Preoperative Evaluation and Management — MCQs

Preoperative Evaluation and Management Indian Medical PG Practice Questions and MCQs

Question 111: A moribund patient unlikely to survive 24 hours without surgery is classified as

A. ASA V (Correct Answer)
B. ASA III
C. ASA VI
D. ASA I

Explanation: ***ASA V*** - An **ASA V** patient is defined as a **moribund patient** who is not expected to survive without the operation. - This classification applies to patients with a high risk of death, often within **24 hours**, even with surgical intervention. *ASA III* - An **ASA III** patient has **severe systemic disease** that functional limitations, but is not incapacitating. - While serious, their condition is not immediately life-threatening to the extent of a moribund patient. *ASA VI* - An **ASA VI** patient is declared **brain-dead** and is undergoing surgery for **organ donation**. - This classification describes a patient who is already deceased from a neurological perspective, rather than one on the verge of death. *ASA I* - An **ASA I** patient is a **normal healthy** individual with no systemic disease. - This is the lowest risk category and contrasts sharply with the critical condition described in the question.

Question 112: 45 year old woman is posted for elective incisional hernia repair. On reviewing her history, she is known hypertensive patient for the past 10 years on regular captopril. What is your concern for the patient

A. Stop captopril a week before surgery and switch to a calcium channel blocker like amlodipine.
B. Stop captopril a week before surgery and restart only if needed.
C. Stop captopril one day before surgery to prevent intraoperative hypotension.
D. Continue captopril until the day of surgery to maintain blood pressure control. (Correct Answer)

Explanation: ***Continue captopril until the day of surgery to maintain blood pressure control.*** - Maintaining **blood pressure control** is crucial in hypertensive patients undergoing surgery to prevent perioperative cardiovascular events. - **Captopril**, an ACE inhibitor, helps manage chronic hypertension, and discontinuing it without a strong indication could lead to a **rebound hypertensive crisis**. *Stop captopril one day before surgery to prevent intraoperative hypotension.* - While ACE inhibitors can cause **hypotension** under anesthesia, the risk of **uncontrolled hypertension** from stopping it acutely may outweigh this concern for elective surgery. - Recent guidelines often recommend **continuing ACE inhibitors** until the day of surgery, especially for patients with well-controlled hypertension. *Stop captopril a week before surgery and switch to a calcium channel blocker like amlodipine.* - Switching medications a week before surgery introduces a new variable that might not be fully monitored, potentially leading to **unpredictable blood pressure responses**. - There is no strong evidence to suggest that switching to a **calcium channel blocker** offers a significant advantage over continuing a stable ACE inhibitor immediately before elective surgery. *Stop captopril a week before surgery and restart only if needed.* - Discontinuing captopril a week in advance without substituting it would leave the patient's **hypertension untreated** for an extended period, increasing the risk of adverse cardiovascular events. - **Abrupt cessation** of antihypertensive medication can lead to poorer outcomes, including **hypertensive crisis**, particularly with short-acting medications like captopril.

Question 113: Lithium therapy must be stopped how many hours before surgery:-

A. 96 hrs
B. 48 hrs (Correct Answer)
C. 24 hrs
D. 72 hrs

Explanation: ***48 hrs*** - It is recommended to stop lithium **24 to 48 hours** before major surgery to minimize the risk of **lithium toxicity** and adverse interactions. - The risk of **renal impairment** and dehydration during surgery can lead to increased lithium levels and toxicity. *96 hrs* - Stopping lithium for **96 hours (4 days)** is generally not necessary and could lead to a relapse of the underlying psychiatric condition due to the prolonged absence of the medication. - The half-life of lithium is typically around **18-36 hours**, so 48 hours is sufficient for significant clearance. *24 hrs* - While stopping for **24 hours** might be considered in some minor procedures, it may not be sufficient for major surgeries where fluid shifts and renal function changes are more pronounced. - The risk of toxicity might still be present, especially if the patient has any degree of **renal insufficiency** or experiences significant dehydration. *72 hrs* - Similar to 96 hours, stopping lithium for **72 hours (3 days)** is often longer than necessary for most surgical procedures. - This extended period could also increase the risk of a **psychiatric episode** in patients who rely on lithium for mood stabilization.

