ANESTHETIC TECHNIQUES | Preoperative Evaluation

Question 1

A patient who is able climb 1 flight of stairs would have a MET score of:

A. 5

B. 9

C. 3

Answer 1

A. 5

Question 2

In preoperative assessment of patients, physical activity is graded in terms of metabolic equivalents (METs). The value that corresponds to oxygen consumption of 1 MET in an adult is:

A. oxygen consumption of 3.5 mL/min/kg

B. oxygen consumption of 2.5 mL/min/kg

C. oxygen consumption of 1.5 mL/min/kg

Answer 2

A. oxygen consumption of 3.5 mL/min/kg

Question 3

A patient’s ASA physical status (ASA-PS) classifcation
correlates with:

(A) risk of cancellation of surgery
(B) cost of surgery
(C) unplanned admission after surgery
(D) adverse cardiopulmonary complications
(E) surgical procedure risk

Answer 3

(D) adverse cardiopulmonary complications

Question 4

A Cormack and Lehane grade 2 view is best described
by which of the following?

(A) Full view of vocal cords
(B) view of epiglottis only
(C) view of soft palate only
(D) view of arytenoid cartilages only
(E) no view of vocal cords

Answer 4

(D) view of arytenoid cartilages only

A Cormack and Lehane grade 2 view includes a partial view of the vocal cords and a full view of the arytenoid cartilage. The modified Cormack/Lehane grading system is shown in the figure:

• Grade 1: Full view of vocal cords
• Grade 2a: Partial view of vocal cords
• Grade 2b: View of arytenoid cartilages only
• Grade 3a: View of epiglottis only, no vocal cords
  (epiglottis able to be lifted of posterior hypopharynx

Question 5

What is the ASA physical status (ASA-PS) or a patient
who is moribund and not expected to survive without
the operation?

(A) 2
(B) 3
(C) 4
(D) 5
(E) 6

Answer 5

(D) 5

Question 6

A patient is given clonidine preoperatively in an effort to improve postoperative pain management. What is a likely side effect of administering clonidine as a preoperative medication?

(A) tachycardia
(B) amnesia
(C) respiratory depression
(D) increased gastric fluid volume
(E) hypotension

Answer 6

(E) hypotension

Alpha-2 agonists (clonidine, dexmedetomidine) can be
administered as premedication to cause sedation, blunt
the hemodynamic changes associated with laryngoscopy
or awake fiberoptic intubation, and improve analgesia.

The common side effects of alpha-2 agonists
include: hypotension and bradycardia.

Clinically, alpha-2 agonists are not felt to have significant effect on memory, respiratory depression, or gastric fluid
volume.

Barash | 9th edit

Question 7

Which of the following is NOT a component of Modified Child–Pugh Scoring:

A. Albumin
B. Prothrombin time
C. ALT
D. Ascites
E. Encephalopathy

Answer 7

C. ALT

Question 8

Which of the following is ACCURATE regarding Modified Child–Pugh Score as a preoperative tool for liver assessment?

A. For cholestatic diseases, the bilirubin level of 4 mg/dL is equivalent to 2 points

B. Grade I-II encephalopathy is equivalent to 2 points

C. Tense/severe ascites is equivalent to 5 points

D. the 3-month mortality for hospitalized patients not undergoing surgery was 14% for Child A.

Answer 8

B. Grade I-II encephalopathy is equivalent to 2 points

• The 3-month mortality for hospitalized patients not undergoing surgery was 4% for Child A, 14% for Child B, and 51% for Child C.

Question 9

A patient with ASA physical status > IV is approximately equivalent to which MELD points?

A. 5

B. 3

C. 10

Answer 9

A. 5

Other than the MELD score, other important predictors of perioperative mortality in cirrhotics were age (age >70 equated to 3 MELD points) and coexisting disease (ASA physical status > IV equated to 5 MELD points).

MELD score is a mathematical formula used for Liver transplant candidates with the following parameters:

INR
Bilirubin
Creatinine

Question 10

A patient with liver disease can be safely anesthetized with which of the following inhaled anesthetics?

