morbidly
obese patient?
A. Pretracheal tissue volume
B. Body mass index
C. Mallampati score
D. Thyromental distance
12.
A
young female patient with anorexia nervosa has just started eating again. After
4 days, she develops dyspnea and is found to have cardiac failure. Which of the
following is most important to correct?
A. Potassium
B. Phosphate
C. Glucose
D. Sodium
13.
A
65-year-old patient is being treated for congestive cardiac failure. He is able
to take a shower but gets dyspneic on mowing the lawn. His New York Heart
Association classification is
A. Class 1
B. Class 2
C. Class 3a
D. Class 3b
14.
Smoking
cessation for 24 hours before a scheduled surgery will lead to
A. Improvement of ciliary function
B. Decrease in mucous production
C. Decrease in airway irritability
D. Decrease in level of carboxyhemoglobin
15.
Maximum
international normalized ratio (INR) before proceeding for elective surgery
should be
A. 1.0
B. 1.2
C. 1.4
D. 1.6
16.
As
per American Society of Regional Anesthesia (ASRA) guidelines, intravenous
infusion of unfractionated heparin should be stopped how long prior to a
planned epidural?
A. 1 to 1.5 hours
B. 2 to 4 hours
C. at least 12 hours
D. at least 24 hours
17.
Neuraxial
block is not contraindicated for patients on which of the following drugs?
A. Warfarin
B. Low-molecular-weight heparin
C. Aspirin
D. Clopidogrel
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18.
All
of the following are risk factors for obstructive sleep apnea, except
A. Obesity
B. Short neck
C. Enlarged tonsils
D. Female gender
19.
A
70-year-old male, who is diabetic for the last 20 years, is scheduled for an
elective surgery. Which of the following is not a sign of autonomic diabetic
neuropathy?
A. History of recurrent diarrhea
B. History of postural hypotension
C. History of recurrent constipation
D. History of urinary retention
20.
Which
of the following perioperative factors in patients undergoing dialysis prior to
surgery predicts the possibility of hypotension (due to increased volume
removed)?
A. Change in serum sodium
B. Change in body weight
C. Change in serum potassium
D. Change in pH after dialysis
21.
A
patient with a history of severe asthma is scheduled for an appendectomy. Which
of the following induction agents will cause the least respiratory depression?
A. Ketamine
B. Propofol
C. Etomidate
D. Thiopental
22.
Which
of the following drugs can significantly prolong the QT interval on the ECG?
A. Dexamethasone
B. Droperidol
C. Aprepitant
D. Glycopyrrolate
23.
Which
of the following tests is used to confirm coagulation after stopping
lowmolecular-weight heparin (LMWH)?
A. PT
B. aPTT
C. ACT
D. None of the above
24.
Effect
of combined administration of midazolam and fentanyl is
A. Additive
B. Synergistic
C. Competitively antagonistic
D. Noncompetitively antagonistic
25.
Preoperative
anesthetic evaluation is likely to bring down the incidence of all the
following, except
A. Case cancellations
B. Patient morbidity
C. Preoperative anxiety
D. Direct procedural costs
26.
For
elective procedures, an anesthesia provider must obtain informed and preferably
written consent
A. Just prior to transferring the patient to the operating room for surgery
B. During preoperative anesthetic evaluation
C. At the same time that a surgeon obtains consent for the surgical procedure
D. Just prior to induction of anesthesia in the operating room
27.
An
optimal preoperative evaluation is designed
A. To screen for and properly manage comorbid conditions
B. To assess the risk of anesthesia and surgery and lower it
C. To identify patients who may require special anesthetic techniques or
postoperative care
D. All the above
28.
A
2-year-old child is to undergo a tonsillectomy. The child had formula milk 2
hours ago. As per ASA guidelines, optimal NPO status would be to wait another
____ before proceeding to surgery
A. No waiting, since it is a child
B. 2 hours
C. 4 hours
D. 6 hours
29.
A
45-year-old patient is scheduled for an abdominal hysterectomy. She states that
her aunt had a severe reaction to anesthesia and was in the ICU for 1 week. You
would avoid which of the following drugs for her general anesthesia?
A. Droperidol
B. Ketamine
C. Sevoflurane
D. Etomidate
30.
Elective
surgery should be postponed after a myocardial infarction for at least
A. 30 days
B. 6 weeks
C. 3 months
D. 6 months
31.
The
most significant risk factor for developing pulmonary complications is
A. Site of surgery (abdominal/thoracic)
B. Presence of respiratory infection
C. Presence of obstructive sleep apnea
D. Smoking
32.
