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28 Part II&Anesthesia
RISK FACTORS
6. What is the threshold level of metabolic equivalents (METs), below which functional status is considered
poor?
A. 2 METs.
B. 4 METs.
C. 6 METs.
D. 8 METs.
E. 10 METs.
RISK FACTORS
7. Which of the following tasks approximates 4 METs, if the patient can carry out the task without becoming
short of breath?
A. Eating, dressing, or using the toilet.
B. Climbing a flight of stairs.
C. Walking two blocks on level ground at 2 to 3 miles per hour.
D. Participating in moderate recreational activities, such as golf or bowling.
E. Running a marathon.
PHARMACOLOGY
8. To which class of drugs does dexmedetomidine belong?
A. Opiate agonist-antagonist.
B. Benzodiazepine.
C. Phencyclidine.
D. Alpha-2-adrenergic agonist.
E. Alkylphenols.
SURGICAL JUDGMENT
9. Which of the following responses to stimulation indicates “moderate sedation”?
A. Normal response to verbal stimulation.
B. Reflex withdrawal to pain.
C. Purposeful response to verbal or tactile stimulation.
D. Purposeful response with repeated or painful stimulation.
E. Swallow or gag reflex present.
SURGICAL JUDGMENT
10. Which of the following is the most common injury in the operating room related to positioning?
A. Thermal injury.
B. Corneal abrasion.
C. Pressure sore.
D. Peripheral neuropathy.
E. Postoperative vision loss (POVL).
RISK FACTORS
11. Which of the following is a risk factor for postoperative nausea and vomiting (PONV)?
A. Male gender.
B. Female gender.
C. Smoking.
D. Total int ravenous anesthesia.
E. High BMI patients.
PHARMACOLOGY
12. Which of the following is the drug of choice for malignant hyperthermia?
A. Sodium bicarbonate.
B. Sodium dantrolene.
C. Flumazenil.
D. Furosemide.
E. Naloxone.
Chapter 5&Basics of Anesthesia for the Aesthetic Surgery Patient 29
Answers
SURGICAL JUDGMENT
1. What is one of the advantages of total intravenous anesthesia (TIVA)?
D. Reduced incidence of postoperative nausea and vomiting (PONV).
Total intravenous anesthesia can be helpful in patients with a history of severe postoperative nausea and
vomiting. However, it is more complex to administer and is more expensive than traditional general anesthesia. Usually, it has a better patient experience after surgery. However, it still requires an anesthesiologist
to administer.
REFERENCES
1. Blakely KR, Klein KW, White PF, et al. A total intravenous anesthetic technique for outpatient facial laser
resurfacing. Anesth Analg 1998;87:827
2. Barinholtz D. Intravenous anesthesia for cosmetic surgery. In: Friedberg BL, ed. Anesthesia in Cosmetic Surgery.
New York: Cambridge University Press; 2007
RISK FACTORS
2. Which of the following comorbidities indicates a patient who is not suitable for general anesthesia in an
ambulatory surgical center or office?
A. End-stage renal disease (ESRD).
ESRD is a contraindication to undergoing general anesthesia in an ambulatory surgical center or office.
Patients with well-controlled atrial fibrillation (as opposed to those with higher-grade arrhythmias or who
have permanent pacemakers/implantable cardioverter-defibrillators), paraplegia, peripheral vascular
disease, and those with mild OSA may be appropriate to undergo general anesthesia in these settings.
Severe OSA would be a red flag to undergoing general anesthesia in an ambulatory surgical center or office.
1,2
1
REFERENCE
1. Kataria K, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40:371
PREOPERATIVE TESTING
3. Which of the following is an accurate statement regarding hCG testing in females undergoing aesthetic surgery?
C. The American Society of Anesthesiologists recommends “offering” rather than “requiring” hCG testing.
hCG testing is institution dependent. The American Society of Anesthesiologists does not specifically recommend obtaining hCG testing in all females but does recommend offering the test to patients. Evidence is mixed
regarding the effect of anesthetics on pregnant females. A POC urine hCG test is a reliable preoperative test.
