Lippincott's Anesthesia Review: 1001 Questions and Answers
Chapter 1. Perioperative Evaluation and Management
Preet Singh, Manish Purohit, Ashish Sinha, and Paul Sikka
1. Preoperative application of scopolamine patch to prevent postoperative nausea and vomiting should be avoided in
A. Female, 35 years old
B. Smoker, 20 years old
C. Patient with a blood pressure of 160/96 mm Hg
D. Male, 70 years old
2. Which of the following drugs is least likely to be effective for prophylaxis for postoperative nausea and vomiting?
B. Scopolamine patch
3. Famotidine, when used for stress ulcer prophylaxis, must be avoided preoperatively in which of the following patients?
A. Patients with replaced mitral valve on warfarin
B. Patients with idiopathic thrombocytopenic purpura (ITP) for splenectomy
C. Patients with achalasia cardia for esophageal myotomy
D. Patients with a history of coronary stenting on aspirin
4. Which of the following drugs antagonizes substance P in the central nervous system and is used as premedication to prevent postoperative nausea and vomiting?
5. Which of the following predictors is likely to be associated with lower incidence of perioperative nausea and vomiting?
A. Female gender
B. Use of fentanyl for pain relief
C. Patients with a history of smoking
D. Patients undergoing laparoscopic surgery
6. All of the following have an antiemetic action, except
7. Cefazolin, as a component of perioperative antimicrobial prophylaxis for surgery, must begin within what time before incision?
A. Simultaneously with incision
B. Within 30 minutes prior to incision
C. Within 60 minutes prior to incision
D. Within 120 minutes prior to incision
8. Vancomycin, as a component of perioperative antimicrobial prophylaxis for surgery, must begin within what time before incision?
A. Simultaneously with incision
B. Within 30 minutes prior to incision
C. Within 60 minutes prior to incision
D. Within 120 minutes prior to incision
9. A 65-year-old male with a history of hypertension and diabetes presents to emergency department with altered sensation with a likely subdural hematoma. To assess his cardiorespiratory status, he is asked about his level of physical activity. If he is capable of performing at least which of the following activities independently, he is less likely to have significant cardiopulmonary ailment during surgery?
A. Walk to washroom on level floor
B. Play the accordion
C. Walk one block
D. Climb a flight of stairs
10. 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. 2 mL/kg/min
B. 7 mL/kg/min
C. 3.5 mL/kg/min
D. 5.5 mL/kg/min
11. As per American Society of Regional Anesthesia (ASRA) guidelines, intravenous infusion of unfractionated heparin should be stopped how long prior to a planned epidural?
A. 1 to 1.5 hours
B. 2 to 4 hours
C. at least 12 hours
D. at least 24 hours
12. For emergent surgery, anticoagulation produced by warfarin can be reversed by using
A. Fresh-frozen plasma (FFP)
B. Injectable vitamin K
C. Prothrombin complex concentrate
D. Factor VIII concentrate
13. Neuraxial block is not contraindicated for patients on which of the following drugs?
B. Low-molecular-weight heparin
14. All of the following are risk factors for obstructive sleep apnea, except
B. Short neck
C. Enlarged tonsils
D. Female gender
15. A 70-year-old male, who is diabetic for the last 20 years, is scheduled for an elective surgery. Which of the following is not a sign of autonomic diabetic neuropathy?
A. History of recurrent diarrhea
B. History of postural hypotension
C. History of recurrent constipation
D. History of urinary retention
16. Which of the following perioperative factors in patients undergoing dialysis prior to surgery predicts the possibility of hypotension (due to increased volume removed)?
A. Change in serum sodium
B. Change in body weight
C. Change in serum potassium
D. Change in pH after dialysis
17. A patient with a history of severe asthma is scheduled for an appendectomy. Which of the following induction agents will cause the least respiratory depression?
18. Which of the following drugs can significantly prolong the QT interval on the ECG?
19. Which of the following tests is used to confirm coagulation after stopping low-molecular-weight heparin (LMWH)?
D. None of the above
20. Effect of combined administration of midazolam and fentanyl is
C. Competitively antagonistic
D. Noncompetitively antagonistic
21. Preoperative anesthetic evaluation is likely to bring down the incidence of all the following, except
A. Case cancellations
B. Patient morbidity
C. Preoperative anxiety
D. Direct procedural costs
22. For elective procedures, an anesthesia provider must obtain informed and preferably written consent
A. Just prior to transferring the patient to the operating room for surgery
B. During preoperative anesthetic evaluation
C. At the same time that a surgeon obtains consent for the surgical procedure
D. Just prior to induction of anesthesia in the operating room
23. An optimal preoperative evaluation is designed
A. To screen for and properly manage comorbid conditions
B. To assess the risk of anesthesia and surgery and lower it
C. To identify patients who may require special anesthetic techniques or postoperative care
D. All the above
24. ASA classification for risk stratification is validated for predicting preoperative morbidity associated with the following, except
A. General or regional anesthesia
B. Conscious sedation
C. Monitored anesthesia care
D. Surgical procedure
25. A healthy pregnant patient in labor has which of the following ASA classifications?
26. Sedatives, as premedication, must be avoided in which of the following patients?
A. Uncontrolled hypertensive
B. Toddler for tonsillectomy
C. Brain tumor patients
D. Patients with alcohol abuse
27. As per the American Society of Regional Anesthesia (ASRA) guidelines, which of the following drugs can be continued preoperatively in patients planned for neuraxial blockade for an elective procedure?
