Preoperative and Postoperative Care Practice Questions

Q: A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

Hydrocortisone only. ***Hydrocortisone only*** - Patients on chronic **high-dose steroid therapy** (>5 mg prednisolone daily for >3 weeks) are at risk of **adrenal insufficiency** during surgical stress due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. - **Hydrocortisone stress dose** (100 mg IV at induction, followed by 50 mg every 8 hours) is the **most essential and immediate requirement** to prevent **adrenal crisis** during major surgery. - Hydrocortisone has both glucocorticoid and mineralocorticoid activity, mimicking the body's natural cortisol response to surgical stress. *Insulin only* - While steroids can cause **hyperglycemia** requiring insulin management, this is a **secondary concern** compared to preventing life-threatening **adrenal crisis**. - Insulin addresses a metabolic complication but does not protect against **inadequate cortisol response** to surgical stress. - **Without stress-dose steroids**, the patient risks hemodynamic collapse regardless of glucose control. *Both* - Although **both** medications might eventually be needed if hyperglycemia develops, the question asks for the **most essential** requirement. - **Hydrocortisone is non-negotiable** and must be given prophylactically; insulin is only needed if blood glucose is elevated. - Prioritizing both equally misses the critical time-sensitive need for **adrenal axis support**. *None of the options* - This is incorrect because patients on chronic high-dose steroids undergoing major surgery **absolutely require stress-dose steroid coverage**. - Failure to administer hydrocortisone can result in **acute adrenal crisis** with severe hypotension, shock, and potential mortality. - Modern guidelines confirm the need for perioperative steroid supplementation in high-risk patients.

Q: Thyroid storm during surgery is due to?

Inadequate preoperative preparation. ***Inadequate preoperative preparation*** - **Thyroid storm** is a life-threatening exaggeration of hyperthyroidism, often triggered in patients who are **inadequately prepared** for surgery. - This typically means insufficient control of thyroid hormone levels (e.g., with antithyroid drugs, beta-blockers) prior to a surgical stressor. *Perioperative intervention* - While surgery itself is a stressor, a properly performed **perioperative intervention** on a well-prepared patient is less likely to trigger thyroid storm. - The problem is not the intervention itself, but the patient's underlying uncontrolled hyperthyroid state. *Glucocorticoid side effect* - **Glucocorticoids** are often used to treat thyroid storm, not cause it. - They help reduce peripheral conversion of T4 to T3 and provide adrenal support. *Rough handling during surgery* - While **rough handling** during thyroid surgery (e.g., excessive manipulation of the thyroid gland) can, in theory, release some thyroid hormone, it is a less significant factor in triggering thyroid storm than overall systemic hyperthyroidism. - The primary cause remains **inadequate systemic control** of thyroid hormone levels.

Q: Burst abdomen most commonly occurs at what time after surgery?

7-10 days. ***7 - 10 days*** - **Burst abdomen**, also known as **wound dehiscence**, typically occurs when the wound healing process is at its weakest, around **7 to 10 days post-surgery**. - This period corresponds to the peak of the **inflammatory phase** and the beginning of the **proliferative phase** of wound healing, where collagen is being laid down but has not yet gained sufficient tensile strength. *3 - 5 days* - This period is generally too early for a full burst abdomen, as the initial wound closure is usually more secure, and the **lag phase of healing** is still predominant. - While local complications like **seroma** or **hematoma** can occur during this time, complete wound dehiscence is less common. *1 - 4 days* - In the first few days post-surgery, the wound is primarily held together by sutures and initial fibrin clots; complete dehiscence is very rare unless there's **gross technical error** during closure. - The inflammatory response is just beginning, and **collagen synthesis** is minimal. *10-12 days* - While dehiscence can still occur during this period, the **tensile strength** of the wound significantly increases after day 10 as collagen cross-linking progresses. - Most cases of burst abdomen have already manifested by day 10, making later occurrences less frequent, though not impossible.

