Question: Local anesthetic that can cause Methemoglobinemia

Ans. b (Prilocaine) (Ref. KDT 5th ed., 325; Anaesthsia by Ajay Yadav 3rd ed., 218-appendix; 114)Local anesthetic is associated with the risk of Methemoglobinemia- Prilocaine.PRILOCAINE# Prilocaine is an amide type local anesthetic agent.# Safest Local Anesthetic# Metabolized in liver, kidney and lung# Maximum safest dose is 5 mg/kg with adrenaline 8 mg/kg# Most suitable for Bier's block (0.5%)# Methemoglobinemia occurs at higher dose (prilocaine is unique amongst the local anesthetic agents for its ability to reduce the blood's oxygen carrying capacity to cause clinically detectable cyanosis.)# Stored in cool place# Metabolized by pseudocholine esterase# Agent of choice in patients with history of malignant hyperthermia.# It is the first synthetic local anesthetic introduced in 1905.# Practically, it is not used today.# Prilocaine can however be used for Bier's block (or intravenous regional anaesthesia--IVRA). No serious complications have been documented.# Equipotent with lignocaine, but its duration of action is longer and it is less toxic.# It is not a surface anesthetic.Chart 1: Drug capable of inducing methemoglobinemia AcetaminophenAnti malaria drugsNitratesNitric oxidep-Aminislicylic acidChloroquineAmmonum nitrateNitrous oxideLocal anestheticsPrimaquineSilver nitratePiperazineBenzocaineQuinacrineSodium nitrateRifampinBupivacaineMethylene blueNitroglycerineRiluzoleLidocaineDapsoneNitroprussideSulfonamidesPolocainePhenacetinsBismuth subnitrateSulfasalazineEMLA*PhenazopyndineNitntesSulfamethoxazoleAnticonvusantsFlutamideAmyl nitrateSulfadiazineVaiproic acidHydroxylamineIsobutyl nitrateSulfapyridinePhenytoinOral hypoglycemicMetochlopramideNitrofurantoinSulfonesSulfanilamide


Question: Bradycardia is common after injection of

Succinylchole is the only muscle relaxant, which stimulates vague nerve - BRADYCARDIA.(attenuates tachycardia and hypeension) This effect is more predominant in the pediatric age group. Therefore, I. V. Atropine is given prior to the first dose of scholine in the children and prior to the second dose in the adults. Ref.morgan 5th/e


Question: Laughing gas is

Humphry Davy coined the name "laughing gas" for nitrous oxide. Nitrous oxide, commonly known as laughing gas or nitrous, is a chemical compound, an oxide of nitrogen with the formula N2O. At room temperature, it is a colourless, non-flammable gas, with a slight metallic scent and taste. At elevated temperatures, nitrous oxide is a powerful oxidiser similar to molecular oxygen. It is soluble in water. Nitrous oxide is a weak general anaesthetic, and so is generally not used alone in general anaesthesia, but used as a carrier gas (mixed with oxygen) for more powerful general anaesthetic drugs such as sevoflurane or desflurane. It has a minimum alveolar concentration of 105% and a blood/gas paition coefficient of 0.46. The use of nitrous oxide in anaesthesia, however, can increase the risk of postoperative nausea and vomiting. Recreational inhalation of nitrous oxide, with the purpose of causing euphoria and/or slight hallucinations, began as a phenomenon for the British upper class in 1799, known as "laughing gas paies". In rats, N2O stimulates the mesolimbic reward pathway by inducing dopamine release and activating dopaminergic neurons in the ventral tegmental area and nucleus accumbens, presumably through antagonistic of NMDA receptors localised in the system. This action has been implicated in its euphoric effects and, notably, appears to augment its analgesic propeies as well. It is remarkable, however, that in mice, N2O blocks amphetamine-induced carrier-mediated dopamine release in the nucleus accumbens and behavioural sensitisation, abolishes the conditioned place preference (CPP) of cocaine and morphine, and does not produce reinforcing (or aversive) effects of its own. Effects of CPP of N2O in rats are mixed, consisting of reinforcement, aversion and no change. In contrast, it is a positive reinforcer in squirrel monkeys, and is well known as a drug of abuse in humans. These discrepancies in response to N2O may reflect species variation or methodological differences. In human clinical studies, N2O was found to produce mixed responses, similarly to rats, reflecting high subjective individual variability.


Question: Anaesthetic circuit that prevents rebreathing of CO2

Different anaesthetic breathing circuits are Mapleson circuits and circle system. Circle system is a closed circuit, so called because it has inbuilt CO2 absorbers. It prevents rebreathing of exhaled air


Question: Drug contraindicated in renal failure is

B i.e. Pethidine Meperidine (pethidine, demerol), a phenylpiperidine is metabolized chiefly in liver to nonmeperidine, which is eliminated by the kidney and liver. In patients or addicts who are tolerant to the depressant effects of meperidine, large doses repeated at sho interval may produce an excitatory syndrome including hallncination, tremors, muscle twitches, dilated pupils, hyperactive reflexes and convulsions. These excitatory symptoms are d/t accumulation of normeperidine, which has a half life of 15-20 hours, compared to 3 hours for meperidine. In patients with cirrhosis, the bioavailability of meperidine is --80% increased and t1/2 of both meperidine and normeperidine are prolonged. Since normeperidine is eleminated by kidney and liver, decreased renal or hepatic function predispose to neurotoxic effects of nor-meperidineQ. Meperidine is also not recommended for the treatment of chronic pain b/o concerns of metabolite toxicity. It should not be used for longer than 48 hours or in doses > 600 mg/day. Major pathway for morphine metabolism is conjugation with glucuronic acid forming morphine -6- glucuronide and morphine -3- glucuronide. Morphine-6-glucuronide is twice as potent as morphine with somewhat longer t1/2. (t1/2 of morphine is 2 hours) and pharmacological actions indistinguishable from those of morphine. With chronic morphine administration, the 6-glucuronide accounts for most of analgesia and its blood levels exceed those of morphine. Morphine-6-glucuronide is excreted by kidney, so its levels increase in renal failure, perhaps explaining morphine's potency and long action in compromised renal function. So in patients with renal failure decreased protein binding of morphine (resulting in higher plasma free drug level) and accumulation of morphine -6- glucuronide predispose them to respiratory depression. So morphine is given cautiously in low doses in renal failure. Respiratory depression is also repoed in patients with CRF receiving sufentanyl. Except for slightly decreased protein binding, the free drug volume of distribution and clearance of alfentanil appears to be unaffected by renal failure. Fentanyl, has sho half life and its metabolites are inactive. Therefore, it is a good choice in patients with renal diseaseQ. In renal disease (renal failure) remifentanil > fentanyl > alfentanil > sufentanil are safe. Whereas morphine (d/t morphine 6 glucoronide) 1/t respiratory depression is used very cautiously in low dose and meperidine (pethidine) is contraindicated d/t very long acting metabolite nor-meperidine causing neurotoxic excitatory syndrome.


Question: Lumbar puncture was done in a patient with raised intracranial tension. The patient died suddenly on the table. The cause of the death is most likely to be

(B) Tentorial herniation # Lumbar puncture was done in a patient with raised intracranial tension. The patient died suddenly on the table. The cause of the death is most likely to be:- Tentorial herniation


Question: During induction of general anesthesia, administration of oxygen with high concentration of nitrous oxide and halothane hastens the uptake of halothane, this is known as

During induction ofgeneral anesthesia, when a large volume of a gas (nitrous oxide) is taken up from alveoli into pulmonary capillary blood, the concentration of gases remaining in the alveoli is increased. This results in effects known as the second gas effect. These effects occur because of the contraction of alveolar volume associated with the uptake of the nitrous oxide. this effect makes speed of induction fast


Question: During G.A. shivering is abolished by suppression of

A i.e. Hypothalmus Temperature regulation during G.A. OWI Normally hypothalmus maintain core body temperatureQ (central blood temperature) within very narrow range (intehreshold range). Temperature of patient undergoing G.A. should be monitored (except for < 15 minutes procedure) by thermistor or thermocouple with a probe placed over tympanic membrane, rectum, nasopharynx, esophagus, bladder & skin. Hypothermia (ie body temperatureprotective during times of cerebral or cardiac ischemiaQ Raising body temperature induces vasodialation & sweating while hypothermia triggers vasoconstriction & shivering as compensatory mechanism. During G.A. body cannot compensate for hypothermia because anesthetics inhibit central thermoregulation by interfering with hypothalamic function.Q Spinal & epidural anesthesia also lead to hypothermia by vasodialation & internal redistribution of heat. The accompanying thermoregulatory impairment from regional anesthesia is due to an altered perception of temperature in bloacked dermatomes by hypothalmus as opposed to central effect of G.A. Postanesthetic shivering or shaking that is not related to hypehermia can be abolished by ceain opioids e.g. meperidine, butrophanol & tramadol (but not morphine).


Question: Shoest acting skeletal muscle relaxant is

Suxamethonium (succinylcholine) is the shoest acting skeletal muscle relaxantMivacurium is the shoest acting nondepolarizing skeletal muscle relaxant.(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no.205-211)


Question: Most commonly used local anaesthetics

BupivacaineBupivacaine is 2nd most commonly used local anaesthetic (after lidocaine)Bupivacaine has the highest local tissue irritancy amongst local anaestheticsIt is the most cardiotoxic local anaestheticLevobupivacaine (The S(-) enantiomer of bupivacaine) is less cardiotoxic and less prone to cause seizureConcentrations used for bupivacaine are:- Nerve block :0.5%, epidural: 0.25-0.5% and spinal: 0.5% Maximum safe dose is 2mg/kg without adrenaline and 3mg/kg with epinephrine(Refer: stoelting's pharmacology and physiology in anaesthetic practice, 5th edition, pg no.294)


Question: Nephrotoxic agent is


Question: Gas cylinder with single pin index

Entonox has an pin index number of 7 . Air - 1 , 5 ; Oxygen- 2 , 5 ; N20 - 3 , 5 . CO2 - 1 ,6 ; Cyclopropane - 3 , 6 ; Heliox - 4 , 6 . PIN index number is developed to prevent incorect cylinder attachment .


Question: Levosimendan is approved in

Levosimendan is a calcium sensitizer -- it increases the sensitivity of the hea to calcium, thus increasing cardiac contractility without a rise in intracellular calcium.Has been approved for use in acute cardiac failure in EuropeKatzung 13e pg: 220


Question: Malignant hyperthermia is

Malignant hyperthermia is autosomal dominant disease. It is characterized by metabolic acidosis and hyperkalemia.
i.v dantrolene infusion is used for treatment.