D. Low-molecular-weight heparin
28. As per ASA classification, a controlled hypertensive patient with no target end-organ damage scheduled for elective surgery will be classified as
A. ASA I
B. ASA II
C. ASA III
D. ASA VI
29. A brain-dead organ donor undergoing laparotomy for “kidney harvesting” will be classified as an
A. ASA III
B. ASA IV
C. ASA V
D. ASA VI
30. A moribund patient who is not expected to survive without the operation is categorized as an
A. ASA III
B. ASA IV
C. ASA V
D. ASA VI
31. A patient with a history of uncontrolled hypertension, diabetes, and angina, who is to undergo a laparoscopic cholecystectomy, will be classified as an
A. ASA II
B. ASA III
C. ASA IV
D. ASA V
32. A 65-year-old male with a history of mitral valve replacement 2 years back presents for a knee replacement. He is on warfarin since the time of valve replacement. As per ASRA guidelines, the ideal time to stop his warfarin prior to surgery would be
A. 12 hours
B. 3 days
C. 5 days
D. 10 days
33. A 26-year-old female, with a history of rheumatic mitral stenosis, is scheduled for an elective cesarean section at 38 weeks of gestation. Just prior to surgery, she is diagnosed to have atrial fibrillation (AF) with no hemodynamic instability. The first step in preparation for surgery is
A. Perform an echocardiogram to rule out left-atrial clot
B. Synchronized DC cardioversion under sedation
C. Antiarrhythmic medication
D. Plan for therapy postdelivery
34. A 72-year-old patient with a history of hypertension and angina at moderate activity is to undergo a laparoscopic cholecystectomy. Due to decreased effort tolerance and a significant blockade of left anterior descending coronary artery onstress thallium, a preprocedure coronary intervention is planned. Which of the following procedures performed prior to the elective surgery is least likely to delay the laparoscopic surgery?
A. Coronary artery bypass graft (CABG)
B. Percutaneous coronary stenting—bare-metallic stent
C. Percutaneous coronary stenting—drug-eluting stent
D. Percutaneous balloon dilatation
35. Which of the following is not seen as a result of primary renal disease in patients with chronic renal failure?
A. Hypocoagulable state
B. Hypercoagulable state
36. A 2-year-old child is to undergo a tonsillectomy. The child had formula milk 2 hours ago. As per ASA guidelines, optimal NPO status would be to wait another _____ before proceeding to surgery:
A. No waiting, since it is a child
B. 2 hours
C. 4 hours
D. 6 hours
37. A 45-year-old patient is scheduled for an abdominal hysterectomy. She states that her aunt had a severe reaction to anesthesia and was in the ICU for 1 week. You would avoid which of the following drugs for her general anesthesia?
38. Elective surgery should be postponed after a myocardial infarction for at least
A. 30 days
B. 6 weeks
C. 3 months
D. 6 months
39. The most significant risk factor for developing pulmonary complications is
A. Site of surgery (abdominal/thoracic)
B. Presence of respiratory infection
C. Presence of obstructive sleep apnea
40. Maximum international normalized ratio (INR) before proceeding for elective surgery should be
41. A 73-year-old patient has residual weakness on the right arm and leg following a stroke 5 years ago. He is now scheduled for laparoscopic cholecystectomy under general anesthesia. Which of the following sites should be preferably used to monitor the train of four muscle twitches for estimating neuromuscular blockade?
A. Right ulnar nerve–innervated muscles
B. Right posterior tibial nerve–innervated muscles
C. Left ulnar nerve–innervated muscles
D. Left facial nerve
42. A 32-year-old patient after being involved in a road traffic accident due to alcohol intoxication is taken to the operating room for open fracture reduction of an ankle fracture. His blood alcohol level is above the legal limit. Compared to a patient who is not intoxicated with alcohol, you would expect the minimum alveolar concentration (MAC) of sevoflurane to be
D. Unpredictable due to pharmacodynamic variations
43. A 55-year-old patient with a history of asthma and heart failure is to undergo a hernia repair. On physical examination, you notice that the patient is wheezing. Following treatment with albuterol, the patient should be monitored for which electrolyte?
44. Smoking cessation for 24 hours before a scheduled surgery will lead to
A. Improvement of ciliary function
B. Decrease in mucous production
C. Decrease in airway irritability
D. Decrease in level of carboxyhemoglobin
45. Which of the following tests is likely to detect clinically relevant bleeding tendency most efficiently?
A. Activated partial thromboplastin time
B. Prothrombin time
C. Activated clotting time
D. Thromboelastogram (TEG)
46. As per AHA guidelines, which of the following is not a major clinical risk predictor in a patient with cardiac disease scheduled for noncardiac surgery?
A. Recent myocardial infarction
B. Symptomatic mitral stenosis
C. Presence of congestive cardiac failure
D. Uncontrolled systolic hypertension
47. Glycopyrrolate, when given preoperatively, can cause all of the following, except
A. Skin flushing
B. Dry mouth
48. Which of the following is true about metoclopramide?
A. Decreases lower esophageal sphincter tone
B. Delays gastric emptying
C. Can cause extrapyramidal side effects
D. Useful in preventing postoperative nausea
49. Which of the following occurs during the preoxygenation of a patient?
A. Increase in functional residual capacity
C. Increase in CO2 clearance from lungs
D. Increase in closing capacity of lungs
50. Which of the following agents is associated with the highest incidence of hepatitis postoperatively?
51. The inhalation agent of choice in a 2-year-old child for ophthalmologic surgery is
D. Nitrous oxide
52. Which of the following is true of nitrous oxide?
A. Acts on central nervous system GABA receptors
B. Lowers pulmonary vascular resistance
C. Suppresses EEG pattern in the cerebral cortex
D. Precipitates vitamin B12 deficiency anemia
53. The antiemetic effect of propofol is thought to occur due to
A. Depressant effect on the chemoreceptor trigger zone
B. Inhibition of dopamine activity
C. Inhibition of glutamate release
D. All of the above
54. Which of the following is the preferred intravenous agent of induction of anesthesia for maintaining spontaneous breathing and airway tone?
55. Succinylcholine is contraindicated in a patient with
A. Chronic renal failure
B. Duchene muscular dystrophy
C. Myasthenia gravis
D. Patient with full stomach
56. A 75-year-old patient with a history of hypertension is to undergo laparoscopic colectomy for carcinoma colon. Continuing of which of the following antihypertensive drugs, preoperatively, in the geriatric age group, can be associated with profound hypotension on induction of general anesthesia?
B. Angiotensin-converting-enzyme (ACE) inhibitors
57. Which of the following findings in the preoperative evaluation cannot be attributed to obesity with obstructive sleep apnea (OSA) in a patient planned for bariatric surgery?