Positive pregnancy tests have been reported in 0.3 to 1.3% of premenopausal menstruating females.
1,2
REFERENCES
1. Committee on Standards and Practice Parameters, et al. Practice Advisory for Preanesthetic Evaluation. An
updated report by the American Society of Anesthesiologists Taskforce on Preanesthesia Evaluation.
Anesthesiology 2012;116:522
2. Choosing wisely: an initiative of the ABIM Foundation. Available at www.choosingwisely.org
RISK FACTORS
4. Which of the following factors is a reason to obtain a preoperative electrocardiogram (ECG) in a patient?
C. Renal insufficiency.
Renal insufficiency is a component of the Revised Cardiac Risk Index and is an indication to obtain a
preoperative electrocardiogram (ECG) within 6 months of surgery. Age alone is not a reason to obtain an
ECG. Diabetes on insulin is another reason to obtain an ECG, but diabetes controlled with oral medication
is not. Obesity is not a direct indication to obtain an ECG as well.
1,2
30 Part II&Anesthesia
REFERENCES
1. Cohn SL, Fleisher LA. Evaluation of cardiac risk prior to noncardiac surgery. Available at https://www.uptodate.
com/contents/evaluation-of-cardiac-risk-prior-to-noncardiac-surgery
2. Committee on Standards and Practice Parameters, et al. Practice Advisory for Preanesthetic Evaluation. An
updated report by the American Society of Anesthesiologists Taskforce on Preanesthesia Evaluation.
Anesthesiology 2012;116:522
RISK FACTORS
5. Which of the following is one of the Revised Cardiac Risk Index (RCRI) risk factors?
B. Cerebral vascular disease with history of stroke or transient ischemic attack.
Cerebral vascular disease is one of the components of the RCRI. The rest of the above are not.
1
REFERENCE
1. Cohn SL, Fleisher LA. Evaluation of cardiac risk prior to noncardiac surgery. Available at https://www.uptodate.
com/contents/evaluation-of-cardiac-risk-prior-to-noncardiac-surgery
RISK FACTORS
6. What is the threshold level of metabolic equivalents (METs), below which functional status is considered poor?
B. 4 METs.
Patients with less than 4 METs are considered to have poor functional status with increased risk of cardiopulmonary complications.
1,2
REFERENCES
1. Kataria K, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40:371
2. Cohn SL, Fleisher LA. Evaluation of cardiac risk prior to noncardiac surgery. Available at https://www.uptodate.
com/contents/evaluation-of-cardiac-risk-prior-to-noncardiac-surgery
RISK FACTORS
7. Which of the following tasks approximates 4 METs, if the patient can carry out the task without becoming
short of breath?
B. Climbing a flight of stairs.
Climbing a flight of stairs is the approximate equivalent of 4 METs. The rest of the mentioned activities
require more or less effort. 1 MET = 3.5 mL O
ting position. Eating, dressing, or using the toilet is equivalent to 1 MET. Walking two blocks at 2 to 3
mph is a little less than 4 METs. Moderate recreational activity is approximately 8 METs and strenuous
activity such as a marathon is >10 METs. It is a proxy to assess for cardiac risk and <4 METs is a concern
for poor functional risk with worse cardiopulmonary complications perioperatively.
uptake/kg/min which is the resting oxygen uptake in sit-
2
1,2
REFERENCES
1. Kataria K, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40:371
2. Cohn SL, Fleisher LA. Evaluation of cardiac risk prior to noncardiac surgery. Available at https://www.uptodate.
com/contents/evaluation-of-cardiac-risk-prior-to-noncardiac-surgery
PHARMACOLOGY
8. To which class of drugs does dexmedetomidine belong?
D. Alpha-2-adrenergic agonist.
Dexmedetomidine is an alpha-2-adrenergic agonist commonly used for sedation. The other classes of
drugs are also used in sedation with different goals and responses.