Autosomal recessive pharamacogenetic disease


Question: Commonly used route of administration for general anaesthesia is

Ans. b (Intravenous). (Ref: Anesthesia by Ajay Yadav 2nd/pg. 71; KD Tripathi, 5th/pg. 342)INTRAVENOUS ANAESTHESIA# The most commonly used route of administration used for general anesthesia is IV for induction of anesthesia and inhalational agents are preferred for maintenance.# The most commonly used IV anesthetic agent for induction is thiopentone,# Ideal characteristics of IV anesthetics are- Compatible with other dugs- High therapeutic index- Inexpensive- Independent of liver/kidneys for metabolism/excretion- No toxic metabolites- Long shelf life and resistance to microbial contamination- Non-cumulative- Non-allergenic- No cardiopulmonary depression- No effect on cerebral blood flow- No endocrinologic effect- No pain on injection- Quick and smooth induction-recovery- Reversible with specific antagonist- Potent, so small volume is required for anesthetic induction/maintenanceIV Anesthetic agents:BarbituratesNon-barbituratesDissociatives- Oxybarbiturate - pentobarbital and methohexital- Thiobarbiturates - thiopental and thiamylal- Propofol- Etomidate- Alphaxalone- PropanididKetamineTiletamine


Question: Duration of action of Lidocaine with adrenaline

Duration of action of lidocaine with adrenaline is 2-3 hours. Adrenaline enhances both speed and quality of block, It also prolong effect of lignocaine and reduce the peak blood level and toxicity by reducing the local blood supply duration of action of lidocaine whithout adrenaline is 30-90min


Question: Percentage of hepatitis after halothane use

The first modern halogenated volatile anesthetic, halothane, was introduced in 1955. Clinical exposure to halothane is associated with two distinct types of hepatic injury. Subclinical hepatotoxicity occurs in 20% of adults who receive halothane. It is characterized by mild postoperative elevations in alanine aminotransferase and aspaate aminotransferase, but is reversible and innocuous. Anaerobic halothane reduction by CYP2A6 to a 2-chloro-1,1,1-trifluoroethyl radical is thought to mediate this mild hepatic injury. The fulminant form of hepatotoxicity, commonly known as halothane hepatitis, It is characterized by elevated alanine aminotransferase, aspaate aminotransferase, bilirubin, and alkaline phosphatase levels, and massive hepatic necrosis following the administration of halothane. Halothane hepatitis is rare (1 in 5000 to 35,000 administrations in adults), but is fatal in 50% to 75% of these cases. Because of the potential for fatal hepatitis, halothane is no longer used in adult patients in many countries. Halothane hepatitis is caused by a hypersensitivity reaction associated with the oxidative metabolism of halothane. The highly reactive trifluoroacetyl chloride metabolite of halothane oxidation can react with nearby liver proteins. In most patients who developed hepatic necrosis after halothane anesthesia, antibodies against TFA-modified proteins were detected, suggesting that the hepatic damage is linked to an immune response against the modified protein, which acts as a neoantigen. Accordingly, patients who develop halothane hepatitis often have a history of prior exposures to halothane or other volatile anesthetics, together with symptoms suggestive of immune reactivity, such as fever, rash, ahralgia, and eosinophilia. A current hypothesis is that TFA-protein adducts induce a cytotoxic T cell reaction in sensitized individuals, which leads to liver damage. However, the immune responses observed in halothane hepatitis might not mediate liver injury. Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: Dissociative anaesthesia is produced by

Dissociative anaesthesia is characterized by profound analgesia, immobility, amnesia with light sleep and feeling of dissociation from once own body and the surroundings - Cataleptic stateKetamine (phencyclidine) induces dissociative anaesthesia.(Refer: stoelting's pharmacology and physiology in anaesthetic practice, 5th edition, pg no.294)


Question: Maximum global warming is by

Desflurane is a greenhouse gasIt causes maximum global warmingGlobal warming potential (as an equal amount of CO2)Isoflurane210 timesSevoflurane510 timesDesflurane 1620 times (Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no. 170)


Question: Maximum safe dose of bupivacaine

Maximum safe dose of bupivacaine is 2 mg/kg with or without adrenaline.


Question: Anaesthetic agent of choice in congenital heart disease with right to left shunt is

Ketamine being sympathomimetic causes raised left sided pressures, which obstructs shunt flow.


Question: Best antagonist of Morphine

Ans. is 'c' Naloxone T/t of choice for morphine poisoning is Naloxone (6 mg. IV) repeated every 3 min till respiration picks up) It is preferred due to no agonistic action and no respiratory depression. Nalorphine is given only when Naloxone not available


Question: Least Cardiotoxic anaesthetic agent

B i.e. Isoflurane Isoflurane increases ICT but less than halothane & enflurane; which can be reversed by hyperventilation. So isoflurane is a preferable agent in raised ICT. Isoflurane is anaesthesia of choice (AOC) for neurosurgical procedureQ as it does not increase cerebral blood flow & CSF pressure. Of various inhalation agents available, isoflurane has the advantage of providing stability of cardiac rhythm & lack of sensitizention of the hea to exogenous & endogenous adrenalineQ. In coronary aery disease isoflurane should be avoided Wt coronary steel phenomenonQ. In ischemia of cardiac muscle selective vasodialation of vessels of Ischemic zone and maintained tone of non ischemic zone //t selective increase of blood supply to ischemic areas. But in coronary steal phenomenon (Isoflurane & Dipyridomole) there is dialation of vessels of non ischemic zone also so there is decrease of flow in ischemic zone.Q That is why isoflurane is avoided in ischemic hea disease. In Myocardial Infarction operation should be with held for 6 monthsQ. Goldman Index is for cardiac risk factor and when it is > 13 it is associated with poor prognosis. In hypeension, halothane is AOC (for hypotensive surgery) In hypovolumia, Light G.A. (preferably Ether and Cyclopropane) with IPPV is method of choice Isoflurane increases ICT but less than halothane & enflurane; which can be reversed by hyperventilation. So isoflurane is a preferable agent in raised ICT. Isoflurane is anaesthesia of choice (AOC) for neurosurgical procedureQ as it does not increase cerebral blood flow & CSF pressure. Of various inhalation agents available, isoflurane has the advantage of providing stability of cardiac rhythm & lack of sensitizention of the hea to exogenous & endogenous adrenalineQ. In coronary aery disease isoflurane should be avoided Wt coronary steel phenomenonQ. In ischemia of cardiac muscle selective vasodialation of vessels of Ischemic zone and maintained tone of non ischemic zone //t selective increase of blood supply to ischemic areas. But in coronary steal phenomenon (Isoflurane & Dipyridomole) there is dialation of vessels of non ischemic zone also so there is decrease of flow in ischemic zone.Q That is why isoflurane is avoided in ischemic hea disease. In Myocardial Infarction operation should be with held for 6 monthsQ. Goldman Index is for cardiac risk factor and when it is > 13 it is associated with poor prognosis. In hypeension, halothane is AOC (for hypotensive surgery) In hypovolumia, Light G.A. (preferably Ether and Cyclopropane) with IPPV is method of choice


Question: Longest acting L.A


Question: Local anaesthetic acts by inhibition of

The nerve resting membrane potential is little affected by local anesthetics. As the concentration of local anesthetic applied to the nerve is increased, a decrease in the rate of depolarization and in the peak amplitude of the action potential occurs until the impulse is abolished. It is not possible, however, to derive data on the binding of local anesthetics to Na+ channels from measurement of the changes in nerve impulses. By using a "voltage-clamp" procedure, Na+ currents and their inhibition by local anesthetics can be directly assayed. When the membrane of isolated neurons is rapidly depolarized to a constant value, the time course of ionic currents is observed. Sodium currents during one initial depolarization are reduced by subclinical doses of local anesthetic (e.g., 0.2mM lidocaine) and totally abolished by clinical doses (e.g., 1% lidocaine, [?]40mM). If the test depolarization is applied repeatedly, for example, at frequencies higher than 5Hz (five pulses per second), the paially depressed (tonically inhibited) Na+ current is fuher reduced incrementally for each pulse until a new steady-state level of inhibition is reached. This frequency-dependent inhibition, also called phasic inhibition. Local anesthetics bind in the inner vestibule of the closed Na+ channel. Amino acid mutations in the S6 segments of D-1, D-3, and D-4 all modify local anesthetic action, thus suggesting either that these regions form a pharmacophore small enough to simultaneously contact the drug at three surfaces or that the local anesthetic molecule moves rapidly among these three segments. X - binding site of LA. Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: The inhalational agent of choice in children is

An inhaled induction of anesthesia with sevoflurane in oxygen with or without nitrous oxide is a common method used in children because it does not require IV access. IV induction is selected in children who already have IV access, who request an IV induction, or for whom an IV induction is indicated (full stomach, persistent gastroesophageal reflux disease, significant potential for cardiopulmonary compromise). The most common induction anesthetic in children is propofol 2 to 3 mg/kg Basics of Anaesthesia 7e pg: 603


Question: Colour coding of halothane , isoflurane, sevoflurane and desflurane is respectively


Question: For anesthesiology mild Systemic disease Included in ASA grade


Question: Maximum dose of lignocaine with adrenaline is (in mg/ kg)

Ans. c (7). (Ref. Harrisons Medicine, 18th/735)LIGNOCAINE# Maximum safest dose 3 mg/kg or 200 mg and with adrenaline 7 mg/kg or 500 mg.# Duration of effect 45 to 60 min and with adrenaline it is 2-3 hours.# Should not be given in patients with history of malignant hyperthermia.# Concentration usedo Surface topical analgesia- 4%o As jelly, for urethra- 2%o Nerve blocks/epidural/infiltration block-- 1-2%o Spinal- 5%# Lignocaine is an amide# It is 4 times less potent than bupivacaine# Drug of choice for lignocaine-induced arrhythmia is bretylium tosylate (SGPGI 2002)# Repeated doses of 4-5 mL of 0.5% bupivacaine or 1% lignocaine are used to maintain epidural analgesia.# 'Transient neurological symptoms' is an disntinct side-effect of LignocaineEducational point:The baricity of the local anesthetic solution. Baricity is defined by the ratio of the density of the local anesthetic solution to the density of CSF. A solution with a ratio > 1 is hyperbaric and tends to sink with gravity within the CSF. An isobaric solution has a baricity of 1 and tends to remain in the immediate area of injection. A ratio < 1 is a hypobaric solution, which rises in the CSF.


Question: Second gas effect is seen with

The second gas effect is a distinct phenomenon that occurs independently of the concentration effect. The ability of the large-volume uptake of one gas (first gas) to accelerate the rate of increase of the Pa of a concurrently administered companion gas (second gas) is known as the second gas effect. For example, the initial large volume uptake of nitrous oxide accelerates the uptake of companion gases such as volatile anesthetics and oxygen. Basics of Anaesthesia 7e pg: 99


Question: Concentration of adrenaline used with lignocaine

local anaesthetic + adrenaline (1:200000)

Fast onset
Less systemic toxicity
Prolonged duration


Question: For reduction of shoulder one of the following technique is appropriate

Interscalene approach: most intense at C5-C7 dermatomes and least intense at C8-T1(ulnar nerve area), most optimal for procedures on shoulderAxillary approach: most optimal for a procedure from elbow to hand


Question: Anesthetic agent (s) safe to use in TICP

B i.e. Thiopentone Anesthetic agents safe to use in raised intracranial pressure (ICP) are thiopentone, propofol & etomidateQ


Question: Eutectic mixture of local anaesthetic (EMLA) cream is

Eutectic mixture of local anaesthetic (EMLA)This is unique topical preparation which can anaesthetize the intact skinIt is a mixture of 2.5% lidocaine and 2.5 prilocaineIt acts slowly and the cream must head in contact with the skin for at least 1 hourEMLA is used: to make venepuncture painless especially for children, and for the procedure like skin grafting & circumcisionAs systemic absorption of prilocaine can cause methemoglobinemia, EMLA should not be used on the mucocutaneous membrane or in very small child.(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no. 754, 856)


Question: The most impoant constituent in soda lime for reabsorption of CO2 in a closed circuit

Sodalime is most common Co2 absorbant . Indicators added to sodalime changes the color of sodalime . It contains 94% Ca(OH)2 , 5%NaOH,1% KOH.


