Preoperative Evaluation
ASA physical status, RCRI, antiplatelet/anticoagulation bridging, NPO guidelines, medication management, herbal supplements, stress dose steroids, MET capacity. ← All topics
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. This patient is ASA II because they have mild systemic disease without substantive functional limitation. ASA II includes patients with controlled hypertension, well-controlled diabetes mellitus, BMI 30–40 without symptoms of obstructive sleep apnea, current smokers, and social alcohol use. ASA III designates severe systemic disease with substantive functional limitation, including poorly controlled or uncontrolled diabetes or hypertension, BMI greater than 40, and myocardial infarction or stroke more than 3 months ago. ASA IV indicates severe systemic disease that is a constant threat to life. ASA V is a moribund patient not expected to survive without the operation. ASA VI (not listed) is a declared brain-dead patient whose organs are being removed for donor purposes. The letter E can be added as a suffix to any class to denote an emergency procedure.
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
D. ≥10 METs
E. Cannot be quantified
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Answer: C. Climbing 2 flights of stairs without stopping represents a functional capacity of 4 METs. Other activities at this level include walking on level ground at 4 mph, playing golf, dancing, and gardening. In contrast, 10 METs represents strenuous sports such as basketball or tennis singles. According to ACC/AHA guidelines, patients with functional capacity ≥4 METs without symptoms have acceptable cardiac risk for elevated-risk non-cardiac surgery and do not require further cardiac testing. The Duke Activity Status Index (DASI) questionnaire is also commonly used to assess functional capacity in the preoperative setting.
Q3. RCRI scoring
The Revised Cardiac Risk Index assigns one point each for all EXCEPT:
A. Ischemic heart disease history
B. Congestive heart failure history
C. Cerebrovascular disease history
D. Diabetes mellitus treated with insulin
E. Age greater than 65 years
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Answer: E. The Revised Cardiac Risk Index (RCRI) includes 6 factors, each worth one point: ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-treated diabetes mellitus, preoperative creatinine ≥2 mg/dL, and high-risk surgery (suprainguinal vascular, intrathoracic, or intra-abdominal). Age is NOT included in the RCRI scoring system. Patients with RCRI ≥2 points plus poor functional capacity should be considered for stress testing if results would change perioperative management. The NSQIP MICA calculator is an alternative validated perioperative risk assessment tool.
Q4. ACC/AHA stress testing
Per ACC/AHA 2014 guidelines, preoperative stress testing for non-cardiac surgery is reasonable for:
A. All patients over age 65 undergoing any non-cardiac surgical procedure regardless of functional capacity or cardiac risk factors
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 patients including total joint arthroplasty regardless of baseline functional capacity or comorbid conditions
D. Routine preoperative assessment for all non-cardiac surgery patients as part of standard cardiovascular risk stratification protocols
E. Anyone with diabetes mellitus (type 1 or type 2) undergoing non-cardiac surgery regardless of glycemic control or complications
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Answer: B. Per ACC/AHA 2014 guidelines, preoperative stress testing for non-cardiac surgery is reasonable only when three criteria are met: (1) elevated-risk surgery, (2) poor functional capacity (less than 4 METs), and (3) the results would actually change perioperative management. The patient must also have 2 or more Revised Cardiac Risk Index (RCRI) factors. Without meeting all these criteria, stress testing has low yield and is not recommended. For patients who cannot exercise, pharmacologic stress testing options include dobutamine stress echocardiography or dipyridamole nuclear imaging. Age alone, diabetes alone, or surgery type alone do not justify routine stress testing without consideration of functional capacity and whether results will alter management decisions.
Q5. NPO guidelines
Current ASA NPO guidelines for healthy elective patients allow:
A. Clear liquids until 6 hours preop, breast milk until 8 hours preop, infant formula until 8 hours preop, light meal until 8 hours preop
B. Clear liquids until 2 hours preop, breast milk until 4 hours preop, infant formula until 6 hours preop, light meal until 6 hours preop, fatty meal until 8 hours preop
C. Clear liquids until 4 hours preop, breast milk until 6 hours preop, infant formula until 8 hours preop, solid food until 8 hours preop
D. Clear liquids until 1 hour preop, breast milk until 2 hours preop, infant formula until 4 hours preop, light meal until 4 hours preop
E. Clear liquids until 4 hours preop, breast milk until 4 hours preop, infant formula until 6 hours preop, solid food until 6 hours preop
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Answer: B. The ASA NPO guidelines for healthy elective patients follow the 2-4-6-8 rule: clear liquids until 2 hours preoperatively, breast milk until 4 hours, infant formula and light meals until 6 hours, and fatty or heavy meals until 8 hours before surgery. Recent evidence supports clear liquids up to 1 hour preoperatively at many institutions, though this is not yet the official ASA guideline. Acetaminophen with a sip of water is acceptable. Gum and hard candy are generally considered equivalent to clear liquids. Special populations such as diabetic patients may require holding solid food for longer periods due to delayed gastric emptying.
