Preoperative Evaluation and Management — MCQs

Preoperative Evaluation and Management Indian Medical PG Practice Questions and MCQs

Question 121: Nil per oral orders for an 8-year-old child posted for elective nasal polyp surgery at 8 AM include all of the following EXCEPT:

A. Apple juice can be taken at 10 PM previous night
B. Milk can be taken at 7 AM in morning (Correct Answer)
C. Can take sips of water up to 6 AM in morning
D. Rice can be consumed at 11 PM previous night

Explanation: **Milk can be taken at 7 AM in morning** - For an 8-year-old undergoing elective surgery at 8 AM, **milk is considered a solid or heavy fluid** and should be stopped at least **6 hours pre-operatively**. - Taking milk at 7 AM, just one hour before surgery, significantly increases the risk of **pulmonary aspiration** during anesthesia. *Apple juice can be taken at 10 PM previous night* - **Clear liquids**, such as apple juice, can generally be consumed up to **2 hours before surgery** in children. - Taking apple juice at 10 PM the night before for an 8 AM surgery falls well within the safe fasting window for clear liquids. *Can take sips of water up to 6 AM in morning* - **Sips of water** are considered a clear liquid and can be consumed up to **2 hours before surgery** in children. - Allowing water until 6 AM for an 8 AM surgery is appropriate and helps prevent dehydration without increasing aspiration risk. *Rice can be consumed at 11 PM previous night* - **Solid foods**, like rice, require a longer fasting period, typically at least **6-8 hours before surgery**. - Consuming rice at 11 PM the night before, for an 8 AM surgery, allows for sufficient gastric emptying and is generally safe.

Question 122: Which of the following signs of congestive cardiac failure constitute a major risk to the surgical patient undergoing anaesthesia ?

A. Pedal oedema
B. Jugular venous distention and third heart sound (Correct Answer)
C. Basal crepitations on auscultation
D. Cardiomegaly

Explanation: ***Jugular venous distention and third heart sound*** - **Jugular venous distention (JVD)** indicates elevated right atrial pressure and **central venous pressure**, signifying significant volume overload and potential right ventricular dysfunction. - A **third heart sound (S3)** is a strong indicator of **ventricular dysfunction** and high filling pressures, suggesting severe heart failure and poor cardiac reserve, which poses a major risk during anesthesia. *Pedal oedema* - **Pedal edema** can be a sign of fluid overload, but it is a relatively mild and chronic symptom of heart failure compared to acute decompensation. - While it reflects increased hydrostatic pressure, it doesn't alone signify the immediate, critical hemodynamic instability that poses a major perioperative risk. *Basal crepitations on auscultation* - **Basal crepitations** (rales) suggest **pulmonary congestion** due to left ventricular failure, indicating fluid in the small airways. - Although concerning, this sign primarily reflects lung involvement and not necessarily the critical, global hemodynamic compromise indicated by JVD and S3. *Cardiomegaly* - **Cardiomegaly** (enlarged heart) is an imaging finding that reflects chronic cardiac remodeling due to long-standing heart disease. - It indicates a history of heart failure but does not directly reflect the **acute hemodynamic status** and immediate risk of decompensation during surgery.

Question 123: Which of the following drugs need not be stopped before surgery?

A. High Dose Aspirin
B. Metformin
C. Digitalis (Correct Answer)
D. Warfarin

Explanation: ***Digitalis*** - **Digitalis (digoxin)** is often continued through surgery, especially in patients with **heart failure** or **atrial fibrillation** to maintain cardiac function. - Its cessation could precipitate **cardiac decompensation** or arrhythmias, which are high-risk events during surgery. *High Dose Aspirin* - **High-dose aspirin** should generally be stopped before surgery due to its **antiplatelet effects**, increasing the risk of perioperative bleeding. - The duration of discontinuation depends on the type of surgery and individual patient risk. *Metformin* - **Metformin** should be stopped before surgery due to the risk of **lactic acidosis**, especially in situations involving **renal impairment** or hypoperfusion associated with surgery. - It's typically held on the day of surgery and for 24-48 hours post-operatively, depending on renal function. *Warfarin* - **Warfarin** is a strong oral anticoagulant that must be discontinued before most surgeries to prevent **excessive bleeding**. - It is typically stopped 5 days pre-op, and patients often receive **bridging therapy** with heparin, depending on their risk for thromboembolism.

