Preoperative and Postoperative Care

Preoperative and Postoperative Care Indian Medical PG Question 1: A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification

• A. ASA II
• B. ASA I
• C. ASA IV
• D. ASA III (Correct Answer)

Preoperative and Postoperative Care Explanation: ***ASA III*** - This patient has **severe systemic disease** (angina at rest, COPD, obesity) that limits activity but is not incapacitating, aligning with the criteria for **ASA III**. - **Angina at rest** and **chronic obstructive pulmonary disease (COPD)** are significant comorbidities that place the patient in this category. *ASA II* - **ASA II** is defined by **mild systemic disease** that does not limit activity. - The patient's conditions such as **angina at rest** and **COPD** are more severe than what would be considered mild. *ASA I* - **ASA I** is reserved for a **normal, healthy patient** with no systemic disease. - This patient has multiple significant systemic diseases, unequivocally ruling out ASA I. *ASA IV* - **ASA IV** describes a patient with **severe systemic disease** that is a constant threat to life. - While critical, the patient's conditions (angina at rest, COPD) are stabilised enough for an **elective procedure** and are not an immediate, constant threat to life.

Preoperative and Postoperative Care Indian Medical PG Question 2: A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

• A. Postoperative administration for 5 to 7 days of parenteral antibiotics effective against aerobes and anaerobes
• B. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes may provide initial coverage. (Correct Answer)
• C. Postoperative administration for 2 to 4 days of parenteral antibiotics effective against aerobes and anaerobes
• D. Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile

Preoperative and Postoperative Care Explanation: ***Single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes*** - For **elective colorectal surgery**, a single dose of a **broad-spectrum parenteral antibiotic** administered within 60 minutes prior to incision is the standard of care to reduce surgical site infections. - This approach ensures adequate drug levels in the tissues during the period of potential bacterial contamination and is a cornerstone of modern surgical prophylaxis. - Current guidelines (WHO, SCIP) recommend a single preoperative dose, which may be redosed intraoperatively if the procedure is prolonged beyond 3-4 hours. *Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile* - This is **incorrect**. **Oral antibiotics** (such as neomycin and metronidazole) are routinely used preoperatively in conjunction with mechanical bowel preparation for colorectal surgery to reduce intraluminal bacterial load. - The concern for *Clostridioides difficile* infection is generally low with short-term, targeted prophylactic antibiotic regimens compared to broad-spectrum, prolonged use. - The combination of oral and parenteral antibiotics has been shown to further reduce surgical site infections. *Postoperative administration for 5 to 7 days of parenteral antibiotics* - **Prolonged postoperative antibiotic administration** beyond 24 hours in uncomplicated cases is not recommended as it increases the risk of **antibiotic resistance**, *C. difficile* infection, and adverse drug reactions without additional benefit. - The goal of prophylactic antibiotics is to cover the period of contamination during surgery, not to treat presumed ongoing infection postoperatively. *Postoperative administration for 2 to 4 days of parenteral antibiotics* - While administration for up to 24 hours post-operatively may be considered in some high-risk cases, routine **prolonged postoperative antibiotics** (2-4 days) are unnecessary for most elective colorectal resections. - Evidence suggests that continuing antibiotics beyond the immediate perioperative period does not further reduce the incidence of **surgical site infections** in clean-contaminated surgeries.

Preoperative and Postoperative Care Indian Medical PG Question 3: Pre-operative Nutrition Screening in a patient with morbid obesity planned for Gastric Bypass includes all EXCEPT:

• A. Serum Insulin (Correct Answer)
• B. Serum Vitamin B12
• C. Serum Calcium
• D. Serum Magnesium

Preoperative and Postoperative Care Explanation: ***Serum Insulin*** - While relevant to **diabetes** and metabolic health, routine **pre-operative insulin screening** is not standard for gastric bypass. - Nutritional screening focuses on identifying and correcting deficiencies that could complicate surgery or post-operative recovery. *Serum Vitamin B12* - Patients undergoing **gastric bypass** are at high risk for **Vitamin B12 deficiency** due to altered absorption in the bypassed stomach and small intestine. - Pre-operative screening is essential to identify and replete deficiencies to prevent post-operative neurological complications. *Serum Calcium* - **Malabsorption of calcium** is a known risk after gastric bypass due to changes in the digestive tract. - Pre-operative **calcium levels** are crucial for bone health assessment and to guide supplementation strategies. *Serum Magnesium* - **Magnesium deficiency** can occur post-gastric bypass due to malabsorption. - Pre-operative screening helps to identify existing deficiencies, which can impact cardiac function and neuromuscular health.

