MCQ bank · 36 questions · free
Perioperative care MCQs with answers
36 single-best-answer questions on pre-operative assessment, anticoagulation, diabetes, frailty and enhanced recovery. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
On day 2 after a hemicolectomy, a 60-year-old man without heart disease has a haemoglobin of 75 g/L. He is well, not bleeding and haemodynamically stable. What do you do?
- Transfuse 2 units
- Transfuse 1 unit before every blood test
- Transfuse to keep Hb above 100 g/L
- No transfusion; investigate and treat iron deficiency
- Give fresh frozen plasma
Show the answer and explanation
Answer: D. No transfusion; investigate and treat iron deficiency. A restrictive threshold of 70 g/L is safe for most stable patients without acute coronary disease (80 g/L is used in some cardiac and orthopaedic groups). Transfusion carries risks and should be given one unit at a time with reassessment.
Why not the others? Liberal thresholds do not improve outcomes.
References
A healthy patient is on the afternoon list for an elective laparoscopic cholecystectomy. What fasting advice do you give?
- Fasting is not needed for laparoscopic surgery
- Nothing by mouth from midnight
- No fluids for 12 hours
- Only water in the 24 hours before surgery
- No solid food for 6 hours; clear fluids are allowed until 2 hours before surgery
Show the answer and explanation
Answer: E. No solid food for 6 hours; clear fluids are allowed until 2 hours before surgery. Clear fluids up to 2 hours before anaesthesia do not increase aspiration risk, and they reduce thirst, hunger and dehydration. Prolonged fasting from midnight is unnecessary and harmful.
Why not the others? Long fasting worsens dehydration and insulin resistance, especially in the elderly.
References
Cefazolin is to be given as prophylaxis for an elective colectomy expected to last 5 hours. Which plan is correct?
- Give the night before surgery
- Give one dose only, regardless of duration
- Give after the incision
- Continue for 5 days after surgery
- Give within 60 minutes before the incision, and repeat after 4 hours
Show the answer and explanation
Answer: E. Give within 60 minutes before the incision, and repeat after 4 hours. The antibiotic must be in the tissues when the skin is cut, so it is given within 60 minutes before incision. Cefazolin is repeated every 4 hours (about two half-lives) during long operations, and also after blood loss of more than 1500 mL. Prophylaxis should not continue beyond 24 hours.
Why not the others? Prolonged prophylaxis does not reduce infection and increases resistance and C. difficile.
References
An 81-year-old needs an emergency laparotomy for perforated diverticulitis. The predicted 30-day mortality is 12%. Which plan meets current UK standards?
- Return to the ward unless complications occur
- A consultant surgeon and a consultant anaesthetist in theatre, and planned admission to critical care
- Delay surgery until the morning list
- Avoid calculating a risk score in emergencies
- Surgery by the on-call registrar, ward care afterwards
Show the answer and explanation
Answer: B. A consultant surgeon and a consultant anaesthetist in theatre, and planned admission to critical care. For high-risk emergency laparotomy (predicted mortality of 5% or more), consultant surgeon and anaesthetist presence and planned critical care admission are recommended standards, along with documented risk assessment.
Why not the others? The risk score guides the level of care and the conversation with the patient.
References
On day 2 after surgery, a patient has a potassium of 6.9 mmol/L, and the ECG shows peaked T waves and a widened QRS. What do you give first?
- Intravenous potassium chloride
- Repeat the blood test before treating
- Intravenous calcium gluconate (or chloride) to protect the heart
- Oral calcium resonium
- Furosemide
Show the answer and explanation
Answer: C. Intravenous calcium gluconate (or chloride) to protect the heart. Calcium stabilises the myocardium within minutes but does not lower potassium. It is followed immediately by insulin with glucose (and salbutamol) to shift potassium into the cells, then treatment of the cause and removal of potassium.
Why not the others? Resins act too slowly in an emergency. Waiting for a repeat sample with ECG changes is unsafe.
References
A 68-year-old with atrial fibrillation (CHA₂DS₂-VASc 3, no mechanical valve, no recent stroke) takes warfarin and needs an elective hernia repair. What is the correct plan?
