Preoperative Evaluation and Management Practice Questions

Q: Preanesthetic medication comprises of all the following, except:

Lignocaine. **Explanation:** Preanesthetic medication refers to the administration of drugs before the induction of anesthesia to reduce anxiety, provide sedation, prevent autonomic reflex responses, and minimize the risk of aspiration. **Why Lignocaine is the Correct Answer:** Lignocaine is a local anesthetic and Class Ib anti-arrhythmic agent. While it is used intraoperatively (e.g., to blunt the pressor response during intubation or as part of a multimodal analgesic infusion), it is **not** classified as a standard preanesthetic medication. Its primary role is procedural or therapeutic rather than preparatory. **Analysis of Other Options:** * **Diazepam:** A benzodiazepine used as a sedative-hypnotic to provide anxiolysis and anterograde amnesia. It is a classic premedicant. * **Atropine:** An anticholinergic (antimuscarinic) agent used to reduce salivary and bronchial secretions and to prevent vagally-mediated bradycardia during surgery. * **Metoclopramide:** A prokinetic and antiemetic agent. It is used in premedication to increase lower esophageal sphincter tone and promote gastric emptying, reducing the risk of aspiration pneumonitis (Mendelson’s Syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **Mendelson’s Syndrome:** Aspiration pneumonitis characterized by a gastric volume >25 ml and pH <2.5. Premedication with Metoclopramide and H2 blockers (Ranitidine) helps mitigate this. * **Glycopyrrolate vs. Atropine:** Glycopyrrolate is often preferred over Atropine as a premedicant because it does not cross the blood-brain barrier (quaternary ammonium), causing less tachycardia and no central anticholinergic syndrome. * **Midazolam:** Currently the most common benzodiazepine used for premedication due to its rapid onset and shorter duration compared to Diazepam.

Q: A brain-dead patient falls under which category in the ASA classification?

ASA 6. **Explanation:** The **ASA Physical Status Classification System** is a standardized tool used by anesthesiologists to assess a patient's preoperative physical state and predict perioperative risk. **Why ASA 6 is correct:** The ASA 6 category was specifically added to the classification system to identify **declared brain-dead patients** whose organs are being removed for donor purposes. These patients are maintained on life support (ventilatory and hemodynamic) solely to ensure organ viability until the procurement surgery is completed. **Analysis of Incorrect Options:** * **ASA 1:** Refers to a normal, healthy, non-smoking patient with no systemic disease and minimal alcohol use. * **ASA 3:** Refers to a patient with **severe systemic disease** that results in functional limitations (e.g., poorly controlled DM or HTN, stable angina, or a history of MI >3 months ago). * **ASA 4:** Refers to a patient with severe systemic disease that is a **constant threat to life** (e.g., recent MI <3 months ago, ongoing cardiac ischemia, or end-stage renal disease not undergoing regular dialysis). **High-Yield Clinical Pearls for NEET-PG:** * **The "E" Suffix:** If a surgery is an emergency, the letter "E" is added to the classification (e.g., ASA 2E). * **ASA 2:** Includes mild systemic disease without substantive functional limitations (e.g., social smoker, pregnancy, well-controlled DM/HTN). * **ASA 5:** A moribund patient who is not expected to survive without the operation (e.g., ruptured abdominal aortic aneurysm, massive trauma). * **Note:** The ASA grade is an assessment of physical status, not a predictor of anesthetic risk by itself, though the two are highly correlated.

Q: Which of the following drugs should be discontinued on the day of surgery?

Metformin. **Explanation:** The correct answer is **Metformin**. The primary concern with continuing Metformin on the day of surgery is the risk of **lactic acidosis**, especially in the context of perioperative dehydration, hypotension, or the use of IV contrast, which can impair renal function. Most guidelines recommend withholding Metformin **24 to 48 hours** before major surgery. **Why the other options are incorrect:** * **Atenolol (Beta-blockers):** These must be **continued** on the day of surgery. Abrupt withdrawal can lead to rebound tachycardia, hypertension, and increased myocardial oxygen demand, potentially triggering a perioperative MI. * **Amlodipine (Calcium Channel Blockers):** These are generally **continued** to maintain hemodynamic stability and blood pressure control throughout the procedure. * **Statins:** These are **continued** due to their pleiotropic effects, which include stabilizing atherosclerotic plaques and reducing the risk of perioperative cardiovascular events. **High-Yield Clinical Pearls for NEET-PG:** 1. **ACE Inhibitors/ARBs:** Usually **held** on the day of surgery to prevent "refractory hypotension" during induction of anesthesia. 2. **Oral Hypoglycemic Agents (OHAs):** Generally held on the morning of surgery (NPO status). SGLT-2 inhibitors (e.g., Empagliflozin) should be stopped **3–4 days** prior due to the risk of euglycemic ketoacidosis. 3. **Insulin:** Long-acting insulin doses are typically reduced (e.g., 50-80% of the dose), but never completely stopped in Type 1 Diabetics. 4. **Steroids:** Should be **continued**; patients on chronic steroids may require "stress doses" of Hydrocortisone to prevent adrenal crisis.

