Preoperative Evaluation
ASA physical status, RCRI, antiplatelet/anticoagulation bridging, NPO guidelines, medication management, herbal supplements, stress dose steroids, MET capacity. ← Back to Q-Bank
Q1. ASA physical status
A 65-year-old with diabetes, controlled hypertension, and BMI 35 (no symptoms of OSA) is ASA:
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V
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Answer: B. ASA II = mild systemic disease (controlled HTN, well-controlled DM, BMI 30–40, smoker, social ETOH). ASA III = severe systemic disease (uncontrolled diseases, BMI >40, MI/stroke >3 months ago). ASA IV = severe systemic disease that's a constant threat to life. ASA V = moribund, not expected to survive without surgery. ASA VI = brain dead organ donor. "E" for emergency added as suffix.
Q2. METs preoperative assessment
A patient who can climb 2 flights of stairs without stopping has functional capacity of:
A. <1 MET
B. 1–3 METs
C. ≥4 METs (acceptable for most non-cardiac surgery)
D. ≥10 METs
E. Cannot be quantified
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Answer: C. 4 METs = climbing 2 flights of stairs, walking on level ground at 4 mph, golf, dancing, gardening. 10 METs = strenuous sports (basketball, tennis singles). Per ACC/AHA: ≥4 METs without symptoms = acceptable for elevated-risk surgery without further cardiac testing. The DASI questionnaire is also commonly used.
Q3. RCRI scoring
The Revised Cardiac Risk Index assigns one point each for all EXCEPT:
A. Ischemic heart disease
B. Congestive heart failure history
C. Cerebrovascular disease history
D. Diabetes treated with insulin
E. Age >65
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Answer: E. RCRI 6 factors: IHD, HF, CVA, insulin-treated DM, Cr ≥2 mg/dL, suprainguinal vascular/intrathoracic/intra-abdominal surgery. Age is NOT in RCRI. ≥2 points + poor functional capacity → consider stress testing if results would change management. NSQIP MICA calculator is alternative validated risk tool.
Q4. ACC/AHA stress testing
Per ACC/AHA 2014 guidelines, preoperative stress testing for non-cardiac surgery is reasonable for:
A. All patients >65
B. Elevated-risk surgery with poor functional capacity (<4 METs) AND ≥2 RCRI factors, only if results will change management
C. All major orthopedic surgery
D. Routine pre-op assessment
E. Anyone with diabetes
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Answer: B. Stress testing only if (1) elevated-risk surgery + (2) poor functional capacity + (3) results would change management. Otherwise low yield. Pharmacologic stress (dobutamine echo, dipyridamole nuclear) for patients who can't exercise.
Q5. NPO guidelines
Current ASA NPO guidelines for healthy elective patients allow:
A. Clear liquids until 6 hours preop
B. Clear liquids until 2 hours, breast milk 4 hours, infant formula/light meal 6 hours, fatty/heavy meal 8 hours
C. No food or drink after midnight
D. Clear liquids until 1 hour
E. Solid food until 4 hours
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Answer: B. 2-4-6-8 rule. Recent evidence supports clear liquids up to 1 hour preop for many institutions. Tylenol with sip OK. Gum and hard candy generally OK as clear liquids. Diabetic patients: hold solid food longer for delayed gastric emptying.
Q6. Mallampati classification
Mallampati class is assessed with the patient:
A. Supine, mouth closed
B. Sitting, mouth open, tongue protruded fully, no phonation
C. Standing
D. Sniffing position
E. With laryngoscope blade in place
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Answer: B. Mallampati: sitting, neutral neck, mouth wide open, tongue maximally protruded without phonation. Class I: soft palate, uvula, tonsillar pillars visible. Class II: soft palate, uvula. Class III: soft palate, base of uvula. Class IV: hard palate only. Phonation falsely improves visibility — don't include.
Q7. Difficult intubation predictors (MIST)
Difficult airway predictors include all EXCEPT:
A. Mallampati ≥3
B. Inter-incisor distance <3 cm
C. Sternomental distance <12.5 cm
D. Thyromental distance <6.5 cm
E. Tongue protrusion >2 cm
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Answer: E. MIST: Mallampati ≥3, Interincisor <3 cm, Sternomental <12.5, Thyromental <6.5. Also: limited neck extension/flexion, large/protruding incisors, neck mass, restricted mandibular protrusion. None individually highly predictive — use as composite. Cormack-Lehane is the laryngoscopic grading (1–4).
