BCA Preoperative Evaluation & Risk Assessment 2 — Questions and Answers
Question 1: A 68-year-old patient with severe aortic stenosis (valve area 0.6 cm²) requires emergency hip fracture repair. Which anesthetic consideration is most important?
- Avoid tachycardia and maintain sinus rhythm (Correct answer)
- Induce hypotension to reduce afterload
- Use neuraxial anesthesia exclusively to reduce preload
- Administer beta-blockers to increase diastolic filling time
Correct answer: Avoid tachycardia and maintain sinus rhythm
Severe aortic stenosis requires maintaining sinus rhythm and avoiding tachycardia to preserve adequate diastolic filling and cardiac output.
Question 2: The Revised Cardiac Risk Index (RCRI) assigns one point each for which of the following conditions?
- High-risk surgery, ischemic heart disease, CHF, cerebrovascular disease, diabetes on insulin, creatinine >2.0 mg/dL (Correct answer)
- Age >70, hypertension, smoking, obesity, prior MI, atrial fibrillation
- EF <40%, NYHA class III, prior CABG, renal failure, pulmonary hypertension, diabetes
- Prior cardiac arrest, pacemaker, active angina, CHF, renal insufficiency, peripheral arterial disease
Correct answer: High-risk surgery, ischemic heart disease, CHF, cerebrovascular disease, diabetes on insulin, creatinine >2.0 mg/dL
The RCRI includes six factors: high-risk surgery, ischemic heart disease, CHF, cerebrovascular disease, insulin-dependent diabetes, and creatinine >2.0 mg/dL.
Question 3: A patient is scheduled for elective total knee replacement. Preoperative ECG shows new left bundle branch block (LBBB) not present on prior ECG. What is the most appropriate next step?
- Postpone surgery and refer for cardiology evaluation (Correct answer)
- Proceed with surgery using intraoperative monitoring
- Cancel surgery permanently pending pacemaker placement
- Order cardiac enzymes and proceed if negative
Correct answer: Postpone surgery and refer for cardiology evaluation
New LBBB may indicate acute myocardial ischemia or significant structural heart disease and warrants cardiology evaluation before elective surgery.
Question 4: Which pulmonary function test result most strongly predicts postoperative pulmonary complications after pneumonectomy?
- Predicted postoperative FEV1 <40% of predicted (Correct answer)
- Preoperative FVC <80% of predicted
- DLCO <60% of predicted
- RV/TLC ratio >0.35
Correct answer: Predicted postoperative FEV1 <40% of predicted
Predicted postoperative FEV1 (ppo-FEV1) <40% of predicted is the most established threshold associated with significantly increased postoperative pulmonary complications after lung resection.
Question 5: A patient taking clopidogrel for a drug-eluting coronary stent placed 8 months ago requires urgent colectomy for bowel obstruction. What is the best management strategy?
- Continue clopidogrel perioperatively and use surgical hemostatic techniques (Correct answer)
- Stop clopidogrel 5–7 days before surgery
- Bridge with IV heparin after stopping clopidogrel
- Reverse with platelet transfusion immediately before incision
Correct answer: Continue clopidogrel perioperatively and use surgical hemostatic techniques
For urgent surgery within 12 months of drug-eluting stent placement, continuing antiplatelet therapy is preferred to prevent in-stent thrombosis, with surgical hemostasis techniques employed.
Question 6: Which preoperative factor is most predictive of difficult mask ventilation?
- BMI >26, age >55, history of snoring, no teeth, presence of beard (Correct answer)
- Mallampati class III/IV, short neck, limited neck extension
- Thyromental distance <6 cm, mouth opening <3 cm
- Interincisor distance <2 cm, high arched palate, retrognathia
Correct answer: BMI >26, age >55, history of snoring, no teeth, presence of beard
The MOANS mnemonic (Mask seal difficulty, Obesity/Obstruction, Age >55, No teeth, Stiff lungs/Snoring) identifies predictors of difficult mask ventilation.
Question 7: A 55-year-old woman with systemic lupus erythematosus presents for elective hysterectomy. She takes prednisone 10 mg daily. Which perioperative steroid management is most appropriate?
- Continue home dose and give hydrocortisone 50 mg IV at induction, then 25 mg q8h for 24 hours (Correct answer)
- Double the oral dose on the day of surgery only
- Hold steroids perioperatively to reduce infection risk
- Give methylprednisolone 1 g IV the evening before surgery
Correct answer: Continue home dose and give hydrocortisone 50 mg IV at induction, then 25 mg q8h for 24 hours
Patients on chronic steroids require stress-dose supplementation for major surgery; hydrocortisone 50 mg at induction followed by 25 mg q8h for 24 hours covers HPA axis suppression.
BCA Preoperative Evaluation & Risk Assessment 2
A 68-year-old patient with severe aortic stenosis (valve area 0.6 cm²) requires emergency hip fracture repair.
Which anesthetic consideration is most important?