Perioperative Medication Management — MCQs

10 questions

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

A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

What is the correct sequence of medication administration for pre-operative prophylaxis in pheochromocytoma?

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

A middle-aged male patient who was involved in a road traffic accident and brought to the emergency department in an unconscious state. A computed tomography (CT) scan of the abdomen revealed a splenic laceration, and emergency splenectomy was performed. The patient was then transferred to the intensive care unit (ICU). Despite receiving a bolus of normal saline, his blood pressure remained low in the postoperative period. On examination, he was afebrile, had a moon-like face with central obesity, and exhibited violet striae on his abdomen. A repeat CT scan of the chest, abdomen, and pelvis showed no evidence of hemorrhage. What is the next best step in managing this patient?

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 patient after valve replacement will require follow up treatment with

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

A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?

Q10

What is the most appropriate perioperative management regarding the antihypertensive medication of a 55-year-old male with a history of hypertension who has been taking ACE inhibitors for the past 5 years and is scheduled for elective hernia repair surgery?

Perioperative Medication Management Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

A. Factor VIII
B. Desmopressin (DDAVP) (Correct Answer)
C. Platelets
D. Vitamin K

Explanation: ***Desmopressin (DDAVP)*** - **Desmopressin** is the first-line treatment for **von Willebrand disease (vWD)** [1], especially for type 1, which this patient's profile suggests (prolonged aPTT, normal PT, normal platelet count, and abnormal bleeding time). - It works by stimulating the release of endogenous **von Willebrand factor (vWF)** and **factor VIII** from endothelial cells [1]. *Factor VIII* - While Factor VIII deficiency can cause prolonged aPTT, this patient's presentation with a family history of **vWD**, normal PT, and abnormal bleeding time points specifically to a **vWF** defect rather than isolated **Factor VIII** deficiency [1]. - Administration of direct **Factor VIII** is not the primary treatment for **vWD**, although vWF concentrate (which contains Factor VIII) may be used for severe cases [1]. *Platelets* - The patient's **platelet count is normal** (350,000/mm³), indicating that a platelet transfusion is not necessary. - **vWD** is a disorder of platelet adhesion, not a problem with platelet quantity. *Vitamin K* - **Vitamin K** is essential for the synthesis of coagulation factors II, VII, IX, and X, as well as proteins C and S. - A deficiency in **Vitamin K** typically results in a prolonged **PT** [2], which is normal in this patient.

Question 3: What is the correct sequence of medication administration for pre-operative prophylaxis in pheochromocytoma?

A. Beta blockade followed by alpha blockade
B. Simultaneous alpha and beta blockade
C. Alpha blockade followed by beta blockade (Correct Answer)
D. Alpha blockade only

Explanation: ***Alpha blockade followed by beta blockade*** - **Alpha blockade** should always be initiated first to control **hypertension** and prevent a **hypertensive crisis** during surgery. This is critical because pheochromocytoma causes excessive catecholamine release, leading to profound vasoconstriction. - **Beta blockade** is then added only after adequate alpha blockade has been achieved to control **tachycardia** and arrhythmias, preventing **unopposed alpha-adrenergic stimulation** which could paradoxically worsen hypertension. *Simultaneous alpha and beta blockade* - Administering both simultaneously is dangerous because **beta blockade** can mask the effects of inadequate alpha blockade. - This can lead to **unopposed alpha-adrenergic stimulation** after beta blockade, causing severe **vasoconstriction** and hypertensive crisis. *Beta blockade followed by alpha blockade* - Initiating with **beta blockade** without prior **alpha blockade** is absolutely contraindicated in pheochromocytoma. - This can lead to severe and potentially fatal **hypertension** due to **unopposed alpha-adrenergic stimulation** as beta blockade prevents vasodilation. *Alpha blockade only* - While essential for initial management, **alpha blockade alone** might not fully control all symptoms, especially **tachycardia** and **arrhythmias** caused by high circulating catecholamine levels. - Adding a **beta blocker** after achieving adequate alpha blockade helps in controlling these cardiac effects, optimizing patient preparation for surgery.

Question 4: 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 5: A middle-aged male patient who was involved in a road traffic accident and brought to the emergency department in an unconscious state. A computed tomography (CT) scan of the abdomen revealed a splenic laceration, and emergency splenectomy was performed. The patient was then transferred to the intensive care unit (ICU). Despite receiving a bolus of normal saline, his blood pressure remained low in the postoperative period. On examination, he was afebrile, had a moon-like face with central obesity, and exhibited violet striae on his abdomen. A repeat CT scan of the chest, abdomen, and pelvis showed no evidence of hemorrhage. What is the next best step in managing this patient?