Q8. Antihypertensive perioperative — ACE inhibitors
The current recommendation for ACE inhibitors/ARBs preoperatively is:
A. Continue all morning
B. Hold morning of surgery (especially for hypovolemia or hypotension risk surgeries)
C. Triple the dose
D. Convert to β-blocker
E. Always continue
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Answer: B. ACEi/ARB associated with refractory hypotension on induction (renin-angiotensin blocked, vasopressin and norepi may be needed). Hold morning of surgery for most patients (especially if hypovolemia, regional anesthesia, major surgery). Treat hypotension with phenylephrine and vasopressin (better than ephedrine).
Q9. β-blocker initiation
The POISE trial demonstrated that initiating β-blockers acutely preoperatively (without proper titration) increases:
A. Cardiac mortality
B. Stroke and total mortality despite reducing non-fatal MI
C. Pulmonary complications
D. Wound infection
E. No effect
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Answer: B. POISE 2008: metoprolol started immediately preop → fewer MIs but more strokes, more deaths from hypotension. Current recs: continue β-blockers in patients already on them; do not initiate <24 hr before surgery. If indicated, start ≥1 week before, titrate to HR 50–60.
Q10. Statins perioperative
For a patient on chronic statin therapy:
A. Hold 1 week before surgery
B. Continue statins perioperatively (associated with reduced cardiovascular events)
C. Switch to alternative drug
D. Half the dose
E. Hold only the day of surgery
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Answer: B. Continue statins perioperatively — reduced cardiac mortality, MI, stroke. Withdrawal may transiently increase events. Multiple guideline recommendations to continue.
Q11. Aspirin perioperative — cardiovascular
For a patient on aspirin for secondary CV prevention undergoing non-cardiac surgery:
A. Continue ASA in most cases; stop 7 days before only for high-bleeding-risk surgery (intracranial, posterior eye, prostatectomy)
B. Stop 7 days before all surgery
C. Continue only on day of surgery
D. Switch to clopidogrel
E. Stop indefinitely
Show answer
Answer: A. POISE-2 (2014): perioperative ASA increased major bleeding without reducing death/MI. But for patients on chronic ASA for secondary prevention (prior stent, MI, stroke), most experts continue ASA throughout. Stop ~5–7 days before only for cases where bleeding catastrophic (CNS, posterior eye, TURP).
Q12. Herbal supplements perioperative
Most herbal supplements should be discontinued before surgery:
A. 24 hours
B. 7–14 days (taper valerian to avoid withdrawal)
C. 1 month
D. Continue
E. 1 hour
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Answer: B. 7–14 days. Garlic, ginkgo, ginger, ginseng increase bleeding. Ma huang (ephedra) sympathomimetic. St. John's wort → CYP induction. Kava → hepatotoxicity. Valerian → benzo-like withdrawal (taper). Always ask about supplements in preop interview.
Q13. Stress dose steroids — threshold
Stress dose steroid coverage should be considered if the patient has taken which dose of prednisone equivalent for ≥3 weeks in the past year?
A. ≥5 mg/day
B. ≥10 mg/day
C. ≥20 mg/day
D. ≥40 mg/day
E. Any oral steroid
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Answer: C. ≥20 mg prednisone/day for ≥3 weeks = HPA suppression likely. <5 mg/day usually not suppressed. 5–20 mg/day intermediate — consider cosyntropin stim test or empiric coverage. Inhaled steroids >800 mcg/day, topical >2 g/day also potentially suppressive.
Q14. Pregnancy testing preoperative
Preoperative pregnancy testing in women of reproductive age:
A. Required for all
B. Should be offered to women of childbearing potential — joint decision
C. Always avoidable
D. Routine in pediatrics
E. Tested only with abdominal surgery
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Answer: B. ASA recommends offering pregnancy testing to women of childbearing potential. Pregnant patients have anesthetic considerations (avoid teratogens in 1st trimester, aortocaval compression after 20 weeks). Postpone elective surgery until postpartum if possible.