Question 124: A 4-month-old child can be given clear fluid until how many hours prior to surgery?

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

Explanation: ***2 hrs*** - Current guidelines from the **American Society of Anesthesiologists (ASA)** recommend a minimum fasting period of **2 hours for clear liquids** in infants and children. - This recommendation balances the risk of **pulmonary aspiration** with the benefit of preventing dehydration and patient discomfort. *4 hrs* - A 4-hour fasting period for clear fluids is longer than typically required for infants and children and may lead to unnecessary dehydration without additional safety benefits. - This duration is more commonly associated with non-human milk formula or solid food. *3 hrs* - While closer to the recommended time, 3 hours for clear fluids in an infant is still slightly longer than the current standard. - It does not offer a significant advantage over the 2-hour guideline and may still contribute to prolonged fasting. *1 hr* - A 1-hour fasting period for clear fluids in an infant is generally considered too short and carries an increased risk of **pulmonary aspiration** during induction of anesthesia. - Insufficient time for gastric emptying could lead to complications if regurgitation occurs.

Question 125: In anesthesiology, mild systemic disease is classified under which ASA grade?

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

Explanation: 2 - ASA Grade 2 is defined as a patient with mild systemic disease 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). 4 - ASA Grade 4 indicates a patient with severe systemic disease 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. 3 - ASA Grade 3 describes a patient with severe systemic disease that limits activity but is not incapacitating. - Examples include poorly controlled hypertension or diabetes, stable angina, or moderate chronic obstructive pulmonary disease (COPD). 1 - ASA Grade 1 is assigned to a healthy patient without any systemic disease. - This classification implies no physiological, physical, or psychological disturbance, other than the condition requiring surgery.

Question 126: ASA classification is done for – a) Status of patient b) Risk c) Pain d) Lung disease

A. ac
B. a
C. ab (Correct Answer)
D. bc

Explanation: ***ab*** - The **American Society of Anesthesiologists (ASA) Physical Status Classification System** is used to assess a patient's **overall health (status)** before surgery. - This classification helps in determining the **anesthetic risk** and guides anesthetic management. *ac* - While patient status is assessed, ASA classification does not primarily classify **pain** or pain management strategies. - **Lung disease** can influence a patient's ASA status, but it's not the sole or primary factor being classified independently. *a* - The ASA classification evaluates the patient's **overall health or status** but significantly aims to assess the **risk** associated with anesthesia and surgery. - Without considering risk, the classification loses its primary purpose in surgical planning. *bc* - The ASA system is indeed used to stratify **risk** for anesthesia and surgery, but it primarily does this by categorizing the patient's **overall physical status**. - It does not directly classify **pain** as an independent variable; patient conditions causing pain would contribute to their overall status.

Question 127: A moribund patient who has little chance of survival but is submitted to surgery as a last resort belongs to ASA class-

A. II
B. V (Correct Answer)
C. VI
D. IV

Explanation: ***V*** - An ASA Physical Status **Class V** patient is defined as a **moribund patient** who is not expected to survive without the operation, often with a high risk of mortality within 24 hours even with surgery. - The description of a patient with "**little chance of survival** but submitted to surgery as a last resort" perfectly matches this classification. *II* - ASA Class II describes a patient with a **mild systemic disease** that is well-controlled and does not limit activity, such as well-controlled hypertension or diabetes. - This patient's condition is far more severe than what is classified as ASA Class II. *VI* - ASA Class VI is reserved for a **declared brain-dead patient** whose organs are being removed for donor purposes. - While the patient is moribund, they are not brain dead, and the surgery is for their own survival, not organ donation. *IV* - ASA Class IV describes a patient with a **severe systemic disease** that is a constant threat to life, such as unstable angina or severe cardiac disease. - While severe, Class IV patients generally have a better chance of survival than the patient described, who is already considered moribund and unlikely to survive without the surgery.