Question: Commonest complication of subclan venous puncture is

Pleura being in close proximity subclan cannulation has high incidence of pneumothorax other common problem is malposition of catheter due to its touous course.


Question: Cis atracurium is prefferd over atracurium due to advantage of aEUR'

No histamine release Cisatracurium is a stereoisomer of Atracurium Unlike atracurium cisatracurium does not produce a consistent dose dependent increase in plasma histamine -Atracurium triggers dose dependent histamine release that becomes significant at dose above 5mg/kg. - The release is dose dependent such that with increasing dose administered at the same rate there is greater propensity for eliciting histamine release. The histamine release resulted in:- - Flushing - Hypotension - Reflex tachycardia These effects are transient and the extent of hypotensive effect and reflex tachycardia were rarely of clinical significance. - Cisatracurium does not cause increase in histamine secretion, does not affect hea rate or blood pressure nor does it produce autonomic effects. Cisatracurium does not cause bronchospasmQ Atracurium use has been associated with bronchospasm and it should be avoided in patients with Asthma. To date cisatracurium has not been repoed to elicit bronchospasm at doses that are clinically prescribed Cisatracurium produces less laudanosineQ Laudanosine results from Hoffman elimination of Atracurium and cisatracurium Laudanosine may cause C.N.S. toxicity Cisatracurium produces less laudanosine Cisatracurium is 4 times as potent as Atracurium and produces less Laudanosine and has longer duration of intubation dose


Question: Dexmedetomidine is

Dexmedetomidine is alpha 2 agonist, more sensitive than clonidine. It is used to produce conscious sedation.

Less sensitive to alpha 2 receptors than clonidine


Question: Percentage of tetracaine used in eye surgery

Cataract surgery can be performed using topical anaesthesia alone. Tetracaine 0.5% and Lidocaine 4% can be used. Advantages of this method are that it avoids the potential complications with retrobulbar and peribulbar injections. Disadvantages include the potential for eye movement during surgery, increased patient anxiety, and discomfo from the microscope light.(Refer: stoelting's pharmacology and physiology in anaesthetic practice ,5th edition ,pg no.282-283)


Question: In spinal anaesthesia the needle pierced upto

Ans. d (Subarachnoid space). (Ref. Harrisons, Medicine, 18th/735)SPINAL ANESTHESIA# The term "spinal anesthesia" was coined in 1885 by Leonard Corning.Technique of spinal anesthesia:# In spinal anaesthesia the spinal needle is pierced upto subarachnoid space where the anaesthetic agent is injected to produce the anaesthesia.# The selected level should be below LI in an adult and L3 in a child to avoid needle trauma to the spinal cord. As an anatomic landmark, the L3-L4 interspace is located at the line intersecting the top of the iliac crests. Either a midline or paramedian approach can be used.# The anatomic layers passed through include skin, subcutaneous structures, supraspinous ligament, interspinous ligament, ligamentum flavum, dura mater, and arachnoid membrane.# Once the needle tip is believed to be in the subarachnoid space, the stylet is removed to see if CSF appears at the needle hub. With small diameter needles (26 to 29 gauge) this generally requires 5 to 10 seconds, but may require >1 minute in some patients. Gentle aspiration may speed the appearance of CSF. If CSF does not appear, the needle orifice may be obstructed by a nerve root and rotating the needle 90 degrees may result in CSF flow. Alternatively, the needle orifice may not be completely in the subarachnoid space and advancing an additional 1 to 2 mm may result in brisk CSF flow. This is particularly true of pencil-point needles, which have their orifice on the side of the needle shaft proximal to the needle tip.# Finally, failure to obtain CSF suggests that the needle orifice is not in the subarachnoid space and the needle should be reinserted.# Common complications include hypotension, bradycardia, increased sensitivity to sedative medications, nausea and vomiting (possibly secondary to hypotension), postdural puncture headache, nerve injury, total spinal, and hematoma/abscess formation at the site of puncture.# Total spinal anesthesia results from local anesthetic depression of the cervical spinal cord and brain stem. Signs and symptoms include dysphonia, dyspnea, upper extremity weakness, loss of consciousness, pupillary dilation, hypotension, bradycardia, and cardiopulmonary arrest. Eaily recognition is the key to management. Treatment includes securing the airway, mechanical ventilation, volume infusion, and pressor support.# Absolute contraindications include local infection at the puncture site, bacteremia, severe hypovolemia, coagulopathy, severe stenotic valvular disease, infection at the site of the procedure, and intracranial hypertension. Relative contraindications include progressive degenerative (demyelinating) neurologic disease (multiple sclerosis), low back pain, and sepsis.# Intrathecal opioids:- Opioids produce intense visceral analgesia and may prolong sensory blockade without affecting motor or sympathetic function.- Fentanyl and sufentanil have a rapid onset of action and an effective duration greater than 6 hours.- Morphine lasts 6-24 hours.- Side effects include respiratory depression (which may occur late with hydrophilic agents), nausea, vomiting, pruritus, and urinary retention.


Question: Total cerebral metabolic failure occurs at blood flow of


Question: Anaesthetic agent that predisposes to maximum arrhhmias

Halothane-catecholamine sensitization also promotes abnormal automaticity of dominant and latent atrial pacemakers. These effects may produce premature ventricular contractions and arrhythmias originating from the His bundle. Intact sinoatrial node function reduces the incidence of epinephrine induced ventricular escape during halothane anesthesia and is protective against His bundle arrhythmias. Halothane and, to a lesser extent, other volatile anesthetics sensitize the myocardium to the arrhythmogenic effects of epinephrine. Sensitization is the interaction between volatile anesthetics and catecholamines that leads to reductions in the threshold for both atrial and ventricular arrhythmias. Halothane and, to a lesser extent, isoflurane may be arrhythmogenic in Purkinje fibers in experimental myocardial infarction by facilitating reentrant activity or increasing temporal dispersion of the refractory period recovery. Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: Least analgesic


Question: Thiopentone is contraindicated in

Being an enzyme inducer (ALA synthetase)  thiopentone precipitates porphyria.


Question: A 30 yr old man with paraplegia, the muscle relaxant should be avoided for tracheal intubation will be

Succinylcholine can cause hyperkalemia in paraplegic patients due to proliferation of extrajunctional receptor. Conditions causing susceptibility to succinylcholine-induced hyperkalemia in an order. Myopathies (eg, Duchenne's dystrophy) Spinal cord injury Encephalitis Stroke Guillain-Barre syndrome Severe Parkinson's disease Burn injury Massive trauma Severe intraabdominal infection Tetanus Hence the use of succinyl choline is avoided in all the above conditions.


Question: site of action of vecuronium is

Vecuronium is the non-depolarising neuromuscular blocker, acts on nicotinic receptors(Nm) at myoneural junction.


Question: Depth of anaesthesia can be best assessed by

Monitors used to assess depth of anesthesia: Electroencephalography (EEG) Bispectral index (BIS) Entropy Evoked responses (EP) - Motor EP, sensory EP (Auditory, visual, brain stem evoked potential) Patient safety index Narcotrend


Question: Anti pruritic property is seen with


Question: Safe inducing agent in malignant hyperpyrexia is


Question: Local Anesthetic first used

Cocaine was the earliest used local anaesthesia(1st time used by Carl Koller in 1884 for occular surgery) cocaine is a naturaly occuring ester linked local anesthetic


Question: Aschners reflex is seen in

Aschners reflex is also called occulocardiac reflex. Aschners reflex is called oculocardiac reflex. The Oculocardiac reflex, also known as Aschner phenomenon, Aschner reflex, or Aschner-Dagnini reflex, is a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression of the eyeball. The reflex is mediated by nerve connections between the ophthalmic branch of the trigeminal cranial nerve the ciliary ganglion, and the vagus nerve of the parasympathetic nervous system. Nerve fibres from the maxillary and mandibular divisionsof the trigeminal nerve have also been documented. These afferents synapse with the visceral motor nucleus of the vagus nerve, located in the reticular formation of the brain stem. The efferent poion is carried by the vagus nerve from the cardiovascular centerof the medulla to the hea, of which increased stimulation leads to decreased output of the sinoatrial node. This reflex is especially seen children, paicularly during strabismus correction surgery.However, this reflex may also occur with adults. Bradycardia,junctional rhythm and asystole, all of which may be life-threatening, can be induced through this reflex. This reflex has been seen to occur during many pan facial trauma surgeries due to stimulation of any of the three branches of trigeminal nerve.


Question: Maximum duration of action is seen with

Non-depolarising blockers : Long acting (>50mins) : d-Tubocurare, Pancuronium, Doxacurium, Pipecuronium. Intermediate acting (20-50mins) : Vecuronium, Atracurium ,Cisatracurium, Rocuronium . Sho acting (<20mins) : Mivacurium,Rapacuronium.


Question: Colour of O2 cylinder


Question: High air flow oxygen enriched devices

High air flow oxygen enriched devices are fixed performance devices and deliver constant concentration of oxygen. They require face masks with holes to enable high volumes of air to entrained.

