Preoperative Evaluation and Management Practice Questions

Q: A 40-year-old male is scheduled for an elective cholecystectomy. As a night duty doctor in the surgical ward, you are asked to advise the patient on when to stop oral intake. How many hours prior to surgery should the patient have their last light meal?

6 hours. ### Explanation The core objective of preoperative fasting (NPO status) is to reduce the volume and acidity of gastric contents, thereby minimizing the risk of **pulmonary aspiration**—a life-threatening complication during the induction of general anesthesia. **Why 6 hours is the correct answer:** According to the **ASA (American Society of Anesthesiologists) guidelines**, a minimum fasting period of **6 hours** is required after a **light meal** (e.g., toast and clear liquid) or non-human milk. This duration allows for adequate gastric emptying of solid particles. **Analysis of Incorrect Options:** * **4 hours (Option A):** This is the fasting requirement specifically for **breast milk** in infants. It is insufficient for solid food or light meals in adults. * **8 hours (Option C):** This is the recommended fasting period for a **heavy meal** (specifically those containing fried foods, fatty foods, or meat), as fat significantly delays gastric emptying. * **12 hours (Option D):** While "NPO after midnight" was a traditional practice, modern guidelines discourage prolonged fasting to prevent dehydration, hypoglycemia, and patient discomfort. **High-Yield Clinical Pearls for NEET-PG:** * **Clear Liquids:** 2 hours (e.g., water, fruit juices without pulp, carbonated beverages, clear tea, black coffee). * **Breast Milk:** 4 hours. * **Infant Formula:** 6 hours. * **Light Meal/Non-human milk:** 6 hours. * **Heavy Meal (Fatty/Fried):** 8 hours. * **Chewing Gum:** Generally, elective surgery is not delayed for gum chewing if no solids were swallowed, but it is best avoided. * **High-Risk Patients:** Patients with GERD, morbid obesity, or diabetes mellitus (gastroparesis) are often treated as "full stomachs" regardless of fasting time.

Q: A patient who is a heavy smoker is scheduled for elective hernia repair. How long before surgery should smoking be stopped?

6-8 weeks. **Explanation:** The primary goal of preoperative smoking cessation is to reduce the risk of postoperative pulmonary complications (PPCs). **1. Why 6-8 weeks is correct:** Smoking cessation for **6-8 weeks** is the minimum duration required to significantly reduce the incidence of PPCs. This timeframe allows for: * **Restoration of ciliary function:** Improving the clearance of secretions. * **Reduction in sputum production:** Decreasing airway irritability and mucus plugging. * **Improvement in small airway function:** Enhancing gas exchange and lung compliance. * **Immune recovery:** Improving macrophage function to prevent postoperative pneumonia. **2. Analysis of incorrect options:** * **A & B (4-10 days):** While short-term abstinence (12–48 hours) is beneficial for cardiovascular health (it reduces carboxyhemoglobin levels and shifts the oxyhemoglobin dissociation curve to the right, improving oxygen delivery), it is **insufficient** to reduce pulmonary complications. In fact, stopping for only 1-2 weeks may paradoxically increase secretions and coughing due to the "awakening" of cilia. * **C (3-4 weeks):** While some physiological recovery begins, clinical studies show that the risk of PPCs does not significantly drop until the 6-8 week mark. **3. High-Yield Clinical Pearls for NEET-PG:** * **12-24 hours:** Carboxyhemoglobin levels normalize; heart rate and blood pressure stabilize. * **48 hours:** Ciliary function begins to recover. * **Paradoxical effect:** Short-term cessation (<4 weeks) may lead to increased sputum production and reactive airways; however, surgery should **never** be postponed solely because a patient stopped smoking recently. * **Nicotine Replacement Therapy (NRT):** It is generally recommended to help patients quit, as the benefits of quitting outweigh the risks of nicotine during the perioperative period.

Q: Which of the following medications can be continued on the day of surgery?