Q6. Mallampati classification
Mallampati class is assessed with the patient:
A. Supine, mouth closed, neutral neck position, no phonation
B. Sitting, mouth open, tongue protruded fully, no phonation
C. Standing, mouth open, tongue protruded fully, no phonation
D. Sitting, sniffing position, mouth open, tongue at rest
E. Supine, laryngoscope blade in place, tongue depressed anteriorly
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Answer: B. Mallampati classification is properly assessed with the patient sitting upright with the neck in a neutral position, mouth opened wide, and tongue maximally protruded without phonation. Phonation (saying 'ahh') falsely improves visibility of posterior pharyngeal structures and should not be included in the assessment. Class I: soft palate, uvula, and tonsillar pillars visible. Class II: soft palate and uvula visible. Class III: soft palate and base of uvula visible. Class IV: only hard palate visible. The sitting position with neutral neck alignment and absence of phonation are critical to standardize the assessment and avoid overestimating airway visibility.
Q7. Difficult intubation predictors (MIST)
Difficult airway predictors include all EXCEPT:
A. Mallampati score ≥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. The MIST mnemonic for difficult airway predictors includes: Mallampati score ≥3, Interincisor distance <3 cm, Sternomental distance <12.5 cm, and Thyromental distance <6.5 cm. Tongue protrusion is not part of MIST; rather, restricted mandibular protrusion (inability to advance lower incisors beyond upper incisors) is a predictor. Additional predictors include limited neck extension/flexion, large or protruding incisors, and neck mass. No single predictor is highly sensitive or specific, so they should be used as a composite assessment. Cormack-Lehane grading (1–4) is used during direct laryngoscopy to describe the laryngeal view obtained.
Q8. Antihypertensive perioperative — ACE inhibitors
The current recommendation for ACE inhibitors/ARBs preoperatively is:
A. Continue all antihypertensive medications on the morning of surgery without any modifications
B. Hold on the morning of surgery, especially for surgeries with hypovolemia or hypotension risk
C. Convert to a short-acting calcium channel blocker on the morning of surgery instead
D. Hold for 48 hours preoperatively and resume only after hemodynamic stability is confirmed
E. Continue only if the patient has severe hypertension or recent myocardial infarction history
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Answer: B. ACE inhibitors and ARBs are typically held on the morning of surgery for most patients because they are associated with refractory hypotension on induction due to blockade of the renin-angiotensin system. This is especially important for patients undergoing surgeries with hypovolemia risk, those receiving regional anesthesia, or those having major surgery. When hypotension occurs in patients on ACE inhibitors or ARBs, it should be treated with phenylephrine and vasopressin, which are more effective than ephedrine because both vasopressin and norepinephrine pathways may be needed when the renin-angiotensin system is blocked.
Q9. β-blocker initiation
The POISE trial demonstrated that initiating β-blockers acutely preoperatively (without proper titration) increases:
A. Cardiac mortality and perioperative arrhythmias without reducing myocardial infarction
B. Stroke and total mortality despite reducing the incidence of non-fatal myocardial infarction
C. Pulmonary complications and pneumonia without reducing overall cardiovascular morbidity
D. Wound infection and delayed healing without improving any cardiovascular outcomes
E. No effect on mortality or cardiovascular outcomes in the perioperative period
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Answer: B. The POISE trial (2008) demonstrated that metoprolol started immediately preoperatively without titration resulted in fewer myocardial infarctions but significantly more strokes and increased total mortality, largely attributed to hypotension and bradycardia. Current recommendations emphasize continuing β-blockers in patients already taking them chronically, but strongly advise against initiating β-blockers less than 24 hours before surgery. If β-blocker therapy is indicated for a patient not already on one, it should be started at least 1 week (ideally several weeks) before surgery and carefully titrated to achieve a target heart rate of 50-60 beats per minute while monitoring for hypotension.