A. Sevoflurane

B. Isoflurane

C. Enflurane

D. Desflurane

Answer 10

A. Sevoflurane

Halothane hepatitis, described earlier in this chapter, is
largely responsible for these concerns. However, there is little evidence to suggest that other volatile anesthetics are responsible for hepatic complications. With the exception of sevoflurane, volatile anesthetics undergo metabolism that yields reactive TFA intermediates. These bind to
hepatic proteins and produce an immunologic reaction.

Sevoflurane undergoes more extensive metabolism than isoflurane or desflurane, rapidly producing detectable plasma concentrations of fluoride and hexafluoroisopropanol (HFIP), which are conjugated by the liver and excreted by the kidney. In distinction to the other agents, sevoflurane does not produce reactive TFA metabolites or fluoroacetylated liver proteins.

• This fact led to the suggestion that patients sensitized to other volatile anesthetics could be safely anesthetized with sevoflurane.

Barash | 9th edit

Question 11

TRUE or FALSE

The clearance of Propofol in the systemic circulation is prolonged in cirrhotic patients.

Answer 11

FALSE!

Most induction agents, including ketamine, etomidate, propofol, and thiopental, are highly lipophilic and have high extraction ratios. Although elimination should be prolonged in the presence of liver disease,** clearance in cirrhotics is similar to normal patients. **

However, the pharmacodynamic effects are more pronounced, and in some cases, as with dexmedetomidine
and the benzodiazepines, the duration of action can be prolonged.

Question 12

Mitral stenosis typically has a mid-diastolic opening snap, low-pitched rumble type of murmur. Which of the following anatomical location can this murmur be heard?

A. Apex

B. 5th ICS MCL

C. 2nd parasternal interspace

D. Base of the heart

Answer 12

A. Apex

Question 13

TRUE or FALSE

Corticosteroid supplementation is not required for individuals who have received less than 5 mg prednisone (or its equivalent) daily or less than 3 weeks of corticosteroids (regardless of dose).

Answer 13

TRUE

Perioperative corticosteroid supplementation is
needed only when a patient is likely to have suppression of the hypothalamic-pituitary-adrenal axis. Thus, supplementation is not required for individuals who have received less than 5 mg prednisone (or its equivalent) daily or less than 3 weeks of corticosteroids (regardless of dose).

Question 14

Based on the current ASA guideline, a patient diagnosed with ESRD undergoing regular dialysis treatment can be classified as:

A. ASA IV

B. ASA II

C. ASA III

Answer 14

C. ASA III

Question 15

Cannabinoids should IDEALLY be discontinued ___ prior to anesthetic exposure:

A. 1 week

B. 2 weeks

C. 3 days

D. 5 days

Answer 15

B. 2 weeks

Discontinue at least 3 days but ideally 2 weeks.

Minimum: 3 days
Ideal: 2 weeks

Question 16

Which of the following oral hypoglycemic drugs MUST be discontinued 24 hours prior tp surgery?

A. SGLT-2

B. Biguanides

C. DDP-4

D. GLP-1 agonist

Answer 16

A. SGLT-2

Question 17

Valeria as an anxiolytic should be ___ prior to surgery.

A. continued

B. discontinued 24 hrs

C. discontinued 12 hrs

Answer 17

A. continued

MOA: Mild sedative and anxiolytic

Preoperatively, it is continued prior to surgery.

Question 18

Which of the following medications must be withheld 48 hours prior to surgery?

A. NSAIDS

B. Metformin

C. Thiazides

D. Sildenafil

Answer 18

A. NSAIDS

Question 19

A patient is scheduled for a major surgery, which of the following is an accurate pre-operative plan considering the steroid dose of this patient?

A. Take usual morning steroid dose. No supplementation is needed

B. Take usual morning steroid dose and administer 50 mg hydrocortisone IV prior to induction and 25 mg q8h for 24–36 h

C. Take usual morning steroid dose. Administer 100 mg IV hydrocortisone IV prior to induction and 50 mg IV q8h for 24–36 h

D. Skip the morning dose and Administer 250 mg IV hydrocortisone IV prior to induction and 50 mg IV q8h for 24–36 h

Answer 19

C. Take usual morning steroid dose. Administer 100 mg IV hydrocortisone IV prior to induction and 50 mg IV q8h for 24–36 h

Question 20

A patient with chronic kidney disease (CKD) requiring
hemodialysis is evaluated preoperatively. Which of the following abnormalities is common or a patient with CKD?