Deliver constant concentrations of oxygen


Question: Afferent nerve fibre affected by local anesthesia first


Question: Bone marrow depression is seen with chronic administration of

(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no.163-168)


Question: The most appropriate circuit for ventilating a spontaneously breathing infant during anaesthersia is

(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no.33)

Jackson rees modification of Ayre's t piece

Mapleson c or Waters to and fro canister


Question: Anaesthesia breathing circuit recommended for spontaneous breathing is

TypeA or Magills circuit is used in Spontaneous ventilation. Type D is used in controlled ventilation. TypeB and Type C are obselete nowadays


Question: Hoffman's elimination is feature of

Ans. d (Atracurium) (Ref KDT 6th !345; Anaesthesia by Ajay yadav, 2nd ed., p. 90)The unique feature of atracurium is inactivation in plasma by spontaneous nonenzymatic degradation (Hofmann elimination) in addition to that by cholinesterases. Consequently its duration of action is not altered in patients with hepatic/renal insufficiency or hypodynamic circulation. It is the preferred muscle relaxant for such patients as well as for neonates and the elderly. Hypotension may occur due to histamine release.Cisatracurium, R-Cis, R-Cis enantiomer of atracurium is nearly 4 times more potent, slower in onset, but similar in duration of action. Like atracurium it undergoes Hofmann elimination, but in contrast it is not hydrolysed by plasma cholinesterase. Most importantly, it does not provoke histamine release.ATRACURIUM BESYLATE# Long acting and non-depolarising muscle relaxant.# Muscle relaxant of choice in renal failure or anephric patients.# pH of solution is 3.5.; Stored at 4degC.; Duration of action doubled at 25degC.# Metabolism mainly by Hofmann elimination (chemical degradation) and hydrolysis in plasma and elsewhere in body.# Major metabolite is laudanosine, which is CNS stimulant.# Cisatracurium is one of the ten isomers of atracurium and its active metabolites contain less laudanosine which causeless hypotension, central nervous system excitement, and seizures than that of atracurium.# It is considered an intermediate-acting agent in terms of duration of action.Notable features of Few muscle relaxantsPropertyMuscle relaxant (MR)Rapid onset of ActionShortest ActingLongest ActingSch (overall); Rocuronium (non-depolarising)Sch (overall); Mivacurium (non-depolarising)DoxacuriumExcreted in LiverRocuronium; VecuroniumNo placenta crossingd -TCHistamine released-TC (maximum) Atracuronium Mivacuronium SchLeast Histamine releaseVecuroniumMost CardiostableVecuroniumM.R. used to decrease BPd -TCM.R. Used to maintain BPPancuroniumM.R. Safe in asthmaVecronium; CisatracuroniumM.R. Causing epilepsyAtracurium; secondary LaunodocinM.R. Causing epilepsyCisatracurium; Atracurium


Question: Dose of Thiopentone used for induction is


Question: The most common cranial nerve involved in spinal anesthesia

cranial nerve VI is most commonly affected during spinal Anaesthesia. Dural puncture - a critical step in performing spinal anesthesia - was first introduced by Quinke in 1891, and sholy thereafter, Bier repoed the first case of post-dural puncture headache (PDPH). Bier proposed that ongoing leakage of cerebrospinal fluid (CSF) causes the headache, ie, leakage of CSF through the dural puncture site exceeds the rate of CSF production and results in low CSF pressure. Magnetic resonance imaging has confirmed that this leads to intracranial hypotension with descent of the brain, thereby causing traction of the sixth cranial nerve and pain-sensitive structures. The stretching of the nerve is thought to cause local ischemia as well as nerve dysfunction and can be seen in association with other signs of intracranial hypotension such as veigo, nausea, and vomiting.


Question: Foleys catheter 16 F means


Question: Maternal supine hypotension syndrome can be minimized by

Removal of aortocaval compression with left-uterine displacement in patients undergoing general or regional anaesthesia, can minimize maternal supine hypotension.


Question: An 8 year old child is brought to the emergency room with testicular torsion. The parents tell you that he ate sandwich 6 hours ago. Surgeon wants to operate immediately. Your response should be

Testicular torsion requires immediate investigation and possible surgery to preserve viable testis.

Wait for 2 more hours, deem it urgent, do rapid-sequence intubation

Take him to the OT, deem it emergent, do rapid-sequence intubation

He is adequately fasting, consider elective intubation

Wait for 2 hours, consider elective intubation


Question: Shoest acting local anesthetic agent is

Classification Amide type Long acting * Bupivacaine * Levo-Bupivacaine * Ropivacaine * Dibucaine Intermediate acting * Lidocaine (lignocaine) * Mepivacaine * Prilocaine * Aicaine Ester type Long acting * Tetracaine (amethocaine) Intermediate acting * Cocaine Sho acting * Procaine * Chloroprocaine * Benzocaine * Proparacaine i.e. Procaine Ref: willer 10th ed.


Question: Arrange following structures as pierced by spinal needle during spinal block (from outside to inside) i) Interspinous ligaments ii) Ligamentum flavum iii) Supra spinous ligament iv) Epidural space

Structures as pierced by spinal needle during spinal block (from outside to inside): iii)Supra spinous ligament i) Interspinous ligaments ii) Ligamentum flavum iv) Epidural space


Question: A five year old is scheduled for strabismus surgery. As the surgeon grasps medial rectus muscle anesthesiologist carefully monitors the pulse. This is for

Aschners reflex is called oculocardiac reflex. TheOculocardiac reflex, also known asAschner phenomenon, Aschner reflex, or Aschner-Dagnini reflex, is a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression of the eyeball. The reflex is mediated by nerve connections between the ophthalmic branch of the trigeminal cranial nerve the ciliary ganglion, and the vagus nerve of the parasympathetic nervous system. Nerve fibres from the maxillary and mandibular divisions of the trigeminal nerve have also been documented. These afferents synapse with the visceral motor nucleus of the vagus nerve, located in the reticular formation of the brain stem. The efferent poion is carried by the vagus nerve from the cardiovascular centerof the medulla to the hea, of which increased stimulation leads to decreased output of the sinoatrial node. This reflex is especially sensitive in neonates and children, paicularly during strabismus correction surgery.However, this reflex may also occur with adults. Bradycardia, junctional rhythm and asystole all of which may be life-threatening,can be induced through this reflex. This reflex has been seen to occur during many pan facial trauma surgeries due to stimulation of any of the three branches of trigeminal nerve.


Question: Indication for nasotracheal intubation is

It is the most common method used for giving anaesthesia in oral surgeries as it provides a good field for surgeons to operate.Other options are contraindications.


Question: Site of action of epidural analgesia

C i.e. Substantia gelatinosa Opoid receptors are maximum in Lamina 2 (substantia gelatinosa) Lamina 5 of spinal cord. So Epidural Narcotics acts mainly on substantia gelatinosa Common side effects of intraspinal/ epidural opioids are pruritis (itching), nausea - vomiting; urinary retention, sedation, ileus and dose dependent respiratory depression (most serious)Q


Question: The following combination of agents are the most preferred for short day care surgeries

Ans. is 'a' i.e. Propofol, fentanyl, isoflurane For day care surgery patients are sent back home the same day. Therefore you need agents which are rapidly eliminated so that no after effects are left. The agents used are-PropofolAlfentanilRemifentanilN2OIsofluraneSevofluraneDesflurane


Question: Respiratory irritation is seen with


Question: Seen after tracheostomy

Tracheostomy decreases all three :- V/P ratio, dead space, resistance to air flow.


Question: Circuit of choice for controlled ventilation

Bains co-axial system is used in controlled ventilation.Fresh gas flow required to prevent rebreathing is 1.6MV.


Question: Emergency tracheostomy is not indicated in

Emergency tracheostomy is not indicated in asthma.

Preoperative assessment and monitoring in anaesthesia


Question: The penaz technique

Penaz technique is a continuous non-invasive method of BP monitoring. Infra-red plethysmograph is mounted on the pneumatic cuff.

Is suitable in presence of peripheral vascular disease


Question: Gas stored in liquid form is

N20 is stored in blue steel cylinders as a colorless liquid under 745 psi pressure and is in equilibrium with the gas phase (approximately 50 atmospheres at room temperature). The tank maintains that pressure until it is empty.


Question: Person with RYR1 receptor mutation should avoid

(A) Succinylcholine# Malignant Hyperthermia (MH) or Malignant Hyperpyrexia is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia -- specifically the volatile anesthetic agents and succinylcholine, a neuromuscular blocking agent.> In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in oxidative metabolism in skeletal muscle, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not immediately treated.> Susceptibility to MH is often inherited as an autosomal dominant disorder, for which there are at least 6 genetic loci of interest, most prominently the ryanodine receptor gene (RYR1).> MH susceptibility is phenotypically and genetically related to central core disease (CCD), an autosomal dominant disorder characterized both by MH signs and myopathy.> MH is usually revealed upon or shortly after exposure to certain general anesthetic agents.> There is no simple, straightforward test to diagnose the condition.> Treatment with Dantrolene and other drugs is usually initiated when MH is strongly suspected.> Dantrolene and the avoidance of triggering agents in susceptible people have markedly reduced the mortality from this condition.


Question: Pain Assessment Tool is best done by

(B) TachycardiaPAT - Pain Assessment ToolParameters012Posture/tone ExtendedDigits widespreadShoulders raised off bedFlexed and/or tenseFists clenchedTrunk guardingLimbs drawn to midlineHead and shoulder resist posturingCryNo YesWhen disturbedDoesn't settle after handlingLoudWhimperingWhiningSleep patternRelaxed Agirated or withdrawnWakes with startleEasily wokenRestlessSquirmingNo clear sleep/wake patternEye aversion "shut out"Expression FrownShallow furrowsEyes lightly closedGrimaceDeep furrowsEyes tightly closedPupils dilatedColorPink, well perfused Pale/dusky/flushed, Palmar swearingRespirations TachypneaArt restApneaAt rest or with handlingHeart rate TachycardiaAt restFluctuatingSpontaneous or at restOxygen saturationNormal Desaturation with or without handlingBlood pressureNormal Hypo-/hypertension at restNurse's perceptionNo pain perceived by me I think the baby is in painNote: Infants are assessed and scores obtained every 2 to 4 hours. An infant with a score > 5 requires comfort measures; >10 requires analgesia dose adjustment# Pain causes stress. The endocrine system reacts by releasing an excessive amount of hormones, ultimately resulting in carbohydrate, protein, and fat catabolism (destruction); poor glucose use; and other harmful effects. This reaction combined with inflammatory processes can produce weight loss, tachycardia, increased respiratory rate, fever, shock, and death. Unrelieved pain prolongs the stress response, adversely affecting the patient's recovery.> Cardiovascular system responds to stress of pain by activating the sympathetic nervous system, which produces a variety of unwanted effects.> In the postoperative period, these include hypercoagulation and increased heart rate, blood pressure, cardiac work load, and oxygen demand.> Aggressive pain control is required to reduce these effects and prevent thromboembolic complications.> Cardiac morbidity is the primary cause of death after anesthesia and surgery


Question: Hepatitis can be a complication of ......

Metabolic byproduct of halothane can cause autoimmune hepatitis. Halothane hepatitisis rare with an incidence of 1 per 35,000 cases but very fatal, with amoality of 50-75%. It is an immune mediated due to antibodies against highly reactive trifluoroacetyl chloride which is a metabolite of halothane. Risk factors for halothane hepatitis: Multiple exposures to halothane at sho intervals middle-aged obese women - because halothane undergo extensive metabolism in obese patients familial predisposition to halothane Another theory for halothane hepatitis is that it is caused by a hypersensitivity reaction associated with oxidative metabolism of halothane. The liver in halothane hepatitis shows centrilobular necrosis. In a patient with prior history of halothane hepatitis, inhalational induction agent of choice is Sevoflurane. Other points related to effect of halothane on hepatic system : Disrupts dual blood supply of liver ( Among all volatile anesthetic agent , it cause max decrease in hepatic flow) Contraindicated in Pre-existing liver days function C/I in hepatic surgery


Question: Intraocular Pressure is lowered by A/E (or increased by)


Question: The given device is used for

The device shown is a peripheral nerve stimulator, which delivers train of four stimulus to peripheral nerve (ulnar nerve) to assess adequacy of muscle relaxation.


Question: Vasoconstriction is seen with

Ans. is 'b' i.e. cocaine All local anaesthetic cause vasodilation except for cocaine which causes vasoconstriction.

