6.23.16 - Pre-OP Evaluation

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| By Aco2118
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Aco2118
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6.23.16 - Pre-OP Evaluation - Quiz


6.23.16 Pre-conference comprehension quiz


Questions and Answers
  • 1. 

    A 52 year-old woman with chest pain is considered for coronary angiography because of her risk factors. Which of the following statements is true?

    • A.

      Atypical patients with borderline positive results of stress tests need arteriography

    • B.

      Patients who need valve procedures do not need arteriography

    • C.

      All patients with typical anginal symptoms need coronary arteriography

    • D.

      Patients with refractory heart failure awaiting cardiac transplantation need coronary arteriography

    Correct Answer
    A. Atypical patients with borderline positive results of stress tests need arteriography
    Explanation
    Patients with atypical symptoms and borderline positive results on stress tests may still require coronary angiography. This is because these patients have a higher likelihood of having significant coronary artery disease, and angiography can provide more accurate information about the extent of the disease. The presence of risk factors also increases the likelihood of significant disease in these patients. Therefore, arteriography is necessary to confirm the diagnosis and guide further management in these individuals.

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  • 2. 

    A 65 year-old man with a history of CAD and recent MI needs elective colon resection for a non-obstructing neoplasm. Which of the following factors adversely affects the risk of perioperative cardiac complications and re-infarction for this patient?

    • A.

      Prior CABG for CAD

    • B.

      Length of surgical procedure less than 3 hours

    • C.

      One or two ventricular beats per minute on an EKG rhythm strip

    • D.

      Withdrawal of medical therapy with beta blockers

    • E.

      The anesthetic technique used

    Correct Answer
    D. Withdrawal of medical therapy with beta blockers
    Explanation
    Withdrawal of medical therapy with beta blockers can adversely affect the risk of perioperative cardiac complications and re-infarction for this patient. Beta blockers are commonly used in patients with CAD to reduce the risk of cardiac events. Abrupt withdrawal of beta blockers can lead to rebound hypertension, increased heart rate, and increased myocardial oxygen demand, which can increase the risk of perioperative cardiac complications and re-infarction. Therefore, it is important to continue beta blocker therapy perioperatively in patients with CAD.

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  • 3. 

    A 68 year-old man with severe arthritis of both knees is scheduled to undergo a major hepatic resection. He has no cardiac symptoms and his EKG is normal. He should undergo:

    • A.

      Cardiac catheterization

    • B.

      Treadmill stress echocardiography

    • C.

      Trans-esophageal 2-D echocardiography before and after administration of dobutamine

    • D.

      Hepatectomy without further cardiac evaluation

    • E.

      Dipyridamole-thallium cardiac imaging

    Correct Answer
    D. Hepatectomy without further cardiac evaluation
    Explanation
    The patient in this scenario is a 68-year-old man with severe arthritis of both knees who is scheduled to undergo a major hepatic resection. He has no cardiac symptoms and his EKG is normal. Based on this information, it is reasonable to proceed with the hepatectomy without further cardiac evaluation. The absence of cardiac symptoms and normal EKG suggest a low risk for significant cardiac disease. Additional cardiac evaluations such as cardiac catheterization, stress echocardiography, or cardiac imaging with dobutamine or dipyridamole-thallium would not be necessary in this case.

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  • 4. 

    Anesthetic techniques used in the care of patients with severe pulmonary disease include:

    • A.

      A choice of anesthetic that produces bronchodilation

    • B.

      The use of epidural analgesia for post-operative pain control

    • C.

      Intubation at a deep level of anesthesia

    • D.

      All of the above

    Correct Answer
    D. All of the above
    Explanation
    Patients with severe pulmonary disease often have compromised lung function, making it important to choose an anesthetic technique that minimizes respiratory depression. An anesthetic that produces bronchodilation can help improve airway function and reduce the risk of complications. Epidural analgesia is preferred for post-operative pain control as it avoids the use of systemic opioids, which can depress respiration. Intubating the patient at a deep level of anesthesia ensures a smooth intubation process and reduces the risk of bronchospasm or coughing. Therefore, all of the above choices are appropriate anesthetic techniques for patients with severe pulmonary disease.

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  • 5. 

    A 42 year-old attorney who does not have symptoms undergoes a routine exercise test that has a positive result for myocardial ischemia. Which of the following statements is true?

    • A.

      This event is rare because fewer than 5% of patients with CAD have no symptoms with exercise

    • B.

      Dyspnea on exertion can represent an angina equivalent

    • C.

      Such a condition can progress to heart failure from non-ischemia cardiomyopathy

    • D.

      Typical angina pectoris is promptly relieved by increased activity

    Correct Answer
    B. Dyspnea on exertion can represent an angina equivalent
    Explanation
    Dyspnea on exertion can represent an angina equivalent. This means that experiencing shortness of breath during physical activity can be a symptom of myocardial ischemia, even if the person does not experience chest pain. Angina equivalent refers to symptoms other than chest pain that can indicate a heart condition. In this case, the positive exercise test for myocardial ischemia suggests that the attorney may have a heart condition, despite not having any symptoms.