Preoperative and Postoperative Care Indian Medical PG Question 4: In anesthesiology, mild systemic disease is classified under which ASA grade?

• A. 2 (Correct Answer)
• B. 4
• C. 3
• D. 1

Preoperative and Postoperative Care Explanation: <b style="font-weight: bold;"><i>2</i></b> - <b style="font-weight: bold;">ASA Grade 2</b> is defined as a patient with <b style="font-weight: bold;">mild systemic disease</b> that is well-controlled and does not limit daily activities. - Examples include a controlled hypertension, controlled type 2 diabetes without systemic complications, or a mild obesity (BMI 30-40). <i>4</i> - <b style="font-weight: bold;">ASA Grade 4</b> indicates a patient with <b style="font-weight: bold;">severe systemic disease</b> that is a constant threat to life. - This includes conditions such as recent myocardial infarction, stroke, or severe valvular disease, which pose significant risks to patient safety during surgery. <i>3</i> - <b style="font-weight: bold;">ASA Grade 3</b> describes a patient with <b style="font-weight: bold;">severe systemic disease</b> that limits activity but is not incapacitating. - Examples include poorly controlled hypertension or diabetes, stable angina, or moderate chronic obstructive pulmonary disease (COPD). <i>1</i> - <b style="font-weight: bold;">ASA Grade 1</b> is assigned to a <b style="font-weight: bold;">healthy patient</b> without any systemic disease. - This classification implies no physiological, physical, or psychological disturbance, other than the condition requiring surgery.

Preoperative and Postoperative Care Indian Medical PG Question 5: Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

• A. NIBP
• B. ECG
• C. Pulse oximeter
• D. TEE (Correct Answer)

Preoperative and Postoperative Care Explanation: ***TEE*** - **Transesophageal echocardiography (TEE)** is the most sensitive method for detecting perioperative myocardial ischemia because it can visualize **regional wall motion abnormalities** and changes in **ventricular function** much earlier than ECG. - **Ischemia** directly impairs the contractility of the affected myocardium, leading to subtle changes in wall motion that TEE can identify. *NIBP* - **Non-invasive blood pressure (NIBP)** monitoring can detect **hemodynamic changes** (like hypotension or hypertension) that may precede or accompany ischemia. - However, these changes are **non-specific** and occur relatively late, making NIBP a less sensitive indicator of early ischemia. *ECG* - **Electrocardiography (ECG)** monitors the electrical activity of the heart and can detect **ST-segment changes** indicative of ischemia. - While useful, ECG changes may appear later than wall motion abnormalities, and **silent ischemia** can be missed if the leads are not optimally placed or if the ischemia does not produce significant electrical changes. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation** in the peripheral blood. - It is primarily used to assess **respiratory function** and tissue oxygenation, and it does not directly monitor myocardial ischemia or cardiac function.

Preoperative and Postoperative Care Indian Medical PG Question 6: A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

• A. nurses safety checklist
• B. WHO surgical safety checklist (Correct Answer)
• C. universal precautions checklist
• D. MCI patient safety checklist

Preoperative and Postoperative Care Explanation: **WHO surgical safety checklist** - The questions about patient identity, procedure site, and anticipated critical events are key components of the **"Sign In"** and **"Time Out"** sections of the **WHO Surgical Safety Checklist**. - This checklist is designed to improve **patient safety** by ensuring communication and adherence to essential steps before, during, and after surgery, thereby reducing surgical errors. *nurses safety checklist* - While nurses play a crucial role in patient safety, there isn't a universally recognized "nurses safety checklist" that specifically encompasses these exact comprehensive surgical verification steps. - The comprehensive framework described, with its specific questions, aligns more closely with the broader, interdisciplinary **WHO Surgical Safety Checklist**. *universal precautions checklist* - **Universal precautions** focus on preventing the transmission of bloodborne pathogens and other infectious agents by treating all bodily fluids as potentially infectious. - This checklist primarily addresses **infection control** measures and does not cover patient identification, surgical site verification, or critical event anticipation. *MCI patient safety checklist* - A "MCI patient safety checklist" is not a widely recognized or standardized medical safety protocol. - The scenario describes a standard, internationally adopted set of safety checks specifically for surgical procedures, which is the **WHO Surgical Safety Checklist**.

