General Surgery Board Review General Surgery Board Review Perioperative Care & Complications 2 — Questions and Answers
Question 1: What is the most appropriate immediate treatment for suspected malignant hyperthermia intraoperatively?
- Ice packs and cooling blankets alone
- Administer dantrolene 2.5 mg/kg IV immediately (Correct answer)
- Administer succinylcholine to relax muscles
- Increase inspired oxygen and await spontaneous resolution
Correct answer: Administer dantrolene 2.5 mg/kg IV immediately
Dantrolene 2.5 mg/kg IV is the specific antidote for malignant hyperthermia; it inhibits ryanodine receptor-mediated calcium release from the sarcoplasmic reticulum.
Question 2: Enhanced Recovery After Surgery (ERAS) protocols reduce surgical stress and hospital length of stay primarily through which mechanism?
- Aggressive opioid analgesia postoperatively
- Multimodal, evidence-based care bundles reducing physiologic stress response (Correct answer)
- Routine nasogastric tube decompression
- Mandatory 5-day bed rest postoperatively
Correct answer: Multimodal, evidence-based care bundles reducing physiologic stress response
ERAS bundles combine preoperative, intraoperative, and postoperative evidence-based interventions (early oral feeding, opioid-sparing analgesia, early mobilization) to blunt surgical stress.
Question 3: Intraoperative hypotension following pneumoperitoneum establishment in laparoscopic surgery is most commonly caused by:
- Vagal stimulation from CO2 absorption
- Decreased venous return from elevated intra-abdominal pressure (Correct answer)
- CO2 embolism into the inferior vena cava
- Tension pneumothorax from trocar injury
Correct answer: Decreased venous return from elevated intra-abdominal pressure
Elevated intra-abdominal pressure from pneumoperitoneum compresses the inferior vena cava, reducing venous return and cardiac preload, causing hypotension.
Question 4: The Pringle maneuver controls hepatic inflow during liver surgery by clamping which structure?
- Portal vein only
- Hepatic artery only
- Hepatoduodenal ligament containing the portal triad (Correct answer)
- Inferior vena cava above the hepatic veins
Correct answer: Hepatoduodenal ligament containing the portal triad
The Pringle maneuver involves manual or vascular clamp occlusion of the hepatoduodenal ligament, which contains the portal vein, hepatic artery, and common bile duct, temporarily halting hepatic inflow.
Question 5: Per current Surviving Sepsis Campaign guidelines, which fluid is recommended as first-line resuscitation in septic shock?
- 5% albumin as first line
- Crystalloid (balanced solutions or normal saline) as first line (Correct answer)
- Colloid solutions (hydroxyethyl starch) as first line
- Hypertonic saline 3% as first line
Correct answer: Crystalloid (balanced solutions or normal saline) as first line
Crystalloids (30 mL/kg IV) are the first-line resuscitation fluid in septic shock per SSC guidelines; balanced crystalloids like lactated Ringer's are preferred over normal saline to reduce hyperchloremic acidosis.
Question 6: Which intraoperative finding is the most reliable indicator of bowel ischemia during surgery?
- Absence of bowel sounds on intraoperative auscultation
- Loss of arterial pulsations on Doppler only
- Dusky-gray discoloration combined with absent peristalsis (Correct answer)
- Distended bowel loops without visible mucosa
Correct answer: Dusky-gray discoloration combined with absent peristalsis
Gray-black discoloration and absence of peristalsis together are the most reliable clinical indicators of full-thickness bowel ischemia; Doppler alone may be falsely reassuring.
General Surgery Board Review General Surgery Board Review Perioperative Care & Complications 2
What is the most appropriate immediate treatment for suspected malignant hyperthermia intraoperatively?