A. Pulmonary artery hypertension
B. Congestive heart failure
C. Peripheral neuropathy
58. All of the following medications can be administered via an epidural anesthesia, except
59. Ondansetron causes its antiemetic effect by acting as an
A. Agonist at 5-HT2 receptors
B. Antagonist at 5-HT2 receptors
C. Agonist at 5-HT3 receptors
D. Antagonist at 5-HT3 receptors
60. Which of the following statements is false regarding scopolamine patch applied preoperatively?
A. May produce sedation
B. Decreases the risk of nausea
C. Adds to the analgesia
D. Inhibits muscarinic receptors
61. Overdose with dexmedetomidine results in
C. Hypertension and bradycardia
D. Hypotension and bradycardia
62. Abrupt withdrawal of steroids can lead to
A. Malignant hypertension
B. Sickle cell crisis
C. Addisonian crisis
63. Promethazine primarily inhibits which of the following receptors?
64. All of the following surgeries are associated with an increased risk of postoperative nausea and vomiting, except
A. Shoulder arthroscopy
B. Laparoscopic surgery
C. Strabismus repair
65. Abrupt stoppage of total parenteral nutrition (TPN) would most likely cause
66. Glycopyrrolate causes all of the following, except
C. Antisialagogue effect
D. Lowers lower esophageal sphincter tone
67. In general, herbal medications should be stopped before surgery for at least _____ days:
68. Which of the following antibiotics can prolong the action of neuromuscular-blocking drugs?
69. Estrogen in birth control pills increases the perioperative risk of
D. Myocardial infarction
70. A 42-year-old patient is scheduled for a hernia repair under general anesthesia. His medications include fluoxetine, alprazolam, and lithium for bipolar disorder. In the preoperative area, he appears confused, has tremors, and is ataxic. Your next step would be to
A. Cancel the case
B. Proceed with the case
C. Order a lithium blood level
D. Consult a psychiatrist
71. A 34-year-old patient is to undergo an appendectomy under general anesthesia. He is taking a monoamine oxidase inhibitor (MAOI) for depression. Intraoperatively, his blood pressure drops to 72/36 mm Hg and a medication is administered. His blood pressure suddenly increases to 220/120 mm Hg. The most likely medicine that was administered is
72. All of the following are true about diabetic patients, except
A. Patients should take half or one-third of their insulin dose the morning of the surgery
B. Patients should continue their oral hypoglycemic agents the morning of the surgery
C. Finger-stick blood glucose should be tested before taking the patient to the operating room
D. Patient with an insulin pump should continue the insulin at their basal rate
73. Digoxin toxicity is most likely exacerbated by
74. The most common complication of inserting a central venous catheter is
A. Carotid artery puncture
C. Cardiac arrhythmias
D. Air embolism
75. A patient is administered cephalexin preoperatively. Within 5 minutes of starting the antibiotic, the patient starts to wheeze and develops tachycardia, and the blood pressure drops to 78/42 mm Hg. Your next step would be to administer
76. All of the following may occur with an interscalene block, except
A. Subarachnoid injection
B. Radial nerve blockade
C. Median nerve blockade
D. Ulnar nerve blockade
77. An axillary nerve block would not produce loss of sensation of the
A. Lateral aspect of the forearm
B. Medial aspect of the forearm
C. The entire forearm
D. None of the above
78. The femoral nerve lies
A. Medial to the femoral artery
B. Anterior to the femoral artery
C. Posterior to the femoral artery
D. Lateral to the femoral artery
79. All of the following nerves are blocked by an ankle block, except
B. Superficial peroneal
C. Deep peroneal
D. Anterior tibial
80. Sore throat is
A. More common after using an endotracheal tube
B. More common after using a laryngeal mask airway
C. Similar incidence with either endotracheal tube or a laryngeal mask airway
D. More common after using an oral airway
81. A patient with hypertrophic obstructive cardiomyopathy (HOCM) presents with dyspnea and angina on exertion. Which of the following is the best agent to treat these symptoms?
82. St. John wort (Hypericum perforatum) potentiates the effects of
83. The most powerful predictor of atrial fibrillation post–cardiac surgery is
A. History of diabetes
B. History of hypertension
D. Time on bypass
84. A patient with Parkinson disease undergoes a general anesthetic. Your plan to treat his nausea would include all of the following, except
B. Scopolamine patch
85. A 65-year-old patient is being treated for congestive cardiac failure. He is able to take a shower but gets dyspneic on mowing the lawn. His New York Heart Association classification is
A. Class 1
B. Class 2
C. Class 3a
D. Class 3b
86. The percentage of postdural puncture headaches that would resolve spontaneously by 1 week is approximately
87. A 46-year-old lady is seen at the preoperative assessment clinic. She is taking 180 mg/day methadone. The most likely change to be found in her preoperative ECG is
A. Prolonged PR interval
B. Prolonged QTc
C. U wave
D. Tented T-waves
88. You are about to anesthetize a 55-year-old man who is undergoing liver resection for removal of metastatic carcinoid tumor. The drug of choice to treat intraoperative hypotension is
89. You are performing an interscalene brachial plexus block on an awake 40-year-old patient who is healthy with no significant medical history. Soon after injecting 20 mL of 0.25% bupivacaine the patient becomes agitated, has a seizure, and loses consciousness. Your first step in management is
A. Administer intralipid
B. Administer midazolam or propofol to control the seizure
C. Establish airway and give 100% O2 via a face mask
D. Administer epinephrine
90. Patients with dilated cardiomyopathy exhibit all of the following, except
A. Decreased myocardial contractility
B. Afterload should be maximized
C. Increased preload
D. Left ventricular hypertrophy
91. A septic patient has a central venous pressure of 10 mm Hg, a blood pressure of 80/40 mm Hg, and a pulse rate of 96 beats/min. The best agent to treat the hypotension is
92. Which of the following organs is least tolerant of ischemia for removal for transplantation?
93. You have administered a patient 1.2 mg/kg of rocuronium to do an intubation. You are unable to intubate or ventilate the patient and decide to reverse the patient’s paralysis with sugammadex. The dosage you would use is
A. 2 mg/kg
B. 4 mg/kg
C. 8 mg/kg
D. 16 mg/kg
94. A young female patient with anorexia nervosa has just started eating again. After 4 days, she develops dyspnea and is found to have cardiac failure. Which of the following is most important to correct?