1
REFERENCE
1. ASA continuum of depth of sedation: definition of general anesthesia and level of sedation/analgesia. Available
at www.asahq.org.
Chapter 5&Basics of Anesthesia for the Aesthetic Surgery Patient 31
SURGICAL JUDGMENT
9. Which of the following responses to stimulation indicates “moderate sedation”?
C. Purposeful response to verbal or tactile stimulation.
Moderate sedation is defined by a purposeful response to verbal or tactile stimulation. Normal response
implies minimal sedation, whereas repeated or painful stimulation implies that the patient is under deep
sedation. Swallow or gag reflex is present in minimal sedation.
1
REFERENCE
1. ASA continuum of depth of sedation: definition of general anesthesia and level of sedation/analgesia. Available
at www.asahq.org.
SURGICAL JUDGMENT
10. Which of the following is the most common injury in the operating room related to positioning?
D. Peripheral neuropathy.
Peripheral neuropathies are the most common intraoperative injury related to positioning. Corneal
abrasions are the most common intraoperative injury overall but are not related to positioning. Nerve
injuries are the second most frequent liability claim in anesthesia practice. The other options are all
rare or “never” events related to the perioperative period.
1,2
REFERENCES
1. Hansen J, Botney R. Safe patient positioning. In: Young VL, Botney R, eds. Patient Safety in Plastic Surgery. New
York: Thieme Publishers; 2009
2. Cheney FW, Domino KB, Kaplan RA, et al. Nerve injury associated with anesthesia: a closed claim analysis.
Anesthesiology 1999;90:1062
RISK FACTORS
11. Which of the following is a risk factor for postoperative nausea and vomiting (PONV)?
B. Female gender.
Females are at higher risk for postoperative nausea and vomiting. Additional risk factors include nonsmokers, prior history of PONV or motion sickness, postoperative opioids, age less than 50 years, and general anesthesia. Total int ravenous anesthesia is protective against PONV. The literature does not support
that high BMI patients are more likely to be at risk for PONV.
1
REFERENCE
1. Le TP, Gan TJ. Update on the management of postoperative nausea and vomiting and postdischarge nausea and
vomiting in ambulatory surgery. Anesthesiol Clin 2010;28:225
PHARMACOLOGY
12. Which of the following is the drug of choice for malignant hyperthermia?
B. Sodium dantrolene.
Dantrolene, or the new preparation Ryanodex, is the only effective treatment for malignant
hyperthermia. Flumazenil is used to reverse benzodiazepine overdose. Naloxone is used to reverse
narcotic overdose. It is important to know that these two drugs have half-lives shorter than the
offending agent so watch out for re-narcotization or re-sedation. Sodium bicarbonate is used for
multiple other indications but not for malignant hyperthermia. Furosemide is a diuretic.
1
REFERENCE
1. Litman RL, Flood CD, Kaplan RF, et al. Postoperative malignant hyperthermia: an analysis of cases from the North
American Malignant Hyperthermia Registry. Anesthesiology 2008;109:825
6. Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient
Aaron M. Kearney, Sammy Sinno
See Essentials of Aesthetic Surger y, pp. 85–94
HOME MEDICATION CONTINUATION IN THE PERIOPERATIVE PERIOD
1. Which of the following medications should patients continue to take on the morning of surgery?
A. Metoprolol.
B. Metformin.
C. Furosemide.
D. Hydrochlorothiazide.
E. Estradiol.
IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PREOPERATIVE EVALUATION
2. Within what time frame should patients with implantable cardioverter-defibrillators (ICDs) have their device
checked prior to elective surgery?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.
E. 24 months.
PREOPERATIVE ANESTHESIOLOGY EVALUATION
3. Which of the following patients may benefit from an evaluation by an anesthesiologist prior to the day of
surgery?
