Preoperative and Postoperative Care Practice Questions

Q: A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

Hydrocortisone only. ***Hydrocortisone only*** - Patients on chronic **high-dose steroid therapy** (>5 mg prednisolone daily for >3 weeks) are at risk of **adrenal insufficiency** during surgical stress due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. - **Hydrocortisone stress dose** (100 mg IV at induction, followed by 50 mg every 8 hours) is the **most essential and immediate requirement** to prevent **adrenal crisis** during major surgery. - Hydrocortisone has both glucocorticoid and mineralocorticoid activity, mimicking the body's natural cortisol response to surgical stress. *Insulin only* - While steroids can cause **hyperglycemia** requiring insulin management, this is a **secondary concern** compared to preventing life-threatening **adrenal crisis**. - Insulin addresses a metabolic complication but does not protect against **inadequate cortisol response** to surgical stress. - **Without stress-dose steroids**, the patient risks hemodynamic collapse regardless of glucose control. *Both* - Although **both** medications might eventually be needed if hyperglycemia develops, the question asks for the **most essential** requirement. - **Hydrocortisone is non-negotiable** and must be given prophylactically; insulin is only needed if blood glucose is elevated. - Prioritizing both equally misses the critical time-sensitive need for **adrenal axis support**. *None of the options* - This is incorrect because patients on chronic high-dose steroids undergoing major surgery **absolutely require stress-dose steroid coverage**. - Failure to administer hydrocortisone can result in **acute adrenal crisis** with severe hypotension, shock, and potential mortality. - Modern guidelines confirm the need for perioperative steroid supplementation in high-risk patients.

Q: How much daily sodium does an average patient with maxillofacial trauma require?

100 mmol. ***100 mmol*** - An average adult patient with **maxillofacial trauma** typically requires around **100 mmol** of sodium daily for maintenance. - This amount helps maintain **fluid balance**, nerve impulse transmission, and muscle function without causing hypernatremia or hyponatremia. *1000 mmol* - This quantity of sodium is excessively high and could lead to **hypernatremia**, **fluid overload**, and significant **electrolyte imbalances**, which are dangerous for most patients. - Such high doses are generally only seen in cases of severe sodium depletion or massive fluid resuscitation, neither of which is implied for routine daily needs after trauma. *50-60 mmol* - This amount of sodium is generally **insufficient** for the daily maintenance needs of an average adult, especially in the context of trauma where needs might be slightly elevated due to stress response. - Inadequate sodium intake could lead to **hyponatremia** over time, causing symptoms like nausea, headaches, and confusion. *10 mmol* - This is an extremely low amount of sodium and would almost certainly lead to **severe hyponatremia** in an average adult within a short period. - Such a low intake would not meet basic physiological requirements and could rapidly result in life-threatening complications.

Q: Burst abdomen most commonly occurs at what time after surgery?

7-10 days. ***7 - 10 days*** - **Burst abdomen**, also known as **wound dehiscence**, typically occurs when the wound healing process is at its weakest, around **7 to 10 days post-surgery**. - This period corresponds to the peak of the **inflammatory phase** and the beginning of the **proliferative phase** of wound healing, where collagen is being laid down but has not yet gained sufficient tensile strength. *3 - 5 days* - This period is generally too early for a full burst abdomen, as the initial wound closure is usually more secure, and the **lag phase of healing** is still predominant. - While local complications like **seroma** or **hematoma** can occur during this time, complete wound dehiscence is less common. *1 - 4 days* - In the first few days post-surgery, the wound is primarily held together by sutures and initial fibrin clots; complete dehiscence is very rare unless there's **gross technical error** during closure. - The inflammatory response is just beginning, and **collagen synthesis** is minimal. *10-12 days* - While dehiscence can still occur during this period, the **tensile strength** of the wound significantly increases after day 10 as collagen cross-linking progresses. - Most cases of burst abdomen have already manifested by day 10, making later occurrences less frequent, though not impossible.

Q: Deep vein thrombosis is MOST common after which of the following procedures?