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  • 6. 

    Choose the correct ASA Class for the following patients:29 year-old female with exercise-induced asthma booked for an elective knee arthroscopy, ACL repair

    • A.

      ASA Class I

    • B.

      ASA Class II

    • C.

      ASA Class III

    • D.

      ASA Class IV

    • E.

      ASA Class V

    • F.

      ASA Class VI

    Correct Answer
    B. ASA Class II
    Explanation
    The correct answer is ASA Class II. ASA (American Society of Anesthesiologists) classification is used to assess the overall health status of a patient before surgery. ASA Class II is assigned to patients with mild systemic disease, in this case, exercise-induced asthma. These patients have well-controlled disease and are able to perform daily activities without limitations. They have a low risk of complications during surgery.

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  • 7. 

    57 year-old man with alcoholic cirrhosis, history of esophageal variceal bleed, history of encephalopathy, booked for open portal-mesenteric shunt

    • A.

      ASA Class I

    • B.

      ASA Class II

    • C.

      ASA Class III

    • D.

      ASA Class IV

    • E.

      ASA Class V

    • F.

      ASA Class VI

    Correct Answer
    E. ASA Class V
    Explanation
    The correct answer is ASA Class V. ASA classifies the physical status of patients before surgery, with Class V indicating a moribund patient who is not expected to survive without the surgery. In this case, the patient has alcoholic cirrhosis, a history of esophageal variceal bleed, and encephalopathy, indicating severe liver disease and complications. This patient's condition is critical, and without the portal-mesenteric shunt, their survival is unlikely.

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  • 8. 

    Which of the following is NOT considered a RCRI risk factor?

    • A.

      History of CHF

    • B.

      History of diabetes

    • C.

      Serum creatinine > 2.0 mg/dL

    • D.

      History of COPD on home O2

    Correct Answer
    D. History of COPD on home O2
    Explanation
    The RCRI (Revised Cardiac Risk Index) is a risk assessment tool used to predict the risk of cardiac complications following non-cardiac surgery. It includes various risk factors such as history of CHF, history of diabetes, and serum creatinine > 2.0 mg/dL. However, a history of COPD on home O2 is not considered a risk factor in the RCRI. This may be because COPD itself is already a risk factor for cardiac complications, and the use of home oxygen therapy may indicate more severe disease but does not add additional risk beyond the presence of COPD.

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  • 9. 

    A 55 year-old man presents to your office with a painful groin bulge that has been growing for the past 6 months. Eighteen months ago, he was admitted with acute-onset chest pain, found to have elevated troponins, and had two bare metal stents placed. His medications include a beta blocker, a statin, an ACE-inhibitor, Plavix, and Aspirin. How should you manage this patient's medication regimen perioperatively?

    • A.

      Continue beta blocker, continue statin, HOLD ACE-i, continue Aspirin, HOLD Plavix for 5 days pre-operatively

    • B.

      Continue beta blocker, continue statin, continue ACE-i, HOLD both Aspirin and Plavix for 5 days pre-operatively

    • C.

      HOLD beta blocker, continue statin, HOLD ACE-i, HOLD both Aspirin and Plavix for 5 days pre-operatively

    • D.

      Kindly refer the patient elsewhere

    Correct Answer
    A. Continue beta blocker, continue statin, HOLD ACE-i, continue Aspirin, HOLD Plavix for 5 days pre-operatively
    Explanation
    The patient in this scenario has a growing painful groin bulge, which is likely a hernia. The fact that he had elevated troponins and underwent stent placement in the past suggests that he has coronary artery disease. The medications he is currently taking, including the beta blocker and statin, are important for managing his cardiovascular health. However, the ACE-inhibitor, Plavix, and Aspirin may increase the risk of bleeding during surgery. Therefore, it is recommended to continue the beta blocker and statin for cardiovascular protection, hold the ACE-inhibitor to minimize the risk of hypotension during surgery, continue Aspirin for its antiplatelet effects, and hold Plavix for 5 days pre-operatively to reduce the risk of bleeding.

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  • 10. 

    Which of the following patients should receive pre-op PT/INR and PTT before an elective umbilical hernia repair?

    • A.

      54 year-old woman with no past medical history who takes a prophylactic baby aspirin daily

    • B.

      45 year-old man with obesity, type II diabetes, and biopsy-proven non-alcoholic fatty liver disease

    • C.

      21 year-old man with history of prior umbilical hernia repair

    • D.

      82 year-old man with hypertension and hyperlipidemia, but no history of coronary or cerebrovascular events

    Correct Answer
    B. 45 year-old man with obesity, type II diabetes, and biopsy-proven non-alcoholic fatty liver disease
    Explanation
    The 45-year-old man with obesity, type II diabetes, and biopsy-proven non-alcoholic fatty liver disease should receive pre-op PT/INR and PTT before an elective umbilical hernia repair. Non-alcoholic fatty liver disease is associated with impaired liver function and coagulopathy, which can increase the risk of bleeding during surgery. Therefore, it is important to assess the patient's clotting profile before the procedure to ensure safe surgical outcomes.

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