Maximum
international normalized ratio (INR) before proceeding for elective surgery
should be
A. 1.0
B. 1.2
C. 1.4
D. 1.6
33.
A
73-year-old patient has residual weakness on the right arm and leg following a
stroke 5 years ago. He is now scheduled for laparoscopic cholecystectomy under
general anesthesia. Which of the following sites should be preferably used to
monitor the train of four muscle twitches for estimating neuromuscular
blockade?
A. Right ulnar nerve–innervated muscles
B. Right posterior tibial nerve–innervated muscles
C. Left ulnar nerve–innervated muscles
D. Left facial nerve
34.
A
55-year-old patient with a history of asthma and heart failure is to undergo a
hernia repair. On physical examination, you notice that the patient is
wheezing. Following treatment with albuterol, the patient should be monitored
for which electrolyte?
A. Potassium
B. Calcium
C. Sodium
D. Chloride
35.
Which
of the following tests is likely to detect clinically relevant bleeding
tendency most efficiently?
A. Activated partial thromboplastin time
B. Prothrombin time
C. Activated clotting time
D. Thromboelastogram (TEG)
36.
As
per AHA guidelines, which of the following is not a major clinical risk
predictor in a patient with cardiac disease scheduled for noncardiac surgery?
A. Recent myocardial infarction
B. Symptomatic mitral stenosis
C. Presence of congestive cardiac failure
D. Uncontrolled systolic hypertension
37.
Glycopyrrolate,
when given preoperatively, can cause all of the following, except
A. Skin flushing
B. Dry mouth
C. Bronchoconstriction
D. Tachycardia
38.
Which
of the following is true about metoclopramide?
A. Decreases lower esophageal sphincter tone
B. Delays gastric emptying
C. Can cause extrapyramidal side effects
D. Useful in preventing postoperative nausea
39.
Which
of the following occurs during the preoxygenation of a patient?
A. Increase in functional residual capacity
B. Denitrogenation
C. Increase in CO2 clearance from lungs
D. Increase in closing capacity of lungs
40.
The
inhalation agent of choice in a 2-year-old child for ophthalmologic surgery is
A. Halothane
B. Desflurane
C. Sevoflurane
D. Nitrous oxide
41.
Which
of the following is contraindicated to use during pregnancy?
A. Aspirin
B. Enalapril
C. Metoprolol
D. Hydralazine
42.
During
scoliosis surgery, monitoring of somatosensory-evoked potentials indicates
monitoring of
A. Anterior horn
B. Anterior corticospinal tract
C. Dorsal column
D. Spinothalamic tract
43.
The
desflurane vaporizer is heated because of desflurane’s
A. High vapor pressure
B. High boiling point
C. High minimum alveolar concentration
D. High volatility
44.
Which
of the following is the most effective way to reduce renal failure in a patient
having an abdominal aortic aneurysm repair?
A. Fluid bolus prior to aortic clamping
B. Fluid bolus after aortic clamp release
C. Administration of mannitol
D. Minimization of cross-clamp time
45.
All
of the following help increase the excretion of calcium, except
A. Bisphosphonates
B. Calcitonin
C. Furosemide
D. IV crystalloids
46.
A
patient with a history of chronic obstructive pulmonary disease presents for
lung volume–reduction surgery. Which of the following is a contraindication for
surgery?
A. Age > 60 years
B. Chronic asthma
C. FEV < 25%
D. Evidence of bullous disease
47.
A
pregnant lady is to undergo general anesthesia for acute appendicitis. At what
gestational age should you monitor fetal heart rate?
A. 16 weeks
B. 18 weeks
C. 24 weeks
D. 28 weeks
48.
You
have administered a patient 1.2 mg/kg of rocuronium to do an intubation. You
are unable to intubate or ventilate the patient and decide to reverse the
patient’s paralysis with sugammadex. The dosage you would use is
A. 2 mg/kg
B. 4 mg/kg
C. 8 mg/kg
D. 16 mg/kg
49.
Which
of the following organs is least tolerant of ischemia for removal for
transplantation?
A. Cornea
B. Heart
C. Kidney
D. Pancreas
50.
A
septic patient has a central venous pressure of 10 mm Hg, a blood pressure of
80/40 mm Hg, and a pulse rate of 96 beats/min. The best agent to treat the hypotension
is
A. Dopamine
B. Dobutamine
C. Noradrenaline
D. Epinephrine
Correct answers and explanations
1.
D. Scopolamine,
an anticholinergic drug, is often applied as a transdermal patch preoperatively
for the prevention of postoperative nausea and vomiting. However, like
atropine, and unlike glycopyrrolate, scopolamine passes through the blood–brain
barrier and can cause confusion, especially in the elderly. Hence, application
of scopolamine patch should be avoided in the elderly. Treatment of scopolamineinduced
confusion may require administration of physostigmine
2.