95. A pregnant lady is to undergo general anesthesia for acute appendicitis. At what gestational age should you monitor fetal heart rate?
A. 16 weeks
B. 18 weeks
C. 24 weeks
D. 28 weeks
96. Which of the following is the best predictor of a difficult intubation in a morbidly obese patient?
A. Pretracheal tissue volume
B. Body mass index
C. Mallampati score
D. Thyromental distance
97. A patient with a history of chronic obstructive pulmonary disease presents for lung volume–reduction surgery. Which of the following is a contraindication for surgery?
A. Age >60 years
B. Chronic asthma
C. FEV <25%
D. Evidence of bullous disease
98. All of the following help increase the excretion of calcium, except
D. IV crystalloids
99. Which of the following is contraindicated to use during pregnancy?
100. During scoliosis surgery, monitoring of somatosensory-evoked potentials indicates monitoring of
A. Anterior horn
B. Anterior corticospinal tract
C. Dorsal column
D. Spinothalamic tract
101. The desflurane vaporizer is heated because of desflurane’s
A. High vapor pressure
B. High boiling point
C. High minimum alveolar concentration
D. High volatility
102. Which of the following is the most effective way to reduce renal failure in a patient having an abdominal aortic aneurysm repair?
A. Fluid bolus prior to aortic clamping
B. Fluid bolus after aortic clamp release
C. Administration of mannitol
D. Minimization of cross-clamp time
CHAPTER 1 ANSWERS
1. D. Scopolamine, an anticholinergic drug, is often applied as a transdermal patch preoperatively for the prevention of postoperative nausea and vomiting. However, like atropine, and unlike glycopyrrolate, scopolamine passes through the blood–brain barrier and can cause confusion, especially in the elderly. Hence, application of scopolamine patch should be avoided in the elderly. Treatment of scopolamine-induced confusion may require administration of physostigmine.
2. D. Metoclopramide is a prokinetic agent and helps to increase gastric motility. The ASA does not recommend preoperative administration of metoclopramide for prevention of postoperative nausea and vomiting. All the other agents have proven benefit in preventing postoperative nausea and vomiting.
3. B. Famotidine is known to cause thrombocytopenia (both quantitative and qualitative platelet dysfunction). Patients with ITP already have low platelets; thus, such premedication should be avoided. Warfarin does not affect platelet function or number, thus has no relation to perioperative bleeding due to platelet pathology; however, it is an independent risk factor for bleeding.
4. B. Aprepitant is an NK1 receptor antagonist that antagonizes the action of substance P in the central nervous system to prevent nausea and vomiting. Palonosetron is a 5-HT3 antagonist, metoclopramide is an antidopaminergic agent, and prochlorperazine is a dopamine (D2) receptor antagonist (antipsychotic drug) with additional antiemetic activity.
5. C. The Apfel score can be used to predict patients with a high risk for perioperative nausea and vomiting (PONV). It includes four factors: female gender, nonsmoking, postoperative use of opioids, and previous PONV or motion sickness in the patients’ history. Surgeries like laparoscopy, middle-ear surgery, and strabismus surgery are associated with a higher risk of PONV.
6. C. Etomidate administration can cause an increase in the incidence of perioperative nausea and vomiting (PONV). Promethazine, haloperidol, and propofol all are used in the treatment of PONV. The latter two are usually used for the treatment of refractory PONV.
7. C. β-Lactam antibiotics must be given within 60 minutes prior to incision. Vancomycin and fluoroquinolones require administration within 120 minutes prior to incision.
8. D. Vancomycin and fluoroquinolones require administration within 120 minutes prior to incision. β-Lactam antibiotics must be given within 60 minutes prior to incision.
9. D. Effort tolerance of around 4 METs (metabolic equivalent of tasks) or more is suggested to be a good predictor for postoperative cardiopulmonary outcome. These activities are classified as per physical strain involved.
10. C. One metabolic equivalent is defined as the amount of oxygen consumed at rest, and is equal to 3.5 mL O2/kg/min. The energy cost of any activity can be determined by multiplying 3.5 to the oxygen consumption (mL O2/kg/min). METs can be assessed as follows:
• 1 MET—can take care of self (eating, dressing, toilet)
• 4 METs—can walk up a flight of steps or a hill
• 4 to 10 METs—can do heavy household work (scrubbing floors, lifting heavy furniture)
• >10 METs—can participate in strenuous sports (swimming, tennis, basketball, skiing)
11. B. As per ASRA guidelines 2010, heparin infusion should be stopped at least 2 to 4 hours before placing an epidural. This is to prevent the potential formation of an epidural hematoma.
12. A. As per the AHA/ACC Scientific Statement, reversal of warfarin can be achieved by using all, except choice D. However, for emergent surgery the fastest method is the administration of fresh-frozen plasma. Peak action of injectable vitamin K takes up to 6 to 12 hours.
13. C. As per ASRA guidelines (2010), aspirin intake by the patient is no more considered as a contraindication to performing a neuraxial block.
14. D. The assessment of preoperative predictability for obstructive sleep apnea can be done by using the “STOP-BANG” questionnaire. In this scoring, male gender, and not female gender, is classified as a risk factor (S, snoring; T, tired during daytime; O, observed for apnea during sleep; P, high blood pressure; B, BMI >35 kg/m2; A, age >50 years; N, neck circumference >40 cm; G, male gender). In addition to the questionnaire, upper airway anatomical abnormalities that increase the likelihood of obstruction are tonsillar hypertrophy, tumors of the upper airway, or facio maxillary abnormalities.
15. D. All, except choice D, are signs of diabetic autonomic neuropathy. Urinary retention at this age is more likely due to prostate hypertrophy.