Miscellaneous (Local and Regional Anesthesia)


Question: The anaesthetic agent that causes maximum increase in intracranial pressure is

By dilating cerebral vessels, halothane lowers cerebral vascular resistance and increases cerebral blood volume and CBF. Autoregulation, the maintenance of constant CBF during changes in aerial blood pressure, is blunted. Concomitant rises in intracranial pressure can be prevented by establishing hyperventilation before the administration of halothane. Cerebral activity is decreased, leading to electroencephalographic slowing and modest reductions in metabolic oxygen requirements. Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: Best anaesthesia for status asthamaticus


Question: Arrange the following the anticoagulant drug's last dose to be stopped before surgery in ascending order{time} 1)Clopidogrel 2)Ticlopidine 3)low molecular wt heparin 4)Warfarin

The following drugs has tobe continued on the day of surgery: Antihypeensive medications Cardiac medications (e.g.,b-blockers, digoxin) Antidepressants, anxiolytics, and other psychiatric medications Thyroid medications Anticonvulsantmedications Asthma medications. Steroids (oral and inhaled) Drugs that should be discontinued on the day of surgery Oral hypoglycemic agents NSAIDs - Discontinue 48 hours before the day of surgery Warfarin - Discontinue 4 days before surgery, except for patients having cataract surgery without a bulbar block. Sho acting Insulins except when given by a continuous pump Thienopyridines (e.g., clopidogrel, ticlopidine) except in cataract surgery, patients with metallic/drug eluting stents Aspirin in selected cases where reversal of platelet inhibition is necessary MAO Inhibitors - 2 weeks prior (MAO Inhibitors are usually continued.They should be discontinued if the patient and anesthesiologist factors are not orable to continue them)


Question: The pulse oximetry reading is affected in

Pulse oximetry values can be erroneous in dark skin. But in all other cases it is normal.


Question: Malignant hypehermia is caused by

Ans. is 'a' i.e., Succinylcholine + halothane


Question: Fulminant hepatic failure can be caused by

The first modern halogenated volatile anesthetic, halothane, was introduced in 1955. Clinical exposure to halothane is associated with two distinct types of hepatic injury. Subclinical hepatotoxicity occurs in 20% of adults who receive halothane. It is characterized by mild postoperative elevations in alanine aminotransferase and aspaate aminotransferase, but is reversible and innocuous. Anaerobic halothane reduction by CYP2A6 to a 2-chloro-1,1,1-trifluoroethyl radical is thought to mediate this mild hepatic injury. The fulminant form of hepatotoxicity, commonly known as halothane hepatitis, is characterized by elevated alanine aminotransferase, aspaate aminotransferase, bilirubin, and alkaline phosphatase levels, massive hepatic necrosis following the administration of halothane. Halothane hepatitis is rare (1 in 5000 to 35,000 administrations in adults), but is fatal in 50% to 75% of these cases. Because of the potential for fatal hepatitis, halothane is no longer used in adult patients in many countries. Halothane hepatitis is caused by a hypersensitivity reaction associated with the oxidative metabolism of halothane. The highly reactive trifluoroacetyl chloride metabolite of halothane oxidation can react with nearby liver proteins. In most patients who developed hepatic necrosis after halothane anesthesia, antibodies against TFA-modified proteins were detected, suggesting that the hepatic damage is linked to an immune response against the modified protein, which acts as a neoantigen. Accordingly, patients who develop halothane hepatitis often have a history of prior exposures to halothane or other volatile anesthetics, together with symptoms suggestive of immune reactivity, such as fever, rash, ahralgia, and eosinophilia. A current hypothesis is that TFA-protein adducts induce a cytotoxic T cell reaction in sensitized individuals, which leads to liver damage. However, the immune responses observed in halothane hepatitis might not mediate liver injury. Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: Absolute contraindication for Thiopentone sodium is\

(B) Acute intermittent porphyria # ThiOPENTONE SODIUM - Contraindications: Thiopentone sodium is contraindicated in history of Barbiturate hypersensitivity.> Acute intermittent porphyria (cause LMN paralysis or CVS collapse); Anticipated airway obstruction.> Fixed cardiac output states> Shock, Hepatic/Renal dysfunction> Asthmatic/Myxoedema> Adrenocortical failure> Myotonia dystrophia> Extremes of age


Question: Ketamine is safe in


Question: Position for orotracheal intubation

Flexing of cervical joint at neck approx. 25-30degrees and extension of atlanto -occipital joint (head) approx. 85-110degrees enables oropharyngeal, pharyngolaryngeal and laryngotracheal axis in one line that allows easy intubation -This position is called as SNIFFING POSITION.

Extension of neck and atlanto-occipital joint

Flexion of neck and extension of atlanto-occipital joint


Question: Helium is used along with oxygen instead of plain oxygen because

Helium is used because it decreases the turbulence.

Preoperative assessment and monitoring in anaesthesia


Question: Local anaesthetics act by


Question: A severely ill patient was maintained on an infusional anaesthetic agent. On the 2nd day he staed detiorating. The probable culprit may be

A i.e. Etomidate; B i.e. Propofol Increased infection and moality in a group of patients sedated with etomidate infusion in an ICU was associated with low coisol levelsQ and is attributed to etomidate induced supression of adrenal coisal synthesisQ. Etomidate is a dose dependent but reversible inhibitor of 11 - hydroxylase in the adrenal coex and is more potent than metyrapone. This enzyme is required for both mineralocoicoid and coicosteroid production. Minor adrenocoical supressive effects (i.e. impaired response to ACTH) follow induction doses or sho infusion doses. Propofol is not recommended for sedation of critically ill pediatric patients in ICU. The drug has been associated with higher moality d/t propofol infusion syndrome. Its essential features are metabolic acidosis, multiple organ failure, hemodynamic instability, hepatomegaly, and rhabdomyolysis. Very rarely, it may occur in adults, and in patients undergoing long term propofol infusion (> 48 hours) for sedation at high doses (>5 mg/ kg/ hr).


Question: Plan C of anesthetic airway management is

C i.e. Inseion of laryngeal mask airway& fibrotic bronchoscopy American Society of Anesthsiologist (ASA) developed practice guidelines & an algorithm that involves four plans: Plans A, B, C, and D, which go in sequence.

Inseion of laryngeal mask airway & fiberoptic bronchoscopy

Cancel the surgery or perform tracheostony


Question: Not an intravenous anaesthetic


Question: Shoest acting muscle relaxant

MivacuriumMivacurium is the shoest acting competitive blockersIt does not need reversal -can be used as an alternative to SCh for endotracheal intubationIt is metabolized rapidly by plasma cholinesterases -prolonged paralysis can occur in pseudocholinesterase deficiency Mivacurium is the only nondepolarising (competitive) blocker that is metabolized by plasma cholinesterase (pseudocholinesterase).(Refer: stoelting's pharmacology and physiology in anaesthetic practice, 5th edition, pg no.328)


Question: Depth of anesthesia can be best assessed by

Ans. d (Bispectral Index) (Ref. CSDT 12th/pg. Chapter 11 & Anaesthesia by Ajay Yadav, 2nd/pg. 45)MONITORING THE DEPTH OF ANESTHESIA# The Bispectral Index is a monitor that can be used in many cases to assess anesthetic depth.# It is measured from superficial scalp electrodes and is a processed electroencephalogram.# It is possible that this type of monitoring approach will be increasingly used to assess anesthetic depth.# A Bispectral index (BIS) monitor is a modern neurophysiological monitoring device which continually analyses a patient's electroencephalogram during general anesthesia to assess the level of consciousness during anesthesia.# The "depth of anesthesia" is commonly used as a surrogate for "the likelihood of forming experiences or memory."# BIS is therefore best described as a monitor of the depth of the hypnotic component of anesthesia or sedation.# BIS demonstrates a dose-response relationship with inhalational and hypnotic intravenous agents, such as propofol and midazolam, which is independent of the agent(s) being used and correlates with clinical assessments of the level of consciousness.# Ketamine, however, causes EEG activation, complicating BIS interpretation.


Question: Pin index for Air is

PIN index number prevents wrong fitting of the cylinders . AIR - 1 ,5 02 - 2 ,5 N20 - 3 ,5 CO2 - 1 ,6 ; 2,6(Liquid) Cyclopropane 3 ,6 Entonox 7


Question: Best to monitor intraoperative myocardial ischemia (infarction) is

C i.e. Transesophageal echocardiography Tranoesophageal echocardiography provides a real time picture of all 4 cardiac chambers and valves. It can identify any malfunctioning valves in addition to any wall motion abnormalities related to myocardia ischemia. It is very useful during anesthesia. Abnormal motion of ventricular wall detected in this way is a reliable index of myocardial ischemia and may guide drug therapy, can identify if therapy has successfully treated the ischemia or indicate the need for fuher surgical revascularization CVP (catheer in central vein) measures right sided filling pressure whereas pulmonary aery catheter measures/monitors left hea filling pressure. Aerial cannulation measures direct systemic aerial pressure and facilitate sampling of aerial blood for analysis.


Question: Administration of scoline (Sch) produces dangerous hyperkalemia in

Sch can cause dangerous hyperkalemia in burn, massive trauma, Crush injury ,Severe intraabdominal infection(sepsis),spinal cord injury, hemiplegia / paraplegia, muscular dystrophy ,GB syndrome, Rhabdomyolysis, Myasthenia Gracia, tetanus, severe parkinsonism,polyneuropathy,closed head injury, stroke ,encephalitis. Ref: Morgan 4th/e p214.


Question: Fasciculations are caused by

Ans. a (Scoline). (Ref. KD Tripathi, Pharamacology, 6th ed., 150)SUXAMETHONIUM CHLORIDE OR SUCCINYL CHOLINE (SCOLINE)Introduction- It is a short acting muscle relaxant.- It is a phase II blocker.- Depolarising muscle i.e. depolarising block at motor end-plate.- It is dichlor ester of succinic acid.- The action lasts for 3-5 minutes.- Action is prolonged in liver disease.- Metabolised by pseudocholinesterase.- It gives good intubating condition in shortest time (less than one minute).Uses- Endotracheal intubation in dose of 1 to 2 mg/kg body weight.- To modify electroconvulsive therapy.- For procedures requiring short duration relaxation.- Excellent for operative abet and caesaerian section.Side effects(Mnemonic=ABRHAM on FTV)- Apnoea (Prolonged),- Bradycardia,- Raised intraocular pressure- Hyperkalemia- Ache (Myalgia/ Post-operative muscle ache)- Malignant hyperpyrexia- Fasciculation,- Tachyphylaxis- Ventricular fibrillationIts S/E can be prevented by- Self-taming with 10 mg suxamethonium given a minute before induction of an anaesthesia.PrecurarizationAlso remember:# Malignant hyperpyrexia:- It is due to release of Ca++ from sarcoplasmic reticulum in sensitive person- It can be caused also bya) Halothane,b) Methoxyflurane andc) Isoflurane- Rx- dantrolene.- Dantrolene is muscle relaxant acting directly on muscle. {MH 2006)


Question: Amount of water that constitutes soda lime in carbon dioxide absorber is


Question: The second gas effect is

Removal of oxygen by N20 from alveoli during recovery from general anaesthesia

Facilitation of inhalation of Halothane by N20


Question: A mid tracheostomy is done over

a mid tracheostomy is done at 2nd and 3rd tracheal rings behind the isthumus,it is the operation of choice .


