Preoperative and Postoperative Care Practice Questions

Q: Consider the following statements regarding Opportunistic post-splenectomy infections (OPSI): 1. Haemophilus influenzae, Neisseria meningitidis and Streptococcus pneumoniae are the most common causative agents 2. Risk is greatest in the patients who have undergone splenectomy for trauma 3. Risk is greatest within the first 2–3 years following splenectomy 4. Prophylactic vaccination should be done 2 weeks prior to elective splenectomy Which of the statements given above are correct?

1, 3 and 4. ***1, 3 and 4*** - **Haemophilus influenzae**, **Neisseria meningitidis**, and **Streptococcus pneumoniae** are encapsulated bacteria that are the most common causative agents of **OPSI** due to impaired splenic clearance function. - The risk is **greatest within the first 2-3 years** following splenectomy, though it remains a lifelong concern, and prophylactic vaccination should be done **at least 2 weeks prior** to elective splenectomy for optimal immune response. *2, 3 and 4* - This option incorrectly includes statement 2, as the **highest risk of OPSI** occurs in patients with **hematological conditions** (thalassemia, sickle cell disease, lymphoma), not trauma. - Splenectomy for **trauma** actually carries the **lowest risk** of OPSI compared to other indications due to the previously normal splenic function. *1, 2 and 3* - This option incorrectly includes statement 2 and excludes the correct statement 4 about **vaccination timing**. - Statement 2 is false because **hematological disorders** requiring splenectomy pose the **greatest OPSI risk**, not traumatic splenectomy. *1, 2 and 4* - This option incorrectly includes statement 2 about trauma having the highest risk, which is **false**. - It also excludes statement 3, which is correct regarding the **peak risk period** of 2-3 years post-splenectomy.

Q: During subclavian vein puncture in a surgical ward suddenly a patient developed severe breathlessness. On auscultation breath sound was absent and the ipsilateral chest was tympanitic on percussion. The probable diagnosis is:

Iatrogenic pneumothorax. ***Iatrogenic pneumothorax*** - The sudden onset of breathlessness after **subclavian vein puncture** points towards an iatrogenic cause due to accidental pleural injury. - **Absent breath sounds** and **tympanitic percussion** on the ipsilateral side are classic signs of air in the pleural space. *Tension pneumothorax* - While it shares features of pneumothorax, **tension pneumothorax** would typically present with **tracheal deviation**, severe hypotension, and signs of cardiovascular collapse due to mediastinal shift. - The description lacks these critical signs of hemodynamic instability and significant mediastinal compression. *Spontaneous pneumothorax* - **Spontaneous pneumothorax** occurs without any preceding trauma or medical procedure, usually due to rupture of subpleural blebs. - The history of a recent **subclavian vein puncture** makes an iatrogenic cause much more likely than a spontaneous event. *Iatrogenic hemothorax* - **Iatrogenic hemothorax** would also be a complication of subclavian vein puncture, but it would present with **dullness to percussion** instead of tympany, and signs of hypovolemic shock if severe. - The **tympanitic percussion** directly indicates the presence of air, not blood, in the pleural cavity.

Q: Which one of the following is NOT a risk factor for development of venous thrombosis in surgical patients?

Male gender. ***Male gender*** - While there may be slight differences in **VTE incidence** between sexes, male gender is **not considered an independent risk factor** for venous thrombosis in surgical patients; rather, other comorbidities or specific surgical procedures are more influential. - Risk factors like **age, obesity, and pregnancy** are well-established and significantly increase the risk of thrombosis, unlike male gender. *Age > 60 years* - **Advancing age** is a significant risk factor for venous thrombosis due to age-related changes in coagulation factors, endothelial function, and reduced mobility. - Older patients undergoing surgery have a higher likelihood of developing **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**. *Obesity (BMI > 30 kg/m2)* - **Obesity** is a well-established risk factor for venous thrombosis due to chronic inflammation, endothelial dysfunction, and increased procoagulant factors. - Obese surgical patients have a higher risk of **VTE** compared to those with a normal BMI. *Pregnancy* - **Pregnancy** is a hypercoagulable state due to hormonal changes, increased coagulation factors, and venous stasis, significantly increasing the risk of venous thrombosis. - The risk of VTE is elevated throughout pregnancy and the **postpartum period**, especially after surgical interventions like Cesarean sections.