Statins. **Explanation:** The management of perioperative medications is a high-yield topic for NEET-PG, focusing on balancing the risk of withdrawal syndromes against the risk of surgical complications (like bleeding). **1. Why Statins (Option B) are correct:** Statins (HMG-CoA reductase inhibitors) should be **continued** on the day of surgery. Beyond their lipid-lowering effects, statins possess "pleiotropic effects," including anti-inflammatory properties and plaque stabilization. Continuing statins perioperatively reduces the risk of major adverse cardiovascular events (MACE) and postoperative mortality, especially in patients undergoing vascular surgery. **2. Why the other options are incorrect:** * **Heparin (Option A):** While Heparin has a short half-life, it is typically held prior to surgery to minimize intraoperative bleeding. For patients at high risk of thromboembolism, "bridging therapy" is used, but the dose is timed to ensure normal coagulation during the procedure. * **Warfarin (Option C):** This must be stopped **5 days** prior to surgery to allow the INR to normalize (<1.5). Failure to stop Warfarin poses a significant risk of uncontrollable surgical hemorrhage. * **Amitriptyline (Option D):** As a Tricyclic Antidepressant (TCA), it is generally **tapered and stopped** (usually 24–48 hours prior) because it can interact with anesthetic agents (e.g., sympathomimetics) leading to hypertensive crises or cardiac arrhythmias. **Clinical Pearls for NEET-PG:** * **Continue:** Antihypertensives (except ACEIs/ARBs), Beta-blockers (do not start acutely, but do not stop), Statins, and Thyroid medications. * **Stop:** ACE inhibitors/ARBs (24 hours prior to avoid refractory hypotension), Oral Hypoglycemics (on the morning of surgery), and Antiplatelets (Clopidogrel: 5–7 days prior). * **Steroids:** Never stop; patients on chronic steroids need "stress doses" to prevent adrenal crisis.

Q: A 48-year-old patient with a history of stable angina becomes dyspneic after walking 3 km. To which ASA physical status classification system class does this patient belong?

III. ### Explanation The **ASA Physical Status Classification System** is a global standard used to assess a patient's preoperative physical state and predict perioperative risk. **Why Option C (ASA III) is Correct:** ASA III is defined as a patient with **severe systemic disease** that results in **functional limitation**. In this clinical scenario, the patient has stable angina (a chronic systemic condition). The key indicator is the development of dyspnea after walking 3 km. While the patient is "stable," the fact that their systemic disease limits their physical activity (functional limitation) categorizes them as ASA III. **Why Other Options are Incorrect:** * **Option A (ASA I):** Reserved for a normal, healthy, non-smoking patient with no systemic disease and minimal/no alcohol use. * **Option B (ASA II):** Represents a patient with **mild systemic disease** without substantive functional limitations. Examples include well-controlled DM/HTN, social drinking, or pregnancy. If the patient could walk long distances without symptoms, they might fall here. * **Option C (ASA IV):** Represents a patient with severe systemic disease that is a **constant threat to life**. Examples include unstable angina, recent MI (<3 months), or symptomatic CHF. **High-Yield Clinical Pearls for NEET-PG:** * **ASA V:** A moribund patient not expected to survive without the operation (e.g., ruptured aortic aneurysm). * **ASA VI:** A declared brain-dead patient whose organs are being removed for donor purposes. * **The "E" Suffix:** Added to any classification if the surgery is an **Emergency** (e.g., ASA IIE). * **Functional Capacity:** Often measured in METs (Metabolic Equivalents). Walking 3 km (roughly 2 miles) at a brisk pace is ~3-4 METs. Limitation at this level confirms "substantive" functional impairment.

Q: Which oral hypoglycemic drug should be discontinued prior to general anesthesia and surgery?

