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ABSITE - Preoperative
Evaluation Questions and Correct Answers
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A 78-year-old man is brought to your office in a wheelchair. He says his abdominal wall
hernia has been getting bigger and wonders if he needs surgery. He looks thin and pale, but
in no distress. He is mildly hypertensive (150/90), had a CABG 3 years prior, and is on a
statin and a diuretic. He feels weak, his appetite is poor, and he lives in a skilled nursing
facility. He has a 10x8 non- incarcerated midline incisional hernia. His postoperative risk is
best determined by which of the following?
A. Echocardiogram
B. Pulmonary function testing
C. Frailty index
D. Serum electrolytes
E. Abdominal CT scan
✓ C.
✓
✓ Frailty has gained in importance as a predictor of post-operative outcomes, especially in
the geriatric population. The frailty index includes functional, nutritional and Charlson
Comorbidity Index. This patient had a moderate cardiac risk. His procedure is elective and
a frailty assessment would likely make him a significant risk.
A 56-year-old female is scheduled to undergo a total thyroidectomy for papillary carcinoma.
She is currently taking warfarin (Coumadin) 5 mg daily due to a femoral DVT 4 months ago.
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Her current INR is 2.9. Regarding her anticoagulation regimen, what is the most appropriate
course of action before surgery?
A. Decrease Coumadin dose to 1 mg daily 7 days before surgery.
B. Decrease Coumadin dose to 1 mg daily 5 days before surgery.
C. Stop Coumadin 7 days before surgery.
D. Stop Coumadin 5 days before surgery.
E. Stop Coumadin 3 days before surgery.
✓ D
✓
✓ The usual recommendation is to withhold warfarin starting 4 to 5 days preoperatively (if
the INR is between 2.0 and 3.0) to allow the INR to decrease to less than 1.5, which is a
level considered safe for surgical procedures and neuraxial blockade. Only if the INR is
greater than 3.0 is it usually necessary to stop warfarin longer than 4 to 5 days. If the
INR is higher than 1.8 the day of surgery, a small dose of vitamin K (1 to 5 mg
administrated orally or subcutaneously) can reverse anticoagulation.
A 61-year-old male with pancreatic cancer presents for preoperative evaluation prior to
pancreaticoduodenectomy. He is unable to walk two city blocks. His history is significant for
GERD, hyperlipidemia and diabetes mellitus. Which of the following is an indication that this
patient should undergo a preoperative echocardiogram?
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E. High-risk surgical procedure
✓ A
✓
✓ Echocardiography testing preoperatively should be used selectively in patients at high risk
for cardiac complications perioperatively. This includes patients who are unable to achieve
four metabolic equivalents (METs), defined as climbing two flights of stairs or walking
four city blocks. Achieving less than 4 METs indicates poor cardiac reserve, and
echocardiogram is indicated before intermediate or major risk surgery. Diabetes,
hyperlipidemia, age, and the operation risk are not reasons for preoperative
echocardiography.
A 75-year-old man complains of severe rest pain in his right leg. He has no pulse in the
femoral artery or below with an ABI index of .2, but no gangrene. He has pulses in the left
leg. His BP is 150/80 mmHg, pulse 60 bpm, RR 18 breaths/min. He is on clopidogrel (Plavix),
a beta blocker, and a statin. His EKG and echocardiogram show no acute changes and his
ejection fraction is 60%. Which of the following medications should he receive the day of
surgery?
A. Beta blocker alone
B. Clopidogrel and statin
C. Beta blocker and statin
D. Beta blocker, statin, and low molecular weight heparin
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