Q: A 50-year old lady underwent uneventful bariatric surgery for morbid obesity. On the third post operative day, she develops breathlessness and pulmonary embolism is suspected. The next investigation to confirm the diagnosis will be:

CT pulmonary angiography. ***CT pulmonary angiography*** - **CT pulmonary angiography (CTPA)** is the **gold standard** for diagnosing pulmonary embolism due to its high sensitivity and specificity in visualizing pulmonary arteries. - It rapidly provides detailed images of the pulmonary vasculature, allowing for the direct visualization of **thrombi** within the vessels. *MR angiography* - **MR angiography (MRA)** can be used for diagnosing pulmonary embolism but is generally less available and often takes longer than CTPA. - It is usually reserved for patients with contraindications to CT, such as **renal impairment** or **iodine allergy**, which are not indicated in this case. *Echocardiography* - **Echocardiography** can help assess the **right ventricular strain** caused by pulmonary embolism, but it is not diagnostic for the embolism itself. - It is more useful in evaluating the **hemodynamic impact** of the PE and ruling out other cardiac causes of breathlessness. *Duplex venography* - **Duplex venography** (or ultrasound of the lower extremities) is used to detect **deep vein thrombosis (DVT)** in the legs. - While DVT is a common cause of pulmonary embolism, this investigation does not directly visualize the embolism in the **pulmonary arteries**.

Q: A 72-year-old man undergoes elective total knee replacement. On postoperative day 2, he develops acute onset of dyspnea, chest pain, and hypoxemia. His D-dimer is elevated at 2,500 ng/mL (normal <500). CT pulmonary angiogram shows multiple pulmonary emboli. What is the most important factor that contributed to this complication?

Combination of surgery, immobilization, and age. ***Combination of surgery, immobilization, and age*** - This scenario exemplifies **Virchow's triad**, where **venous stasis** (postoperative immobilization), **endothelial injury** (surgery), and a **hypercoagulable state** (surgery, inflammation, advanced age) together significantly elevate the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). - A 72-year-old patient undergoing a major orthopedic surgery like total knee replacement has multiple inherent risk factors converging, making the combined effect the most important contributing factor rather than a single isolated element. *Inadequate postoperative mobilization* - While inadequate mobilization contributes to **venous stasis**, it represents only one component of the multifactorial risk for PE in this patient. - Mobilization is crucial, but it does not address the hypercoagulable state or endothelial injury inherent to surgery and age. *Prolonged immobilization during surgery* - This factor primarily contributes to **venous stasis** in the lower extremities, increasing the risk of thrombus formation. - However, it does not account for the additional pro-thrombotic effects of **surgical trauma** and the patient's advanced age, which also contribute significantly to the hypercoagulable state and endothelial damage. *Failure to use compression stockings* - Compression stockings help prevent venous stasis by **improving venous return** and reducing venous dilation. - While beneficial, their absence is a contributing factor to venous stasis, but not as comprehensive as the combination of surgical trauma, immobilization, and age in driving the overall risk.

Q: Which of the following is a common topical use of the medicine shown in the image?

Post-adenoidectomy to control bleeding. ***Post-adenoidectomy to control bleeding*** - The image shows **Neo-Synephrine (phenylephrine)**, a potent **alpha-adrenergic agonist** that causes **vasoconstriction**. - Its vasoconstrictive properties make it useful topically to reduce **bleeding** during and after surgical procedures like **adenoidectomy**. *Rhino cerebral mucormycosis* - This is a serious fungal infection requiring systemic antifungal therapy, often **amphotericin B**. Topical phenylephrine has no role in treating the infection itself. - While bleeding might be a symptom of mucormycosis, phenylephrine would only offer temporary symptomatic relief, not address the underlying fungal pathology. *Inlay type I myringoplasty* - Myringoplasty is a surgical procedure to repair a perforated eardrum. Topical phenylephrine is not indicated for this procedure. - The primary goal of this surgery is to reconstruct the **tympanic membrane**, and phenylephrine would not contribute to tissue healing or graft integration. *Subglottic stenosis* - This condition involves narrowing of the airway below the vocal cords, often requiring surgical intervention or corticosteroids. - Phenylephrine is a decongestant and vasoconstrictor, and as such, it does not have a therapeutic role in resolving the **fibrotic narrowing** characteristic of subglottic stenosis.

Q: What is the baseline platelet count required for surgery?

50,000/µL (50 × 10^9/L). ***50,000/µL (50 × 10^9/L)*** - A platelet count of **50,000/µL** is considered the **minimum threshold** for safe surgical procedures. - This level is generally sufficient to achieve **adequate primary hemostasis** and minimize the risk of significant perioperative bleeding. *20,000/µL (20 × 10^9/L)* - A platelet count of **20,000/µL** is generally **too low** for most surgical interventions, as it significantly increases the risk of serious bleeding. - This level is often associated with a risk of **spontaneous bleeding**, particularly in mucous membranes. *40,000/µL (40 × 10^9/L)* - While closer to the safe threshold, a platelet count of **40,000/µL** might still be considered **suboptimal** for major surgeries, especially those with a high risk of blood loss. - Some surgeons and anesthesiologists may prefer a slightly higher count to ensure a wider **safety margin**. *30,000/µL (30 × 10^9/L)* - A platelet count of **30,000/µL** is generally **insufficient** for most surgical procedures and would likely necessitate **platelet transfusion** preoperatively. - Patients at this level are at an **increased risk of bleeding** during and after surgery.

Q: After laparoscopic cholecystectomy what should be the urine output of the patient if the renal function of the patient is normal?