- Give vitamin K the morning of surgery to every patient
- Stop warfarin and bridge with full-dose LMWH
- Stop warfarin 1 day before
- Continue warfarin through surgery
- Stop warfarin 5 days before surgery without heparin bridging, check the INR the day before, and restart when bleeding risk allows
Show the answer and explanation
Answer: E. Stop warfarin 5 days before surgery without heparin bridging, check the INR the day before, and restart when bleeding risk allows. For atrial fibrillation without a mechanical valve or recent stroke, bridging with heparin does not reduce stroke and doubles major bleeding (BRIDGE trial). Warfarin is stopped 5 days before surgery and restarted 12–24 hours after it, once haemostasis is secure.
Why not the others? Bridging is reserved for very high thrombotic risk, such as a mechanical mitral valve or a recent clot.
References
A 60-year-old had a drug-eluting stent for stable angina 2 months ago and takes aspirin and clopidogrel. He has symptomatic gallstones and asks for a cholecystectomy. What do you advise?
- Replace both with LMWH
- Operate tomorrow on dual antiplatelet therapy
- Stop aspirin and keep clopidogrel
- Stop both antiplatelets now and operate next week
- Postpone this elective operation until at least 6 months after the stent if possible, and do not stop antiplatelets without discussion with his cardiologist
Show the answer and explanation
Answer: E. Postpone this elective operation until at least 6 months after the stent if possible, and do not stop antiplatelets without discussion with his cardiologist. Stopping dual antiplatelet therapy early after a stent carries a high risk of stent thrombosis, which often causes a large myocardial infarction. Elective non-cardiac surgery should be deferred until DAPT is complete (6 months after elective stenting), and aspirin is usually continued through surgery.
Why not the others? Heparin does not protect against stent thrombosis. Emergency surgery cannot wait and is done with cardiology input.
References
A patient with type 2 diabetes takes empagliflozin (an SGLT2 inhibitor) and is booked for an elective sleeve gastrectomy. When should it be stopped?
- On the morning of surgery
- It does not need to be stopped
- 3 days before surgery (including the day of surgery)
- 2 weeks before
- Only if the glucose is high
Show the answer and explanation
Answer: C. 3 days before surgery (including the day of surgery). SGLT2 inhibitors can cause euglycaemic diabetic ketoacidosis around surgery, especially with fasting and the low-calorie diet after bariatric surgery. They should be stopped 3 days before (4 for ertugliflozin) and restarted only once the patient is eating and drinking normally. Check ketones if the patient is unwell, even if the glucose is normal.
Why not the others? The ketoacidosis can occur with a normal glucose, so a normal reading does not exclude it.
References
A patient is on an enhanced recovery (ERAS) pathway after an elective laparoscopic right hemicolectomy. When should oral intake start?
- After bowel opening
- After 5 days
- After flatus has been passed
- Within 24 hours of surgery, starting the day of surgery if tolerated
- After a contrast study
Show the answer and explanation
Answer: D. Within 24 hours of surgery, starting the day of surgery if tolerated. Early oral intake after colorectal surgery is safe and is linked with faster recovery of bowel function and shorter stay, with no increase in anastomotic leak. Other ERAS elements include avoiding long fasting, carbohydrate loading, opioid-sparing analgesia, early mobilisation and avoiding routine drains and nasogastric tubes.
Why not the others? Waiting for flatus delays recovery without benefit.
References
During a laparoscopic cholecystectomy under volatile anaesthesia, the patient’s end-tidal CO₂ rises steeply despite more ventilation, with tachycardia, muscle rigidity and a rising temperature. What is the specific treatment?
- Give more suxamethonium
- Stop the volatile agent, call for help and give intravenous dantrolene
- Release the pneumoperitoneum and continue the volatile agent
- Paracetamol and cooling only
- Intravenous antibiotics
Show the answer and explanation
Answer: B. Stop the volatile agent, call for help and give intravenous dantrolene. This is malignant hyperthermia, a genetic reaction to volatile anaesthetics and suxamethonium. The trigger is stopped, the patient is hyperventilated with 100% oxygen, and dantrolene is given, followed by active cooling and treatment of hyperkalaemia and acidosis.
Why not the others? Suxamethonium is a trigger. Raised CO₂ from the pneumoperitoneum does not cause rigidity or fever.
References
On the second night after a hip fracture operation, an 86-year-old woman becomes confused, agitated and inattentive. What is the first approach?