Question 114: Which drug is most commonly used for anxiolysis in pre-anaesthetic medication?

A. Morphine
B. Atropine
C. Scopolamine
D. Diazepam (Correct Answer)

Explanation: **Diazepam** * **Diazepam**, a **benzodiazepine**, is widely used for **pre-anaesthetic anxiolysis** due to its potent **sedative**, **anxiolytic**, and **amnesic** properties. * It helps reduce patient anxiety and psychological stress before surgery, improving the overall perioperative experience. *Morphine* * **Morphine** is a powerful **opioid analgesic** primarily used for **pain relief**, not anxiolysis. * While it has some sedative effects, its main role in **pre-anaesthetic medication** is to reduce **intraoperative and postoperative pain**. *Atropine* * **Atropine** is an **anticholinergic drug** used to reduce **salivary and bronchial secretions** and to prevent **bradycardia** during intubation or surgery. * It does **not possess anxiolytic properties** and is not used to relieve pre-operative anxiety. *Scopolamine* * **Scopolamine** is another **anticholinergic drug** that can cause **sedation** and **amnesia**, making it useful for preventing **postoperative nausea and vomiting**. * However, its primary role is not anxiolysis, and its sedative effects are often accompanied by other undesirable anticholinergic side effects.

Question 115: A 28-year-old female who is a known case of bipolar disorder on lithium therapy is posted for varicose vein repair. What should be done regarding lithium?

A. Replace lithium with diazepam
B. Continue lithium till the day of surgery
C. Stop lithium 24 hours prior to surgery (Correct Answer)
D. None of the above

Explanation: ***Stop lithium 24 hours prior to surgery*** - Lithium has a relatively long half-life, and stopping it 24 hours prior allows sufficient time for the drug to be cleared, reducing the risk of drug interactions and toxicity during surgery. - Continuing lithium perioperatively can lead to complications such as **nephrogenic diabetes insipidus** and interactions with anesthetics, affecting **electrolyte balance** and **renal function**. *Replace lithium with diazepam* - **Diazepam** is a benzodiazepine used for anxiety and acute agitation, not as a primary mood stabilizer for **bipolar disorder**. - Switching to diazepam would not provide adequate mood stabilization and could lead to a **mood episode** due to the abrupt cessation of lithium. *Continue lithium till the day of surgery* - This practice increases the risk of **lithium toxicity** as surgical stress, fluid shifts, and certain anesthetics can impair renal lithium excretion. - The risk of perioperative complications, including **cardiac arrhythmias** and **postoperative delirium**, is elevated with continued lithium use. *None of the above* - This option is incorrect because there is indeed a recommended protocol for managing lithium prior to surgery due to its **pharmacokinetic properties** and potential interactions.

Question 116: Which of the following used as preanesthetic medication causes longest amnesia?

A. Diazepam
B. Midazolam
C. Lorazepam (Correct Answer)
D. Flunitrazepam

Explanation: ***Lorazepam*** - **Lorazepam** has a relatively **long duration of action** and is noted for producing the **longest period of anterograde amnesia** among the benzodiazepines listed, making it effective for preanesthetic medication. - Its slower elimination rate contributes to sustained sedative and amnesic effects, which can be beneficial for patient comfort and anxiety reduction before surgery. *Diazepam* - While **diazepam** provides good anxiolysis and sedation, its amnesic effects are generally **shorter-lived** compared to lorazepam. - It has a long half-life due to active metabolites but its peak amnesic action is not as prolonged as lorazepam. *Midazolam* - **Midazolam** is known for its **rapid onset and short duration of action**, making it ideal for procedures requiring quick recovery from sedation. - Its amnesic effects are significant but wear off more quickly than those of lorazepam due to its rapid metabolism. *Flunitrazepam* - **Flunitrazepam** is a potent benzodiazepine with strong amnesic properties, but it is **not commonly used as a preanesthetic medication** in many regions due to its association with misuse and abuse. - While effective, its amnesic duration is usually considered comparable to or slightly shorter than lorazepam in a clinical context, and its use is restricted.

Question 117: AMPLE history involved all except?