Question 128: A 62-year-old patient with uncontrolled hypertension resulting in a ruptured aortic aneurysm submitted to surgery belongs to ASA class-

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

Explanation: ***IV*** - An **ASA Class IV** patient has a **severe systemic disease** that is a constant threat to life. - An **uncontrolled ruptured aortic aneurysm** with uncontrolled hypertension clearly signifies a life-threatening condition, which is the hallmark of ASA Class IV. *VI* - **ASA Class VI** is reserved for a **brain-dead patient** whose organs are being removed for donor purposes. - This patient is alive and undergoing surgery, so Class VI does not apply. *V* - **ASA Class V** describes a **moribund patient** who is not expected to survive without the operation. - While a ruptured aortic aneurysm is severe, ASA V implies an even more immediate and profound risk of death, often associated with multiple organ failure or profound shock, which is not explicitly stated here. *III* - **ASA Class III** is defined by **severe systemic disease** that limits activity but is not incapacitating. - Uncontrolled hypertension and a ruptured aortic aneurysm represent a critical, life-threatening situation, classifying the patient beyond a simple Class III.

Question 129: Breast milk should be discontinued for how long prior to surgery

A. 6 hours
B. 8 hours
C. 4 hours (Correct Answer)
D. 2 hours

Explanation: ***4 hours*** - The American Society of Anesthesiologists (ASA) guidelines recommend a minimum **fasting period of 4 hours** for infants who are fed breast milk prior to elective procedures requiring general anesthesia or sedation. - Breast milk is digested relatively quickly compared to formula or solid foods, reducing the risk of **pulmonary aspiration** if this guideline is followed. *6 hours* - A 6-hour fasting period is typically recommended for **cow's milk-based formula**, nonhuman milk, or light meals, as these take longer to digest than breast milk. - For breast milk, this duration is unnecessarily long and could lead to **dehydration or discomfort** in the infant. *8 hours* - An 8-hour fasting period is usually reserved for **heavy or fatty meals** and is not applicable to breast milk, which is a liquid and is rapidly digested. - Such a long fasting interval for breastfed infants could increase the risk of **hypoglycemia** and dehydration. *2 hours* - A 2-hour fasting period is generally recommended only for **clear liquids** (e.g., water, clear apple juice) in infants and children. - Breast milk contains proteins and fats that require a longer digestion time than clear liquids, making a 2-hour fast insufficient to minimize the risk of **pulmonary aspiration**.

Question 130: A patient with hypertension, under control by medication falls under which grade

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

Explanation: ***ASA 2*** - **ASA 2** is assigned to patients with **mild systemic disease** that is well-controlled and poses no significant functional limitations. - Well-controlled hypertension falls under this category as it represents a stable, managed chronic condition. *ASA 1* - **ASA 1** is reserved for **healthy patients** with no systemic disease, either physiological or psychological. - This patient has hypertension, which is a systemic disease, thus excluding ASA 1. *ASA 3* - **ASA 3** is for patients with **severe systemic disease** that has functional limitations but is not incapacitating. - Uncontrolled hypertension or hypertension with significant organ damage would fall into this category, unlike the well-controlled status described. *ASA 4* - **ASA 4** is assigned to patients with **severe systemic disease** that is a constant threat to life. - Examples include unstable angina, severe congestive heart failure, or uncontrolled hypertension with ongoing end-organ damage, which are not present here.

Practice by Chapter

Preoperative Assessment Framework

Practice Questions

ASA Physical Status Classification

Practice Questions

Preoperative Laboratory Testing

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Cardiovascular Evaluation

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Pulmonary Evaluation

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Assessment of the Difficult Airway

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Medication Management

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NPO Guidelines

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Perioperative Anticoagulation Management

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Premedication

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Informed Consent

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Risk Stratification

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