Patient Selection for Ambulatory Surgery — MCQs
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
Severe Obstructive sleep apnea is defined as AHI of greater than
What is the narcotic of choice for outpatient anesthesia?
Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?
Which of the following is not a diagnostic criterion for SIRS?
Preoperative medication of thyrotoxicosis are all except?
A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting
In triage, which category of patients is classified as green?
Green colour of triage is for which patient ?
A patient is admitted to a day care nursing home for a laparoscopic cholecystectomy. This patient is otherwise healthy. What is the anesthetic of choice in this patient?
Patient Selection for Ambulatory Surgery Indian Medical PG Practice Questions and MCQs
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)
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.
Question 2: Severe Obstructive sleep apnea is defined as AHI of greater than
- A. 15 events/hour
- B. 30 events/hour (Correct Answer)
- C. 25 events/hour
- D. 20 events/hour
Explanation: ***30 events/hour*** - A **severe form of obstructive sleep apnea (OSA)** is diagnosed when the Apnea-Hypopnea Index (AHI) is greater than or equal to **30 events per hour** [1]. - The AHI represents the average number of **apnea and hypopnea events** per hour of sleep [1]. *15 events/hour* - An AHI of **15 to 30 events/hour** typically defines **moderate sleep apnea**, not severe. - This level indicates a significant number of sleep disturbances, but less than what is categorized as severe. *25 events/hour* - An AHI of **25 events/hour** falls within the **moderate range** of OSA severity (15-30 events/hour). - It does not meet the criteria for severe OSA, which requires a higher AHI. *20 events/hour* - An AHI of **20 events/hour** also falls into the **moderate category** of OSA. - This value is above the threshold for mild OSA (5-15 events/hour) but below the threshold for severe OSA.
Question 3: What is the narcotic of choice for outpatient anesthesia?
- A. Morphine
- B. Alfentanil (Correct Answer)
- C. Fentanyl
- D. Pethidine
Explanation: ***Alfentanil*** - **Alfentanil** has a **rapid onset** and **short duration of action** due to its low pKa (6.5) and high unionized fraction at physiologic pH, making it ideal for maintaining a stable anesthetic plane and rapid recovery in an outpatient setting. - Its **predictable pharmacokinetic profile** allows for precise titration and minimizes the risk of prolonged sedation post-procedure. *Morphine* - **Morphine** has a relatively **long duration of action** and active metabolites that can prolong sedation and respiratory depression, which is undesirable for outpatient procedures. - Its slower onset often requires higher initial doses, increasing the risk of **postoperative nausea and vomiting (PONV)**. *Fentanyl* - While **fentanyl** has a rapid onset and is potent, its **longer context-sensitive half-time** compared to alfentanil can lead to a slightly longer recovery profile, especially with prolonged infusions. - Its high lipophilicity can lead to drug accumulation in tissues, potentially prolonging its effects in outpatient settings. *Pethidine* - **Pethidine** (meperidine) has an **active metabolite, normeperidine**, which can accumulate and cause neurotoxicity (e.g., seizures), particularly with repeated doses or in patients with renal impairment. - It also has a **longer duration of action** and is associated with a higher incidence of tachycardia and other side effects compared to newer synthetic opioids.
Question 4: Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?
- A. Green
- B. Yellow (Correct Answer)
- C. Blue
- D. Black
Explanation: ***Yellow*** - Patients in the **yellow category** are those who require **significant medical attention** and intervention, such as surgery, but whose condition is stable enough to withstand a delay of a few hours up to 24 hours without immediate threat to life or limb. - This category indicates a **delayed but urgent need** for treatment, distinguishing them from immediate (red) or minor (green) cases. *Blue* - The color **blue** is generally **not a standard triage category** in most commonly used disaster protocols (e.g., START, JumpSTART). - Triage systems typically use red, yellow, green, and black to prioritize patients based on immediate medical need and prognosis. *Green* - The **green category** is for patients with **minor injuries** who are considered "walking wounded" and can often wait for treatment for several hours, sometimes up to a few days. - These individuals are **stable** and do not require immediate intervention to preserve life or limb. *Black* - The **black category** is reserved for individuals who are **deceased** or have injuries so severe that survival is unlikely given the available resources, often implying **palliative care** rather than active life-saving interventions in a mass casualty event. - This category signifies that resources would be better allocated to patients with a higher chance of survival.