16. B. Weight loss due to dialysis is attributed to actual volume (ultrafiltrate) removed from the body. Thus, a high weight loss can predict higher circulatory volume lost, which can lead to poor compensation of hypotension in patients undergoing surgery.
17. A. Ketamine causes the least respiratory depression among the intravenous induction agents. Therefore, it may be beneficial as an induction agent in patients with severe asthma. However, ketamine causes an increase in secretions, and may produce emergence delirium (vivid dreams). Pretreatment with glycopyrrolate and midazolam alleviates these effects of ketamine. The other induction agents cause dose-dependent respiratory depression.
18. B. Droperidol can cause a significant prolongation of the QT interval on the ECG. Patients should have a preoperative ECG, and ECG monitoring should be continued postoperatively for at least 2 hours, before discharging the patient.
19. D. At present, no conventional test (PT, PTT) can be used to quantify the clinical effects of LMWH on the coagulation system. Anti–Factor Xa estimation may be used in specific patients to monitor the coagulative effects of LMWH.
20. B. As these drugs act on different receptors, their effects are generally considered to be synergistic. Patients receiving both these drugs may be prone to greater sedation and respiratory depression than when receiving the drug alone.
21. D. Preoperative evaluation in fact includes a battery of tests and adds additional costs to the total perioperative costs. However, preoperative evaluation is vital, as it recognizes patient comorbidities, which can worsen perioperatively and cause increased patient morbidity. Preoperative evaluation eventually lowers indirect costs that may be incurred to treat the worsening aliment, postoperatively. During preoperative interaction, patient anxiety is usually lowered as the risks and procedure are explained to the patient.
22. B. An anesthesia consent should be obtained during preanesthetic evaluation, whenever possible. This is one of the prime aims that need to be fulfilled as a component of preoperative anesthetic evaluation.
23. D. The goals of preanesthetic evaluation include all those listed in the question. In addition, other targets of preanesthetic evaluation include education of patients and families about anesthesia and the anesthesiologist’s role, obtaining informed consent, motivation of patients to stop smoking and lose weight, or commit to other preventive care.
24. D. ASA classification does not include the nature of procedure in predicting perioperative morbidity and mortality. It only includes patient-based morbidity rather than type of surgery.
25. B. Healthy pregnant patients in labor are classified as an ASA II. Patients with controlled diabetes or essential hypertension are still classified as an ASA II. Presence of preeclampsia will step up the classification to an ASA III.
26. C. Sedatives typically alleviate anxiety in hypertensive patients (preventing blood pressure elevations due to surgery-related anxiety), in patients with chronic alcohol abuse, and in children to maintain cooperation for induction of anesthesia. In neurosurgical patients, sedatives can lead to depression of respiratory drive, which can cause hypercarbia and an increase in intracranial pressure.
27. A. As per ASRA guidelines, warfarin must be stopped at least 5 days prior and clopidogrel 7 to 10 days prior to elective surgery. Low-molecular-weight heparin in therapeutic doses must be stopped at least 24 hours prior, and when being used in prophylactic doses, it must be stopped at least 12 hours prior to an elective surgery requiring central neuraxial blockade. Aspirin use is no more considered as a contraindication to performing a neuraxial block.
28. B. ASA classifies any medical comorbidity without functional limitation (i.e., hypertensive without coronary artery disease or angina) as an ASA II. Once the patient’s activity is limited due to the disease, the patient is then categorized as an ASA III.
29. D. By definition, such patients are categorized as ASA Class VI.
30. C. By definition, these patients require surgery despite being really sick. Most often, the surgical correction of the underlying pathology (that may have led to multiorgan involvement) may be the only option of improving their chances of survival. A hemodynamically unstable patient secondary to perforation peritonitis, with an acute kidney injury, would be an example. Although the patient may be extremely sick, until the perforation peritonitis is surgically treated, the chances of survival may not improve.
31. B. ASA III is a patient with severe systemic disease that is a constant threat to life (functionality incapacitated).
32. C. Warfarin should be stopped at least 5 days prior to surgery. On the day of the surgery, the prothrombin time (international normalized ratio or INR) is checked. An INR of 1.4 or less is desirable to perform the surgery.
33. A. Before any rate/rhythm control in patients likely to have AF for more than 48 hours, left-atrial clots must be ruled out. An undiagnosed clot can lead to catastrophic embolic consequences.
34. D. For a drug-eluting stent, it is advised to avoid elective surgery for a year (to continue dual antiplatelet medication), and for a bare-metallic stent, it is advised to avoid elective surgery for about 4 weeks. Performing laparoscopic surgery post–CABG surgery is highly risky. So when surgery needs to be planned in the near future, the patient should be advised to undergo balloon dilatation and then delay the elective procedure for 2 to 3 weeks thereafter.
35. C. Renal failure can induce platelet dysfunction, and therefore, central neuraxial blockade is still debated in these patients. They also have coagulation factor abnormalities that may predispose them to deep vein thrombosis. Anemia is a result of decreased erythropoietin production and is often labeled as “anemia of chronic disease.”
36. C. As per ASA guidelines, it is recommended to wait at least 6 hours after ingestion of nonhuman milk before performing an elective operation in a child.
37. C. Volatile inhalation agents and succinylcholine are considered triggers for malignant hyperthermia (MH) reaction. MH has a genetic component, and runs in families. Since her aunt had a severe reaction to anesthesia, further details should be obtained from the history. If any doubt about the history, the patient should be assumed to be prone to developing MH. Volatile agents and succinylcholine should be avoided in this patient.
38. B. Elective surgery should be postponed for at least 6 weeks after a myocardial infarction. Risk of reinfarction is approximately 5.5% for surgeries between 0 and 3 months, 2.5% between 3 and 6 months, and 2% after 6 months of a myocardial infarction.
39. A. The most significant risk factor for developing pulmonary complications is the upper abdominal or thoracic site of surgery. As such, all patients undergoing such surgeries should be optimally prepared for the surgery. This includes pulmonary toilet: chest physiotherapy/exercises, and postural drainage of mucus and secretions.
