Perioperative Care

A 58-year-old woman is scheduled for delayed bilateral DIEP flap breast reconstruction. Preoperative testing shows a hemoglobin level of 76 g/L, low ferritin, and microcytosis. She is hemodynamically stable and has no active bleeding. What is the most appropriate perioperative plan?

A 63-year-old woman is scheduled for unilateral free-flap breast reconstruction. She has obesity, a previous postoperative pulmonary embolism, limited mobility, and an expected operative time of nine hours. She has no active bleeding or indication for therapeutic anticoagulation. What is the most appropriate thromboprophylaxis strategy?

A 52-year-old woman taking apixaban for a remote provoked deep venous thrombosis requests elective facelift surgery. She has normal renal function, no recent thrombotic event, and no additional high-risk indication for continuous anticoagulation. What is the most appropriate perioperative plan?

A 47-year-old man undergoes free anterolateral thigh flap coverage of a clean lower-leg defect. Cefazolin is given before incision. Seven hours later, the operation is continuing and estimated blood loss has reached 1,700 mL. What is the most appropriate antibiotic-management step?

A 61-year-old man with diabetes undergoes pedicled flap coverage of a lower-extremity wound. Postoperatively, his glucose repeatedly measures 17 mmol/L, but he has no ketoacidosis or hemodynamic instability. What is the most appropriate management?

During a prolonged free-flap operation, the patient’s core temperature falls to 34.0°C. Diffuse oozing develops, transfusion requirements increase, and flap perfusion becomes sluggish despite patent anastomoses. What is the most appropriate management?

During a ten-hour lower-extremity free-flap reconstruction, a 66-year-old man remains hypotensive after receiving several liters of crystalloid. There is no active bleeding, pulmonary crackles are present, and the flap is becoming increasingly edematous. What is the most appropriate hemodynamic strategy?

Two hours after facelift and neck-lift surgery, a 64-year-old woman develops rapidly increasing neck swelling, severe pressure, a muffled voice, and progressive respiratory difficulty. What is the most appropriate immediate management?

On postoperative day 2 after circumferential body-lift surgery, a 49-year-old woman develops sudden dyspnea, pleuritic chest pain, tachycardia, and oxygen saturation of 84%. She is normotensive, and the operative wounds show no active bleeding. What is the most appropriate next step?

During a nine-hour free-flap procedure, a patient is positioned supine with the arm abducted beyond 90 degrees and the head rotated away from that side. Postoperatively, he has weakness of shoulder abduction and elbow flexion with numbness over the lateral forearm. What is the most likely perioperative complication?

A 42-year-old woman who smokes cigarettes and uses nicotine-containing vaping products requests elective abdominoplasty with extensive undermining and rectus plication. She has no urgent indication for surgery. What is the most appropriate perioperative management?

A 55-year-old woman with rheumatoid arthritis takes prednisone 15 mg daily and is scheduled for prolonged free-flap breast reconstruction. She has used systemic corticosteroids continuously for nine months. What is the most appropriate perioperative steroid plan?

A 36-year-old woman with a history of severe postoperative nausea and motion sickness is scheduled for outpatient augmentation mammaplasty under general anesthesia. She is a nonsmoker and is expected to require postoperative analgesia. What is the most appropriate prevention strategy?

A 68-year-old man undergoes an eight-hour pedicled flap reconstruction of a posterior trunk defect in the prone position. On awakening, he has a new foot drop and sensory loss over the dorsum of the foot. What is the most likely perioperative cause?

On the first evening after a lower-body lift, a 51-year-old woman is unable to void despite bladder discomfort and repeated attempts. Bladder scanning shows 720 mL of retained urine. She is receiving opioids and has no neurologic deficit. What is the most appropriate next step?

A 64-year-old woman is recovering after free-flap breast reconstruction. She is hemodynamically stable but reports chest pressure and dyspnea. Electrocardiography shows new ischemic changes, and cardiac biomarkers are elevated. What is the most appropriate next step?

A 45-year-old woman undergoes implant-based breast reconstruction. On postoperative day 3, she develops increasing breast erythema, pain, fever, and cloudy drain output. The skin remains intact, and there is no implant exposure. What is the most appropriate initial management?

A 70-year-old man becomes acutely confused on the second day after major head-and-neck free-flap reconstruction. He is restless, intermittently inattentive, and disoriented. Oxygen saturation is low, and laboratory testing shows hyponatremia. What is the most appropriate management?

A 29-year-old woman presents on the day of elective abdominoplasty and reports that her menstrual period is two weeks late. She is sexually active and pregnancy status is unknown. What is the most appropriate next step?

A 58-year-old man undergoes free-flap reconstruction and has a postoperative hemoglobin of 72 g/L. He is tachycardic, becomes dizzy on sitting, and has evidence of inadequate systemic oxygen delivery despite control of surgical bleeding. What is the most appropriate management?