(A) hypercalcemia
(B) polycythemia
(C) secondary hypoparathyroidism
(D) hypovolemia
(E) hypertension

Answer 20

(E) hypertension

Question 21

A patient with a cecal carcinoma is scheduled or open hemicolectomy. Preoperative assessment identifes a past medical history of COPD. Which of the following is an additional risk actor or postoperative pulmonary complications?

(A) age > 60
(B) asthma
(C) exercise tolerance < 2 blocks
(D) abnormal pulmonary functions tests (PFT’s)
(E) abnormal arterial blood gas (ABG)

Answer 21

(C) exercise tolerance < 2 blocks

Question 22

A patient with a history o medically managed glaucoma presents or preoperative anesthetic assessment. Which glaucoma treatment may increase the duration of action of succinylcholine?

(A) acetazolamide
(B) brimonidine
(C) cyclopentolate
(D) echothiophate
(E) bimatoprost

Answer 22

(D) echothiophate

Echothiophate is a cholinesterase inhibitor. It will prolong
the duration of action of succinylcholine ( or an additional
2 to 14 minutes).

Acetazolamide inhibits carbonic anhydrase and reduces aqueous humor production. Brimonidine (Alphagan) is an alpha-2 receptor agonist. Cyclopentolate is a muscarinic antagonist. Bimatoprost (Lumigan) is a prostaglandin analog that increases uveoscleral outflow.

Question 23

A geriatric patient is scheduled or surgery. Which of
the ollowing intravenous premedications is least likely
to require a dosage adjustment?

(A) midazolam
(B) fentanyl
(C) dexmedetomidine
(D) ranitidine
(E) metoclopramide

Answer 23

(D) ranitidine

For a geriatric patient, ranitidine is least likely to require
dosage adjustment. In general, due to pharmacokinetic or
pharmacodynamic changes, elderly patients often require
a decreased dose of medication compared to younger
adults. Ranitidine, due to age related decreases in renal
function, may require a longer interval (q12–24h) or
repeated dosing but the initial dose (50 mg IV) remains
the same.

Mainly due to changes in brain sensitivity, both midazolam and fentanyl require significant dosage reduction or geriatric patients. Dexmedetomidine may have a higher incidence of bradycardia and hypotension in patients younger than 65 years, and a dose reduction may be required. Geriatric patients may be at increased risk of side effects of metoclopramide (sedation, confusion, parkinsonian- like symptoms, and tardive dyskinesia) and a dosage reduction may be required.

Ref: Miller RD. Miller’s Anesthesia | 8th ed.

Question 24

Which of the following medications should be discontinued at least 24 hours before surgery to reduce the risk o drug-induced LACTIC ACIDOSIS?

(A) glyburide
(B) glipizide
(C) gliclazide
(D) metformin
(E) repaglinide

Answer 24

(D) Metformin

Metformin is a biguanide that decreases hepatic glucose output and enhances the sensitivity of both hepatic and peripheral tissues to insulin. If this fails to control glucose
levels or the diabetes worsens, therapy with insulin and additional oral agents is indicated.

Question 25

TRUE or FALSE

No oral hypoglycemic medications are administered
or advised on the morning of surgery.

Answer 25

TRUE

Question 26

SGLT2 inhibitors must be discontinued ___ before surgery.

A. 3 - 4 days before surgery

B. 1 - 2 days before surgery

C. 24 hours before surgery

D. 12 hours before surgery

Answer 26

A. 3 - 4 days before surgery

Common examples of SGLT-2 Inhibitors

Canagliflozin
Dapagliflozin
Empagliflozin

MOA: Inhibits SGLT2 in the proximal nephron and block glucose reabsorption by the kidney thereby increasing glucosuria

Question 27

A low risk patient with a long standing DM type II should have a glucose monitoring ___ once place on nil per os:

A. every 4 - 6 hrs

B. every 12 hrs

C. every 2 hrs

D. every 8 hrs

Answer 27

Blood glucose levels should be measured before, during, and after surgery. Blood glucose should be monitored every 4 to 6 hours while the patient is nil per os.