Total hip replacement. ***Total hip replacement*** - **Total hip replacement surgery** is a significant risk factor for DVT due to extensive tissue trauma, prolonged immobility, and potential damage to venous endothelium during the procedure. - The incidence of **postoperative DVT** can be as high as 40-60% without prophylaxis, earning it a classification as a **very high-risk procedure** for VTE. *Neurosurgery* - While neurosurgery carries a risk of DVT, it is generally **lower compared to major orthopedic surgeries** like total hip replacement. - The focus in neurosurgery often revolves around avoiding **intracranial bleeding**, which can limit the intensity of anticoagulant prophylaxis. *Gastrectomy* - Gastrectomy, a major abdominal surgery, does increase the risk of DVT, but typically **less profoundly than total hip replacement**. - Risk factors like **anesthesia duration** and degree of inflammation contribute to DVT risk, but not to the same extent as direct trauma to large veins in the lower extremities. *Prostatic operation* - **Prostatic operations**, such as prostatectomy, carry a moderate risk of DVT, but this risk is generally **lower than that associated with major orthopedic procedures**. - The risk is influenced by factors such as **surgical time**, patient age, and the presence of malignancy, but the extent of venous stasis and damage is typically less severe.

Q: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

Dressing of wound & observe for dehiscence. ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.

Q: A patient with ITP on steroids underwent splenectomy. Patient got fever on 3rd post-operative day. Next investigation is likely to reveal?

Pulmonary consolidation. ***Pulmonary consolidation*** - Post-splenectomy patients are at increased risk of **pulmonary complications**, including atelectasis and pneumonia, due to reduced diaphragmatic excursion and pain. Fever on day 3 suggests a developing infection or inflammatory process in the lungs. - **Splenectomy** affects the immune response, making patients more susceptible to infections and exaggerating inflammatory responses to surgical trauma, which can manifest as pulmonary issues. *Focal Intra-abdominal collection* - While intra-abdominal collections can cause fever post-operatively, they typically present later (around day 5-7), and symptoms are often localized with abdominal pain or distension. - This patient had ITP and underwent splenectomy, making **pulmonary complications** more prominent earlier on. *UTI* - Urinary tract infections can cause fever post-operatively, but are usually associated with **urinary symptoms** like dysuria, frequency, or urgency, which are not mentioned. - While prolonged catheterization increases risk, it is less common to be the primary cause of fever on day 3 after splenectomy compared to pulmonary issues. *Po site infection* - Surgical site infections more commonly manifest with localized signs of inflammation such as **redness, warmth, swelling, or purulent discharge**, which are not described. - While possible, a prominent fever on day 3 following a splenectomy, especially in a patient on steroids (which can mask some inflammatory signs), places **pulmonary issues** higher on the differential.

Q: Most clinically significant characteristic of Ringer's Lactate is -

Isotonic. ***Isotonic*** - Ringer's lactate is **isotonic** because its osmolality (approximately $ ext{273 mOsmol/L}$) is similar to that of human plasma ($ ext{275-295 mOsmol/L}$), making it suitable for intravenous fluid replacement [1]. - This characteristic prevents significant shifts of fluid in or out of cells, reducing the risk of **cellular edema** or **dehydration** [1]. *Provides bicarbonate precursors to help in metabolic acidosis.* - While Ringer's lactate contains **lactate**, which is metabolized in the liver to **bicarbonate**, this effect is considered a secondary benefit rather than its most clinically significant characteristic [2]. - The primary clinical utility of Ringer's lactate is its ability to effectively restore **intravascular volume** due to its isotonic nature [2]. *Crystalloid solution.* - Ringer's lactate is indeed a **crystalloid solution**, meaning it contains small molecules that can freely cross semipermeable membranes [1]. - However, being a crystalloid is a classification, while its **isotonicity** is a more direct and clinically significant characteristic regarding its physiological impact and primary use. *Contains potassium in a concentration lower than serum potassium.* - Ringer's lactate contains **potassium** (4 mEq/L), but this concentration is lower than typical serum potassium levels ($ ext{3.5-5.0 mEq/L}$) [2]. - This characteristic is important for fluid balance but not its most defining or clinically significant feature compared to its overall isotonicity.