- Look for and treat causes (infection, pain, urinary retention, constipation, drugs, low oxygen, electrolytes) and use non-drug measures
- Assume she has dementia
- Restrain her in bed
- Give haloperidol to every confused patient
- Give a benzodiazepine
Show the answer and explanation
Answer: A. Look for and treat causes (infection, pain, urinary retention, constipation, drugs, low oxygen, electrolytes) and use non-drug measures. Postoperative delirium is common and usually has several reversible causes. Treat those causes and use non-drug measures: orientation, glasses and hearing aids, sleep, mobilisation and family presence. A short course of low-dose haloperidol is used only if she is distressed or at risk, and benzodiazepines are avoided except in alcohol withdrawal.
Why not the others? Restraints and sedatives worsen delirium.
References
A patient taking prednisolone 15 mg daily for 2 years for rheumatoid arthritis is having an elective laparoscopic colectomy. What should be done about steroids?
- Continue the usual dose and give extra hydrocortisone at induction and for the first post-operative period
- No change; the usual dose is enough
- Double the prednisolone for a month
- Stop prednisolone a week before surgery
- Give only fludrocortisone
Show the answer and explanation
Answer: A. Continue the usual dose and give extra hydrocortisone at induction and for the first post-operative period. Long-term glucocorticoids (5 mg prednisolone or more for over 4 weeks) suppress the adrenal response to surgical stress. Without extra cover, patients can develop adrenal crisis with hypotension. Guidelines recommend hydrocortisone 100 mg at induction, then an infusion or regular doses until eating and drinking, then the usual dose (doubled briefly after major surgery).
Why not the others? Stopping steroids before surgery is dangerous.
References
A 64-year-old is booked for a right hemicolectomy in 5 weeks. His haemoglobin is 98 g/L with low ferritin, from the tumour. What is the best preparation?
- Transfuse 2 units the day before surgery
- Intravenous iron now, to raise haemoglobin before surgery
- No treatment; anaemia does not matter
- Oral iron the day before surgery
- Postpone surgery for 6 months
Show the answer and explanation
Answer: B. Intravenous iron now, to raise haemoglobin before surgery. Preoperative anaemia increases transfusion, complications and mortality. Iron deficiency is identified and treated early; with only a few weeks available, intravenous iron works faster and better than oral iron, which is also poorly absorbed in active cancer. This is part of patient blood management.
Why not the others? Transfusion carries risks and should not replace correcting iron deficiency.
References
A patient with type 2 diabetes is listed for an elective hernia repair. His HbA1c is 84 mmol/mol (9.8%). What do you advise?
- Start insulin on the day of surgery only
- Cancel surgery permanently
- Refer for optimisation of diabetes control and consider postponing elective surgery until HbA1c is improved
- Proceed; HbA1c does not matter
- Stop all diabetes medication for a week before surgery
Show the answer and explanation
Answer: C. Refer for optimisation of diabetes control and consider postponing elective surgery until HbA1c is improved. Poor glycaemic control increases wound infection, cardiovascular complications and length of stay. UK guidance suggests that elective surgery be reconsidered when HbA1c is above 69 mmol/mol (8.5%), with optimisation through primary care or the diabetes team where it is safe to wait.
Why not the others? Urgent or cancer surgery is not delayed for this reason; glucose is managed carefully around the operation instead.
References
A man with a BMI of 41 snores loudly, his wife has seen him stop breathing at night, and he has a STOP-BANG score of 6. He is booked for a laparoscopic cholecystectomy. Which plan is best?
- Give long-acting opioids at home
- Cancel surgery until he loses 50 kg
- Recognise a high risk of obstructive sleep apnoea: consider a sleep study if time allows, use opioid-sparing analgesia and monitor oxygen after surgery; continue CPAP if he already uses it
- Ignore the score
- Use a heavy benzodiazepine premedication
Show the answer and explanation
Answer: C. Recognise a high risk of obstructive sleep apnoea: consider a sleep study if time allows, use opioid-sparing analgesia and monitor oxygen after surgery; continue CPAP if he already uses it. Undiagnosed obstructive sleep apnoea increases airway and cardiopulmonary complications, particularly with opioids and sedatives. Patients at high risk can usually proceed with precautions: regional or multimodal analgesia, careful extubation, semi-upright positioning and postoperative monitoring.
Why not the others? Sedatives and long-acting opioids worsen apnoea.
References
A smoker is booked for an elective open incisional hernia repair in 8 weeks. What should you tell him about smoking?