40. C. There is no specific value of INR before a patient is taken to the OR for elective surgery. However, it is recommended that an INR value of 1.4 or less should be aimed for before taking the patient to the OR for elective surgery. In case of emergency, the INR can be normalized by infusing fresh-frozen plasma.
41. C. The paralyzed muscles due to central denervation eventually develop atrophy. Extrajunctional receptors are then synthesized at the muscle sites, which remain resistant to the effects of neuromuscular blockade for varying degrees. Thus, these paralyzed muscles give an exaggerated response on direct stimulation with a nerve stimulator. Therefore, muscle twitch monitoring should be done on the nonaffected sites to correctly monitor the degree of neuromuscular blockade.
42. B. MAC typically is found to be lower for patients on sedatives, anxiolytics, alcohol intoxication, hypothermia, extremes of age, moribund/sick patients, and patients with obtunded consciousness. Chronic alcohol abuse, however, increases MAC.
43. A. All β2 agonists are known to cause internalization of potassium (from plasma to cell), thus causing hypokalemia. This principle is sometimes used in the treatment of patients with hyperkalemia.
44. D. Smoking cessation for 24 hours before surgery reduces carboxyhemoglobin (COHb) levels. Reduced levels of COHb increases levels of oxygenated Hb, which decreases the risk of myocardial ischemia and perioperative cardiac morbidity. Delayed benefits (cessation more than 8 weeks) are known to improve airway immunologic and ciliary function.
45. D. Among all these tests, TEG has the highest positive predictive value for diagnosing a bleeding tendency. Deranged values from other tests listed have not shown to always correlate well with bleeding tendency. For example, the other tests will be deranged in a patient with sepsis but may not show a clinically relevant bleeding tendency.
46. D. All the other choices need evaluation/optimization prior to elective noncardiac surgery. Uncontrolled systolic hypertension without target end-organ damage is a minor predictor/risk factor. It can be usually controlled with intraoperative antihypertensive medications without evidence of significant adverse outcomes.
47. C. Glycopyrrolate is a synthetic quaternary amine with antimuscarinic properties and no central side effects like sedation. All the other choices are as a result of direct consequence of cholinergic blockade.
48. C. Metoclopramide is a prokinetic agent that enhances gastric clearance and increases lower esophageal sphincter tone, preventing vomiting, but may not actually work for nausea (vomiting rather than nausea is prevented). It blocks the dopaminergic receptors to cause parkinsonism-like extrapyramidal side effects.
49. B. Preoxygenation of lungs primarily acts to increase safe apnea time by denitrogenating functional residual capacity (FRC) and increasing dissolved oxygen content in the blood. It does not alter any physical measurements of lungs; that is, it has no effect on FRC or on closing volume/capacity.
50. A. Halothane, especially on repeated administration, can cause two subtypes of hepatitis (type 1 is immunogenic—mild—and type 2 is due to direct effect of halothane on liver cells). The incidence of halothane hepatitis is around 1 in 10,000 to 1 in 35,000 halothane anesthetics.
51. C. Both halothane and sevoflurane have been used for inhalation induction in the pediatric population. Sevoflurane has largely replaced halothane due to a better safety profile, and has emerged as the induction agent of choice in pediatric population.
52. D. Nitrous oxide is known to inhibit the enzyme “methionine synthase,” inhibiting DNA synthesis and precipitating B12 deficiency, causing pernicious megaloblastic anemia. Nitrous oxide is also known to act on NMDA receptors and also increase pulmonary vascular resistance.
53. D. All the mechanisms have been proposed for propofol in preventing nausea and vomiting in the postoperative period (PONV). Propofol, when used, is used in refractory cases of PONV and in low doses.
54. C. Ketamine preserves spontaneous respiration and airway tone without causing apnea at induction doses. Propofol and benzodiazepines are associated with respiratory depression at induction doses and cause apnea.
55. B. Succinylcholine should not be used in patients with a history of muscular dystrophy or patients with a history of malignant hyperthermia. Myasthenia gravis patients may show resistance to Phase I block of succinylcholine. In patients with full stomach, succinylcholine is used in “rapid sequence intubation” to prevent aspiration.
56. B. Multiple studies have shown propensity of ACE inhibitors to precipitate profound hypotension at induction of general anesthesia, especially in the geriatric age group. Hence, ACE inhibitors should be with held on the day of the surgery, especially in the elderly and for major surgeries.
57. D. Morbidly obese patients with OSA are often subject to persistent hypoxia, which leads to increased pulmonary vascular resistance, eventually leading to pulmonary artery hypertension. Obese patients are also known to have a higher incidence of cardiac problems, including a dilated heart and heart failure. Compression neuropathies are also common in this subpopulation. Dementia is a central-nervous-system–related complication not associated directly with obesity.
58. D. Remifentanil preparations available in the market have glycine as the preservative, which can cause direct neurotoxicity. Thus, it is recommended that remifentanil preparations be not used for central neuraxial blockade.
59. D. Ondansetron exerts its antiemetic effect by acting as an antagonist on the 5-HT3 receptors. Drugs in the same category include palonosetron and granisetron. Rarely reported side effects of these agents include QT prolongation, hypotension, and headache.
60. C. Scopolamine is an antimuscarinic drug that can cross the blood–brain barrier and cause sedation and confusion, especially in the elderly. It does not produce analgesia.
61. D. Dexmedetomidine is an α2 receptor agonist, with about eight times greater affinity for the receptor than clonidine. Continuous infusion is more likely to result in hypotension and bradycardia.
62. C. Addisonian crisis or acute adrenal insufficiency during the perioperative period occurs in patients with known adrenal insufficiency or in those receiving chronic steroid therapy. The latter causes hypothalamic–pituitary axis suppression. Patients with adrenal insufficiency may present with refractory shock with electrolyte and glucose abnormalities. Treatment consists of administration of hydrocortisone and correction of associated derangements.
63. B. Promethazine is commonly used as an antiemetic. It has antidopaminergic activity, and in addition also has antihistaminic and anti–α-adrenergic activity.
64. A. Factors that are associated with an increased risk of postoperative nausea and vomiting include previous history of postoperative nausea and vomiting, female gender, obesity, nonsmoking, pain, eye or ear surgery, laparoscopic surgery, anesthetic drugs, and gastric distention.