Question: Drug of choice in cardiogenic shock is

Dopamine or dobutamine are positive inotropic drugs with the prompt onset and sho duration of action; they are most useful in patients with failure complicated by severe hypotension.Katzung 13e pg: 220


Question: Most common complication seen after Block 2 is


Question: Surest indicator of reversal of anaesthesia is

After reversal * good muscle tone - as assessed clinically .being able to cough, raise his or her head from the pillow for at least 5 s, protrude the tongue and have good grip strength

Preoperative assessment and monitoring in anaesthesia


Question: The current mode of analgesia best for intrapaum pain relief is

Bupivacaine as the most commonly used local anesthetic for epidural anesthesia during labor and for postoperative pain management. Given at level of L2-L5Basics of anesthesia 7e pg: 280


Question: Cis atracurium is preferred over atracurium due to advantage of

Cisatracurium is preferred over atracurium as it does not release histamine. Onset of action is same for both atracurium and cisatracurium. Cis-atracurium has longer duration of action.


Question: Pudendal nerve block involves


Question: This law of plethysmography explains principle of working in

The  law of plethysmography explains working of pulse oximeter.


Question: Induction agent of choice in a child with cyanotic hea disease

In cyanotic hea disease (right to left shunt), systemic vascular resistance should be increased by anaesthetics - ketamine is the anaesthetic of choiceIn acyanotic hea disease (left to right shunt), systemic vascular resistance should be decreased - volatile anaesthetics (isoflurane, sevoflurane or desflurane) should be used.(Refer: stoelting's pharmacology and physiology in anaesthetic practice, 5th edition, pg no.294)


Question: Foster Kennedy syndrome is

Ans. is 'c ib., I/L Optic atrophy C/L papilloedema Foster-Kennedy syndrome : - The frontal lobe, pituitary and middle-ear tumor such as meningiomata of the oflactory groove are sometimes associated with Ipsilateral pressure atrophy of the optic nerve and contralateral papilledema. Pseudo-Foster-kennedy syndrome : - It is characterized by occurence of unilateral papilloedema associated with raised ICT (due to any cause) and a pre-existing optic atrophy (due to any cause) on the other side.


Question: Ideal intubating position (modified chevalier Jackson position) is

It is also called morning sniffing position or barking dog position. Explanation Prior to direct laryngoscopy and intubation, the patient is placed in the sniffing position which consists of cervical flexion with atlantooccipital extension. This is to ensure a line of sight from the mouth to the larynx so that intubation can be performed with ease. Cervical flexion of 35 degrees is provided by elevating the patient's head by 7-9 cm (folded sheet under the head). This aligns the pharyngeal and laryngeal axes. Atlantooccipital extension is provided by the head tilt. This brings into alignment the visual axis of the mouth with that of pharyngeal and laryngeal axes. Adequacy of head elevation can be estimated by checking the horizontal alignment between external auditory meatus and sternal notch.

Flexion of neck and neutral position of head

Extension of head and neutral position of head


Question: Best indicator of Endotracheal tube Extubation is

(D) Negative inspiratory pressure # Mechanical function indicators of Extubation:1. FEV>10-15 ml/Kg2. Tidal volume >/= 4-6 ml/Kg3. FVC IN 1 SEC >10 ml/KG4. Negative inspiratory force >20 cm H205. Vital capacity >/=15 ml/KG6. Dead space ventilation or tidal volume ratio <0.67. Rapid shallow breating index


Question: Phase II block is seen in

Ans. is 'd' i.e. . Suxamethonium Suxamethonium causes Biphasic Block, with dose more than 500mg. Phase I block - Features of classical depolarization block Phase II block - Results from desensitization of receptor to acetylcholine and resembles competitive block and partially antagonized by anticholinesterase.Other frequently asked facts about SuccinylcholineIt is a non-competitive muscle relaxant and has overall shortest duration of action d/t rapid hydrolysis by Pseudocholinesterase.It causes malignant hyperthermia*.It increases muscle tone and causes muscle rigidity.It causes hyperkalemia* in * ParaplegiaTetanusBumIt increases intraocular pressure and intra-abdominal pressure.

Depolarising Neuromuscular Blocking Agents


Question: Earliest and most pathognomic feature of malginant hyperthermia is

Increased CO2 production is earliest sign of malignant hyperthermia.


Question: Lowest concentration of anesthetic agent in aveoli needed to produce immobility in response to painful stimulus in 50% of individual is termed as


Question: Size of the laryngeal mask airway  for normal adults

Voyagis have proposed an alternative method of size selection for the laryngeal mask airway (LMA) based on a common misconception that the No. 3 is for females and the No. 4 for males.
In fact, their new proposal strongly reflects current European practice, which is to use a No. 4 for normal adults and a No. 5 for large adults and to use the No. 3 rarely. We consider, however, that
further conclusive trials are required before the manufacturer's weight-based recommendations are altered.
Judging the correct size of LMA can be difficult since the relationship between gender, weight, height, and upper airway geometry appears inconsistent.
No factors have yet been identified that give an easy measurement of potential pharyngeal volume directly correlating with appropriate LMA size, and certainly, there is no known anatomical difference between the male and the female adult or child pharynx at a given weight.
Some practitioners consider that the smaller sizes are satisfactory for spontaneous ventilation since a less effective seal is required. However, too small a mask may still result in local soft tissue damage due to poor fit around the laryngeal inlet or misplacement into the upper oesophagus or the glottic inlet.
The problems associated with insertion of too large a mask (airway obstruction, airway reflex activation) are probably fewer than those associated with insertion of too small a mask.


Question: The current mode of analgesia best for intrapaum pain relief

Continous lumbar epidural analgesia is the procedure of choice for pain relief during normal labour and vaginal delivery (Intrapaum pain)(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no.953-960 )


Question: Murphy&;s eye is seen in

* The "Murphy eye" is the eponymous name for a hole on the side of most endotracheal tubes (ETTs) that functions as a vent, and prevents the complete obstruction of the patient&;s airway, should the primary distal opening of an ETT become occluded. REF : WILLEY 10TH ED


Question: Position with least vital capacity in G.A.

A i.e. Trendelenburg In trendelenburg position, head end is lowered so due to gravity and weight of intra-abdominal viscera, diaphragm is at its highest level causing compression of lungs; so vital capacity is lowered.


Question: Maximum safe dose of lignocaine for spinal anesthesia is


Question: Estimation of FiO2 calculation during the use of nasal cannula in a child is

Answer: c) 21% + (Nasal Cannula flow (L/min) X 3)Oxygen delivery systems for infants and childrenSystemPercent oxygen deliveredIndicationsCommentsBlow byLess than 30 percentUse for spontaneously breathing children who require low doses of oxygen and do not tolerate a maskMonitor pulse oximetryNasal cannula25 to 40 percentUse to deliver low dose oxygen to spontaneously breathing patientsPercent oxygen delivered affected by respiratory rate, tidal volume, and extent of mouth breathing. Flow rate 2L/min or less for infants Fio2=21% + (Nasal Cannula flow (L/min) X 3)Simple mask35 to 50 percentUse to deliver low dose oxygen to spontaneously breathing patientsPercent oxygen delivered affected by mask fit and respiratory ratePartial rebreather Mask50 to 60 percentUse to conserve oxygen Non rebreather maskUp to 95 percentUse to deliver high dose oxygen to spontaneously breathing patientsTight mask fit required to deliver higher concentrations of oxygenHood80 to 90 percentInfants less than one year of ageNoisy for patientTentLess than 50 percentUse for children who require 30 percent oxygen or lessMist may obscure view of patient. Noisy for patient.Self-inflating ventilation bag95 to 100 percent, with reservoirUse to provide assisted ventilation and oxygenDo not use to provide blow by. Must use with a reservoir to provide higher oxygen concentrations.Flow-inflating ventilation bag100 percentUse to provide assisted ventilation and oxygenMay use to provide blow by. Requires experience to use reliably.


Question: Most potent analgesic agent among following

Ans. a. Nitrous oxide above options, most potent analgesic agent is Nitrous oxide. "Nitrous oxide- 50:50 nitrous oxide and oxygen has revolutionized it as analgesic agent; it has been used as an analgesic agent in obstetric surgeries; dental procedures; in acute trauma; burn dressings and cardiac pain as well."- Wiley and Churchill-Davidson A Practice of Anesthesia 7/e p536 Miller says "Nitrous oxide produce analgesia that is in pa because of release of proenkephalin derived family of endogenous opioids Physical propeies of N20 It is colourless, non-irritating and sweet smelling Boiling point is -89degC. Critical temperature is 36.5degCdeg which is a.bove room temperature, therefore it can be kept in liquefied state. Stored as liquid in blue color cylindersQ 35 times more soluble than nitrogen Remember: Anesthesia with No analgesia HalothaneQ Only analgesia N20Q Profound analgesia KetamineQ Best/maximum analgesia TrileneQ


Question: A 5 year old Child is suffering from patent ductus aeriosus (PDA) with congestive cardiac failure.Ligatio of ductus aeriosus was decided for surgical management.The most apropriate inhalation anaesthetic agent of the choice with minimal haemodynamic alteration for induction of anaethesia is

Sevoflurane is the inducing agent of choice in children . Cardiovascular stability in decreasing order : Isoflurane(nost stable)>desflurane>Sevoflurane>Halothane>Enflurane. Halothane suppresses baroreceptor reflex and causes tachycardia (Arrythmogenic -by sensitising the hea to catecholamines) Enflurane is most cardiovascular unstable agent Isoflurane is the most cardiostable inhalational agent as cardiac output is best maintained by reflex tachycardia as protective baroreceptor reflex is minimally inhibited. Among Isoflurane and sevoflurane, sevoflurane is the agent of choice in children. Ref.:Morgan 4th/e p 929


Question: Dose of thiopentone used is


Question: As per ISO, color of N20 cylinder is

To differentiate color coding is given to the cylinders . Blue - N20 Black - N2 Orange - Cyclopropane Grey - Co2 Black body with white shoulder - O2 Black body with brown shoulder - Heliox ( Helium + 02 )


Question: Wooden chest rigidity is seen with

Fentanyl induced chest wall rigidity seen with high bolus dose of fentanyl. CWR related to opiate administration was first described by Hamilton and Cullen in 1953 . Following opiate administration, clinicians may observe significant difficulty with mask ventilation, respiratory arrest, and a rigid chest wall; this phenomenon has been noted with various opioid substances. The majority of repoed cases and physiologic studies focus on CWR occurring with high opioid doses --administeredas pa of anesthetic induction


Question: Laundosine is a toxic metabolite of

Atracurium The unique feature of atracurium is inactivation in plasma by spontaneous nonenzymatic degradation (Hofman elimination) in addition to that by alkaline ester hydrolysisConsequently, its duration of action is not altered in patients with hepatic/renal insufficiency or hyperdynamic circulation - Preferred muscle relaxant for such patients as well as for neonates and the elderlyAtracurium is metabolized to laudanosine that is responsible for seizuresIt can cause histamine release - Hypotension & bronchoconstriction(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no.216)


Question: Inducing agent of choice in asthma

Ans. is 'b' i.e., Ketamine Inducing agent of choice in Asthma & COPD --> Ketamine. Inhalational agent of choice in Asthma & COPD ---> Halothane. Propofol and etomidate are alternates to ketamine for indcution in asthmatic patients. Drugs considered safe for asthmatics Induction Propofol, etomidate, ketamine Opioids Pethidine, Fentanyl, alfentanil Muscle relaxants Vecuronium, rocuronium, Pancuronium Volatile agents Halothane, Isoflurane, Sevoflurane, Desflurane, N20 Other Benzodiazepines (Amongst hypnotics, BZD are safe)


Question: In a patient with multiple injuries, first thing is to be done is


Question: A patient of alcohlic liver faliure requires general anesthesia AOC is

C i.e. Isoflurane - IsofluraneQ is volatile anesthetic agent of choiceQ in patients with liver disease because it has the least effect on hepatic blood flow. - CisatracuriumQ is neuromuscular blocking agent of choiceQ owing to its unique non hepatic metabolism.