A. Return to the operating room for exploratory laparotomy
B. Administer vancomycin and piperacillin/tazobactam
C. Perform MRI of the spine.
D. Administer hydrocortisone 100 mg IV (Correct Answer)

Explanation: ***Administer hydrocortisone 100 mg IV*** - The patient's presentation with **hypotension unresponsive to fluid resuscitation**, combined with a **moon-like face**, **central obesity**, and **violet striae**, strongly suggests **adrenal insufficiency** as a complication of **Cushing's syndrome**. [1] - **Adrenal crisis** requires immediate administration of **stress-dose corticosteroids** to prevent cardiovascular collapse. [1] *Return to the operating room for exploratory laparotomy* - A **repeat CT scan** confirmed no evidence of hemorrhage, ruling out **active bleeding** as the cause of refractory hypotension. - Therefore, subjecting the patient to another surgery without evidence would be unnecessary and introduce additional risks. *Administer vancomycin and piperacillin/tazobactam* - The patient is **afebrile**, and there are no signs or symptoms suggestive of a **postoperative infection**. - Initiating broad-spectrum antibiotics without an indication in an already compromised patient is not appropriate and could contribute to **antibiotic resistance**. *Perform MRI of the spine.* - There is nothing in the patient's presentation that suggests **spinal cord injury** as the cause of his current unstable condition. - While the patient was in a **road traffic accident**, the primary issues are related to **hemodynamic instability** and suspected **endocrine dysfunction**, not neurological deficit.

Question 6: 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 7: A patient after valve replacement will require follow up treatment with

A. ACE inhibitors
B. Beta blockers
C. Thiazide
D. Warfarin (Correct Answer)

Explanation: ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.

Question 8: 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 9: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?

A. History + c/e + routine labs + V/Q scan
B. History + c/e + routine labs
C. History + c/e + routine labs + stress test (Correct Answer)
D. History + c/e + routine labs + angiography to assess graft patency

Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.

Question 10: What is the most appropriate perioperative management regarding the antihypertensive medication of a 55-year-old male with a history of hypertension who has been taking ACE inhibitors for the past 5 years and is scheduled for elective hernia repair surgery?

A. Switch to a beta-blocker 48 hours before surgery
B. Continue ACE inhibitors until the morning of surgery (Correct Answer)
C. No changes needed in his medication regimen
D. Discontinue ACE inhibitors 24 hours prior to surgery to avoid hypotension.

Explanation: ***Continue ACE inhibitors until the morning of surgery*** - While it's common practice to hold ACE inhibitors on the day of surgery to prevent **intraoperative hypotension**, continuing them until the morning of surgery is often acceptable for elective procedures as it minimizes the risk of **rebound hypertension**. - Following the most recent guidelines, for patients undergoing elective non-cardiac surgery, ACE inhibitors can be continued, but it is important to check the specific institutional guidelines as the decision to hold or continue ACE inhibitors often varies based on the patient's individual risk profile and the type of surgery. *Switch to a beta-blocker 48 hours before surgery* - Switching to a beta-blocker acutely before surgery without a clear indication could lead to **uncontrolled hypertension** or other adverse effects if the patient is not accustomed to beta-blockers. - Beta-blockers are generally continued perioperatively if the patient is already taking them, but initiating them immediately before surgery is not a standard recommendation for routine hypertension management. *No changes needed in his medication regimen* - This is incorrect as current guidelines suggest at least some modification, such as holding the ACE inhibitor on the morning of surgery due to the risk of **refractory hypotension** under anesthesia. - ACE inhibitors can interact with anesthetic agents, making blood pressure management more challenging during surgery. *Discontinue ACE inhibitors 24 hours prior to surgery to avoid hypotension.* - While recommended by some older guidelines and for certain high-risk patients, discontinuing ACE inhibitors 24 hours prior is not universally recommended for all elective surgeries as it may increase the risk of **perioperative hypertension** or rebound effects. - The risk of perioperative hypotension with ACE inhibitors is real, however, in an elective setting, the current trend is to hold the dose on the morning of the surgery rather than a day before unless institution specific guidelines explicitly mention it.

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