A. Last meal
B. Pregnancy
C. Personal history (Correct Answer)
D. Allergy

Explanation: ***Personal history*** - The "P" in **AMPLE** stands for **Past medical history**, not Personal history. Personal history (social history) is a broader category that includes elements like smoking, alcohol use, and occupation, which are not specifically covered by the AMIPLE acronym. - While personal history is important for overall patient assessment, it is not a direct component of the focused **AMPLE** mnemonic used in emergency and critical care settings. *Last meal* - The "L" in **AMPLE** stands for **Last meal** (or Last oral intake). - This information is crucial for assessing aspiration risk, especially before procedures or surgery, and understanding metabolic status. *Pregnancy* - The "P" in **AMPLE** stands for **Past medical history or Pregnancy**. - For female patients of reproductive age, identifying pregnancy status is critical for medication administration, imaging decisions, and overall management. *Allergy* - The "A" in **AMPLE** stands for **Allergies**. - Knowing a patient's allergies is fundamental to prevent adverse reactions to medications, foods, and environmental factors during treatment.

Question 118: A 32-year-old male is a known hypertensive and is being planned for cholecystectomy. Which of the following anesthetic agents is contraindicated in this person?

A. Etomidate
B. Propofol
C. Ketamine (Correct Answer)
D. Midazolam

Explanation: ***Ketamine*** - **Ketamine** can cause significant increases in **heart rate** and **blood pressure**, which are undesirable in a hypertensive patient undergoing surgery. - Its **sympathomimetic effects** can exacerbate pre-existing hypertension and increase the risk of perioperative cardiovascular complications. *Etomidate* - **Etomidate** is known for its **cardiovascular stability**, making it a good choice for hypertensive patients as it has minimal effects on heart rate and blood pressure. - It can, however, suppress adrenal steroid synthesis, which is generally not a contraindication for a single dose in a healthy hypertensive patient. *Propofol* - **Propofol** often causes a **dose-dependent decrease in blood pressure** due to vasodilation and myocardial depression. - While this can be a concern, it is usually managed by careful titration and is less likely to exacerbate hypertension than ketamine. *Midazolam* - **Midazolam** is a benzodiazepine that provides **sedation and anxiolysis**; it has minimal effects on hemodynamics at typical anesthetic induction doses. - It is often used as a co-induction agent, not as a primary induction agent, and generally does not worsen hypertension.

Question 119: 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 120: Premedication is prescribed to – a) Allay anxiety b) Make the patient asleep before coming for operation c) Reduce the dose of induction agents d) Produce amnesia

A. Reduce the dose of induction agents
B. Allay anxiety (Correct Answer)
C. Produce amnesia
D. Make the patient asleep before coming for operation

Explanation: ***Allay anxiety*** - Premedication frequently includes anxiolytic agents like **benzodiazepines** to calm the patient before surgery. - Reducing anxiety helps in achieving a smoother induction of anesthesia and can improve the patient's overall experience. *Reduce the dose of induction agents* - While some premedication agents like **opioids** or sedatives can have an anesthetic-sparing effect, this is a secondary benefit, not the primary goal. - The main aim is patient comfort and psychological preparation, not primarily dose reduction. *Produce amnesia* - Amnesia, particularly **anterograde amnesia**, is a desirable side effect of some premedication drugs like **midazolam**. - However, it's a consequence of the anxiolytic effect rather than the sole or primary reason for prescribing premedication. *Make the patient asleep before coming for operation* - While some premedication agents can cause **somnolence** or light sleep, the goal is not to have the patient fully asleep before entering the operating room. - The primary aim is to make the patient relaxed and comfortable, not unconscious.

Practice by Chapter

Preoperative Assessment Framework

Practice Questions

ASA Physical Status Classification

Practice Questions

Preoperative Laboratory Testing

Practice Questions

Cardiovascular Evaluation

Practice Questions

Pulmonary Evaluation

Practice Questions

Assessment of the Difficult Airway

Practice Questions

Medication Management

Practice Questions

NPO Guidelines

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Perioperative Anticoagulation Management

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Premedication

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Informed Consent

Practice Questions

Risk Stratification

Practice Questions

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