D. ASA
classification does not include the nature of procedure in predicting
perioperative morbidity and mortality. It only includes patient-based morbidity
rather than type of surgery
3.
B. Healthy
pregnant patients in labor are classified as an ASA II. Patients with
controlled diabetes or essential hypertension are still classified as an ASA
II. Presence of preeclampsia will step up the classification to an ASA III.
4.
B. ASA
classifies any medical comorbidity without functional limitation (i.e.,
hypertensive without coronary artery disease or angina) as an ASA II. Once the
patient’s activity is limited due to the disease, the patient is then
categorized as an ASA III.
5.
D. By
definition, such patients are categorized as ASA Class VI
6.
B. Aprepitant is
an NK1 receptor antagonist that antagonizes
the action of substance P in the central nervous system to prevent nausea and
vomiting. Palonosetron is a 5-HT3 antagonist,
metoclopramide is an antidopaminergic agent, and prochlorperazine is a dopamine
(D2) receptor antagonist (antipsychotic
drug) with additional antiemetic activity.
7.
D. Metoclopramide
is a prokinetic agent and helps to increase gastric motility. The ASA does not
recommend preoperative administration of metoclopramide for prevention of
postoperative nausea and vomiting. All the other agents have proven benefit in
preventing postoperative nausea and vomiting.
8.
C. Etomidate
administration can cause an increase in the incidence of perioperative nausea
and vomiting (PONV). Promethazine, haloperidol, and propofol all are used in
the treatment of PONV. The latter two are usually used for the treatment of
refractory PONV
9.
C. The Apfel
score can be used to predict patients with a high risk for perioperative nausea
and vomiting (PONV). It includes four factors: female gender, nonsmoking,
postoperative use of opioids, and previous PONV or motion sickness in the
patients’ history. Surgeries like laparoscopy, middle-ear surgery, and
strabismus surgery are associated with a higher risk of PONV
10.
A. As per the
AHA/ACC Scientific Statement, reversal of warfarin can be achieved by using
all, except choice D. However, for emergent surgery the fastest method is the
administration of fresh-frozen plasma. Peak action of injectable vitamin K
takes up to 6 to 12 hours
11.
A. Airway
management in obese patients begins first with an adequate physical exam as
these patients are more likely to be both more difficult to ventilate and to
intubate. The best predictor of difficulty is a short, thick neck (pretracheal
tissue volume) and a history of obstructive sleep apnea
12.
B. With
prolonged periods of starvation followed by reintroduction of enteral or
parenteral nutrition, the increased release of pancreatic insulin leads to an
anabolic state and an intracellular shift of phosphate, magnesium, and
potassium. Of these derangements, hypophosphatemia leads to the most severe
conditions, including cardiac failure.
13. B. The New York Heart Association classification for heart failure is based on both a functional and objective assessment of the patient’s capabilities and symptoms. This patient is asymptomatic at rest and can go about his activities of daily living without issues. However, with more strenuous activity, he becomes dyspneic.
14.
D. Smoking
cessation for 24 hours before surgery reduces carboxyhemoglobin (COHb)
levels. Reduced levels of COHb increases levels of oxygenated Hb, which
decreases the risk of myocardial ischemia and perioperative cardiac morbidity.
Delayed benefits (cessation more than 8 weeks) are known to improve airway
immunologic and ciliary function.
15.
C. There is no
specific value of INR before a patient is taken to the OR for lective surgery.
However, it is recommended that an INR value of 1.4 or less should be aimed for
before taking the patient to the OR for elective surgery. In case of emergency,
the INR can be normalized by infusing fresh-frozen plasma.
16.
B. As per ASRA
guidelines 2010, heparin infusion should be stopped at least 2 to 4 hours
before placing an epidural. This is to prevent the potential formation of an
epidural hematoma
17.
C. As per ASRA
guidelines (2010), aspirin intake by the patient is no more considered as a
contraindication to performing a neuraxial block
18.
D. The
assessment of preoperative predictability for obstructive sleep apnea can be
done by using the “STOP-BANG” questionnaire. In this scoring, male gender, and
not female gender, is classified as a risk factor (S, snoring; T, tired during
daytime; O, observed for apnea during sleep; P, high blood pressure;
B, BMI >35 kg/m2; A, age >50 years; N, neck
circumference >40 cm; G, male gender). In addition to the questionnaire,
upper airway anatomical abnormalities that increase the likelihood of
obstruction are tonsillar hypertrophy, tumors of the upper airway, or facio
maxillary abnormalities.