Q10. Statins perioperative
For a patient on chronic statin therapy:
A. Hold statins one week before surgery to reduce bleeding risk
B. Continue statins perioperatively to reduce cardiovascular event risk
C. Switch to ezetimibe perioperatively to maintain lipid control
D. Reduce statin dose by half during the perioperative period
E. Hold statins only on the day of surgery
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Answer: B. Statins should be continued perioperatively in patients on chronic therapy. Continuation is associated with reduced cardiac mortality, myocardial infarction, and stroke. Withdrawal of statins may transiently increase cardiovascular events due to rebound inflammatory effects and plaque destabilization. Multiple professional guidelines, including those from the ACC/AHA, recommend continuing statins throughout the perioperative period for patients already taking them chronically. There is no evidence that statins increase bleeding risk or require dose adjustment perioperatively.
Q11. Aspirin perioperative — cardiovascular
For a patient on aspirin for secondary CV prevention undergoing non-cardiac surgery:
A. Continue aspirin in most cases; stop 5–7 days before only for high-bleeding-risk surgery (intracranial, posterior eye, prostatectomy)
B. Stop aspirin 7 days before all elective surgery; resume postoperatively once hemostasis is confirmed and bleeding risk decreases
C. Continue aspirin only on the day of surgery; hold for 3 days preoperatively and resume on postoperative day one
D. Switch to clopidogrel 5 days preoperatively; continue clopidogrel perioperatively and transition back to aspirin after hospital discharge
E. Stop aspirin indefinitely before surgery; do not resume postoperatively given increased bleeding risk demonstrated in perioperative trials
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Answer: A. For patients on chronic aspirin for secondary cardiovascular prevention (prior stent, myocardial infarction, or stroke), most experts recommend continuing aspirin throughout the perioperative period for non-cardiac surgery. Aspirin should be stopped approximately 5 to 7 days before only those procedures where bleeding would be catastrophic, such as intracranial neurosurgery, posterior eye surgery, or transurethral resection of the prostate. The POISE-2 trial (2014) demonstrated that perioperative aspirin increased major bleeding without reducing death or myocardial infarction in aspirin-naive patients. However, the thrombotic risk of stopping aspirin in patients on chronic therapy for secondary prevention generally outweighs the bleeding risk for most surgical procedures. The decision requires individualized assessment balancing thrombotic versus hemorrhagic risk for each patient and procedure.
Q12. Herbal supplements perioperative
Most herbal supplements should be discontinued before surgery:
A. 24 hours before surgery to allow clearance of active metabolites
B. 7–14 days before surgery, tapering valerian to avoid withdrawal symptoms
C. 1 month before surgery to ensure complete elimination from body
D. Continue through surgery as they provide beneficial antioxidant effects
E. 1 hour before surgery to minimize interaction with anesthetic agents
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Answer: B. Most herbal supplements should be discontinued 7–14 days before surgery. Garlic, ginkgo, ginger, and ginseng increase bleeding risk through antiplatelet effects. Ma huang (ephedra) has sympathomimetic properties that can cause hemodynamic instability. St. John's wort induces cytochrome P450 enzymes, altering drug metabolism. Kava is associated with hepatotoxicity. Valerian has benzodiazepine-like effects and should be tapered rather than stopped abruptly to avoid withdrawal symptoms. Always ask about herbal supplement use during the preoperative interview, as patients may not volunteer this information.
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 prednisone equivalent
B. ≥10 mg/day prednisone equivalent
C. ≥20 mg/day prednisone equivalent
D. ≥40 mg/day prednisone equivalent
E. ≥60 mg/day prednisone equivalent
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Answer: C. Stress dose steroid coverage should be considered for patients who have taken ≥20 mg/day of prednisone equivalent for ≥3 weeks in the past year, as this threshold is associated with likely HPA axis suppression. Doses <5 mg/day are usually not suppressive. The intermediate range of 5–20 mg/day presents uncertainty and may warrant cosyntropin stimulation testing or empiric perioperative coverage depending on clinical context. Additionally, high-dose inhaled steroids (>800 mcg/day) or topical steroids (>2 g/day) can also cause HPA suppression and should be considered in the risk assessment.