65. A. Abrupt withdrawal of TPN will most commonly result in hypoglycemia due to the high circulating insulin levels.
66. A. Glycopyrrolate is an anticholinergic drug with a quaternary ammonium structure, which prevents it from crossing the blood–brain barrier. Therefore, it has no central nervous system effects (sedation). Glycopyrrolate increases the heart rate, causes dryness of secretions, and lowers the lower esophageal sphincter tone. The latter may predispose a patient to pulmonary aspiration of gastric contents.
67. B. Patients taking herbal medications for their alleged benefits are often unaware of their potential side effects (bleeding tendency, platelet dysfunction, etc.). Most medications must be stopped for at least 7 days prior to surgery.
68. A. Gentamicin is an aminoglycoside antibiotic that blocks acetylcholine release from the presynaptic terminals and reduces postsynaptic responsiveness. This may prolong neuromuscular blockade associated with nondepolarizing muscle relaxants.
69. B. Estrogen intake can lead to a hypercoagulable state, predisposing women to thromboembolic events. Other risk factors for thromboembolism include major surgery, multiple trauma (hip fracture), lower extremity paralysis, increasing age, cardiac or respiratory failure, prolonged immobility, presence of central venous lines, and a wide variety of hematologic conditions (inherited or acquired).
70. C. Because of its narrow therapeutic index, lithium dosing requires constant surveillance with monitoring of levels and dosage adjustment. Three types of lithium intoxication can occur—acute, acute or chronic, and chronic. Chronic lithium intoxication occurs in those patients on long-term lithium therapy.
• Mild toxicity: manifests as lethargy, drowsiness, coarse hand tremor, muscle weakness, nausea, vomiting, and diarrhea
• Moderate toxicity: manifests as confusion, dysarthria, nystagmus, ataxia, myoclonic twitches, and flat or inverted T-waves on ECG
• Severe toxicity: may be life-threatening. It may present with grossly impaired consciousness, increased deep tendon reflexes, seizures, syncope, renal insufficiency, coma, and death.
71. A. Patients under treatment with MAOIs have an increased availability of endogenous norepinephrine. Therefore, treatment with an indirect-acting drug such as ephedrine can lead to an exaggerated response. Hypotension in these patients is better managed with a direct-acting drug such as phenylephrine.
72. B. Patients taking oral hypoglycemic agents may experience delayed hypoglycemia in the absence of caloric intake in the intraoperative and postoperative periods. Hence, patients should be advised not to take oral hypoglycemic agents the morning of the surgery. In addition, metformin should be stopped at least 48 hours before surgery as it may precipitate the development of lactic acidosis during surgery. Patients on an insulin pump should continue the insulin at the basal rate.
73. B. Digoxin is an inotrope that blocks the Na+/K+ ATPase pump on the myocardial cell. It causes calcium ions to enter the cells, but causes a net K+ loss from the cell. Thus, hypokalemia, more so than hypercalcemia, will exacerbate digitalis toxicity. Signs and symptoms of digoxin toxicity include drowsiness or confusion, nausea/vomiting, loss of appetite, diarrhea, disturbed color vision (yellow or green halos around objects), agitation, and cardiac dysrhythmias. Characteristic EKG changes include bradycardia, a prolonged PR interval, or an accelerated junctional rhythm.
74. C. During central line insertion, the guide wire or the tip of the catheter enters the right atrium and may result in an arrhythmia, which returns to sinus rhythm when the guide wire/catheter tip is withdrawn out of the heart.
75. C. Antibiotic allergies may result in an anaphylactic or anaphylactoid reaction. Based on the patient’s presentation, anaphylactic shock is the most consistent diagnosis and needs to be treated with epinephrine first, which reverses most of the manifestations of anaphylaxis.
76. D. The ulnar nerve is frequently spared with an interscalene block. Complications of an interscalene block include stellate ganglion block, phrenic nerve block, recurrent laryngeal nerve block, Horner syndrome, vertebral artery injection, epidural/subarachnoid/subdural injection, and pneumothorax.
77. A. An axillary nerve block produces blockade of the median, ulnar, and the radial nerves. Sensation to the lateral aspect of the forearm is provided by the musculocutaneous nerve, which must be blocked separately (deep injection into the coracobrachialis muscle).
78. D. The femoral nerve lies lateral to the femoral artery, which is lateral to the femoral vein (VAN—vein, artery, nerve; medial to lateral).
79. D. The ankle block blocks the deep peroneal nerve, the saphenous nerve, the posterior tibial nerve, the sural nerve, and the superficial peroneal nerve.
80. A. Laryngopharyngitis is more common after an endotracheal intubation than when using a laryngeal mask airway. The incidence of sore throat can vary from 15% to 40%, and depends on operator experience (less trauma). Use of smaller endotracheal tubes, smaller cuff sizes (less area of contact with tracheal mucosa), and low pressure in the tracheal cuff decrease the incidence of postoperative sore throat. Using lidocaine jelly to lubricate the endotracheal tube (rather than lubricating jelly) increases the incidence of sore throat. Most cases of sore throat resolve spontaneously.
81. B. In HOCM, obstruction of the ventricular outflow tract can occur from systolic anterior motion of the mitral valve against the hypertrophied septum. In patients with a severe HOCM, myocardial depression is beneficial, which can be obtained by using β-blockers (metoprolol) or calcium channel blockers.
82. D. St. John wort is a commonly used herbal medication that is a CYP2C19- and CYP3A4 inducer. As clopidogrel is activated by the cytochrome P450 system, St. John wort may be used to increase the effect of clopidogrel in hyporesponders. It reduces the effect of warfarin and heparin, with little effect on aspirin.
83. C. Advanced age is the most important predictor of atrial fibrillation not only in patients following cardiac surgery but also in the general population.
84. C. Parkinson disease is characterized by a loss of dopamine in the nigrostriatum, resulting in bradykinesia, rigidity, postural instability, and pill-rolling resting tremor. Metoclopramide (and droperidol) has significant antidopaminergic properties and should be avoided in these patients in the treatment of nausea and vomiting.