- Smoking has no effect on surgery
- Stopping only the night before is enough
- Stopping now, at least 4 weeks before surgery, reduces wound and respiratory complications; offer help to quit
- Switching to cigars is safe
- Stopping just before surgery increases complications, so continue
Show the answer and explanation
Answer: C. Stopping now, at least 4 weeks before surgery, reduces wound and respiratory complications; offer help to quit. Stopping smoking at least 4 weeks before surgery reduces wound infection, wound breakdown and respiratory complications, and longer is better. Surgery is a good opportunity to quit, and nicotine replacement and support should be offered.
Why not the others? The old idea that stopping shortly before surgery is harmful has not been confirmed.
References
A 30-year-old non-smoking woman with a history of motion sickness is having a laparoscopic cholecystectomy and will need opioids afterwards. How should postoperative nausea and vomiting be managed?
- Give a single dose of metoclopramide only
- Avoid all fluids
- Give no prophylaxis, and treat only if she vomits
- Increase the opioids to reduce nausea
- Recognise a high risk (four Apfel factors) and give multimodal prophylaxis with two or more antiemetics, such as dexamethasone and ondansetron
Show the answer and explanation
Answer: E. Recognise a high risk (four Apfel factors) and give multimodal prophylaxis with two or more antiemetics, such as dexamethasone and ondansetron. The Apfel risk factors are female sex, non-smoking, a history of PONV or motion sickness, and postoperative opioids. With three or four, the risk of PONV is high, so prophylaxis with antiemetics from different classes is recommended, along with reducing triggers such as volatile anaesthetics and opioids.
Why not the others? Metoclopramide at standard doses is a weak antiemetic.
References
Two days after surgery, a woman who has received large volumes of hypotonic fluid has a seizure. Her sodium is 116 mmol/L. What is the immediate treatment?
- Rapid correction to a normal sodium within 6 hours
- A bolus of 150 mL of 3% hypertonic saline over 20 minutes, repeated if needed, aiming for a rise of about 5 mmol/L, and no more than 10 mmol/L in the first 24 hours
- Fluid restriction only
- 5% glucose infusion
- Furosemide alone
Show the answer and explanation
Answer: B. A bolus of 150 mL of 3% hypertonic saline over 20 minutes, repeated if needed, aiming for a rise of about 5 mmol/L, and no more than 10 mmol/L in the first 24 hours. Severe symptomatic hyponatraemia (seizures, reduced consciousness) needs hypertonic saline to reduce brain swelling. A small rise of about 5 mmol/L usually stops symptoms. Over-rapid correction risks osmotic demyelination, so the total rise in the first 24 hours is limited to 10 mmol/L.
Why not the others? 5% glucose is effectively free water and worsens hyponatraemia.
References
Minutes after a large volume of local anaesthetic is infiltrated for a hernia repair, the patient becomes agitated, then has a seizure and develops a broad-complex arrhythmia. What is the specific treatment?
- Intravenous calcium
- More local anaesthetic to finish the operation
- Stop the injection, call for help, manage the airway and seizures, and give 20% lipid emulsion intravenously
- Naloxone
- Flumazenil
Show the answer and explanation
Answer: C. Stop the injection, call for help, manage the airway and seizures, and give 20% lipid emulsion intravenously. This is local anaesthetic systemic toxicity. Lipid emulsion binds the drug and reverses cardiotoxicity. Seizures are treated with benzodiazepines; if cardiac arrest occurs, CPR may need to be prolonged. Prevention means calculating the maximum safe dose for the patient’s weight and aspirating before injecting.
Why not the others? Naloxone and flumazenil reverse opioids and benzodiazepines, not local anaesthetics.
References
A patient listed for a colectomy reports a “penicillin allergy”: a mild itchy rash as a child, with no swelling or breathing problems. Which prophylactic antibiotic is appropriate?
- Delay surgery for allergy testing in every case
- Penicillin desensitisation before every operation
- No antibiotic prophylaxis
- Avoid all beta-lactams and use vancomycin alone
- Cefazolin can be given, because cross-reactivity with this history is very low
Show the answer and explanation
Answer: E. Cefazolin can be given, because cross-reactivity with this history is very low. Most reported penicillin allergies are not true allergies, and cefazolin has a different side chain from penicillins, so cross-reactivity is rare. Patients with non-severe, non-IgE-type histories can safely receive cefazolin. Labelling patients as allergic leads to less effective antibiotics and more surgical site infection.