A. A 76-year-old female with coronary artery disease.
B. A 24-year-old male smoker with Hashimoto's thyroiditis.
C. A 55-year-old male with hypertension and obesity class II.
D. A 60-year-old female with diabetes mellitus and stage I chronic kidney disease.
E. An 87-year-old male with well-controlled asthma.
HEMOGLOBIN A1C AND COMPLICATIONS
4. Which hemoglobin A1c threshold would be optimal to reduce complications?
A. ≤4.0.
B. ≤7.4.
C. ≤8.4.
D. ≤9.4.
E. ≤10.4.
MEDICAL RISK FACTORS FOR ANESTHESIA
5. Which of the following is a strong contraindication to undergoing elective cosmetic surgery?
A. Coronary artery disease with drug-eluting stent placed 14 months ago.
B. Severe pulmonary hypertension.
C. End-stage renal disease.
D. Hepatic cirrhosis.
E. 40 pack-year smoking history.
Chapter 6&Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient 33
PREVALENCE OF HERBAL SUPPLEMENT USE
6. Which of the following statements regarding herbal supplements is true?
A. They are regulated by the US Food and Drug Administration (FDA).
B. They can be continued perioperatively without concern.
C. They are taken regularly by over 30% of the US population.
D. Their ingredients are standardized.
E. More than 60% patients reveal use of herbal supplements at their preoperative appointment.
PREOPERATIVE SMOKING CESSATION
7. The Centers for Disease Control (CDC) recommends smoking cessation for at least how long before and after
surgery?
A. 5 days.
B. 2 weeks.
C. 30 days.
D. 6 weeks.
E. 8 weeks.
OBSTRUCTIVE SLEEP APNE A SCREENING
8. Which of the following is a recommended screening method to detect obstructive sleep apnea in patients
undergoing surgery?
A. STOP-BANG questionnaire.
B. Nasal examination by an otolaryngologist.
C. SLEEP questionnaire.
D. Family history of sleep apnea.
E. Assessing oropharynx width.
HERBAL SUPPLEMENT RISKS
9. Which of the following is true regarding herbal supplements?
A. Most lead to low-grade kidney failure.
B. They can increase the risk of bleeding.
C. Fish oil supplementation is safe up until the day of surgery.
D. Aesthetic surgery patients are least likely type of plastic surgery patients to use supplements.
E. Kava kava is not one of the herbs that are considered to impact surgery.
34 Part II&Anesthesia
Answers
HOME MEDICATION CONTINUATION IN THE PERIOPERATIVE PERIOD
1. Which of the following medications should patients continue to take on the morning of surgery?
A. Metoprolol.
Beta blockers taken as a home medication should be continued on the day of surgery. Oral
hypoglycemics and diuretics should generally be held. Estradiol and other oral contraceptive pills should
generally be stopped for at least 2 weeks.
REFERENCE
1. Levin N. Preanesthetic assessment of the cosmetic patient. In: Friedberg BL, ed. Anesthesia in Cosmetic Surgery.
New York: Cambridge University Press; 2007
IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PREOPERATIVE EVALUATION
2. Within what time frame should patients with implantable cardioverter-defibrillators (ICDs) have their device
checked prior to elective surgery?
C. 6 months.
Patients with ICDs should have their device checked within the 6 months prior to undergoing elective surgery. Patients with pacemakers can have their device checked within 12 months. One should consider doing
these cases in a hospital setting.
1
1
REFERENCE
1. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with
cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated
report by the American Society of Anesthesiologists task force on perioperative management of patients
with cardiac implantable electronic devices. Anesthesiology 2011;114:247
PREOPERATIVE ANESTHESIOLOGY EVALUATION
3. Which of the following patients may benefit from an evaluation by an anesthesiologist prior to the day of
surgery?
C. A 55-year-old male with hypertension and obesity class II.
This patient has four of the STOP-BANG criteria used for screening patients to determine the risk of
obstructive sleep apnea (OSA). Patients with three or more risk factors have a high risk of OSA. Patients
with known or presumptive OSA can benefit from preoperative evaluation by an anesthesiologist to
reduce the r isk of postoperative respiratory compromise (Fig. 6.1).