Q: A 38-year-old hypothyroid female patient presents for uterine fibroid excision. She is 5'5" and weighs 60 kg. She last ate at 8 PM the previous night and took her thyroxine tablet with a sip of water in the morning. If the surgery is scheduled to start at 8 AM, what is her estimated fluid deficit?

1.2 L. ### Explanation The calculation of preoperative fluid deficit is a high-yield topic in Anesthesiology, based on the **4-2-1 Rule** (Holliday-Segar formula) for maintenance fluid requirements and the duration of fasting. **1. Step-by-Step Calculation:** * **Maintenance Fluid Requirement:** For a 60 kg patient: * First 10 kg: 10 × 4 mL/hr = 40 mL/hr * Next 10 kg: 10 × 2 mL/hr = 20 mL/hr * Remaining 40 kg: 40 × 1 mL/hr = 40 mL/hr * **Total Maintenance Rate:** 40 + 20 + 40 = **100 mL/hr** * **Fasting Duration:** The patient last ate at 8 PM and the surgery is at 8 AM, totaling **12 hours** of fasting. * **Fluid Deficit:** Maintenance Rate × Fasting Hours = 100 mL/hr × 12 hours = **1200 mL (1.2 L).** **2. Analysis of Options:** * **Option B (1.2 L) is correct** as it accurately reflects the product of the hourly maintenance requirement and the fasting interval. * **Options A, C, and D** are incorrect because they result from miscalculating the maintenance rate (e.g., using a flat 2 mL/kg/hr) or miscounting the fasting hours. **3. Clinical Pearls for NEET-PG:** * **Thyroxine Management:** Patients should continue thyroid medications on the morning of surgery with a sip of water to maintain a euthyroid state, as seen in this vignette. * **Deficit Replacement:** In clinical practice, the calculated deficit is typically replaced using the **50-25-25 rule**: 50% in the 1st hour of surgery, 25% in the 2nd hour, and 25% in the 3rd hour (in addition to maintenance and blood loss). * **NPO Guidelines:** While this patient fasted for 12 hours, standard ASA guidelines allow clear liquids up to 2 hours and a light meal up to 6 hours before induction.

Question 1

Preanesthetic medication comprises of all the following, except:

Accepted Answer

Lignocaine

Answer

Diazepam

Answer

Atropine

Answer

Metoclopramide

Question 2

A brain-dead patient falls under which category in the ASA classification?

Accepted Answer

ASA 6

Answer

ASA I

Answer

ASA 3

Answer

ASA 4

Question 3

Which of the following drugs should be discontinued on the day of surgery?

Accepted Answer

Metformin

Answer

Atenolol

Answer

Amlodipine

Answer

Statin

Question 4

What is the minimum acceptable hematocrit value for elective oral surgery?

Accepted Answer

30%

Answer

11%

Answer

18%

Answer

23%

Question 5

A 38-year-old hypothyroid female patient presents for uterine fibroid excision. She is 5'5" and weighs 60 kg. She last ate at 8 PM the previous night and took her thyroxine tablet with a sip of water in the morning. If the surgery is scheduled to start at 8 AM, what is her estimated fluid deficit?

Accepted Answer

1.2 L

Answer

1.5 L

Answer

1.4 L

Answer

1.6 L

Question 6

A 60-year-old hypertensive patient on angiotensin II receptor antagonists (losartan) is scheduled for hernia repair surgery. How should the antihypertensive medication be managed perioperatively?

Accepted Answer

Continue till the day of operation

Answer

Discontinue 24 hours preoperatively

Answer

Discontinue one week preoperatively

Answer

Administer in increased dosage on the day of operation

Question 7

What are the benefits of stopping smoking before surgery, excluding one?

Accepted Answer

Less risk of malignancies associated with smoking

Answer

Better wound healing

Answer

Better mucociliary clearance

Answer

Better bone healing

Question 8

A 60-year-old woman with a history of diabetes, hypertension, and dyspnea on exertion undergoes pre-anesthetic evaluation for cataract repair. Her ECG shows normal sinus rhythm with left axis deviation. What is the recommended approach for this patient?

Accepted Answer

No further testing is required; proceed with surgery.

Answer

Order a treadmill test for further cardiac evaluation.

Answer

Perform 2D echocardiography.

Answer

Declare the patient unfit for surgery.

Question 9

A 55-year-old woman requires an abdominoperineal operation for rectal cancer. She has a history of stable angina. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?

Accepted Answer

Unstable angina

Answer

Abnormal electrocardiogram

Answer

Prior stroke

Answer

Uncontrolled hypertension

Question 10

A 30-year-old female with a known history of lupus, who has been taking 20 mg of prednisolone daily since the age of 19, is scheduled for a myomectomy. What is your advice regarding perioperative steroid replacement?

Accepted Answer

Administer 20 mg of prednisolone on the morning of the procedure.

Answer

Stop steroids the night before the procedure.

Answer

Replace with 100 mg of hydrocortisone on the morning of the procedure.

Answer

Perform an adrenal function test prior to the procedure to decide on tapering the dose.

Preoperative Evaluation and Management — MCQs

Preoperative Evaluation and Management — MCQs

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