A 39-year-old woman requests circumferential body-contouring surgery 10 months after bariatric surgery. Her weight is still decreasing, she has poor protein intake, lower-extremity edema, and laboratory evidence of iron and vitamin deficiencies. What is the most appropriate perioperative plan?

A 66-year-old man taking a long-term beta blocker for stable coronary artery disease is scheduled for head-and-neck cancer resection with free-flap reconstruction. His heart rate and blood pressure are controlled. What is the most appropriate perioperative medication plan?

A 34-year-old nonsmoking woman with a strong history of motion sickness and severe nausea after previous anesthesia is scheduled for outpatient augmentation mammaplasty. Postoperative opioid use is anticipated. What is the most appropriate perioperative strategy?

A 70-year-old man undergoes a nine-hour free-flap reconstruction with both arms tucked at his sides. After surgery, he has numbness in the little finger and ulnar half of the ring finger with weak finger abduction. What is the most likely perioperative complication?

Twenty minutes after a red-blood-cell transfusion begins during free-flap reconstruction, a patient develops fever, chills, hypotension, flank pain, and dark urine. What is the most appropriate immediate management?

On postoperative day 3 after lower-extremity free-flap reconstruction, a 57-year-old man develops new swelling, warmth, and tenderness of the opposite calf. He has no chest pain or dyspnea. What is the most appropriate next step?

On the evening after a lower-body lift, a 50-year-old woman has suprapubic discomfort and cannot void despite repeated attempts. Bladder ultrasonography shows 780 mL of retained urine. She is receiving opioids and has no neurologic deficit. What is the most appropriate next step?

A 73-year-old man becomes acutely confused and inattentive on the second night after head-and-neck free-flap reconstruction. His symptoms fluctuate, oxygen saturation is reduced, and he has urinary retention and received several sedating medications. What is the most appropriate management?

On postoperative day 1 after a prolonged free-flap procedure, a patient develops oliguria and a rising creatinine level. He is hypotensive, clinically volume depleted, and has received nonsteroidal anti-inflammatory medication. What is the most appropriate initial management?

Two days after pedicled flap coverage of a contaminated lower-leg wound, a 61-year-old man develops fever, confusion, tachycardia, hypotension, and increasing purulent drainage. The flap remains pink with detectable Doppler signals. What is the most appropriate next step?

A 41-year-old woman requests circumferential body-contouring surgery 11 months after bariatric surgery. Her weight is still decreasing, she has bilateral leg edema, poor protein intake, hemoglobin of 91 g/L, and low ferritin, vitamin B12, and vitamin D levels. What is the most appropriate perioperative plan?

A 55-year-old woman taking prednisone 15 mg daily for nine months is scheduled for prolonged autologous breast reconstruction. She has no evidence of active infection, but chronic adrenal suppression is suspected. What is the most appropriate perioperative corticosteroid plan?

A 68-year-old man undergoes oral-cavity cancer resection with a bulky free-flap reconstruction. At the end of surgery, he has significant tongue and neck edema, difficult reintubation anatomy, and stable oxygenation through the endotracheal tube. What is the most appropriate airway plan?

During a prolonged free-flap procedure with major blood loss, a patient receives multiple units of red blood cells and plasma. He develops hypotension, reduced myocardial contractility, prolonged QT interval, and low ionized calcium. What is the most appropriate next management step?

Twenty minutes after a red-blood-cell transfusion begins during free-flap reconstruction, a patient develops fever, chills, flank pain, hypotension, and dark urine. What is the most appropriate immediate management?

A 72-year-old man undergoes a 10-hour posterior trunk flap reconstruction in the prone position. On awakening, he has new foot drop and sensory loss over the dorsum of the foot. What is the most likely perioperative complication?

A 45-year-old woman presents for elective abdominoplasty while taking a weekly glucagon-like peptide-1 receptor agonist. Despite following standard fasting instructions, she reports persistent nausea, early satiety, and abdominal bloating on the morning of surgery. What is the most appropriate next step?

A 34-year-old nonsmoking woman with severe motion sickness and previous postoperative vomiting is scheduled for outpatient augmentation mammaplasty. Postoperative opioid use is anticipated. What is the most appropriate perioperative strategy?

Two hours after facelift surgery, a 59-year-old woman has severe pain, repeated vomiting, agitation, and blood pressure of 188/106 mmHg. The neck is not swollen, and no active bleeding is yet apparent. What is the most appropriate management?

A 52-year-old man with obesity undergoes a 12-hour free-flap reconstruction. On postoperative day 1, he develops severe gluteal muscle pain, dark urine, markedly elevated creatine kinase, hyperkalemia, and rising creatinine. What is the most appropriate next management step?

A 58-year-old woman presents for elective facelift and neck lift. Despite resting in a quiet room, repeated blood-pressure measurements remain between 188/112 and 196/116 mmHg. She has no neurologic symptoms or chest pain but admits that she stopped her antihypertensive medication three days ago. What is the most appropriate perioperative decision?

