SOE sample stem with a worked answer: preoperative evaluation

This stem was written for practice. It is not an ABA question and is not taken from any book or question bank. The answers reflect mainstream practice and current society guidance as we understand it; your institution's protocols and your own judgment govern real patients.

"No. He is four months out from a drug-eluting stent placed for an acute coronary syndrome, so stopping both agents puts him at real risk of stent thrombosis. I would continue aspirin through surgery unless the surgeon tells me bleeding would be catastrophic, which is unusual for a hemicolectomy. Whether and when to stop ticagrelor, and whether the timing of surgery is right, is a joint decision with his cardiologist and surgeon, before the date is set."

"Cancer surgery is time-sensitive, so I would not simply delay indefinitely. If the team agrees to proceed, I would continue aspirin, stop ticagrelor about five days before surgery (its prescribing information advises five days, when possible, before surgery with a major bleeding risk) with the exact timing agreed with cardiology, avoid neuraxial techniques while its effect persists, and restart it as soon as the surgeon judges bleeding risk acceptable. For a patient cardiology considers very high risk, intravenous antiplatelet bridging is an option that cardiology would direct. I would also make sure the surgery is done where interventional cardiology is available."

"No. He has known coronary disease and is having intraperitoneal surgery, so his risk is elevated, but he does well over four METs, he has no new symptoms since revascularization, and he has a recent echo. A stress test would not change his management, so I would proceed with his current medical therapy."

"That is a change in symptoms and possibly unstable angina. I would postpone, and he needs cardiology evaluation before any nonemergent surgery."

"Continue the beta blocker, the statin and aspirin. Hold metformin the morning of surgery. Hold lisinopril that morning to reduce post-induction hypotension, and restart it after surgery once he is eating, euvolemic and normotensive. The empagliflozin needs to stop earlier: at least three days before surgery."

"SGLT2 inhibitors can cause euglycemic diabetic ketoacidosis around surgery and fasting, and any bowel preparation adds dehydration. Its prescribing information advises withholding empagliflozin for at least three days, if possible, before surgery. Glucose can look nearly normal, so on the day of surgery I would check glucose and, if he is unwell, ketones and a blood gas."

"I would check a blood gas and ketones. If there is no acidosis or ketosis, the risk is lower but not zero; I would discuss postponing a day or two with the surgeon, because this is not an emergency, and if we proceed I would monitor glucose, ketones and acid-base status during and after surgery."

"Three things. Airway: he has predictors of difficult mask ventilation and intubation, so I would preoxygenate head-up and have a video laryngoscope and a supraglottic airway ready. Opioids: I would use multimodal analgesia (acetaminophen, local anesthetic infiltration or truncal blocks, and minimal opioids). Recovery: extubate fully awake with reversal confirmed by quantitative monitoring, bring his CPAP, and monitor oxygen saturation continuously after surgery."

"Not routinely. He has risk factors but a full examination without a history of difficult airway. A well-prepared asleep technique with video laryngoscopy is reasonable; I would choose awake intubation if the examination or history suggested I might not be able to ventilate him."

"Yes. This is iron-deficiency anemia from the tumor, and he has two weeks. I would ask the surgeon or primary team about intravenous iron now, send a type and screen, and plan a restrictive transfusion strategy: I would transfuse for symptoms, signs of ischemia or a hemoglobin below about 8 given his coronary disease, not to a number on the morning of surgery."

"For a laparoscopic hemicolectomy, an epidural is usually not needed; truncal blocks or wound infiltration with multimodal analgesia work well. In his case the bigger issue is the ticagrelor: neuraxial techniques should wait until it has been stopped long enough according to ASRA guidance, so I would not plan one."