Question: Following A, a patient suffered splenic ruture. His BP is 90/60 mmHg, PR 126/min and Sp02 92%. Induction agent of choice is

D i.e. Etomidate Ketamine and etomidate are most commonly used induction agents for (non head injury) trauma patientsQ. Ketamine is beneficial in patients with acute hypovolemic shock (d/t indirect sympathetic stimulatory effects). Whereas etomidate provides greater cardiovascular stability (ie no or minimal effects on myocardial contractility, cardiac output and cardiovascular system, mild reduction in peripheral vascular resistance and BP, and no histamine release).


Question: Pneumothorax is a complication of

B i.e. Brachial Plexus block Brachial plexus block with interscalene approach provides most intense anesthesia in C5-C7 dermatomes and least intense in C8-T1 (ulnar nerve) area.


Question: Local Anaesthetic in wound/ulcer management

For management of wound/ulcer, local anaesthetic with topical anaesthetic action is usedAmong the given options, only benzocaine has topical action.(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no. 271)


Question: A 40 year old female underwent surgery.Postoperatively she told the anesthetist that she was aware of preoperative events.Intraoperative awareness is evaluated by

A bispectral index (BIS) monitor is commonly utilized to assess depth of sedation when administering sedative, hypnotic, or anesthetic agents during surgical and medical procedures. The depth of sedation is calculated by measuring cerebral electric activity an electroencephalogram (EEG). The BIS algorithm processes the frontal EEG and conves the signal to a waveform on the BIS monitor 100 to 90-awake and responding appropriately to verbal stimulation 80 to 70-responsive to loud commands or mild shaking 70 to 60-intense tactile stimulation is needed for a response 60 to 40-unresponsive to verbal stimulus; general anesthesia obtained with a low chance for explicit recall less than 40-deep hypnotic state; possible protective responses still intact. less than 20-burst suppression (EEG pattern characterized by cycles of high-voltage electrical movement alternating with cycles of no activity in the brain); respiratory drive is limited, but possible protective responses still intact. 0-totally suppressed EEG (flat line). Ref: Miller's anesthesia 8th edition Ref: Morgan & Mikhail's clinical anesthesiology 6e


Question: Size of LMA used for 25kg child is

Size of LMA used for a 25 kg child is 2.5 LMA size 6 is used in adults weighing over 100 kg


Question: Machine used noninvasively to monitor an external chest compression during cardiopulmonary resuscitation is

Zoll AED -plus automatic external defibrillator


Question: ASA classification is done for


Question: Local anaesthesia causing metheaEUR' moglobinemia


Question: Arrange following inhalational anesthetic agents according to increasing MAC values i) Isoflurane ii) Desflurane iii) Sevoflurane iv) Halothane

MAC: Minimum alveolar concentration of inhalational agent required to produce no movement on surgical stimulus in 50% of test patients. Eg: N2O - 104 Halothane - 0.75 Isoflurane - 1.28 Sevoflurane- 2 Desflurane- 6 Less MAC- high potency High MAC- low potency Most potent inhalational agent- Methoxyflurane Least potent inhalational agent- N2O


Question: Best site for going spinal anaesthesia is interveebral space between.

The spinal canal contains the spinal cord with its covering (the meninges), fatty tissue and venous plexus. The meninges are composed of three layers: the pia mater, the arachnoid mater and the Dura meter. The spinal subdural space is poorly demarcated. The epidural space is a better defined potential space within the spinal canal that is bounded by the Dura meter and ligamentum flavum. There is cerebrospinal fluid between pia meter and Archnoid meter and this space is called sub arachnoid space. The spinal cord normally extends from the foramen magnum to the level of L1 in adults. so in adults we can give spinal anesthesia below this level in L2/L3, L3/L4. L2/L3 IS BETTER SPACE In children the spinal cord ends at L3 and moves up with age. The blood supply to the spinal cord and nerve roots is derived from a single anterior spinal aery and pair posterior aeries.


Question: Arrange Mapelson circuit for spontaneous ventilation in an adult from best to worst

During spontaneous ventilation, alveolar gas containing Co2 will be exhaled into the breathing tube or directly vented through an open APL valve. Before inhalation occurs, if the fresh gas flow exceeds alveolar minute ventilation, the in flow of fresh gas will force the alveolar gas remaining in the breathing tube to exit from the APL valve. Because a fresh gas flow equal to minute ventilation is sufficient to prevent rebreathing, the Mapelson a design is the most efficient for spontaneous ventilation


Question: Best local anaesthetic for ophthalmic surgery is

The choice of local anaesthetic for ocular surgery variesBut lidocaine (2%) and bupivacaine (0.5-0.75%) are used most commonlyGenerally the use of 1:1 mixture of 2% lidocaine (Xylocaine) and 0.50% bupivacaine along with adrenaline and hyaluronidase in facial, retrobulbar and peribulbar blocks is common(Refer: stoelting's pharmacology and physiology in anaesthetic practice, 5th edition, pg no.294)


Question: Best Scale to measure pain in children of 5 years age would be


Question: Dibucaine number is

Dibucaine number gives percentage of abnormal pseudocholinesterase.

Gives percentage of lignocaine levels in blood

Gives percentage of abnormal pseudocholinesterase  in blood.

Gives percentage of metabolised lignocaine levels

Gives percentage of succinylcholine in blood.


Question: The Blade of the laryngoscope used in intubation of newborn is

The Macintosh blade is the most widely used of the curved laryngoscope blades, while the Miller blade is the most popular style of straight blade. The Miller blades are commonly used for infants.Uncuffed tubes are limited mostly to pediatric patients (in small children, the cricoid cailage, the narrowest poion of the pediatric airway, often provides an adequate seal for mechanical ventilation).


Question: Colour of Entonox cylinder is

Entonox cylinder has blue body and white shoulder.


Question: 5 yr old child going to sitting craniotomy while positioning in O.T. developed End Tidal CO2 0mm Hg P02 80 mm Hg implies

C i.e. Venous Air embolism A patient undergoing lapro/thoraco-scopyQ or procedure (eg craniotomy) in sitting, head upQ, park-bench, knee-chest positions that place the operative site above the right atrium carry an increased risk of VAE. Sudden decrease in end-tidal CO2 concentration (ETCO?), sudden hypotension/circulatory arrest and Mill wheel murmur indicate the diagnosisQ.


Question: Induction agent that may cause adrenal cortex suppression is

Synthesis of adrenal steroids (both mineral and glucocorticoids) is inhibited by etomidate.


Question: The probe is used for

This image shows TEE probe, which is used for intraoperative cardiovascular monitoring.


Question: Conc. of Lidocaine used in spinal anesthesia


Question: The maximum safe dose of bupivacaine is

Maximum safe dose of bupivacaine is 2 mg/kg with or without adrenaline


Question: Systemic absorption of local anaesthetic is better with

Intravenous > tracheal > intercostal is order of systemic absorption of local anaesthetic drug.


Question: Duration of action of paraprocaine is

Procaine acts for around 20 minutes, althought it’s onset of action is within 10 seconds.


Question: Least effect on myocardial contractility

Ans:D i.e. Isoflurane. CARDIAC EFFECTS OF ANESTHETIC AGENTS :Anticholinergic agents - Atropine/glycopyrrolate: will cause an increase in hea rate, contractility, cardiac output and myocardial oxygen consumption. Often there will be no changein blood pressure and a decrease in right atrial pressure.Thiopental - BarbiturateReduction in blood pressure - peripheral vasodilation is the main action. Compensatory rise in hea rate - barorecptor response. Commonly associated with ventricular arrhythmias .BenzodiazepinesMidazolam and diazepam: Cause little or no direct myocardial depressant effects.Hypnotics- Etomidate: no direct myocardial depression. Safe to use with cardiac, critical and septic patients. .Mu opioids- Fentanyl is a pure mu agonist causes dose dependant bradycardia (increase in vagal tone). Mixed agonist/antagonist agents= Buprenorphine: a paial mu agonist/antagonist. Slow onset of action, duration of 6-8 hours. Cardiovascular depression and respiratory depression not as profound as pure mu agonists. Butorphanol: paial agonist/antagonist. Similar to buprenorphine in cardiovascular/respiratory effects. Dissociative Agents:Ketamine- Hea rate and aerial pressure increase due to an increase in sympathetic tone .Inhalational Anesthetics: Isoflurane and sevoflurane preserved cardiac index, and isoflurane and fentanyl-midazolam preserved myocardial contractility at baseline levels in this group of patients with congenital hea disease. Halothane depressed cardiac index and myocardial contractility.


Question: Shoest acting non depolarizing muscle relaxant

Non depolarising (competitive) 1)Long Acting - pancuronium,pipecuronium 2) Intermediate Acting-vecuronium,rocuronium,atracurium 3) Sho Acting - Mivacurium


Question: Increased Cardiac Oxygen demand is caused by


Question: Minimum &;starvation time&; required in general anaesthesia

Traditionally, patients are considered to be at risk if their gastric volume is greater than 25 mL (0.4 mL/kg) and their gastric pH is less than 2.5. Some investigators believe that controlling acidity is more impoant than volume and that the criteria should be revised to a pH less than 3.5 with a volume greater than 50 mL. Patients who have eaten immediately prior to emergency surgery are obviously at risk. Traditionally, "NPO after midnight" implied a preoperative fast of at least 6 h. The current opinion allows clear liquids until 2 h before the induction of anesthesia. According to the American Society of Anesthesiologists (ASA) guideline, breast milk is permitted up to 4 h before anesthesia. Infant formula, nonhuman milk, and a light meal are permitted up to 6 h before induction. Patients consuming a heavy meal including meat, fats, and fried foods should fast for 8 h. Ceain patient populations are paicularly likely to have large volumes of acidic gastric fluid: patients with an acute abdomen or peptic ulcer disease, children, the elderly, diabetic patients, pregnant women, and obese patients. Fuhermore, pain, anxiety, or opioids may delay gastric emptying. Note that pregnancy and obesity place patients in double jeopardy by increasing the chance of aspiration (increased intraabdominal pressure and distoion of the lower esophageal sphincter) and the risk of aspiration pneumonia (increased acidity and volume of gastric contents). Aspiration is more common in patients undergoing esophageal, upper abdominal, or emergency laparoscopic surgery. Ref: Morgan & Mikhail&;s clinical anesthesiology 6e


Question: Intraoperative wheezing can be managed by

Among IV induction agents,ketamine has a bronchodilator action.