Q14. Pregnancy testing preoperative
Preoperative pregnancy testing in women of reproductive age:
A. Required for all women of reproductive age regardless of patient preference or clinical context
B. Should be offered to women of childbearing potential as a joint decision with the patient
C. Always avoidable since pregnancy status does not affect anesthetic management or surgical timing
D. Routine in pediatric patients who have not yet reached menarche or reproductive maturity
E. Tested only when abdominal or pelvic surgery is planned regardless of other patient factors
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Answer: B. The ASA recommends offering pregnancy testing to women of childbearing potential as a shared decision between the clinician and patient. This approach respects patient autonomy while addressing important anesthetic considerations. Pregnant patients require special attention to avoid teratogenic agents during the first trimester and to prevent aortocaval compression after 20 weeks of gestation. When pregnancy is confirmed, elective surgery should ideally be postponed until the postpartum period. The decision to test should be individualized based on clinical context, patient history, and the nature of the planned procedure rather than being mandatory or completely avoided.
Q15. Preop CXR indications
Routine preoperative CXR is indicated for:
A. All patients over 40 years of age regardless of medical history or surgical procedure
B. Significant cardiopulmonary disease, suspected pneumonia, severe COPD with bullae, or recent respiratory infection
C. Anyone undergoing general anesthesia regardless of underlying health status or procedure type
D. Pediatric patients under 18 years of age regardless of medical history or procedure
E. All smokers regardless of pack-year history, symptoms, or presence of respiratory disease
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Answer: B. Preoperative chest radiography is not routinely indicated based on age, anesthetic technique, or smoking history alone. Specific clinical indications include active cardiopulmonary symptoms, significant cardiovascular or pulmonary disease, smokers with respiratory symptoms, suspected pneumonia, suspected severe COPD with bullous disease, and recent respiratory infections. The key principle is that preoperative testing should be indication-based rather than routine, driven by patient-specific risk factors and clinical findings rather than demographic characteristics alone. Age-based screening without clinical indication does not improve outcomes and increases healthcare costs unnecessarily.
Q16. Preop ECG
Routine preoperative ECG is indicated for:
A. All patients over 50 years of age undergoing any surgical procedure
B. Patients with cardiovascular disease or risk factors undergoing elevated-risk surgical procedures
C. All healthy adults undergoing routine low-risk elective surgical procedures
D. All patients undergoing outpatient surgery regardless of medical history
E. Pediatric patients undergoing any surgical procedure regardless of cardiac history
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Answer: B. Per ACC/AHA guidelines, preoperative ECG is reasonable (Class IIa recommendation) in patients with known coronary artery disease, significant arrhythmia, peripheral vascular disease, cerebrovascular disease, or structural heart disease who are undergoing elevated-risk surgery. It may be reasonable (Class IIb) for asymptomatic patients undergoing elevated-risk surgeries. Preoperative ECG is NOT recommended for low-risk surgery in asymptomatic patients regardless of age. Age alone is not an indication for routine preoperative ECG; the decision should be based on the presence of cardiovascular disease or risk factors combined with the risk level of the planned surgical procedure.
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
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Answer: B. For bare-metal stents placed for stable ischemic heart disease, the minimum duration of dual antiplatelet therapy before elective surgery is 1 month. In contrast, drug-eluting stents for stable IHD require 6 months of DAPT, and any stent placed in the setting of acute coronary syndrome requires 12 months. Aspirin should be continued throughout the perioperative period if possible. If surgery must occur sooner than the recommended DAPT duration, a multidisciplinary discussion involving cardiology, surgery, and anesthesia is essential to weigh the risks of stent thrombosis against surgical bleeding.
Q18. Bridging anticoagulation
Bridging therapy for warfarin patients before surgery is indicated for which thrombotic risk?