1. Do you Snore loudly? Yes/No
2. Do you feel Tired, fatigued, or sleep during the daytime? Yes/No
3. Has anyone Observed you stop breathing during your sleep? Yes/No
4. Have you been or are you now being treated for high blood Pressure? Yes/No
5. Is your Body Mass Index greater than 35 kg/m
6. Are you over 50 years of Age? Yes/No
7. Is your Neck circumference greater than 40 cm? Yes/No
8. Gender (male)? Yes/No
2
? Yes/No
Fig. 6.1 STOP-BANG questionnaire used for screening patients to determine the risk of OSA. Fewer than three
questions positive = low risk of OSA; three or more questions positive = high risk of OSA; five to eight questions
positive = high probability of moderate to severe OSA.
STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 18:812, 2008.)
(Source: Adapted from Chung F, Yegneswaran B, Liao P, et al.
Chapter 6&Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient 35
REFERENCE
1. Joshi GP, Saravanan PA, Gan TJ, et al. Society of Ambulatory Anesthesia consensus statement of preoperative
selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg
2012;115:1060
HEMOGLOBIN A1C AND COMPLICATIONS
4. Which hemoglobin A1c threshold would be optimal to reduce complications?
B. ≤7.4.
Patients with a hemoglobin A1c of 7.4 or less have a reduced risk for infectious complications. Hemoglobin
A1c greater than 7.4 puts patients at increased risk of complications. Low hemoglobin A1c (<4.0%) was associated with an increased risk of all-cause mortality.
1,2
REFERENCES
1. Braithwaite SS. Perioperative glucose control and diabetes management. In: Young VL, Botney R, eds. Patient
Safety in Plastic Surgery. New York: Thieme Publishers; 2009
2. Joshi GP, Chung F, Vann MA, et al. Society for Ambulator y Anesthesia consensus statement on perioperative blood
glucose management in diabetic patients undergoing ambulatory surgery. Anesth Anal 2010;111:1378
MEDICAL RISK FACTORS FOR ANESTHESIA
5. Which of the following is a strong contraindication to undergoing elective cosmetic surgery?
B. Severe pulmonary hypertension.
Patients with severe pulmonary hypertension are very high-risk patients for general anesthesia and
should not undergo elective cosmetic surgery. The other comorbidities listed can confer increased risk
but may be safe if they are optimized appropriately.
1,2
REFERENCES
1. Levin N. Preanesthetic assessment of the cosmetic patient. In: Friedberg BL, ed. Anesthesia in Cosmetic Surgery.
New York: Cambridge University Press; 2007
2. Kataria K, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40:371
PREVALENCE OF HERBAL SUPPLEMENT USE
6. Which of the following statements regarding herbal supplements is true?
C. They are taken regularly by over 30% of the US population.
Herbal supplements are taken by over 32% of the US population. About 70% of these patients do not
reveal their use to their doctor. These supplements are not regulated by the FDA and do not have
standardized ingredients. Their effects on surgery and their interactions with drugs used perioperatively
are generally unknown, so surgeons should consider having patients discontinue them 2 to 3 weeks prior
to surgery.
1,2
REFERENCES
1. Levin N. Preanesthetic assessment of the cosmetic patient. In: Friedberg BL, ed. Anesthesia in Cosmetic Surgery.
New York: Cambridge University Press; 2007
2. Abe A, Kaye AD, Gritsenko K, et al. Perioperative analgesia and the effects of dietary supplements. Best Pract Res
Clin Anesthesiol 2014;28:183
PREOPERATIVE SMOKING CESSATION
7. The Centers for Disease Control (CDC) recommends smoking cessation for at least how long before and after
surgery?
C. 30 days.
The CDC recommends 30 days of smoking cessation before and after surgery. The other time frames are
incorrect.