19.
D. All, except
choice D, are signs of diabetic autonomic neuropathy. Urinary retention at this
age is more likely due to prostate hypertrophy.
20.
B. Weight loss
due to dialysis is attributed to actual volume (ultrafiltrate) removed from the
body. Thus, a high weight loss can predict higher circulatory volume lost,
which can lead to poor compensation of hypotension in patients undergoing
surgery
21.
A. Ketamine
causes the least respiratory depression among the intravenous induction agents.
Therefore, it may be beneficial as an induction agent in patients with severe
asthma. However, ketamine causes an increase in secretions, and may produce
emergence delirium (vivid dreams). Pretreatment with glycopyrrolate and
midazolam alleviates these effects of ketamine. The other induction agents
cause dose-dependent respiratory depression.
22.
B. Droperidol
can cause a significant prolongation of the QT interval on the ECG. Patients
should have a preoperative ECG, and ECG monitoring should be continued
postoperatively for at least 2 hours, before discharging the patient.
23.
D. At present,
no conventional test (PT, PTT) can be used to quantify the clinical effects of
LMWH on the coagulation system. Anti–Factor Xa estimation may be used in
specific patients to monitor the coagulative effects of LMWH
24.
B. As these
drugs act on different receptors, their effects are generally considered to be
synergistic. Patients receiving both these drugs may be prone to greater
sedation and respiratory depression than when receiving the drug alone
25.
D. Preoperative
evaluation in fact includes a battery of tests and adds additional costs to the
total perioperative costs. However, preoperative evaluation is vital, as it
recognizes patient comorbidities, which can worsen perioperatively and cause
increased patient morbidity. Preoperative evaluation eventually lowers indirect
costs that may be incurred to treat the worsening aliment, postoperatively.
During preoperative interaction, patient anxiety is usually lowered as the
risks and procedure are explained to the patient.
26.
B. An anesthesia
consent should be obtained during preanesthetic evaluation,whenever possible.
This is one of the prime aims that need to be fulfilled as a component of
preoperative anesthetic evaluation.
27.
D. The goals of
preanesthetic evaluation include all those listed in the question. In addition,
other targets of preanesthetic evaluation include education of patients and
families about anesthesia and the anesthesiologist’s role, obtaining informed
consent, motivation of patients to stop smoking and lose weight, or commit to
other preventive care.
28.
C. As per ASA
guidelines, it is recommended to wait at least 6 hours after ingestion of
nonhuman milk before performing an elective operation in a child.
29.
C. Volatile
inhalation agents and succinylcholine are considered triggers for
malignant
hyperthermia (MH) reaction. MH has a genetic component, and runs in families.
Since her aunt had a severe reaction to anesthesia, further details should be
obtained from the history. If any doubt about the history, the patient should
be assumed to be prone to developing MH. Volatile agents and succinylcholine
should be avoided in this patient.
30.
B. Elective
surgery should be postponed for at least 6 weeks after a myocardial infarction.
Risk of reinfarction is approximately 5.5% for surgeries between 0 and 3
months, 2.5% between 3 and 6 months, and 2% after 6 months of a myocardial
infarction.
31.
A. The most
significant risk factor for developing pulmonary complications is the upper
abdominal or thoracic site of surgery. As such, all patients undergoing such
surgeries should be optimally prepare for the surgery. This includes pulmonary
toilet: chest physiotherapy/exercises, and postural drainage of mucus and
secretions
32.
C. There is no
specific value of INR before a patient is taken to the OR for elective surgery.
However, it is recommended that an INR value of 1.4 or less should be aimed for
before taking the patient to the OR for elective surgery. In case of emergency,
the INR can be normalized by infusing fresh-frozen plasma.
33.
C. The paralyzed
muscles due to central denervation eventually develop atrophy. Extrajunctional
receptors are then synthesized at the muscle sites, which remain resistant to
the effects of neuromuscular blockade for varying degrees. Thus, these
paralyzed muscles give an exaggerated response on direct stimulation with a
nerve stimulator. Therefore, muscle twitch monitoring should be done on the
nonaffected sites to correctly monitor the degree of neuromuscular blockade
34.
A. All β2 agonists are
known to cause internalization of potassium (from plasma to cell), thus causing
hypokalemia. This principle is sometimes used in the treatment of patients with
hyperkalemia.
35.
D. Among all
these tests, TEG has the highest positive predictive value for diagnosing a
bleeding tendency. Deranged values from other tests listed have not shown to
always correlate well with bleeding tendency. For example, the other tests will
be deranged in a patient with sepsis but may not show a clinically relevant
bleeding tendency
36.
