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Digoxin Toxicity Assessment — FRCA Final MCQ

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ModeratePreoperative AssessmentDigoxin Toxicity AssessmentFRCA Final

A 62-year-old man (ASA III, 80 kg) with chronic atrial fibrillation on digoxin 125 mcg daily presents for elective hernia repair. His serum digoxin level is 2.8 nmol/L (therapeutic range 1.0-2.6). Pre-operative ECG shows ST depression with reverse-tick morphology and a ventricular rate of 62 bpm. What is the most appropriate management?

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Correct answer: B — Proceed with surgery – the level is only marginally elevated

Digoxin level of 2.8 nmol/L is only marginally above therapeutic range with no signs of toxicity (no heart block, no ventricular arrhythmias). The ST changes described (reverse tick/sagging) are a characteristic effect of digoxin and do NOT indicate toxicity. The rate of 62 bpm suggests adequate rate control. However, the slightly supratherapeutic level warrants caution: withhold the morning dose, monitor for toxicity signs, and proceed with surgery using careful ECG monitoring. Avoid hypokalaemia (potentiates digoxin toxicity) and suxamethonium (theoretical risk of arrhythmias, though controversial).

Reference: BNF – 2025 – Digoxin therapeutic monitoring; RCOA – 2023 – Preoperative cardiac medications