Q: During surgery, a transfusion reaction is manifested as:

Hypotension. ***Hypotension*** - **Hypotension** is the most critical and readily detectable sign of an acute hemolytic transfusion reaction during surgery, often resulting from the release of vasodilatory substances and systemic inflammation. - While under anesthesia, many typical signs of transfusion reaction (e.g., fever, chills, back pain) are masked, making changes in vital signs like a sudden drop in **blood pressure** particularly crucial indicators. - In the anesthetized patient, unexplained hypotension during transfusion should immediately raise suspicion of a transfusion reaction. *Hypothermia* - **Hypothermia** is typically associated with massive transfusions of cold blood products, not directly with an acute immunological transfusion reaction. - Although it can occur during surgery due to various factors, it is not a primary manifestation of a direct transfusion reaction. *Bleeding* - **Bleeding** can be a complication of a severe transfusion reaction, specifically due to **disseminated intravascular coagulation (DIC)**, but it's usually a later or more severe manifestation, not the initial presenting sign. - The primary initial clinical sign of an acute hemolytic reaction is often related to cardiovascular instability rather than overt hemorrhage. *Increased muscle movement* - **Increased muscle movement** is unlikely to be a direct manifestation of a transfusion reaction in an anesthetized patient. - While some reactions can cause muscle spasms or rigidity, these are typically masked by paralytic agents or deep anesthesia during surgery. *Tachycardia* - While **tachycardia** can occur as a compensatory response to hypotension, it is less specific and less reliable as an indicator of transfusion reaction in anesthetized patients. - The anesthesiologist primarily monitors for **hypotension** as the key diagnostic sign rather than tachycardia alone.

Q: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

Dressing of wound & observe for dehiscence. ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.

Q: Most common cause of death after Total Hip Replacement is-

Thromboembolism. ***Thromboembolism*** - **Venous thromboembolism (VTE)**, which includes **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**, is a significant and common complication after total hip replacement. - **Pulmonary embolism (PE)**, a severe manifestation of VTE, is the leading cause of early postoperative death following total hip arthroplasty due to embolization of a DVT. *Pneumonia* - While **postoperative pneumonia** can occur due to immobility and anesthesia, it is generally less common as a cause of death compared to VTE in the early postoperative period after THR. - Effective respiratory physiotherapy and mobility protocols aim to reduce its incidence. *Anemia* - **Postoperative anemia** is common after THR due to blood loss during surgery, but it is rarely a direct cause of death. - It is typically managed with blood transfusions or iron supplementation, and while it can contribute to weakness or other complications, it's not the primary cause of mortality. *Infection* - **Periprosthetic joint infection (PJI)** is a serious complication that can occur early or late after THR, potentially leading to significant morbidity. - While it can be life-threatening if severe or unmanaged, **sepsis** due to PJI is a less common cause of immediate postoperative death compared to the acute cardiovascular events associated with VTE.

Q: A patient with ITP on steroids underwent splenectomy. Patient got fever on 3rd post-operative day. Next investigation is likely to reveal?

Pulmonary consolidation. ***Pulmonary consolidation*** - Post-splenectomy patients are at increased risk of **pulmonary complications**, including atelectasis and pneumonia, due to reduced diaphragmatic excursion and pain. Fever on day 3 suggests a developing infection or inflammatory process in the lungs. - **Splenectomy** affects the immune response, making patients more susceptible to infections and exaggerating inflammatory responses to surgical trauma, which can manifest as pulmonary issues. *Focal Intra-abdominal collection* - While intra-abdominal collections can cause fever post-operatively, they typically present later (around day 5-7), and symptoms are often localized with abdominal pain or distension. - This patient had ITP and underwent splenectomy, making **pulmonary complications** more prominent earlier on. *UTI* - Urinary tract infections can cause fever post-operatively, but are usually associated with **urinary symptoms** like dysuria, frequency, or urgency, which are not mentioned. - While prolonged catheterization increases risk, it is less common to be the primary cause of fever on day 3 after splenectomy compared to pulmonary issues. *Po site infection* - Surgical site infections more commonly manifest with localized signs of inflammation such as **redness, warmth, swelling, or purulent discharge**, which are not described. - While possible, a prominent fever on day 3 following a splenectomy, especially in a patient on steroids (which can mask some inflammatory signs), places **pulmonary issues** higher on the differential.

Q: Which one of the following is not a component of THORACOSCORE?