Q: The highest concentration of potassium is in -

Darrow's solution. ***Darrow's solution*** - **Darrow's solution** is specifically formulated for patients with significant **potassium and fluid deficits**, often seen in conditions like severe diarrhea. - It contains a high concentration of potassium (typically around **35 mEq/L**) along with sodium and lactate, making it suitable for aggressive repletion. *Ringer lactate* - **Ringer lactate** (also known as Hartmann's solution) is an **isotonic crystalloid** used for fluid resuscitation and maintenance [1]. - While it contains potassium, its concentration is relatively low (typically around **4-5 mEq/L**), similar to physiological plasma levels, to prevent hyperkalemia during large-volume infusions [1]. *Isotonic saline* - **Isotonic saline** (0.9% NaCl) is a basic crystalloid solution primarily used for **volume expansion** and does not contain any potassium [1]. - It provides sodium and chloride, making it useful for extracellular fluid replacement but offers no potassium supplementation. *Plasma* - **Plasma** is the liquid component of blood and has a physiological potassium concentration that is tightly regulated, typically ranging from **3.5 to 5.0 mEq/L** [2]. - This concentration is maintained within a narrow range by renal excretion and cellular shifts to prevent cardiac arrhythmias and other electrolyte disturbances [2].

Q: Which one of the following is not a component of THORACOSCORE?

Complication of surgery. ***Complication of surgery*** - THORACOSCORE is a **risk prediction model** for thoracic surgery used to estimate the *probability of mortality and significant morbidity*, but it does not account for the complications of surgery itself as a component. - The score uses **pre-operative patient characteristics** and co-morbidities to predict outcomes, not post-operative events. *Performance status* - **Performance status**, such as the **ECOG scale**, is a crucial component of THORACOSCORE, reflecting the patient's general health and functional capacity prior to surgery. - A lower performance status (indicating poorer functional ability) increases the predicted risk in THORACOSCORE. *Priority of surgery* - The **priority of surgery** (e.g., elective, urgent, emergency) is an important factor in THORACOSCORE, as emergency procedures generally carry a higher risk. - This variable helps to capture the urgency and associated physiological stress on the patient at the time of presentation for surgery. *ASA grading* - The **American Society of Anesthesiologists (ASA) physical status classification system** is a component of THORACOSCORE, assessing the patient's overall health status and anesthetic risk. - A higher ASA grade (indicating more severe systemic disease) contributes to a higher predicted risk in the THORACOSCORE model.

Question 1

A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

Accepted Answer

Hydrocortisone only

Answer

Insulin only

Answer

Both

Answer

None of the options

Question 2

How much daily sodium does an average patient with maxillofacial trauma require?

Accepted Answer

100 mmol

Answer

1000 mmol

Answer

50-60 mmol

Answer

10 mmol

Question 3

A patient on aspirin for secondary prevention of cardiovascular disease is selected for an elective surgery with low-to-moderate bleeding risk. What should be done regarding aspirin management?

Accepted Answer

Go ahead with surgery maintaining adequate hemostasis

Answer

Stop aspirin for 7 days

Answer

Infusion of fresh frozen plasma

Answer

Infusion of platelet concentrate

Question 4

Burst abdomen most commonly occurs at what time after surgery?

Accepted Answer

7-10 days

Answer

3-5 days

Answer

1-4 days

Answer

10-12 days

Question 5

Deep vein thrombosis is MOST common after which of the following procedures?

Accepted Answer

Total hip replacement

Answer

Neurosurgery

Answer

Gastrectomy

Answer

Prostatic operation

Question 6

On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

Accepted Answer

Dressing of wound & observe for dehiscence

Answer

Send for USG abdomen

Answer

Start treatments for peritonitis

Answer

IV fluids

Question 7

A patient with ITP on steroids underwent splenectomy. Patient got fever on 3rd post-operative day. Next investigation is likely to reveal?

Accepted Answer

Pulmonary consolidation

Answer

Focal Intra-abdominal collection

Answer

UTI

Answer

Post-operative site infection

Question 8

Most clinically significant characteristic of Ringer's Lactate is -

Accepted Answer

Isotonic

Answer

Provides bicarbonate precursors to help in metabolic acidosis.

Answer

Crystalloid solution.

Answer

Contains potassium in a concentration lower than serum potassium.

Question 9

The highest concentration of potassium is in -

Accepted Answer

Darrow's solution

Answer

Ringer lactate

Answer

Isotonic saline

Answer

Plasma

Question 10

Which one of the following is not a component of THORACOSCORE?

Accepted Answer

Complication of surgery

Answer

Performance status

Answer

Priority of surgery

Answer

ASA grading

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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