85. B. The New York Heart Association classification for heart failure is based on both a functional and objective assessment of the patient’s capabilities and symptoms. This patient is asymptomatic at rest and can go about his activities of daily living without issues. However, with more strenuous activity, he becomes dyspneic. His classification would, therefore, be 2 (Tables 1-1 and 1-2).
Table 1-1 Functional capacity: How a patient with cardiac disease feels during physical activity
Class I: Patients with cardiac disease but resulting in no limitation of physical activity.
Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
Class II: Patients with cardiac disease resulting in slight limitation of physical activity.
They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
Class III: Patients with cardiac disease resulting in marked limitation of physical activity.
They are comfortable at rest. Less-than-ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.
Table 1-2 Objective assessment
Class A: No objective evidence of cardiovascular disease.
No symptoms and no limitation in ordinary physical activity.
Class B: Objective evidence of minimal cardiovascular disease.
Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
Class C: Objective evidence of moderately severe cardiovascular disease.
Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
Class D: Objective evidence of severe cardiovascular disease.
Severe limitations. Experiences symptoms even while at rest.
86. D. In the event of a postdural puncture headache (PDPH), 53% of headaches resolve in 4 days, 72% in 7 days, and 85% within 6 weeks. Mild–moderate PDPH is usually treated conservatively (fluids, caffeine drinks, analgesics). Severe PDPH may require an epidural blood patch.
87. B. Following a rash of sudden deaths in patients taking methadone, the FDA in 2006 issued a black box warning for all practitioners, specifically detailing the high risk of prolonged QT syndrome and sudden death in patients prescribed this medication.
88. A. Surgery for carcinoid tumor debulking or resection may precipitate a carcinoid crisis in the patient consisting of flushing, hypotension, bronchospasm, acidosis, and ventricular tachycardia. Patients who received octreotide experienced no significant intraoperative complications.
89. C. Injection of large amount of local anesthetic into the vertebral artery or into the subarachnoid or subdural space resulting in a seizure is a well-known complication of the interscalene block. Treatment for this patient is to first establish an airway (ABCs) and then treat the seizure.
90. B. Patients with dilated cardiomyopathy are extremely sensitive to changes in afterload. Therefore, afterload should be minimized to maintain stroke volume.
91. C. In septic shock, both dopamine and norepinephrine can be used to treat persistent hypotension. However, dopamine may promote further tissue acidosis in the splanchnic circulation, whereas norepinephrine does not, thus making it the drug of choice for this scenario.
92. B. The heart, because of its high oxygen requirements, is the least tolerant of ischemia. Hyperkalemic crystalloid cardioplegia at 4°C for a maximum of 4 hours is used to preserve the heart. Thus, reducing the ischemic time of donor hearts will decrease morbidity and costs of cardiac transplantations.
93. D. Sugammadex reverses neuromuscular blockade by nondepolarizing muscle relaxants by directly binding to rocuronium, vecuronium, and pancuronium, without any side effects. Reversal of neuromuscular blockade is achieved in a dose-dependent manner and can be used in the event of failed intubation. For normal reversal, that is, with two twitches, the dose is 2 mg/kg. When the blockade is deeper, the dose must be increased. When reversing following a failed intubation, a dose of 8 mg/kg of sugammadex will effectively reverse rocuronium given at 0.6 mg/kg. If the dose of rocuronium given is 1.2 mg/kg, reversal with sugammadex requires a dose of 16 mg/kg.
94. B. With prolonged periods of starvation followed by reintroduction of enteral or parenteral nutrition, the increased release of pancreatic insulin leads to an anabolic state and an intracellular shift of phosphate, magnesium, and potassium. Of these derangements, hypophosphatemia leads to the most severe conditions, including cardiac failure.
95. C. Fetal heart rate and uterine monitoring should be performed during induction, emergence, recovery, and, if possible, during the surgery in any pregnancy of more than 24 weeks’ gestation. The fetus becomes viable at this gestation age.
96. A. Airway management in obese patients begins first with an adequate physical exam as these patients are more likely to be both more difficult to ventilate and to intubate. The best predictor of difficulty is a short, thick neck (pretracheal tissue volume) and a history of obstructive sleep apnea.
97. C. In pulmonary resections, preoperative impairment is directly related to operative risk. Using routine pulmonary function tests, criteria have been established for high-risk patients.
• PaCO2 >45 mm Hg or PaO2 <50 mm Hg on room air
• FEV <25%
• FEV1 <2 L preoperatively or <0.8 L or <40% of predicted postoperatively
• FEV1/FVC <50% predicted
• Maximum breathing capacity <50% of predicted
• Maximum VO2 <10 mL/kg/min
98. A. Bisphosphonates are used in the treatment of osteoporosis as they inhibit osteoclastic resorption of bone. Biphosphonates do not affect the excretion of calcium.
99. B. Enalapril exposure during the first trimester of pregnancy has been associated with multiple fetal defects, affecting the cardiac, pulmonary, renal, and musculoskeletal systems.
100. C. Somatosensory-evoked potentials are usually monitored on the posterior tibial nerves of the legs during spinal surgery and are used to assess the integrity of the dorsal columns of the spinal cord.
101. A. The main issue with desflurane is that it has a high saturated vapor pressure at room temperature (669 mm Hg at 20°C). It boils at just 22.8°C compared with sevoflurane at 58.5°C or isoflurane at 48.5°C. Therefore, the desflurane vaporizer is heated to 39°C and pressurized at 2 atm.
102. D. The incidence of renal failure after abdominal aortic aneurysm surgery is 5.4%, of which 0.6% requires hemodialysis. Loop diuretics (furosemide), dopamine, mannitol, fenoldopam, and N-acetylcysteine are proposed renal protective agents; however, there is no concrete evidence to support their use. The mainstay of renal preservation is by reducing aortic cross-clamping time, adequate fluid resuscitation, and avoidance of nephrotoxins (nonsteroidal anti-inflammatory drugs, angiotensin-converting-enzyme inhibitors, aminoglycoside antibiotics).