Anesthesia and Perioperative medicine Practice Questions

Q: A 65-year-old man develops postoperative delirium on day 2 after open AAA repair. He is agitated, pulling at his lines, and has waxing-waning confusion. His vital signs are stable, and laboratory values including sodium, glucose, and calcium are normal. He received 4 mg of morphine IV 2 hours ago for pain. Analyze the most appropriate pharmacologic intervention.

Haloperidol 0.5-1 mg IV or IM. ***Haloperidol 0.5-1 mg IV or IM*** - Low-dose **haloperidol** is the first-line pharmacologic agent for managing severe **postoperative delirium** when non-pharmacological measures fail or the patient is a danger to themselves. - It has a safe profile in the elderly for brief use and does not cause significant **respiratory depression** unlike sedatives. *Propofol infusion for sedation* - **Propofol** is reserved for patients who are **intubated** in an ICU setting and is not appropriate for a patient on the general surgical floor. - It can cause profound **hypotension** and requires continuous hemodynamic monitoring which is not indicated for this stable patient. *Increase morphine dose for better pain control* - **Opioids** are common triggers for delirium; increasing the dose of morphine would likely **worsen the confusion** rather than resolve it. - While pain must be managed, alternative strategies like **regional anesthesia** or non-opioid medications should be prioritized in a delirious patient. *Lorazepam 2 mg IV for sedation* - **Benzodiazepines** are generally contraindicated in delirium because they often cause **paradoxical agitation** and worsen cognitive impairment. - They should only be used as a first-line agent when delirium is caused by **alcohol withdrawal** or benzodiazepine withdrawal. *Diphenhydramine 25 mg IV for sleep* - **Diphenhydramine** has significant **anticholinergic** properties, which are strongly associated with the development and prolongation of **delirium**. - Using this for sleep in an elderly postoperative patient increases the risk of **falls and further disorientation**.

Question 1

A 55-year-old man with chronic pain on high-dose opioids (120 mg oral morphine equivalents daily) requires major spine surgery. Intraoperatively, he requires escalating doses of fentanyl with poor pain control. Postoperatively, his pain remains severe (10/10) despite maximum conventional multimodal analgesia including IV hydromorphone PCA, acetaminophen, and ketorolac. He becomes increasingly agitated and tachycardic. Evaluate the most comprehensive pain management strategy addressing the underlying pathophysiology.

Accepted Answer

Ketamine infusion to address opioid-induced hyperalgesia and NMDA receptor sensitization

Answer

Increase PCA opioid dose to match home requirements plus surgical pain needs

Answer

Transition to methadone for better mu-receptor coverage

Answer

Epidural analgesia with local anesthetic and low-dose opioid

Answer

Regional nerve blocks with liposomal bupivacaine

Question 2

A 70-year-old man with severe aortic stenosis (valve area 0.6 cm², mean gradient 55 mmHg) develops acute cholecystitis requiring surgery. He is symptomatic with exertional angina and dyspnea. Cardiology recommends TAVR before surgery, but the patient has signs of gallbladder perforation. The surgical team debates timing of interventions. Evaluate the optimal management strategy weighing cardiac and surgical risks.

Accepted Answer

Percutaneous cholecystostomy tube followed by TAVR, then delayed cholecystectomy

Answer

Emergency cholecystectomy under general anesthesia with careful hemodynamic monitoring

Answer

Medical management of cholecystitis with antibiotics, TAVR in 6 weeks, then cholecystectomy

Answer

Combined TAVR and cholecystectomy in one procedure

Answer

Open cholecystectomy under epidural anesthesia to avoid general anesthesia risks

Question 3

A 42-year-old woman with a history of multiple anesthetic complications presents for elective surgery. Previous records indicate awareness during general anesthesia twice, prolonged paralysis after succinylcholine requiring 6 hours of ventilation, and a sibling with fatal anesthetic complication involving hyperthermia and rhabdomyolysis. Evaluate the comprehensive anesthetic plan that addresses all potential complications.

Accepted Answer

Total intravenous anesthesia with propofol and remifentanil, avoid succinylcholine and volatile agents, use rocuronium with sugammadex reversal

Answer

Genetic testing before proceeding with any anesthetic

Answer

Standard general anesthesia with dantrolene prophylaxis

Answer

Volatile anesthetic with BIS monitoring, avoid all muscle relaxants

Answer

Regional anesthesia only without any general anesthetic agents

Question 4

A 65-year-old man develops postoperative delirium on day 2 after open AAA repair. He is agitated, pulling at his lines, and has waxing-waning confusion. His vital signs are stable, and laboratory values including sodium, glucose, and calcium are normal. He received 4 mg of morphine IV 2 hours ago for pain. Analyze the most appropriate pharmacologic intervention.

Accepted Answer

Haloperidol 0.5-1 mg IV or IM

Answer

Propofol infusion for sedation

Answer

Increase morphine dose for better pain control

Answer

Lorazepam 2 mg IV for sedation

Answer

Diphenhydramine 25 mg IV for sleep

Question 5

A 28-year-old pregnant woman at 32 weeks gestation requires emergency appendectomy for perforated appendicitis. Fetal heart tones are reassuring. The obstetrician recommends fetal monitoring during surgery. Analyze the optimal anesthetic approach considering both maternal and fetal safety.

Accepted Answer

General anesthesia with rapid sequence intubation and left uterine displacement

Answer

Delay surgery until after delivery by cesarean section

Answer

Spinal anesthesia to avoid fetal exposure to volatile anesthetics

Answer

Local anesthesia with conscious sedation to minimize fetal drug exposure

Answer

Epidural anesthesia with incremental dosing to T4 level

Anesthesia and Perioperative medicine — MCQs

Anesthesia and Perioperative medicine — MCQs

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