Why not the others? For colorectal surgery, cefazolin is combined with metronidazole. Vancomycin alone does not cover gram-negative organisms.
References
On day 2 after an emergency laparotomy, a patient’s creatinine has risen from 80 to 170 µmol/L and urine output is low. He takes ibuprofen and ramipril. What are the first steps?
- Give furosemide to increase urine output
- Continue all drugs
- Give a contrast CT to look for a cause
- Assess and correct volume status, stop nephrotoxic drugs (NSAIDs, ACE inhibitor), check for urinary obstruction, and monitor fluid balance and potassium
- Start dialysis immediately
Show the answer and explanation
Answer: D. Assess and correct volume status, stop nephrotoxic drugs (NSAIDs, ACE inhibitor), check for urinary obstruction, and monitor fluid balance and potassium. Postoperative AKI is common and often has several causes, including low volume, nephrotoxins and obstruction. Treatment is supportive: optimise perfusion, stop harmful drugs, exclude a blocked catheter or obstruction, and monitor for hyperkalaemia and fluid overload.
Why not the others? Diuretics do not improve kidney recovery and can cause dehydration.
References
A patient with stable coronary disease is having an elective colectomy next week. He does not take a beta-blocker. Should one be started the day before surgery to protect the heart?
- Only after surgery
- No; routinely starting a beta-blocker just before surgery is not recommended, as it can increase stroke and death
- Only if the heart rate is below 50
- Yes; every surgical patient should receive one
- Yes; high-dose metoprolol on the morning of surgery
Show the answer and explanation
Answer: B. No; routinely starting a beta-blocker just before surgery is not recommended, as it can increase stroke and death. The POISE trial showed that starting high-dose beta-blockers immediately before non-cardiac surgery reduced myocardial infarction but increased stroke and death. Patients already taking beta-blockers should continue them.
Why not the others? Stopping an established beta-blocker before surgery is harmful.
References
A 66-year-old with well-controlled hypertension and no cardiac symptoms is having an elective laparoscopic cholecystectomy. He climbs two flights of stairs without stopping. Does he need further cardiac testing?
- No; good functional capacity (4 METs or more) and a low-risk operation mean no further testing is needed
- Yes; stress echocardiography for everyone over 65
- Postpone surgery for 6 months
- Yes; cardiac MRI
- Yes; coronary angiography
Show the answer and explanation
Answer: A. No; good functional capacity (4 METs or more) and a low-risk operation mean no further testing is needed. Preoperative cardiac testing is guided by the surgical risk, the patient’s risk factors and functional capacity. Patients who can manage 4 METs (such as climbing two flights of stairs) without symptoms rarely benefit from further testing before low- or intermediate-risk surgery.
Why not the others? Unnecessary tests delay surgery and can lead to harmful interventions.
References
A 63-year-old has an open anterior resection for rectal cancer. What VTE prophylaxis is recommended after discharge?
- Aspirin for 1 week
- Stop all prophylaxis at discharge
- Extended low-molecular-weight heparin for 28 days after major abdominal or pelvic cancer surgery
- Warfarin for 1 year
- Compression stockings only, for 6 months
Show the answer and explanation
Answer: C. Extended low-molecular-weight heparin for 28 days after major abdominal or pelvic cancer surgery. The risk of VTE after major cancer surgery continues for weeks after discharge. Extended prophylaxis with LMWH for 28 days reduces VTE. Mechanical prophylaxis is used in hospital alongside it when appropriate.
Why not the others? Aspirin is not recommended for this setting.
References
Which intervention, adopted worldwide, reduced both complications and deaths after surgery in an 8-country study?
- Routine nasogastric tubes
- Routine postoperative antibiotics for 7 days
- The WHO Surgical Safety Checklist
- Routine preoperative chest X-ray
- Shaving the operative site the night before
Show the answer and explanation
Answer: C. The WHO Surgical Safety Checklist. The WHO Surgical Safety Checklist (sign in, time out, sign out) improves teamwork and ensures key steps such as antibiotic prophylaxis, correct patient and site, and counts. Its introduction was associated with significant reductions in complications and mortality.
Why not the others? A checklist only works when the team uses it properly, not as a tick-box exercise.
References
Which measures reduce surgical site infection?