Question: A 25 year old G2P, at 39 weeks gestation is electing to have spinal anaesthesia for a repeat cesarean section. 5 minutes after bupivacaine spinal injection, the patient becomes hypotensive and is complaining of tingling in her fingers with subjective difficulty breathing. Her oxygen saturation remains 100% and blood pressure in 90/60 mmHg The most likely etiology is.

In pregnancy, CSF volume is decreased, thereby decreasing dose requirement of local anaesthetic. This facilitates spread of local anaesthetic when spinal anaesthesia is given.
Option D would have been correct, if question mentioned Epidural anaesthesia.

Increased peripheral nerve sensitization to local anaesthetics

Decrease in volume of CSF in subarachnoid space facilitated higher spread of local anaesthetics

Engorgement of epidural veins contributed to inadvertent intravascular injection of local anaesthetic


Question: Management of prolonged Scoline apnea is by

Suxamethonium apnea and phase 2 block both are managed with mechanical ventilation till recovery. The mainstay treatment for succinylcholine apnea due to atypical pseudocholinesterase is to continue mechanical ventilation until muscle function returns to normal by clinical signs. Administration of neostigmine is controversial as the effects may be transient, possibly followed by intensified neuromuscular blockade. Fresh frozen plasma can augment the patient's endogenous plasma pseudocholinesterase activity but is not recommended because of the risk of iatrogenic viral infectious complications. If human plasma cholinesterase is available, it can be given to reverse neuromuscular blockade. Hence, the best option here would be to continue mechanical ventilation.


Question: After suxamethonium 50mg, apnea persists for one hour

Cholinesterase is a family of enzymes present in the central nervous system, particularly in  of this enzyme in any tissue most likely has no significance in terms of health.
Discriminates three phenotypes: Normal, intermediate, and atypical.

Treatment with cholnesterase is indicated

Probab1y an atypical cholinesterase is present

Treatment with stored blood is indicated

Apnea may be due to low serum potassium concentration


Question: In rapid sequence intubation

Pre-oxygenation is mandatory in rapid sequence intubation. Succinylcholine, depolarizing muscle relaxant is the preferred agent. Short acting opioids can be administered prior to induction.

Non-depolarizing muscle relaxants are used


Question: Intra ocular pressure rises in

Laryngoscopy and intubation of trachea can dramatically increase intraocular pressure to a value as high as 40mm Hg.Administration of intravenous lignocaine prior to intubation has been found to prevent an increase in IOPIOP changes with LMA inseion are less than those following tracheal intubation.(Refer: Morgan and Mikhail's Clinical Anaesthesiology, 5th edition, pg no 325-331)


Question: Most potent antiemitic agent used in preoperative period

D i.e. Metochlopromide Metochlopramide increases lower esophageal sphinter tone, speeds gastric emptying & lowers gastric fluid volume & decreases risk for aspiration pneumonia due to antiemetic effect


Question: The disease with known association with malignant hyperthermia is

KDS-King Denborough syndrome, Muscular dystrophy (DMD),myotonia are musculoskeletal disease associated with malignant hyperthermia.


Question: Muscle most resistant to non depolarizing block is


Question: Xylocaine heavy in subarachnoid space has concentration of


Question: Malignant hypehermia is a rare complication following the administration of Not a complication of epidural anesthesia


Question: Dose of Ketamine is


Question: Tec 6 vaporizer is used with.........

The most common such vaporizer is the Ohmeda Tec 6, designed specifically for use with desflurane. Desflurane has two physical propeies, making it unsuitable for use with a conventional vaporizer. First, it has a very high SVP (88.5 kPa at 20degC). A conventional vaporizer would require high fresh gas flows to dilute it to within clinically useful concentrations, making it uneconomical. Secondly, it has a low boiling point (23.5degC). At room temperature, it will intermittently boil resulting in large fluctuations in agent delivery. When boiling, there will be excessive agent delivery; however, it will then cool due to a large loss of latent heat of vaporization, resulting in an exponential decrease in SVP and under-delivery of agent. The Ohmeda Tec 6 overcomes these problems by using an electrical filament that heats the desflurane to 39degC, raising its SVP to 194 kPa, that is, nearly 2 atm. In addition to providing a stable SVP, this high pressure removes the need for a pressurized carrier gas--instead, the fresh or diluent gas is entirely separate from the vaporizing chamber


Question: A 65 year old male patient with history of coronary aery disease was diagnosed with hemorroides. The anaesthesia modality of choice for haemorrhoidectomy

Saddle anaesthesia is spinal anaesthesia given in sitting position. After giving the drug patient is kept inthis position for 5-10 mins. Drugs only blocks sacral nerve roots and perineal anaesthesia is achieved.Since thoracic and lumbar spinal nerves are not blocked it has is no haemodynamic alteration. Caudal is the other name of sacral epidural anaesthesia commonly done in < 7 yrs old children since it is easy to approach is sacral epidural space because of unfused sacral hiatus. Caudal anesthesia requires identification of the sacral hiatus.


Question: Inducing dose of Propofol in adults

(B) 2 mg/kg > The dose of Propofol is 2-2.5 mg/kg for induction.> The lower dose should be used in the elderly.> The effective blood concentration for anaesthesia (ED 90 - the dose at which the effect is seen for 90% of patients) is 3.4 mg/mL when used with 67% nitrous oxide.> Sedation may be produced with a 0.2 mg/kg bolus dose intravenously or an infusion of 2 mg/kg/h, which produces a blood concentration of about 2 mg/mL.> Co-induction with either an opioid or midazolam enables the induction dose and initial target level for TCI to be reduced.> Myoclonic movements are common on induction, especially with slow injection. Emergence is more rapid than with thiopentc , with less 'hangover'.


Question: Malampati grading is for

Mallampati classification: a frequently performed test that examines the size of the tongue in relation to the oral cavity. The more the tongue obstructs the view of the pharyngeal structures, the more difficult intubation maybe Class I: The entire palatal arch, including the bilateral faucial pillars, is visible down to the bases of the pillars. Class II: The upper pa of the faucial pillars and most of the uvula are visible. Class III: Only the soft and hard palates are visible. Class IV: Only the hard palate is visible. Ref: Miller&;s anesthesia 8th edition Ref: Morgan & Mikhail&;s clinical anesthesiology 6e

Assesment of free rotation of neck before intubation

Inspection of oral cavity before intubation


Question: Rotameters

Rotameters are constant pressure drop-variable orifice devices. They are accurate at values as low as 200mL/min both laminar and turbulent flow determine their accuracy .

Depend on laminar low for their accuracy

Are constant pressure drop-constant orifice devices


Question: The most appropriate inhalational agent for pediatric patients

Sevoflurane fast acting with pleasant smell , most appropriate for pediatric patients. Sevoflurane is the most commonly used inhalational agent for induction. This is because of its lack of pungency and low blood: gas solubility of 0.65 which allows for a smooth induction of anesthesia.


Question: Cuff pressure in endotracheal intubation with prolonged ventilation should be less than

Cuff pressure in the endotracheal intubation is in between 25 to 30 mmHg.

Preoperative assessment and monitoring in anaesthesia


Question: Anaesthetic gas with maximum respiratory irritation

* Desflurane, unlike halothane or sevoflurane has a pungent smell which makes it unpleasant for inhalational induction. * When more than 6% desflurane is used, the pungency produces salivation, airway irritation, breath holding and coughing. Ref:- Stoelting's Pharmacology and Physiology in Anesthetic Practice 5th edition; pg num:- 101


Question: The optimal granule size of soda lime is

The size of the soda lime granules is 4-8 mesh (i.e. will pass through a mesh of 4-8 strands per inch in each axis or 2.36-4.75 mm). Soda lime consists of 4% NaOH, 1% KOH, 14-19% H2O, and the remainder Ca (OH)2. In addition, small amounts of silica or kieselguhr are added for hardening, and to reduce the formation of dust. Absorbents are supplied in pellets or granules. Small granules provide greater surface area but at the cost of increased resistance The most frequently used size of soda lime granule is 4-8 mesh (i.e., 0.25-inch to 0.125-inch diameter). In theory, 100 g of CO2absorbent (soda lime) can absorb 26 L of CO2.


Question: Most commonly involved segment of Lungs in Foreign body aspiration (Supine position)

Cardiopulmonary Resuscitation And Mechanical Ventilation


Question: Methemoglobinemia is seen with

Methemoglobinemia is seen with benzocaine, prilocaine and with EMLA.


Question: In increased ICT, agent used for anesthesia


Question: Laryngeal mask Airway (LMA) is used for;


Question: Muscle relaxant of choice in hepatic and renal failure


Question: Post dural puncture headache is

Post dural puncture headache is occipital > frontal > retroorbital.


Question: Concentration of Local anesthetic agent used for Bier's block is

0.5% (Bier's block: Intravenous regional anesthesia)

Miscellaneous (Local and Regional Anesthesia)


Question: Maximum uterine relaxation


Question: A patient in ICU was on invasive monitoring with intra aerial canulation through right radial aery for last 3 days. Later he developed swelling and discolouration of right hand. The next line of management is

A i.e. Stellate ganglion block The patient has developed vasospasm (reflex sympathetic dystrophy) as indicated by development of swelling & discolouration of hand Stellate (Cervicothoracic) Block in reality blocks upper thoracic and cervical ganglion. It is indicated in : - Reflex sympathetic dystrophyQ - Vasospastic disorder of upper extremityQ - Head, Neck, Arm & Upper chest pain


Question: Post operative shivering is treated with

Shivering is the response of the body because of Hypothermia(32-35oC) Can happen in Intra operative patient with Normothermia, because their Thermoregulation is disturbed because of Anesthesia (GA/Local) According to ASA guideline in the management of Shivering Non pharmacological - Active warming of the patient Pharmacological- Pethidine (meperidine), Best drug for managing shivering - Tramadol Other drugs used for shivering- Ondansetron- Ketamine- Clonidine & dexmedetomidine- Anticholinergic drugs


Question: The most significant change in maternal lung volume that occurs in the third trimester of pregnancy includes.

With enlargement of uterus, diaphragm is forced cephalad that decreases FRC.

Decrease in functional residual capacity


Question: Safety pin index for oxygen cylinder is


Question: Local anaesthetic of choice for IVRA


Question: Armoured enforcement of ET tube is used in

Their distinctive feature of armoured or reinforced tubes has is a metal wire coil embedded in the wall of the tube shaft. Reinforced tubes have ceain advantages over standard endotracheal tubes in several situations due to their resistance to occlusion when bent and their overall greater flexibility:Many practitioners prefer using armoured tubes in head & neck and neurosurgical cases, i.e. when access to the airway is limited and bulky equipment in front of the patient&;s mouth and face can get in the way of the surgeon.