General Surgery Board Review Risk Assessment & Management 4 — Questions and Answers
Question 1: Which of the following best describes the purpose of perioperative beta-blockade in non-cardiac surgery?
- Indicated for all patients undergoing intermediate or high-risk surgery
- Beneficial only if continued chronically — should not be started acutely
- Should be continued in patients already on beta-blockers; routine new initiation is not supported (Correct answer)
- Contraindicated in patients with prior MI undergoing vascular surgery
Correct answer: Should be continued in patients already on beta-blockers; routine new initiation is not supported
Current ACC/AHA guidelines support continuing beta-blockers in patients already taking them but do not support routine new initiation perioperatively due to risk of stroke and hypotension (POISE trial).
Question 2: A 45-year-old woman with a known factor V Leiden mutation requires elective laparoscopic hysterectomy. Which VTE prophylaxis strategy is most appropriate?
- No prophylaxis needed for low-risk laparoscopic surgery
- Pneumatic compression devices alone
- LMWH plus mechanical prophylaxis, continued postoperatively for extended duration (Correct answer)
- Aspirin 325 mg daily starting the day before surgery
Correct answer: LMWH plus mechanical prophylaxis, continued postoperatively for extended duration
Factor V Leiden with major surgery places patients in high VTE risk — combined pharmacological and mechanical prophylaxis with extended duration LMWH (up to 4 weeks) is indicated.
Question 3: The MELD score is used to risk-stratify cirrhotic patients for surgery. A MELD score of 20 carries an approximate 30-day perioperative mortality of:
- 5%
- 10%
- 20% (Correct answer)
- 30%
Correct answer: 20%
MELD score of 20 corresponds to approximately 20% 30-day perioperative mortality for major abdominal surgery in cirrhotic patients.
Question 4: Which of the following intraoperative scenarios represents a class IV hemorrhagic shock?
- HR 105, BP 118/72, UO 28 mL/hr, mild anxiety
- HR 122, BP 98/70, UO 15 mL/hr, confusion
- HR 138, BP 80/50, UO 5 mL/hr, lethargy
- HR 155, BP 60/40, UO 0 mL/hr, unconscious (Correct answer)
Correct answer: HR 155, BP 60/40, UO 0 mL/hr, unconscious
Class IV hemorrhagic shock (>40% blood volume loss) presents with HR >150, systolic BP <70, negligible urine output, and altered consciousness requiring immediate massive transfusion.
Question 5: A patient taking long-term prednisone 10 mg/day requires urgent colectomy. Which perioperative steroid management is most appropriate?
- Withhold steroids perioperatively to reduce infection risk
- Continue home dose only throughout perioperative period
- Administer stress-dose hydrocortisone 50 mg IV q8h perioperatively (Correct answer)
- Give a single dose of dexamethasone 8 mg IV intraoperatively
Correct answer: Administer stress-dose hydrocortisone 50 mg IV q8h perioperatively
Patients on chronic steroids ≥5 mg/day for >3 weeks have suppressed HPA axis and require stress-dose steroids (hydrocortisone 50-100 mg IV q8h) for major surgery to prevent adrenal crisis.
Question 6: Which perioperative risk factor for anastomotic leak has the strongest independent association in colorectal surgery?
- Obesity (BMI >30)
- Intraoperative blood transfusion
- Male sex and distal rectal location (Correct answer)
- Preoperative bowel preparation
Correct answer: Male sex and distal rectal location
Male sex and distal rectal anastomoses are the strongest independent risk factors for anastomotic leak, likely due to pelvic anatomy limiting technical access and blood supply.
Question 7: A 66-year-old man with a recent drug-eluting coronary stent placed 4 months ago requires elective sigmoid colectomy. What is the most appropriate management?
- Proceed with surgery on full dual antiplatelet therapy
- Hold both aspirin and clopidogrel 7 days before surgery
- Defer surgery until 12 months post-stent, then reassess (Correct answer)
- Proceed with surgery after stopping clopidogrel, keeping aspirin
Correct answer: Defer surgery until 12 months post-stent, then reassess
Drug-eluting stents require minimum 12 months of dual antiplatelet therapy; elective surgery during this window carries high risk of in-stent thrombosis and should be deferred if possible.
General Surgery Board Review Risk Assessment & Management 4
Which of the following best describes the purpose of perioperative beta-blockade in non-cardiac surgery?