1
36 Part II&Anesthesia
REFERENCE
1. Cereda M, Neligan PJ. Managing the risk of perioperative pulmonary complications. In: Young VL, Botney R, eds.
Patient Safety in Plastic Surgery. New York: Thieme Publishers; 2009
OBSTRUCTIVE SLEEP APNE A SCREENING
8. Which of the following is a recommended screening method to detect obstructive sleep apnea in patients
undergoing surgery?
A. STOP-BANG questionnaire.
The STOP-BANG questionnaire is a commonly used screening method to detect patients who may have
obstructive sleep apnea. Those who answer three or more questions positively have a high risk of OSA
and may benefit from preoperative evaluation by an anesthesiologist.
1,2
REFERENCES
1. Stephan PJ, Mercier D, Coleman J, et al. Obstructive sleep apnea: implications for the plastic surgeon and ambulatory surgery centers. Plast Reconstr Surg 2009;125:652
2. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive
Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea:
an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of
patients with obstructive sleep apnea. Anesthesiology 2014;120:268
HERBAL SUPPLEMENT RISKS
9. Which of the following is true regarding herbal supplements?
B. They can increase the risk of bleeding.
Herbal supplements can increase risk of bleeding and hematomas. It is inconclusive whether herbal
supplements cause kidney damage. Fish oil supplementation can be a blood thinner and should be
stopped 2 to 3 weeks before surgery. Consideration should be given to holding all supplements for 2 to 3
weeks prior to elective surgery.
1,2
REFERENCES
1. Broughton G, Crosby MA, Coleman J, et al. Use of herbal supplements and vitamins in plastic surgery: a practical
review. Plast Reconstr Surg 2007;119:48e
2. Jalili J, Askeroglu U, Alleyne B, et al. Herbal products that may contribute to hypertension. Plast Reconstr Surg
2013;131:168
7. Procedure-Specific Anesthesia Guidelines for the Aesthetic Surgery Patient
Anmol Chattha, Sammy Sinno, Aaron M. Kearney
See Essentials of Aesthetic Surgery, pp. 95–106
RHYTIDECTOMY
1. A 52-year-old female with no past medical history undergoes an uncomplicated rhytidectomy. As the patient is
being extubated, she experiences a rise in her systolic pressure to 180 mmHg that is sustained for a few minutes. What complication is she most at risk for?
A. Intraoperative stroke.
B. Hematoma.
C. Seroma.
D. Postoperative nausea and vomiting (PONV).
E. Uncontrollable pain.
RHYTIDECTOMY
2. A 43-year-old male with a past medical history of moderate asthma and class I obesity is undergoing a rhyti-
dectomy under total intravenous sedation (TIVA). Which of the following is the biggest risk factor for him to
potentially develop hematoma postoperatively?
A. Male gender.
B. History of asthma.
C. Class I obesity.
D. Undergoing the procedure under TIVA.
E. Judicious use of IV fluids in the case.
FIRE SAFETY
3. A 21-year-old female is about to undergo full-face CO2laser resurfacing. A timeout was performed.
Intraoperatively, there is a combustion in the operating room near the patient's face; however, she is not
harmed. What would have been the best solution to minimize the combustion risk?
A. Use of open-circuit oxygen delivery.
B. Utilizing supplemental narcotic analgesia instead of propofol.
C. Decreasing FiO
D. Using supplemental oxygen.
E. The patient avoiding a chlorhexidine gluconate (CHG) the night before the surgery.
to the lowest level that supports adequate oxygenation.
2
SURGICAL DURATION
4. A 56-year-old female patient who has had massive weight loss plans to undergo liposuction of flanks, back,
hips as well as bilateral mastopexy and abdominoplasty. She calls the office 2 weeks before the surgery asking if she can have a blepharoplasty as well. The surgeon is trying to calculate the surgical duration to see
whether staged procedures should be recommended. After how many hours of surgery it is recommended to
stage the procedures?
A. 4 hours.
B. 6 hours.
C. 8 hours.
D. 10 hours.
E. 12 hours.