Question 28

Which of the following is reported to be the BEST predictor of silent ischemia?

A. METS <4

B. Arrhythmia

C. Autonomic neuropathy

D. Smoking > 20 years

Answer 28

Autonomic neuropathy has been reported as the best predictor of silent ischemia. Because these patients are at very high risk for a silent MI, a preoperative electrocardiogram (ECG) should be obtained to examine for the presence of Q waves.

Question 29

A patient with a diet-controlled GDM is classified as:

A. ASA III

B. ASA II

C. ASA I

Answer 29

B. ASA II

ASA II

Normal pregnancy
well-controlled GDM
controlled pre-eclampsia WITHOUT severe features
controlled gestational hypertension

Question 30

A pediatric patient who is in oncologic remission is classified as:

A. ASA II

B. ASA III

C. ASA IV

Answer 30

A. ASA II

Question 31

A patient with RCRI score of 0 have ___ of cardiovascular complications:

A. 0.4 %

B. 6.6%

C. 2%

Answer 31

A. 0.4 %

In patients with an RCRI score of 0, the risk of perioperative cardiovascular complications is 0.4% compared to approximately 11% in patients with a score of 3 or more

Question 32

A patient with previous history of MI less than 3 months ago was scheduled for elective procedure. After preoperative evaluation, it was determined that the patient METS score is <4. What is the NEXT best step in the pre-operative evaluation of this patient?

A. Dobutamine-stress test

B. Coronary angiogram

C. Proceed with the surgery with precaution

D. Revascularization before surgery

Answer 32

A. Dobutamine-stress test

Question 33

TRUE or FALSE

The ability to exercise without symptoms of ischemia suggests that no further testing is necessary, and exercise ECG stress testing is infrequently indicated.

Answer 33

TRUE

Question 34

TRUE or FALSE

advanced age is independently associated with an increased risk of MACE.

Answer 34

TRUE

Question 35

A patient who’ve had a previous ACS in the absence of coronary intervention should have a delayed noncardiac surgery of at least __

A. 60 days

B. 30 days

C. 15 days

D. 2 weeks

Answer 35

A. 60 days

Recent clinical practice guidelines support delaying noncardiac surgery at least 60 days after an MI in the absence of coronary intervention.

Importantly, recent MI within 6 months of noncardiac surgery appears to be a
risk factor for perioperative stroke

Question 36

What is the OPTIMUM ‘waiting’ period for elective NONCARDIAC surgery after DES (drug-eluting stents)?

A. 2 months

B. 12 months

C. 6 months

Answer 36

12 months

The current 2014 ACC/AHA Clinical Practice Guideline supports the delay of elective noncardiac surgery for 14 days after coronary balloon angioplasty and 30 days after BMS placement.

The optimal waiting period for elective noncardiac surgery after DES placement is 12 months

Question 37

A patient with coronary balloon angioplasty is scheduled for an elective NONCARDIAC surgery. How long can the procedure be delayed based on ACC/AHA guidelines?

A. 1 week

B. 2 weeks

C. 5 days

D. 1 1/2 months

Answer 37

B. 2 weeks

The current 2014 ACC/AHA Clinical Practice Guideline supports the delay of elective noncardiac surgery for 14 days after coronary balloon angioplasty and 30 days after BMS placement.

Coronary balloon angioplasty -* 14 DAYS *

**BMS (bare metal stent) - 30 DAYS! **

Question 38

A 50 year old patient with a significant history of DES 3 weeks ago is scheduled for an ‘elective’ hernia repair. What is the optimum period of waiting before doing the surgery?

A. 12 months

B. 6 months

C. 1 month

Answer 38

A. 12 months

OPTIMUM Period

BMS = 30 days

DES = 365 days

Question 39

Abrupt stoppage of total parenteral nutrition (TPN) would most likely cause:

A. Hypoglycemia
B. Hyperglycemia
C. Hyperphosphatemia
D. Hypophosphatemia

Answer 39

A. Hypoglycemia

this is due to the high circulating level of Insulin

Question 40

Hyperglycemia in hospitalized patients has been defined as:

A. blood glucose 7.8 mmol/L

B. above 120 mg/dL

C. above 180 mg/dL

Answer 40

A. blood glucose 7.8 mmol/L

Question 41

Which of the following diagnostic test is associated to have a higher incidence of post-operative pulmonary complications?