Question 5: Which of the following is not a diagnostic criterion for SIRS?
- A. Hypotension (Correct Answer)
- B. Tachypnoea
- C. Leucocytosis
- D. Tachycardia
Explanation: ### Hypotension - **Hypotension** is a criterion for **sepsis** and **septic shock**, but not for **SIRS** itself. - **SIRS** criteria are based on inflammatory responses, while hypotension indicates a more severe systemic compromise. *Tachycardia* - **Tachycardia**, defined as a **heart rate >90 beats per minute**, is a diagnostic criterion for **SIRS** [1]. - It reflects the body's physiological stress response to a systemic inflammatory state [1]. *Tachypnoea* - **Tachypnoea**, indicated by a **respiratory rate >20 breaths per minute** or a **PaCO2 <32 mmHg**, is a diagnostic criterion for **SIRS** [1]. - This symptom shows the body's effort to compensate for metabolic acidosis or increased oxygen demand. *Leucocytosis* - **Leucocytosis**, defined as a **white blood cell count >12,000/mm³** or **<4,000/mm³**, or the presence of **>10% immature neutrophils (bands)**, is a diagnostic criterion for **SIRS** [1]. - This indicates a significant systemic inflammatory response in the blood [1].
Question 6: Preoperative medication of thyrotoxicosis are all except?
- A. Carbimazole
- B. PTU
- C. Propranolol
- D. Levothyroxine (Correct Answer)
Explanation: Levothyroxine - Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, meaning it increases thyroid hormone levels, which would worsen thyrotoxicosis [1]. - Its administration would be contraindicated in a patient with thyrotoxicosis, as the goal is to reduce thyroid hormone levels preoperatively. Carbimazole - Carbimazole is a thionamide drug that inhibits the synthesis of thyroid hormones, making it a critical medication for treating hyperthyroidism and preparing patients for surgery [1]. - It reduces the amount of thyroid hormone produced by the thyroid gland, thus mitigating the risks associated with thyrotoxicosis during surgery. PTU - Propylthiouracil (PTU), like carbimazole, is a thionamide that blocks thyroid hormone synthesis and also inhibits the conversion of T4 to T3 [1]. - It is used in the preoperative management of thyrotoxicosis to achieve a euthyroid state and prevent a thyroid storm. Propranolol - Propranolol is a beta-blocker used to manage the symptoms of thyrotoxicosis, particularly the cardiovascular effects such as tachycardia, palpitations, and tremors [1]. - While it does not affect thyroid hormone levels directly, it helps control symptoms and stabilize the patient preoperatively, making them a safer candidate for surgery [1].
Question 7: A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting
- A. Water at 12:00 PM
- B. Black coffee at 5:30 AM
- C. Pancakes at 10:00 AM (Correct Answer)
- D. A non-clear liquid (e.g., orange juice) at 7:30 AM
Explanation: **Pancakes at 10:00 AM** - According to ASA guidelines, the fasting period for solid food is typically **6-8 hours** before surgery. Eating pancakes, which are solid food, at 10:00 AM for a 2:00 PM surgery (4-hour interval) violates this guideline. - This short fasting period for solids increases the risk of **pulmonary aspiration** during induction of anesthesia. *Water at 12:00 PM* - Water is considered a clear liquid, and ASA guidelines typically allow clear liquids until **2 hours** before surgery. Drinking water at 12:00 PM for a 2:00 PM surgery is within these guidelines. - Rapid gastric emptying of clear liquids minimizes the risk of aspiration. *Black coffee at 5:30 AM* - Black coffee is considered a clear liquid, and it is consumed well within the **2-hour** fasting window for clear liquids before a 2:00 PM surgery. - The absence of milk or cream ensures it is treated as a clear liquid, which empties quickly from the stomach. *A non-clear liquid (e.g., orange juice) at 7:30 AM* - Non-clear liquids, such as orange juice, are treated similarly to light meals and generally require a fasting period of **6 hours** before surgery. Drinking orange juice at 7:30 AM for a 2:00 PM surgery (6.5-hour interval) is compliant with these guidelines. - The protein and pulp in non-clear liquids delay gastric emptying compared to clear liquids.