Q15. Preop CXR indications
Routine preoperative CXR is indicated for:
A. All patients >40
B. Significant cardiopulmonary disease, suspected pneumonia, suspected severe COPD with bullous disease, recent respiratory infection — not age-based
C. Anyone undergoing GA
D. Pediatric patients
E. Smokers
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Answer: B. CXR not routinely indicated by age alone. Specific indications: active cardiopulmonary symptoms, significant CV/pulmonary disease, smokers with respiratory symptoms, suspected lung disease. Most preoperative tests should be indication-based, not routine.
Q16. Preop ECG
Routine preoperative ECG is indicated for:
A. All patients over 50
B. Patients with significant cardiovascular disease or risk factors undergoing elevated-risk surgery; not age-based
C. Routine surgery in healthy adults
D. All outpatient surgery
E. Pediatric patients
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Answer: B. Per ACC/AHA: reasonable (IIa) in patients with known CAD, significant arrhythmia, PVD, CVD, structural heart disease undergoing elevated-risk surgery. May be reasonable (IIb) for elevated-risk surgeries. NOT recommended for low-risk surgery or asymptomatic patients regardless of age.
Q17. DAPT and timing for elective surgery — BMS
Minimum dual antiplatelet therapy duration after bare-metal stent for stable IHD before elective surgery:
A. 2 weeks
B. 1 month
C. 6 months
D. 12 months
E. Lifetime
Show answer
Answer: B. BMS for stable IHD: 1 month minimum DAPT. DES for stable IHD: 6 months. ACS (any stent): 12 months. Continue ASA throughout if possible during periop. If surgery must occur sooner, multidisciplinary discussion (cardiology, surgery, anesthesia).
Q18. Bridging anticoagulation
Bridging therapy for warfarin patients before surgery is indicated for which thrombotic risk?
A. CHADS₂ score 1
B. Mechanical mitral valve, recent VTE (<3 mo), or atrial fibrillation with CHA₂DS₂-VASc ≥6 or recent stroke
C. All warfarin patients
D. Any patient with INR >2
E. Never indicated
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Answer: B. High thrombotic risk = bridge. Low-moderate risk = no bridge (BRIDGE trial 2015 showed increased bleeding without thromboembolic benefit in moderate-risk AFib). Bridge with therapeutic LMWH or IV UFH. Hold warfarin 5 days, last LMWH 24 hr preop, restart 24 hr postop (or 48–72 hr for high-bleed surgery).
Q19. OSA preop screening
The STOPBANG questionnaire screens for:
A. Pulmonary hypertension
B. Obstructive sleep apnea risk
C. Cognitive impairment
D. Frailty
E. Cardiac disease
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Answer: B. STOPBANG: Snoring, Tired, Observed apnea, Pressure (BP), BMI >35, Age >50, Neck >40 cm, Gender male. ≥3 = intermediate, ≥5 = high risk. Plan postop opioid minimization, regional anesthesia, postop CPAP, prolonged monitoring.
Q20. Frailty assessment
Preoperative frailty assessment is best evaluated with:
A. Age alone
B. ASA class alone
C. Validated tools (e.g., Edmonton Frail Scale, Fried criteria, modified frailty index)
D. BMI
E. Lab values alone
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Answer: C. Frailty (decreased physiologic reserve) predicts postoperative morbidity/mortality independent of age and ASA. Multiple validated tools. Frail patients benefit from prehabilitation, multidisciplinary care, goals of care discussions, possibly less invasive approaches.
Q21. Difficult airway from physical exam
Beyond Mallampati, signs predicting difficult intubation include:
A. Short neck circumference, limited cervical extension, large incisors, receding mandible, inability to advance lower incisors past upper incisors (mandibular protrusion test), high-arched palate, neck mass
B. Mallampati alone
C. Patient age
D. Patient gender
E. Hand grip strength
Show answer
Answer: A. Multifactorial assessment: Mallampati, mouth opening, thyromental distance, sternomental distance, mandibular protrusion, neck extension, body habitus (obesity, short thick neck), facial features (beard, receding chin). HEAVEN, El-Ganzouri, Wilson scoring composites combine factors.