A. Atrial fibrillation with CHADS₂ score of 1 without recent stroke or systemic embolism
B. Mechanical mitral valve, recent VTE within 3 months, or atrial fibrillation with CHA₂DS₂-VASc ≥6 or recent stroke
C. All patients receiving warfarin therapy regardless of underlying indication or thrombotic risk stratification
D. Any patient with therapeutic INR greater than 2.0 at time of preoperative evaluation
E. Bridging is never indicated for any patient on warfarin therapy undergoing elective surgery
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Answer: B. Bridging anticoagulation is indicated only for patients at high thrombotic risk. High-risk conditions include mechanical mitral valve prosthesis, recent venous thromboembolism (within 3 months), atrial fibrillation with CHA₂DS₂-VASc score ≥6, or recent stroke (within 3 months). The BRIDGE trial (2015) demonstrated that patients with moderate-risk atrial fibrillation who underwent bridging had increased bleeding complications without reduction in thromboembolic events, establishing that low-to-moderate risk patients should not be bridged. When bridging is indicated, warfarin should be held 5 days preoperatively, therapeutic LMWH or IV unfractionated heparin should be used for bridging, the last dose of LMWH should be given 24 hours before surgery, and anticoagulation should be restarted 24 hours postoperatively (or 48-72 hours after high-bleeding-risk procedures). A CHADS₂ score of 1 represents low-to-moderate risk and does not require bridging.
Q19. OSA preop screening
The STOPBANG questionnaire screens for:
A. Pulmonary hypertension risk in surgical patients
B. Obstructive sleep apnea risk in surgical patients
C. Cognitive impairment risk in surgical patients
D. Frailty syndrome risk in surgical patients
E. Cardiac disease risk in surgical patients
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Answer: B. The STOPBANG questionnaire is a validated screening tool for obstructive sleep apnea risk in the perioperative setting. The acronym stands for: Snoring, Tired, Observed apnea, Pressure (hypertension), BMI greater than 35, Age greater than 50, Neck circumference greater than 40 cm, and Gender male. A score of 3 or more indicates intermediate risk, while a score of 5 or more indicates high risk for obstructive sleep apnea. For patients screening positive, the anesthetic plan should include postoperative opioid minimization, regional anesthesia when feasible, postoperative CPAP if already prescribed, and prolonged monitoring in a higher level of care.
Q20. Frailty assessment
Preoperative frailty assessment is best evaluated with:
A. Age alone, as chronologic age directly correlates with physiologic reserve and surgical risk
B. ASA physical status classification alone, as it captures overall health and comorbidity burden
C. Validated frailty tools such as Edmonton Frail Scale, Fried criteria, or modified frailty index
D. Body mass index alone, as it reflects nutritional status and metabolic reserve capacity
E. Laboratory values alone, as they provide objective measures of organ function and reserve
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Answer: C. Frailty represents decreased physiologic reserve and predicts postoperative morbidity and mortality independent of age and ASA physical status classification. Multiple validated tools exist to assess frailty, including the Edmonton Frail Scale, Fried frailty criteria, and modified frailty index. These multidimensional tools assess domains such as cognition, functional status, nutrition, mobility, and social support. Identifying frail patients preoperatively allows for targeted interventions including prehabilitation programs, multidisciplinary care coordination, goals of care discussions, and consideration of less invasive surgical approaches. Age alone, ASA class alone, BMI, and laboratory values are inadequate as isolated measures because they do not capture the multidimensional nature of frailty or its independent predictive value for surgical outcomes.
Q21. Difficult airway from physical exam
Beyond Mallampati, signs predicting difficult intubation include:
A. Limited cervical extension, inability to advance lower incisors past upper incisors, short thick neck, receding mandible, high-arched palate, large incisors, neck mass
B. Mallampati score alone without consideration of other anatomic features, mouth opening measurements, thyromental distance, or cervical mobility assessment
C. Patient age as the primary predictor, particularly focusing on extremes of age including very young pediatric patients and elderly patients over seventy years
D. Patient gender as the sole anatomic predictor, with particular emphasis on male versus female differences in airway anatomy and intubation difficulty rates
E. Hand grip strength as a surrogate marker for overall muscle tone, pharyngeal muscle strength, and ability to maintain airway patency during intubation attempts
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Answer: A. Difficult intubation prediction requires multifactorial assessment beyond Mallampati classification alone. Key physical exam findings include limited cervical extension, reduced mouth opening, short thyromental distance (less than 6 cm), short sternomental distance (less than 12.5 cm), inability to advance lower incisors past upper incisors (failed mandibular protrusion test), receding mandible, high-arched palate, large or buck incisors, short thick neck, obesity, beard, and presence of neck mass. Composite scoring systems such as HEAVEN, El-Ganzouri, and Wilson scores combine multiple factors to improve prediction accuracy. Patient age, gender, and grip strength are not validated predictors of difficult intubation.