A. Reduced Albumin

B. Elevated Creatinine

C. Elevated BNP

D. Reduced CK-MB

Answer 41

Reduced Albumin

laboratory studies identifying a reduction in serum albumin levels and increased levels of blood urea nitrogen (BUN) appear associated with an increased risk of perioperative pulmonary morbidity.

Question 42

TRUE or FALSE

A laparoscopic surgery, often longer in duration, is associated with DECREASED pulmonary complications compared with an open procedure despite increased anesthesia duration.

Answer 42

TRUE

Mas mataas ang risk ng pulmonary complications sa mga open procedure versus laparoscopic.

How?

Laparoscopic abdominal surgery is considered to cause less pulmonary dysfunction than open abdominal surgery since it causes less incisional pain in the postoperative period and consequently has less effect on postoperative lung oxygenation. While there are many studies in the literature that compared open and laparoscopic surgery regarding their pulmonary effects in procedures such as cholecystectomy, obesity surgery, esophagogastric surgery, and nephrectomy, there are very few such studies on colorectal surgery.

Question 43

cessation of smoking for ___ can decrease carboxyhemoglobin levels, abolish nicotine effects, and improve mucous clearance:

A. 2 days

B. 2 weeks

C. 12 hours

Answer 43

A. 2 days

• cessation of smoking for 2 days can decrease carboxyhemoglobin levels, abolish nicotine effects, and improve mucous clearance.
• smoking cessation for 4 to 8 weeks appears necessary to reduce the rate of postoperative pulmonary complications.

Question 44

Cessation from smoking need this optimum time to reduce post-operative pulmonary complications:

A. 2 - 4 weeks

B. 4 - 8 weeks

C. 1 - 2 weeks

Answer 44

B. 4 - 8 weeks

• smoking cessation for 4 to 8 weeks appears necessary to reduce the rate of postoperative pulmonary complications.

Barash | 9th edit (preoperative evaluation)

Question 45

The image depicted in the dotted line of this flow-volume loop is accurately represented by which pathology?

(A) Bronchial tumor
(B) Chronic asthmatic bronchitis
(C) Morbid obesity
(D) Paralysis of a vocal cord
(E) Subglottic stenosis

Answer 45

(B) Chronic asthmatic bronchitis

Question 46

Which of the following asthma medications is withheld ON THE DAY of surgery?

A. Bronchodilators

B. Inhaled Corticosteroids

C. Oral Corticosteroids

D. Antibiotics

E. None of the above

Answer 46

E. None of the above

• Bronchodilators, corticosteroids (inhaled and oral), and any antibiotics must be continued on the day of surgery.

β-adrenergic agonists are a useful prophylactic intervention to lower the risk of bronchospasm after induction of anesthesia. This therapy can be supplemented
with a short preoperative course of oral corticosteroids
(prednisone 20 mg-60 mg daily for 3-5 days) in any
newly diagnosed or poorly controlled asthmatic patient

Importantly, some asthmatics on chronic corticosteroid
treatment may need perioperative “stress dose steroids.

Question 47

Which of the following parameter is least specific in differentiating restrictive and obstructive lung pathology?

A. Forced vital capacity (FVC)

B. FEV1

C. maximum voluntary ventilation
(MVV)

D. FEV1/FVC ratio

Answer 47

C. maximum voluntary ventilation
(MVV)

The ratio FEV1/FVC is useful in differentiating between restrictive and obstructive pulmonary diseases. This ratio is normal in restrictive disease because both FEV1 and FVC decrease, whereas in obstructive disease the ratio is usually
low because the FEV1 is markedly decreased compared to the FVC.

• MVV is a nonspecific test and is an indicator of both restriction and obstruction.

FEV1/FVC ratio - most useful in differentiating obstructive from restrictive.