D. All the other
choices need evaluation/optimization prior to elective noncardiac surgery.
Uncontrolled systolic hypertension without target end-organ damage is a minor
predictor/risk factor. It can be usually controlled with intraoperative
antihypertensive medications without evidence of significant adverse outcomes
37.
C. Glycopyrrolate
is a synthetic quaternary amine with antimuscarinic properties and no central
side effects like sedation. All the other choices are as a result of direct
consequence of cholinergic blockade.
38.
C. Metoclopramide
is a prokinetic agent that enhances gastric clearance and increases lower
esophageal sphincter tone, preventing vomiting, but may not actually work for
nausea (vomiting rather than nausea is prevented). It blocks the dopaminergic
receptors to cause parkinsonism-like extrapyramidal side effects.
39.
B. Preoxygenation
of lungs primarily acts to increase safe apnea time by denitrogenating
functional residual capacity (FRC) and increasing dissolved oxygen content in
the blood. It does not alter any physical measurements of lungs; that is, it
has no effect on FRC or on closing volume/capacity.
40.
C. Both
halothane and sevoflurane have been used for inhalation induction in the
pediatric population. Sevoflurane has largely replaced halothane due to a
better safety profile, and has emerged as the induction agent of choice in
pediatric population.
41.
B. Enalapril
exposure during the first trimester of pregnancy has been associated with
multiple fetal defects, affecting the cardiac, pulmonary, renal, and
musculoskeletal systems
42.
C. Somatosensory-evoked
potentials are usually monitored on the posterior tibial nerves of the legs
during spinal surgery and are used to assess the integrity of the dorsal
columns of the spinal cord
43.
A. The main
issue with desflurane is that it has a high saturated vapor pressure at room
temperature (669 mm Hg at 20°C). It boils at just 22.8°C compared with
sevoflurane at 58.5°C or isoflurane at 48.5°C. Therefore, the desflurane
vaporizer is heated to 39°C and pressurized at 2 atm.
44.
D. The incidence
of renal failure after abdominal aortic aneurysm surgery is 5.4%, of which 0.6%
requires hemodialysis. Loop diuretics (furosemide), dopamine, mannitol,
fenoldopam, and N-acetylcysteine are proposed renal
protective agents; however, there is no concrete evidence to support their use.
The mainstay of renal preservation is by reducing aortic cross-clamping time,
adequate fluid resuscitation, and avoidance of nephrotoxins (nonsteroidal
anti-inflammatory drugs, angiotensinconverting-enzyme inhibitors,
aminoglycoside antibiotics).
45.
A. Bisphosphonates
are used in the treatment of osteoporosis as they inhibit osteoclastic
resorption of bone. Biphosphonates do not affect the excretion of calcium.
46.
C. In pulmonary
resections, preoperative impairment is directly related to operative
risk. Using routine pulmonary function tests, criteria have
been established for highrisk patients.
• PaCO2 >45 mm Hg
or PaO2 <50 mm Hg on room air
• FEV <25%
• FEV1 <2 L
preoperatively or <0.8 L or <40% of predicted postoperatively
• FEV1/FVC <50%
predicted
• Maximum breathing capacity <50% of
predicted
• Maximum VO2 <10
mL/kg/min
47.
C. Fetal heart
rate and uterine monitoring should be performed during induction, emergence,
recovery, and, if possible, during the surgery in any pregnancy of more than 24
weeks’ gestation. The fetus becomes viable at this gestation age.
48.
D. Sugammadex
reverses neuromuscular blockade by nondepolarizing muscle relaxants by directly
binding to rocuronium, vecuronium, and pancuronium, without any side effects.
Reversal of neuromuscular blockade is achieved in a dosedependent manner and
can be used in the event of failed intubation. For normal reversal, that is,
with two twitches, the dose is 2 mg/kg. When the blockade is deeper, the dose
must be increased. When reversing following a failed intubation, a dose of 8
mg/kg of sugammadex will effectively reverse rocuronium given at 0.6 mg/kg. If
the dose of rocuronium given is 1.2 mg/kg, reversal with sugammadex requires a
dose of 16 mg/kg.
49.
B. The heart,
because of its high oxygen requirements, is the least tolerant of ischemia.
Hyperkalemic crystalloid cardioplegia at 4°C for a maximum of 4 hours is used to
preserve the heart. Thus, reducing the ischemic time of donor hearts will
decrease morbidity and costs of cardiac transplantations.
50.
C. In septic
shock, both dopamine and norepinephrine can be used to treat persistent
hypotension. However, dopamine may promote further tissue acidosis in the
splanchnic circulation, whereas norepinephrine does not, thus making it the
drug of choice for this scenario.
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