Preoperative and Postoperative Care Indian Medical PG Question 7: Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?

• A. Lorazepam
• B. Metoclopramide
• C. Promethazine
• D. Ondansetron (Correct Answer)

Preoperative and Postoperative Care Explanation: ***Ondansetron*** - **Ondansetron** is a **5-HT3 receptor antagonist** and is considered a first-line agent due to its high efficacy and favorable side effect profile in preventing PONV. - It works by blocking serotonin receptors in the **chemoreceptor trigger zone** and the **gastrointestinal tract**, reducing the sensation of nausea and vomiting. *Lorazepam* - **Lorazepam** is a **benzodiazepine** primarily used for its **anxiolytic** and **sedative effects**, and sometimes as an adjunct for refractory nausea, but not as a first-line antiemetic for PONV prophylaxis. - While it can help indirectly by reducing anxiety, it does not directly target the key pathways involved in PONV as effectively as 5-HT3 antagonists. *Phenytoin* - **Phenytoin** is an **anticonvulsant** medication used to prevent seizures and has no role in the direct treatment or prophylaxis of PONV. - It primarily acts on voltage-gated sodium channels in neurons and does not possess antiemetic properties. *Metoclopramide* - **Metoclopramide** is a **dopamine D2 receptor antagonist** and a **prokinetic agent** that can be used for PONV, particularly when gastric stasis is a concern. - However, it is generally considered a second-line agent due to the risk of **extrapyramidal side effects**, especially with higher doses or prolonged use. *Promethazine* - **Promethazine** is a **first-generation antihistamine** with **antidopaminergic** and **anticholinergic properties** that can be effective for nausea and vomiting. - It is often used as a rescue antiemetic or in combination therapy, but its sedative effects and potential for extrapyramidal symptoms make it less preferable as a first-line prophylactic agent compared to ondansetron.

Preoperative and Postoperative Care Indian Medical PG Question 8: What is the most common cause of postoperative fever within 24 hours?

• A. Sepsis
• B. Deep vein thrombosis
• C. Atelectasis (Correct Answer)
• D. Wound infection

Preoperative and Postoperative Care Explanation: ***Atelectasis*** - **Atelectasis** is the most common cause of **postoperative fever** within the **first 24-48 hours** after surgery. - It results from the collapse of a portion of the lung, usually due to shallow breathing and reduced sigh reflexes under anesthesia, leading to **inflammation** and a mild fever. *Sepsis* - **Sepsis** is a systemic inflammatory response to infection and typically presents with a **high fever**, **tachycardia**, and **hypotension**. - While serious, it is rare for sepsis to manifest as the *most common cause* of fever within the first 24 hours, usually requiring more time for bacterial growth and systemic spread. *Deep vein thrombosis* - **Deep vein thrombosis (DVT)** typically causes fever *later* in the postoperative course, often **3-7 days after surgery**, and is characterized by leg pain, swelling, and redness. - Fever associated with DVT is usually due to the inflammatory response to the clot itself or a resulting **pulmonary embolism**, not an immediate post-operative complication. *Wound infection* - **Wound infections** usually develop **4-7 days postoperatively**, as this timeframe is needed for bacterial proliferation and the inflammatory response to become clinically apparent. - Early fevers (<24 hours) are rarely due to wound infection unless there is significant contamination during surgery, which is uncommon.

Preoperative and Postoperative Care Indian Medical PG Question 9: What is to be addressed first in case of polytrauma -

• A. Circulation
• B. Neurology
• C. Blood Pressure
• D. Airway (Correct Answer)

Preoperative and Postoperative Care Explanation: ***Airway*** - Maintaining a **patent airway** is the absolute first priority in polytrauma management according to the **ATLS (Advanced Trauma Life Support)** protocol. - Failure to secure an airway can lead to **hypoxia** and **brain damage** within minutes, regardless of other injuries. *Circulation* - While critical, addressing **circulation** (C in ABCDE) comes after establishing a secure airway and adequate breathing (A and B). - Uncontrolled hemorrhage would be the focus of circulation management, but only after guaranteeing proper oxygenation. *Neurology* - Neurological assessment (D in ABCDE for Disability) follows the primary survey of airway, breathing, and circulation. - Initial neurological evaluation focuses on **level of consciousness** using the **GCS (Glasgow Coma Scale)**. *Blood Pressure* - **Blood pressure** is an indicator of circulatory status but is not the first thing to be addressed. - It falls under the "C" for circulation in the ATLS protocol, which is secondary to airway and breathing.