- Routine antibiotics for 5 days after clean surgery
- Removing hair only if needed, using clippers on the day of surgery, and skin preparation with alcohol-based chlorhexidine
- Shaving with a razor the night before
- Povidone-iodine in water as first choice for every case
- Leaving wounds uncovered in theatre
Show the answer and explanation
Answer: B. Removing hair only if needed, using clippers on the day of surgery, and skin preparation with alcohol-based chlorhexidine. Razors cause skin micro-trauma that increases infection. Alcohol-based antiseptic skin preparation, ideally chlorhexidine, is recommended. Other measures include timely prophylaxis, normothermia, glucose control and covering the wound with an appropriate dressing.
Why not the others? Prophylaxis beyond the operation does not reduce infection in clean surgery.
References
Before an elective left hemicolectomy, which bowel preparation strategy reduces surgical site infection and anastomotic leak?
- Enemas only
- No preparation at all in every case
- Oral antibiotics for 2 weeks before surgery
- Mechanical preparation alone
- Mechanical bowel preparation combined with oral antibiotics
Show the answer and explanation
Answer: E. Mechanical bowel preparation combined with oral antibiotics. Combined mechanical bowel preparation and oral antibiotics before elective colorectal surgery is associated with lower surgical site infection and leak rates than mechanical preparation alone or no preparation, and is recommended by ASCRS.
Why not the others? Intravenous prophylaxis at induction is still given as well.
References
Why is active warming (for example forced-air warming) used for patients under anaesthesia for more than 30 minutes?
- Only for patient comfort
- To prevent inadvertent perioperative hypothermia, which increases bleeding, wound infection and cardiac events
- It has no proven benefit
- To speed up the operation
- To reduce the need for antibiotics
Show the answer and explanation
Answer: B. To prevent inadvertent perioperative hypothermia, which increases bleeding, wound infection and cardiac events. Anaesthesia impairs temperature regulation, and patients cool quickly. Hypothermia (below 36 °C) increases blood loss, surgical site infection and cardiac complications and delays recovery. Temperature is measured and the patient warmed before, during and after surgery, with warmed fluids for larger volumes.
Why not the others? Hypothermia also slows drug metabolism, prolonging anaesthesia.
References
A patient taking aspirin 75 mg daily for stable coronary disease (no stent in the last year) is having an elective laparoscopic hernia repair. What should be done with the aspirin?
- Double the dose
- Replace with heparin
- Stop aspirin permanently
- Stop aspirin 2 weeks before
- Continue aspirin through surgery in most cases, as the cardiovascular risk of stopping outweighs the small bleeding risk
Show the answer and explanation
Answer: E. Continue aspirin through surgery in most cases, as the cardiovascular risk of stopping outweighs the small bleeding risk. For secondary prevention, aspirin is usually continued around non-cardiac surgery, because stopping increases cardiovascular events. It may be stopped for operations with a very high bleeding risk or in closed spaces, such as intracranial or spinal surgery.
Why not the others? Low-dose aspirin rarely causes significant surgical bleeding.
References
A patient taking apixaban for atrial fibrillation, with normal kidney function, is having an open colectomy (high bleeding risk). When should apixaban be stopped?
- 1 month before
- On the morning of surgery
- It does not need to be stopped
- 7 days before with heparin bridging
- 2 days before surgery (the last dose 3 days before), with no heparin bridging, and restarted 48–72 hours after surgery if bleeding is controlled
Show the answer and explanation
Answer: E. 2 days before surgery (the last dose 3 days before), with no heparin bridging, and restarted 48–72 hours after surgery if bleeding is controlled. The PAUSE study showed that a simple, standardised interruption without bridging was safe for DOACs. For high-bleeding-risk surgery, apixaban is omitted for 2 days before surgery; for low-risk surgery, 1 day. Dabigatran needs longer interruption in kidney impairment.
Why not the others? Heparin bridging is not needed for DOACs, because their effect wears off quickly.
References
A patient with type 1 diabetes on basal-bolus insulin is having an elective operation and will miss more than one meal. What is the correct plan for his insulin?
- Give only his usual mealtime insulin
- Double the basal insulin
- Continue the long-acting (basal) insulin, often at a slightly reduced dose, and use a variable-rate intravenous insulin infusion with glucose while he is not eating
- Stop all insulin until he eats
- Use oral metformin instead
Show the answer and explanation
Answer: C. Continue the long-acting (basal) insulin, often at a slightly reduced dose, and use a variable-rate intravenous insulin infusion with glucose while he is not eating. People with type 1 diabetes make no insulin. Stopping insulin causes diabetic ketoacidosis within hours, even if the glucose is not very high. Basal insulin is continued, and a variable-rate insulin infusion with a glucose-containing fluid covers prolonged fasting.
