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ABSITE - Preoperative Evaluation – Questions and Answers
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ABSITE - Preoperative Evaluation – Questions and Answers
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ABSITE - Preoperative Evaluation –Questions and Answers
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 - Correct Answers -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. 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. - Correct Answers -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?
A. Inability to walk two blocks
B. History of diabetes mellitus
C. History of hyperlipidemia
D. Age over 60 years
E. High-risk surgical procedure - Correct Answers -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
E. ACE inhibitor, aspirin, and statin - Correct Answers -D
Beta blockers and statins have been demonstrated to lower cardiac risk and should be
continued perioperatively. Clopidogrel (Plavix) is difficult to reverse and should be
discontinued preoperatively if there is a risk of bleeding. He should also receive low
molecular weight heparin for prophylaxis. There is no clear indication to add aspirin.
A 65-year-old woman needs a mastectomy and reconstruction for breast cancer. She
had coronary artery drug-eluting stents placed 14 months ago following a STEMI. She
takes warfarin for atrial fibrillation as well as Plavix and aspirin. She has shortness of
breath and ankle edema without chest pain. There are bibasilar rales on chest
examination. She hasn't seen her cardiologist in 3 months. Which of the following is her
major cardiac risk factor, as determined by a Revised Cardiac Risk Index?
A. Atrial fibrillation
B. Congestive heart failure
C. Coronary artery disease
D. The presence of drug-eluting stents - Correct Answers -B
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