Preoperative and Postoperative Care Indian Medical PG Question 10: A patient presents with engorged neck veins, a blood pressure of 80/50 mmHg, and a pulse rate of 100 beats per minute following blunt trauma to the chest. The diagnosis is:

• A. Pneumothorax
• B. Right ventricular failure
• C. Cardiac tamponade (Correct Answer)
• D. Hemothorax

Preoperative and Postoperative Care Explanation: ***Cardiac tamponade*** - The clinical presentation shows **two components of Beck's triad**: **engorged neck veins (elevated JVP)** and **hypotension** (80/50 mmHg). While muffled heart sounds (the third component) are not mentioned, this is not required for diagnosis. - The combination of **blunt chest trauma** and these symptoms strongly suggests fluid accumulation in the pericardial sac, compressing the heart and impairing its filling. - **Tachycardia** (100 bpm) represents a compensatory response to reduced cardiac output. *Pneumothorax* - While pneumothorax can cause respiratory distress and hypotension, it typically presents with **absent breath sounds** on the affected side and **hyperresonance to percussion**, which are not described. - Engorged neck veins are not characteristic of simple pneumothorax. **Tension pneumothorax** can cause distended neck veins and severe hypotension, but would also present with severe respiratory distress and tracheal deviation away from the affected side. *Right ventricular failure* - Right ventricular failure can cause **engorged neck veins** but usually presents with signs of systemic congestion like **peripheral edema** and hepatomegaly, developing over time. - This is not typically an acute, immediate consequence of blunt chest trauma. The **acute hypotension** and **tachycardia** are more indicative of obstructive shock (cardiac tamponade) rather than pump failure. *Hemothorax* - Hemothorax involves blood accumulation in the pleural space, leading to **absent breath sounds** and **dullness to percussion** on the affected side. - While it can cause hypotension and tachycardia due to **hypovolemic shock** from blood loss, **engorged neck veins** are not a feature. In fact, significant blood loss typically causes **flat or collapsed neck veins** due to reduced venous return.

Preoperative and Postoperative Care Flashcard 1 of 10

Question: _____score is used to assess the risk of operative mortality in a patient undergoing thoracic surgery.

Answer: Thoraco

Preoperative and Postoperative Care Flashcard 2 of 10

Question: Antibiotics should be given within _____ mins before the incision to prevent surgical site infections

Answer: 60

Preoperative and Postoperative Care Flashcard 3 of 10

Question: The Romo Vac drain, depicted in the image, is a _____ type of drain

Answer: closed

Preoperative and Postoperative Care Flashcard 4 of 10

Question: The purpose of incentive spirometry in a post-operative patient is to prevent _____.

Answer: pulmonary atelectasis

Preoperative and Postoperative Care Flashcard 5 of 10

Question: A foley's tube with a _____ coloured ring has size 24FR/CH

Answer: blue

Preoperative and Postoperative Care Flashcard 6 of 10

Question: A foley's tube with a _____ coloured ring has size 16FR/CH

Answer: orange

Preoperative and Postoperative Care Flashcard 7 of 10

Question: Tracheostomy is performed in an intubated patient after _____ weeks

Answer: 2-3

Preoperative and Postoperative Care Flashcard 8 of 10

Question: Which hormone levels usually decrease in the ebb phase of surgical stress?_____

Answer: Insulin, IGF-1, Testosterone and T3

Preoperative and Postoperative Care Flashcard 9 of 10

Question: Which sites should be avoided for central access in patients requiring TPN who may potentially require dialysis later?_____

Answer: Subclavian veins

Preoperative and Postoperative Care Flashcard 10 of 10

Question: Sutures can act as foreign body after the initial _____ days

Answer: 7-8