Consultative and Perioperative Medicine Practice Questions

Q: A 45-year-old woman with Child-Pugh Class B cirrhosis requires urgent abdominal surgery. Preoperative labs show: Albumin 2.8 g/dL, Bilirubin 3.2 mg/dL, INR 1.9, Creatinine 1.1 mg/dL. Her MELD score is calculated as 18. What is the approximate 90-day mortality risk?

25-30%. ***25-30%*** - The **MELD score** (Model for End-Stage Liver Disease) is a validated predictor of **90-day mortality** in patients with cirrhosis undergoing major abdominal surgery [1]. - A **MELD score of 15-20** (this patient is 18) typically correlates with a post-operative mortality risk in the **25-30% range**. *5-10%* - This range is associated with **Child-Pugh Class A** or **MELD scores 20** or those with **Child-Pugh Class C** cirrhosis. - Surgical intervention in this group is often avoided unless it is life-saving due to the high risk of **liver failure** and **death** post-operatively. *15-20%* - This range often corresponds to patients with a **MELD score of 10-15** or compensated **Child-Pugh Class B** cirrhosis. - While the risk is significant, it is lower than the mortality predicted for a patient with a score of 18 and signs of **coagulopathy** (INR 1.9) [1].

Q: A 65-year-old man with mechanical aortic valve on warfarin (INR 2.8) requires elective cholecystectomy. What is the most appropriate perioperative anticoagulation management?

Stop warfarin 5 days before, bridge with therapeutic LMWH. Warfarin should be stopped **5 days preoperatively** to allow the INR to normalize, while **therapeutic-dose LMWH** is started once the INR drops below the therapeutic range [1]. *Stop warfarin 3 days before, bridge with unfractionated heparin infusion* - Stopping warfarin only **3 days before** surgery is often insufficient time for the **INR to reach <1.5**, increasing the risk of surgical bleeding [1]. - While **Unfractionated Heparin (UFH)** is an option, it requires hospitalization for IV administration, making **LMWH** the preferred choice for convenience in elective outpatient settings. *Continue warfarin throughout surgery* - Continuing warfarin is contraindicated for major abdominal surgeries like **cholecystectomy** due to the high risk of **intraoperative bleeding**. - This approach is typically reserved only for minor procedures with low bleeding risk, such as **minor dental or skin surgeries**. *Stop warfarin 5 days before, no bridging therapy* - Omitting bridging therapy is appropriate for low-risk patients, but this patient has a **mechanical heart valve**, which carries a high **thromboembolic risk**. - Failure to bridge in this population significantly increases the likelihood of **valvular thrombosis** or a **systemic embolic event** during the perioperative subtherapeutic window.

Question 1

A 62-year-old man with drug-eluting stent placed 4 months ago requires urgent colonoscopy with polypectomy for a bleeding polyp. He is on dual antiplatelet therapy (aspirin and clopidogrel). Analysis of risks shows continued bleeding risk versus stent thrombosis risk. What is the most evidence-based management strategy?

Accepted Answer

Continue aspirin, discontinue clopidogrel 5 days before procedure

Answer

Discontinue clopidogrel only, add prophylactic heparin bridging

Answer

Discontinue both aspirin and clopidogrel 7 days before procedure

Answer

Continue both aspirin and clopidogrel throughout procedure

Question 2

A 72-year-old man develops postoperative delirium on day 2 after hip replacement. His vitals are stable, and examination is unremarkable except for confusion. Laboratory workup including CBC, electrolytes, and arterial blood gas is normal. What is the most likely precipitating factor?

Accepted Answer

Multifactorial including surgery, medications, and environmental factors

Answer

Undiagnosed dementia with acute decompensation

Answer

Hypoxia from subclinical pulmonary embolism

Answer

Occult infection not yet manifested

Question 3

A 45-year-old woman with Child-Pugh Class B cirrhosis requires urgent abdominal surgery. Preoperative labs show: Albumin 2.8 g/dL, Bilirubin 3.2 mg/dL, INR 1.9, Creatinine 1.1 mg/dL. Her MELD score is calculated as 18. What is the approximate 90-day mortality risk?

Accepted Answer

25-30%

Answer

5-10%

Answer

40-50%

Answer

15-20%

Question 4

A 58-year-old diabetic patient on metformin is scheduled for CT scan with iodinated contrast. His serum creatinine is 1.8 mg/dL and eGFR is 42 mL/min/1.73m². What is the most appropriate management of metformin?

Accepted Answer

Hold metformin on day of procedure, restart after 48 hours with normal renal function

Answer

Reduce metformin dose by 50% for 3 days

Answer

Continue metformin and ensure adequate hydration

Answer

Stop metformin permanently and switch to insulin

Question 5

A 65-year-old man with mechanical aortic valve on warfarin (INR 2.8) requires elective cholecystectomy. What is the most appropriate perioperative anticoagulation management?

Accepted Answer

Stop warfarin 5 days before, bridge with therapeutic LMWH

Answer

Stop warfarin 3 days before, bridge with unfractionated heparin infusion

Answer

Continue warfarin throughout surgery

Answer

Stop warfarin 5 days before, no bridging therapy

Consultative and Perioperative Medicine — MCQs

Consultative and Perioperative Medicine — MCQs

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