Question 8: In triage, which category of patients is classified as green?
- A. Medium risk patients
- B. High-risk patients
- C. Dead patients
- D. Minor injury patients (Correct Answer)
Explanation: ***Minor injury patients*** - Patients classified as **green** in triage are those with **minor injuries** that are not immediately life-threatening. - They can often wait for treatment without significant risk of deterioration and may be able to **walk and self-care** to some extent. *Medium risk patients* - This category generally corresponds to **yellow** in triage, indicating patients with **significant injuries** who require care within a few hours. - While not immediately life-threatening, their condition could worsen if treatment is delayed. *High-risk patients* - This category typically corresponds to **red** in triage, signifying patients with **life-threatening injuries** or conditions. - These patients require immediate medical attention to survive. *Dead patients* - Patients who are deceased or have injuries incompatible with life are typically categorized as **black** in triage. - This classification indicates that no medical intervention can save them.
Question 9: Green colour of triage is for which patient ?
- A. Low priority
- B. Morbidity
- C. Ambulatory (Correct Answer)
- D. High priority
Explanation: ***Ambulatory*** - The **green triage tag** is assigned to patients who are considered **"walking wounded"** or have minor injuries. - These individuals can often ambulate on their own and require treatment that can be delayed without significant risk to life or limb. *Low priority* - While green-tagged patients are indeed low priority compared to red or yellow, the term **"ambulatory"** better describes their specific clinical status in the context of triage. - Low priority is a consequence of their minor injuries and ability to self-evacuate or wait for treatment. *Morbidity* - This option refers to the state of being diseased or unhealthy and is not a specific category used for triage color coding. - Triage colors classify patients based on the **severity of their injuries** and the urgency of treatment, not general health status. *High priority* - High priority patients are typically designated with a **red triage tag**, indicating life-threatening injuries requiring immediate intervention. - Green-tagged patients are the opposite of high priority in a mass casualty incident.
Question 10: A patient is admitted to a day care nursing home for a laparoscopic cholecystectomy. This patient is otherwise healthy. What is the anesthetic of choice in this patient?
- A. Halothane
- B. Propofol (Correct Answer)
- C. Ketamine
- D. Ether
Explanation: **Explanation:** The primary goal of **Ambulatory (Day Care) Anesthesia** is to ensure a rapid, smooth recovery with minimal side effects, allowing the patient to be discharged safely on the same day. **Why Propofol is the Correct Answer:** Propofol is the **gold standard induction agent** for daycare surgery due to its unique pharmacokinetic profile: * **Rapid Onset and Recovery:** It has a short context-sensitive half-life, leading to quick emergence and clear-headedness ("clear-headed recovery"). * **Anti-emetic Properties:** Unlike inhalational agents, propofol possesses intrinsic anti-emetic effects, significantly reducing **Postoperative Nausea and Vomiting (PONV)**—the leading cause of delayed discharge in ambulatory settings. * **Smooth Induction:** It suppresses airway reflexes, making it ideal for Laryngeal Mask Airway (LMA) insertion. **Why Other Options are Incorrect:** * **Halothane:** It has a slow onset and recovery. More importantly, it is associated with "halothane hepatitis" and sensitizes the myocardium to catecholamines, making it unsuitable for modern daycare practice. * **Ketamine:** It causes a high incidence of **emergence delirium**, hallucinations, and prolonged recovery times, which are contraindicated in patients needing to go home shortly after surgery. * **Ether:** It is obsolete in modern anesthesia due to its high flammability, slow induction/recovery, and severe incidence of PONV. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for TIVA** (Total Intravenous Anesthesia): Propofol. * **Ideal Inhalational Agent for Daycare:** **Desflurane** (fastest recovery due to lowest blood-gas solubility) or **Sevoflurane** (best for mask induction). * **Discharge Criteria:** The **Aldrete Score** or **PADSS** (Post-Anesthetic Discharge Scoring System) is used to determine if a patient is fit for discharge. A score of $\geq$ 9 is typically required.
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