Complication of surgery. ***Complication of surgery*** - THORACOSCORE is a **risk prediction model** for thoracic surgery used to estimate the *probability of mortality and significant morbidity*, but it does not account for the complications of surgery itself as a component. - The score uses **pre-operative patient characteristics** and co-morbidities to predict outcomes, not post-operative events. *Performance status* - **Performance status**, such as the **ECOG scale**, is a crucial component of THORACOSCORE, reflecting the patient's general health and functional capacity prior to surgery. - A lower performance status (indicating poorer functional ability) increases the predicted risk in THORACOSCORE. *Priority of surgery* - The **priority of surgery** (e.g., elective, urgent, emergency) is an important factor in THORACOSCORE, as emergency procedures generally carry a higher risk. - This variable helps to capture the urgency and associated physiological stress on the patient at the time of presentation for surgery. *ASA grading* - The **American Society of Anesthesiologists (ASA) physical status classification system** is a component of THORACOSCORE, assessing the patient's overall health status and anesthetic risk. - A higher ASA grade (indicating more severe systemic disease) contributes to a higher predicted risk in the THORACOSCORE model.

Q: Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

BMI>30. ***BMI>30*** - While **obesity (BMI >30)** is associated with some surgical risks, it is generally considered a less significant independent risk factor for postoperative pulmonary complications compared to other factors like age, smoking, and surgical site. - The impact of obesity on pulmonary function is complex and varies depending on the type of surgery and presence of comorbid conditions like **sleep apnea**. *Age >70* - **Advanced age (>70)** is a significant independent risk factor due to decreased physiological reserve, reduced pulmonary function (e.g., decreased lung elasticity, impaired cough reflex), and increased prevalence of comorbidities. - Older patients are more susceptible to **atelectasis**, **pneumonia**, and **respiratory failure** postoperatively. *Patient with 7 pack years of smoking* - Even a relatively low cumulative smoking history of **7 pack-years** can impair mucociliary clearance, increase bronchial secretions, and cause airway inflammation, significantly increasing the risk of pulmonary complications. - Smoking compromises lung function and increases the risk of **bronchospasm** and infection. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor because incisions close to the diaphragm interfere with diaphragmatic movement, leading to reduced lung volumes, impaired cough, and increased risk of **atelectasis** and **pneumonia**. - Pain from the incision further restricts deep breaths and coughing, contributing to pulmonary complications.

Question 1

A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

Accepted Answer

Hydrocortisone only

Answer

Insulin only

Answer

Both

Answer

None of the options

Question 2

Thyroid storm during surgery is due to?

Accepted Answer

Inadequate preoperative preparation

Answer

Perioperative intervention

Answer

Glucocorticoid side effect

Answer

Rough handling during surgery

Question 3

A patient on aspirin for secondary prevention of cardiovascular disease is selected for an elective surgery with low-to-moderate bleeding risk. What should be done regarding aspirin management?

Accepted Answer

Go ahead with surgery maintaining adequate hemostasis

Answer

Stop aspirin for 7 days

Answer

Infusion of fresh frozen plasma

Answer

Infusion of platelet concentrate

Question 4

Burst abdomen most commonly occurs at what time after surgery?

Accepted Answer

7-10 days

Answer

3-5 days

Answer

1-4 days

Answer

10-12 days

Question 5

During surgery, a transfusion reaction is manifested as:

Accepted Answer

Hypotension

Answer

Hypothermia

Answer

Bleeding

Answer

Increased muscle movement

Answer

Tachycardia

Question 6

On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

Accepted Answer

Dressing of wound & observe for dehiscence

Answer

Send for USG abdomen

Answer

Start treatments for peritonitis

Answer

IV fluids

Question 7

Most common cause of death after Total Hip Replacement is-

Accepted Answer

Thromboembolism

Answer

Pneumonia

Answer

Anemia

Answer

Infection

Question 8

A patient with ITP on steroids underwent splenectomy. Patient got fever on 3rd post-operative day. Next investigation is likely to reveal?

Accepted Answer

Pulmonary consolidation

Answer

Focal Intra-abdominal collection

Answer

UTI

Answer

Post-operative site infection

Question 9

Which one of the following is not a component of THORACOSCORE?

Accepted Answer

Complication of surgery

Answer

Performance status

Answer

Priority of surgery

Answer

ASA grading

Question 10

Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

Accepted Answer

BMI>30

Answer

Age >70

Answer

Patient with 7 pack years of smoking

Answer

Upper abdominal surgery

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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