Metformin. **Explanation:** The correct answer is **Metformin**. **Why Metformin?** Metformin is a biguanide that inhibits mitochondrial respiration, leading to an increase in lactate production. During the perioperative period, factors such as hypotension, dehydration, hemorrhage, or renal hypoperfusion can occur. These conditions predispose the patient to **Lactic Acidosis**, a rare but life-threatening complication associated with Metformin. To mitigate this risk, Metformin is typically discontinued **24 to 48 hours** before elective major surgery. It is restarted only after renal function has stabilized and oral intake is resumed. **Analysis of Incorrect Options:** * **Glibenclamide & Gliclazide (Sulfonylureas):** These drugs stimulate insulin secretion and carry a high risk of **hypoglycemia** during periods of fasting (NPO status). While they are held on the **morning of the surgery**, they do not carry the same risk of metabolic acidosis as Metformin. * **Pioglitazone (Thiazolidinediones):** These drugs improve insulin sensitivity. While they can cause fluid retention, they do not pose an acute metabolic risk during anesthesia and are generally omitted only on the day of surgery. **Clinical Pearls for NEET-PG:** * **SGLT-2 Inhibitors (e.g., Empagliflozin):** These must be stopped **3–4 days** prior to surgery due to the risk of **euglycemic ketoacidosis**. * **Insulin Management:** Long-acting insulin is usually continued at a reduced dose (60-80%), while short-acting insulin is held while the patient is NPO. * **Gold Standard:** For major surgeries, the preferred method of glycemic control is a **Glucose-Insulin-Potassium (GIK) infusion** or a sliding scale insulin protocol.

Question 1

A 40-year-old male is scheduled for an elective cholecystectomy. As a night duty doctor in the surgical ward, you are asked to advise the patient on when to stop oral intake. How many hours prior to surgery should the patient have their last light meal?

Accepted Answer

6 hours

Answer

4 hours

Answer

8 hours

Answer

12 hours

Question 2

A 55-year-old male patient with hypertension, on ACE inhibitors, and who underwent CABG four years ago, is scheduled for hernia surgery. He has good effort tolerance. Which of the following investigations should be ordered preoperatively?

Accepted Answer

Routine preoperative evaluation, clinical assessment, and stress testing

Answer

Routine preoperative evaluation and clinical assessment

Answer

Routine preoperative evaluation, clinical assessment, and angiography to assess patency

Answer

Routine preoperative evaluation, clinical assessment, and evaluation of surgical scars

Question 3

Preanesthetic medication is used for all except:

Accepted Answer

Decrease blood pressure

Answer

Decrease anesthetic dose

Answer

Prevent aspiration

Answer

Produce amnesia for perioperative events

Question 4

A patient who is a heavy smoker is scheduled for elective hernia repair. How long before surgery should smoking be stopped?

Accepted Answer

6-8 weeks

Answer

4 days

Answer

10 days

Answer

3-4 weeks

Question 5

Which of the following does not represent a significant anaesthetic problem in the morbidly obese patient?

Accepted Answer

Decreased cardiac output relative to total body mass

Answer

Difficulties in endotracheal intubation

Answer

Suboptimal arterial oxygen tension

Answer

Increased metabolism of volatile agents

Question 6

Which of the following medications can be continued on the day of surgery?

Accepted Answer

Statins

Answer

Heparin

Answer

Warfarin

Answer

Amitriptyline

Question 7

A 48-year-old patient with a history of stable angina becomes dyspneic after walking 3 km. To which ASA physical status classification system class does this patient belong?

Accepted Answer

III

Answer

I

Answer

II

Answer

IV

Question 8

Which oral hypoglycemic drug should be discontinued prior to general anesthesia and surgery?

Accepted Answer

Metformin

Answer

Pioglitazone

Answer

Glibenclamide

Answer

Gliclazide

Question 9

What is the target hemoglobin level to be maintained in patients with underlying serious heart disease?

Accepted Answer

11 g/dl

Answer

8 g/dl

Answer

9 g/dl

Answer

10 g/dl

Question 10

Which of the following is NOT a true anaesthetic implication of obesity?

Accepted Answer

There is a decrease in cardiac output.

Answer

There is a high risk of regurgitation.

Answer

There is an increased risk of perioperative hypoxemia.

Answer

There is a high risk of renal disease.

Preoperative Evaluation and Management — MCQs

Preoperative Evaluation and Management — MCQs

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