Preoperative Evaluation and Management Practice Questions

Q: Perioperative benefit from transfusion is with a haemoglobin level of

6 - 8 gm/dl. **6 - 8 gm/dl** - Transfusions are generally recommended for **symptomatic anemia** or when the hemoglobin level falls below **7 g/dL** in most patients. - For patients undergoing surgery, a hemoglobin range of **6-8 gm/dl** often indicates a need for transfusion to optimize oxygen delivery and prevent complications. *8 - 10 gm/dl* - Hemoglobin levels in this range are often considered stable enough for many patients, and transfusion may not be necessary unless there are specific **cardiovascular risks** or **acute bleeding**. - Routine transfusion for non-symptomatic patients with hemoglobin in this range has not shown significant perioperative benefit and can expose patients to transfusion risks. *< 6 gm/dl* - A hemoglobin level below **6 gm/dl** typically indicates **severe anemia** and almost always warrants transfusion regardless of surgical context due to the high risk of **tissue hypoxia** and organ dysfunction. - While transfusion is definitely beneficial in this range, the question asks about the range where benefit *commences* for perioperative settings, which typically falls slightly higher to prevent severe drops. *> 10 gm/dl* - A hemoglobin level **above 10 gm/dl** is generally considered good and does not usually require transfusion, even in the perioperative setting. - Transfusing patients with hemoglobin levels above this threshold is associated with **no significant clinical benefit** and increases the risk of transfusion-related adverse events.

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

ASA V. ***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.

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

48 hrs. ***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.

Q: In a Down's syndrome patient posted for surgery, the necessary preoperative investigation to be done is –

X-ray cervical spine. ***X-ray cervical spine*** - Patients with Down syndrome have **atlantoaxial instability (AAI)** in ~15-20% of cases due to ligamentous laxity, creating high risk of **spinal cord compression** during neck manipulation for intubation. - **Preoperative cervical spine X-ray** (flexion/extension views) is universally mandated to assess AAI and prevent catastrophic neurological injury during airway management. *Echocardiography* - While ~40-50% of Down syndrome patients have **congenital heart defects** (AV canal defects, VSD), echocardiography is ordered based on **clinical cardiac findings** rather than as a universal screening. - Unlike AAI which poses immediate anesthetic hazard during intubation, cardiac evaluation can be **symptom-directed** and doesn't require universal preoperative screening. *CT Brain* - Down syndrome patients may have **structural brain differences** or early dementia, but CT brain is not a routine preoperative investigation unless specific **neurological symptoms** are present. - It doesn't address the immediate surgical risks like **atlantoaxial instability** that directly impact anesthetic safety during airway management. *Ultrasound Abdomen* - Down syndrome patients have higher incidence of **GI anomalies** (duodenal atresia, Hirschsprung's disease) and premature organ aging. - **Abdominal ultrasound** is not standard preoperative screening unless specific abdominal symptoms exist or surgery involves the abdomen.

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

Diazepam. **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.

Q: 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?

Stop lithium 24 hours prior to surgery. ***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.

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

Lorazepam. ***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.

Q: AMPLE history involved all except?

Personal history. ***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.

Q: 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

ASA III. ***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 1

Perioperative benefit from transfusion is with a haemoglobin level of

Accepted Answer

6 - 8 gm/dl

Answer

8 - 10 gm/dl

Answer

< 6 gm/dl

Answer

> 10 gm/dl

Question 2

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

Accepted Answer

ASA V

Answer

ASA III

Answer

ASA VI

Answer

ASA I

Question 3

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

Accepted Answer

Continue captopril until the day of surgery to maintain blood pressure control.

Answer

Stop captopril a week before surgery and switch to a calcium channel blocker like amlodipine.

Answer

Stop captopril a week before surgery and restart only if needed.

Answer

Stop captopril one day before surgery to prevent intraoperative hypotension.

Question 4

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

Accepted Answer

48 hrs

Answer

96 hrs

Answer

24 hrs

Answer

72 hrs

Question 5

In a Down's syndrome patient posted for surgery, the necessary preoperative investigation to be done is –

Accepted Answer

X-ray cervical spine

Answer

CT Brain

Answer

Ultrasound Abdomen

Answer

Echocardiography

Question 6

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

Accepted Answer

Diazepam

Answer

Morphine

Answer

Atropine

Answer

Scopolamine

Question 7

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?

Accepted Answer

Stop lithium 24 hours prior to surgery

Answer

Replace lithium with diazepam

Answer

Continue lithium till the day of surgery

Answer

None of the above

Question 8

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

Accepted Answer

Lorazepam

Answer

Diazepam

Answer

Midazolam

Answer

Flunitrazepam

Question 9

AMPLE history involved all except?

Accepted Answer

Personal history

Answer

Last meal

Answer

Pregnancy

Answer

Allergy

Question 10

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

Accepted Answer

ASA III

Answer

ASA II

Answer

ASA I

Answer

ASA IV

Preoperative Evaluation and Management — MCQs

Preoperative Evaluation and Management — MCQs

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