0.5-1 ml/kg/hr. ***0.5-1 ml/kg/hr*** - The standard acceptable urine output for a postoperative patient with normal renal function is **0.5-1 ml/kg/hr** (some sources extend this to 0.5-1.5 ml/kg/hr). - A minimum of **0.5 ml/kg/hr** is considered adequate renal perfusion and function, while outputs up to 1-1.5 ml/kg/hr indicate excellent hydration and renal function. - This weight-adjusted measure is the gold standard for assessing postoperative urine output and renal function. *0.5 ml/min* - This is an absolute rate (not weight-adjusted) and is inadequate as a general measure. - For a 70 kg patient, this would be only 0.43 ml/kg/hr, which is below the minimum acceptable threshold. *0.1 CC/hr* - This rate is **severely low** and indicates **oliguria** or **anuria**. - This suggests **acute kidney injury**, severe dehydration, or inadequate renal perfusion requiring immediate intervention. *1 ml/kg/hr* - While this value falls within the acceptable range, it represents only a single point rather than the **standard range of 0.5-1 ml/kg/hr**. - The range option is more comprehensive and represents the full spectrum of normal postoperative urine output.

Question 1

Consider the following statements regarding Opportunistic post-splenectomy infections (OPSI):

1. Haemophilus influenzae, Neisseria meningitidis and Streptococcus pneumoniae are the most common causative agents
2. Risk is greatest in the patients who have undergone splenectomy for trauma
3. Risk is greatest within the first 2–3 years following splenectomy
4. Prophylactic vaccination should be done 2 weeks prior to elective splenectomy

Which of the statements given above are correct?

Accepted Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Question 2

During subclavian vein puncture in a surgical ward suddenly a patient developed severe breathlessness. On auscultation breath sound was absent and the ipsilateral chest was tympanitic on percussion. The probable diagnosis is:

Accepted Answer

Iatrogenic pneumothorax

Answer

Tension pneumothorax

Answer

Spontaneous pneumothorax

Answer

Iatrogenic hemothorax

Question 3

Which one of the following is NOT a risk factor for development of venous thrombosis in surgical patients?

Accepted Answer

Male gender

Answer

Age > 60 years

Answer

Obesity (BMI > 30 kg/m2 )

Answer

Pregnancy

Question 4

A 50-year old lady underwent uneventful bariatric surgery for morbid obesity. On the third post operative day, she develops breathlessness and pulmonary embolism is suspected. The next investigation to confirm the diagnosis will be:

Accepted Answer

CT pulmonary angiography

Answer

MR angiography

Answer

Echocardiography

Answer

Duplex venography

Question 5

A 60-year-old man with a history of smoking presents with a 4 cm lung mass on chest CT. Bronchoscopy with biopsy shows squamous cell carcinoma. PET scan shows uptake in the primary tumor and ipsilateral hilar lymph nodes but no distant metastases. What is the most important factor in determining surgical candidacy?

Accepted Answer

Pulmonary function tests and cardiac evaluation

Answer

Presence of hilar lymph nodes

Answer

Size of the primary tumor

Answer

Smoking history

Question 6

A 72-year-old man undergoes elective total knee replacement. On postoperative day 2, he develops acute onset of dyspnea, chest pain, and hypoxemia. His D-dimer is elevated at 2,500 ng/mL (normal <500). CT pulmonary angiogram shows multiple pulmonary emboli. What is the most important factor that contributed to this complication?

Accepted Answer

Combination of surgery, immobilization, and age

Answer

Inadequate postoperative mobilization

Answer

Prolonged immobilization during surgery

Answer

Failure to use compression stockings

Question 7

A 70-year-old man with severe aortic stenosis requires emergency cholecystectomy for acute cholecystitis. His ejection fraction is 35%, and he has a history of recent myocardial infarction 4 weeks ago. Echocardiogram shows an aortic valve area of 0.8 cm² (normal >2.0). What is the most appropriate perioperative management strategy?

Accepted Answer

Perform percutaneous cholecystostomy first, then optimize cardiac status

Answer

Delay surgery for 3 months to allow cardiac recovery

Answer

Proceed with surgery using general anesthesia and careful monitoring

Answer

Cancel surgery and treat with antibiotics alone

Question 8

Which of the following is a common topical use of the medicine shown in the image?

Accepted Answer

Post-adenoidectomy to control bleeding

Answer

Rhino cerebral mucormycosis

Answer

Inlay type I myringoplasty

Answer

Subglottic stenosis

Question 9

What is the baseline platelet count required for surgery?

Accepted Answer

50,000/µL (50 × 10^9/L)

Answer

40,000/µL (40 × 10^9/L)

Answer

20,000/µL (20 × 10^9/L)

Answer

30,000/µL (30 × 10^9/L)

Question 10

After laparoscopic cholecystectomy what should be the urine output of the patient if the renal function of the patient is normal?

Accepted Answer

0.5-1 ml/kg/hr

Answer

0.5 ml/min

Answer

0.1 CC/hr

Answer

1 ml/kg/hr

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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