A 62-year-old woman with type 2 diabetes is scheduled for implant-based breast reconstruction. Her fasting glucose is 16 mmol/L, glycated hemoglobin is 11.2%, and she reports frequent recent hyperglycemic episodes. There is no urgent oncologic reason to perform reconstruction immediately. What is the most appropriate plan?

Three hours after large-volume liposuction performed with tumescent anesthesia, a 36-year-old woman develops circumoral numbness, tinnitus, agitation, and then a generalized seizure. She has no hypoglycemia or electrolyte abnormality. What is the most appropriate immediate management?

A 49-year-old man is undergoing excision of a facial skin cancer under monitored anesthesia care. Supplemental oxygen is being delivered beneath surgical drapes, an alcohol-based skin preparation has been applied, and electrocautery will be used near the nose. What is the most appropriate perioperative safety measure?

A 55-year-old woman undergoing circumferential body lift has an epidural catheter placed for postoperative analgesia. Because of her high venous-thromboembolism risk, pharmacologic prophylaxis with low-molecular-weight heparin is planned. What is the most appropriate perioperative approach?

A 29-year-old man with sickle cell disease requires free-flap reconstruction of a traumatic lower-leg defect. He has no current crisis, but previous crises were triggered by dehydration and hypoxia. What is the most appropriate perioperative strategy?

Four hours after free gracilis flap reconstruction, the flap becomes swollen, violaceous, and warm. Capillary refill is brisk, dark blood appears on pinprick testing, and the venous Doppler signal has disappeared while the arterial signal remains present. What is the most appropriate next step?

On the morning after uncomplicated bilateral DIEP flap breast reconstruction, a 50-year-old woman is hemodynamically stable, tolerating oral fluids, and has controlled pain. What is the most appropriate enhanced-recovery plan?

A 47-year-old woman undergoes immediate implant-based breast reconstruction with closed-suction drains. She has no infection, and perioperative prophylactic antibiotics were correctly administered. What is the most appropriate antibiotic principle after surgery?

During extensive craniofacial reconstruction with major blood loss, diffuse microvascular bleeding persists despite surgical hemostasis. Laboratory testing shows a critically low fibrinogen level, while platelet count is acceptable and ionized calcium has been corrected. What is the most appropriate next management step?

A 64-year-old man is scheduled for mandibular reconstruction with a free fibula flap. He has diabetes, calf claudication, and weak dorsalis pedis and posterior tibial pulses in the proposed donor leg. What is the most appropriate next step before flap harvest?

A 46-year-old woman with breast-cancer-related upper-limb lymphedema is scheduled for lymphovenous bypass. Two days before surgery, she develops rapidly spreading arm erythema, warmth, tenderness, fever, and chills. What is the most appropriate perioperative plan?

On postoperative day 6 after lower-extremity free-flap reconstruction, a patient’s platelet count has fallen from 240 × 10⁹/L to 82 × 10⁹/L. He has received unfractionated heparin, and duplex ultrasonography now shows a new femoral-vein thrombosis. There is no active bleeding. What is the most appropriate next step?

Ninety minutes after upper blepharoplasty, a 58-year-old woman develops severe unilateral orbital pain, rapidly increasing proptosis, a tense orbit, reduced visual acuity, and an afferent pupillary defect. What is the most appropriate immediate management?

Four hours after brachioplasty, a 43-year-old woman reports increasing hand numbness and pain. Her compression garment is extremely tight, the hand is cool, capillary refill is delayed, and the radial pulse is weak. What is the most appropriate immediate step?

A 9-year-old child undergoes a 12-hour craniofacial reconstruction. Two days later, the occipital scalp is tender, swollen, and erythematous without infection. Several weeks afterward, a localized patch of hair loss develops in the same area. What perioperative measure most effectively reduces this complication?

On the evening after radial forearm free-flap harvest, a 52-year-old man develops rapidly increasing forearm pain, pain with passive finger extension, tense swelling, and progressive finger paresthesia. The donor site is covered by a circumferential dressing and splint. What is the most appropriate next step?

A 35-year-old woman is scheduled for abdominoplasty with extensive liposuction. The surgeon plans tumescent lidocaine infiltration, and the anesthesia team also plans bilateral abdominal wall blocks using another amide local anesthetic. What is the most important medication-safety step before injection?

A 50-year-old woman with a documented immediate anaphylactic reaction to cefazolin is scheduled for implant-based breast reconstruction. She has no active infection. What is the most appropriate perioperative antibiotic plan?

Six hours after split-thickness skin grafting to a traumatic foot wound, the patient develops increasing pain and a tense, dark collection beneath the graft. The bolster remains intact, but the graft is visibly elevated from the wound bed. What is the most appropriate next step?