Why not the others? “Nil by mouth” never means “no insulin” in type 1 diabetes.
References
A patient with a mechanical mitral valve on warfarin needs an elective hernia repair. What is the anticoagulation plan?
- Switch to a DOAC permanently
- Continue warfarin with an INR of 3
- Give aspirin instead
- Stop warfarin without bridging
- Stop warfarin about 5 days before and give bridging with low-molecular-weight heparin (or heparin), then restart both after surgery when safe
Show the answer and explanation
Answer: E. Stop warfarin about 5 days before and give bridging with low-molecular-weight heparin (or heparin), then restart both after surgery when safe. Mechanical valves, especially mitral, carry a high risk of thrombosis and stroke when anticoagulation is interrupted. Bridging is recommended for these patients, unlike most patients with atrial fibrillation. DOACs are contraindicated with mechanical valves.
Why not the others? DOACs caused more valve thrombosis than warfarin in mechanical valves.
References
An 84-year-old who needs help with shopping and housework and walks with a stick (Clinical Frailty Scale 5) is being considered for major elective surgery. What is the best approach?
- Proceed as for a fit 50-year-old
- Formal frailty assessment and comprehensive geriatric assessment, with shared decision-making about the risks, alternatives and goals of care
- Decide without involving the patient
- Do not mention the risks to avoid upsetting the patient
- Refuse surgery because of age
Show the answer and explanation
Answer: B. Formal frailty assessment and comprehensive geriatric assessment, with shared decision-making about the risks, alternatives and goals of care. Frailty, rather than age, predicts complications, longer stay, loss of independence and death after surgery. Comprehensive geriatric assessment improves preparation (nutrition, exercise, medicines, cognition) and supports honest shared decisions.
Why not the others? Age alone is not a reason to refuse surgery.
References
A 28-year-old woman is attending pre-operative assessment for an elective laparoscopic cholecystectomy. Which test should be offered?
- A pregnancy test, with her consent, on the day of surgery
- Routine ECG
- Routine coagulation screen
- Routine chest X-ray
- Routine liver ultrasound
Show the answer and explanation
Answer: A. A pregnancy test, with her consent, on the day of surgery. Pregnancy status should be checked in women who could be pregnant, with consent, because it may change anaesthetic and surgical plans. Healthy young patients do not need routine chest X-rays, ECGs or coagulation tests.
Why not the others? Routine tests without a clinical reason rarely change management.
References
A healthy 30-year-old (ASA 1) is having an elective inguinal hernia repair. Which routine pre-operative tests are needed?
- Chest X-ray
- Lung function tests
- Full blood count, kidney function, clotting and ECG for everyone
- None routinely; no full blood count, kidney function, coagulation or ECG is needed for a healthy patient having minor or intermediate surgery
- Echocardiogram
Show the answer and explanation
Answer: D. None routinely; no full blood count, kidney function, coagulation or ECG is needed for a healthy patient having minor or intermediate surgery. NICE advises against routine testing in healthy adults having minor or intermediate surgery. Tests are guided by the patient’s conditions, medications and the size of the operation. Unnecessary tests cause delays and false positives.
Why not the others? Tests are ordered for a reason, not by habit.
References
A 66-year-old with oesophageal cancer has lost 15% of his body weight in 3 months and has a low albumin. Major surgery is planned. What do you recommend?
- Proceed immediately without nutritional support
- Fasting for 3 days before surgery
- No action, because albumin will improve after surgery
- Parenteral nutrition as first choice for everyone
- Preoperative nutritional support (oral supplements or enteral feeding) for 7–14 days, even if surgery is slightly delayed
Show the answer and explanation
Answer: E. Preoperative nutritional support (oral supplements or enteral feeding) for 7–14 days, even if surgery is slightly delayed. Severe nutritional risk (for example weight loss over 10–15% in 6 months) increases complications. ESPEN recommends nutritional therapy before major surgery, delaying surgery if necessary. Enteral routes are preferred; parenteral nutrition is used when the gut cannot be used.
Why not the others? Low albumin reflects inflammation as well as nutrition, but weight loss is a strong risk marker.
References