Anesthesiology Past Paper PDF

Index History of Anaesthesia & Pre - Anaesthetic Evaluation - Page 1 Previous Year Questions (Pre-Anaesthetic Evaluation) - Page 14 Regional + Spinal Anesthesia - Page 26 Previous Year Questions (Regional Anaesthesia) - Page 58 Depolarising & Nondepolarising Muscle Relaxant - Page 69 Previous Year Questions (Neuromuscular Blockade) - Page 77 Intravenous Anesthetic Agents - Page 83 Previous Year Questions (Intravenous Anaesthetic Agents) - Page 111 Inhalational Agents - Page 121 Previous Year Questions (Inhalational Anaesthetic Agents) - Page 143 Fluid Management - Page 151 Monitoring in Anesthesia - Page 163 Previous Year Questions (Monitoring in Anaesthesia) - Page 188 BCLS & ACLS - Page 202 Previous Year Questions (Cardiopulmonary Cerebral Resuscitation) - Page 221 Anaesthesia Machines & Breathing Systems - Page 236 Oxygen Therapy and Airway - Page 256 Previous Year Questions (Oxygen Therapy and Airway) - Page 284 Mechanical Ventilation and Modes of Ventilation - Page 301 Previous Year Questions (Mechanical Ventilation and Modes of Ventilation) - Page 321 Previous Year Questions (Pain Management) - Page 327 History of Anaesthesia & Pre - Anaesthetic Evaluation 1. A 62-year-old patient with uncontrolled hypertension presents to the emergency department with complaints of sharp, sudden pain in the upper back and difficulty in breathing for the past 10 minutes. On examination, the patient had a blood pressure of 80/40 mmHg, pulse rate of 99 beats/minute with low volume, SpO2 of 86% at room air and GCS of 11/15. His hemoglobin level is 3g/dl, and a CT scan shows a ruptured aortic aneurysm. This patient belongs to which ASA class? (or) What ASA class is assigned to a patient with a ruptured aortic aneurysm, presenting with a blood pressure of 80/40 mmHg, pulse rate of 99/min, SpO2 of 86%, and GCS of 11/15. A CT scan shows a ruptured aortic aneurysm. ? A. III B. V C. IV D. VI ---------------------------------------- 2. Which of the following parameters are included to stratify the risk of developing perioperative cardiac events? (or) A 45-year-old male presented to the emergency department with complaints of pale and painful legs for three days. He is a chronic smoker and alcoholic and has been on treatment for systemic hypertension and diabetes for the past two years. On examination, he has absent pulses in both lower limbs. ECG shows pathological Q waves. The angiogram shows a complete occlusion of bilateral external iliac arteries. He is posted for aorto-bifemoral bypass under general anesthesia with epidural analgesia. His preoperative risk stratification for perioperative cardiac events includes? A. History of ischemic heart disease B. History of preoperative treatment with oral hypoglycemic agents C. History of preoperative serum creatinine > 0.7 mg/dL D. Age > 40 years ---------------------------------------- 3. When should the nortriptyline be stopped prior to the surgery? (or) A 49-year-old female is planned for a laparoscopic hernia repair surgery. She has a history of neuropathic pain that is being treated with Nortriptyline. When should this medication be discontinued with regard to her surgery? A. 3 weeks prior B. 24 hours prior C. Continued till the day of surgery D. 6 weeks prior 1 ---------------------------------------- 4. A 7-month-old male child is planned for elective hypospadias repair surgery. The doctor instructs the nurse to keep the patient on nil per oral (NPO). When should the patient withhold clear liquids? A. 2 hour for breast milk B. 4 hours for breast milk C. 6 hours for breast milk D. 8 hours for breast milk ---------------------------------------- 5. A 19-year-old boy is posted for emergency repair of the ruptured globe after sustaining a blow to the eye. The patient had his last meal 5 hours ago. Which of the following is the most appropriate anesthetic technique for this patient? (or) What is the most appropriate anaesthetic technique for an emergency globe repair surgery in a 19-year-old boy? A. Retrobulbar block B. Subtenon block C. General anaesthesia D. Peribulbar block ---------------------------------------- 6. A 35-year-old male with a known history of diabetes and hypertension presents as an outpatient for complaints of vomiting, difficulty in articulation, increased sweating, headache, and blurred vision for 1 month. The patient appears to have an enlarged thyroid, spade-like hands, large feet, and an enlarged lower jaw and tongue with thickened lips and skin. His Mallampati score was assessed to be 4. What could be the most probable diagnosis and the reason for his Mallampatti score? A. Acromegaly, enlarged tongue B. Gigantism, enlarged goiter C. Gigantism, enlarged tongue D. Acromegaly, enlarged goiter ---------------------------------------- 7. A 30-year-old female patient was brought to the hospital by her husband, after noticing that the patient had lost consciousness and was exhibiting abnormal movements with alternating stiffness and jerking of her upper and lower limbs. He recalls that the episode had been going on for about 20 minutes. Oral examination reveals significant tongue biting with swelling; only the hard and soft palate and the base of the uvula are seen. What is the most appropriate diagnosis? Also, calculate the Mallampatti score for this patient. (or) In a 30-year-old female with prolonged seizures and tongue swelling causing airway obstruction, what is the suspected diagnosis, and what Mallampati classification grade is assigned in this case? A. Tonic-clonic seizures, Mallampati classification grade 3 B. Status epilepticus, Mallampati classification grade 3 Page 2 2 C. Tonic-clonic seizures, Mallampati classification grade 4 D. Status epilepticus, Mallampati classification grade 4 ---------------------------------------- 8. A 45-year-old patient is scheduled for intubation before surgery. During the airway assessment, the following findings were noted: Facial trauma, Inter Incisor Distance of >3 finger breadths, Thyroid To Mouth Distance of 2 finger breadths, Mallampati Class III, and the patient can touch his chest with his chin. What is the total Lemon Airway Classification score for this patient? (or) What is the Lemon Airway Classification score for a 45-year-old patient with facial trauma, Inter Incisor Distance >3 finger breadths, Thyroid To Mouth Distance 2 finger breadths, Mallampati Class III, and ability to touch chin to chest? A. 2 points B. 3 points C. 4 points D. 5 points ---------------------------------------- 9. All of the following are contributions of Dr Arthur Guedel's for the field of anesthesia except? A. Introduced cuff in ET tube B. Guedel airway C. Stages of anaesthesia D. Introduction of thiopentone ---------------------------------------- 10. Match the following: 1. Father of IV anesthesia 2. Father of Spinal anesthesia 3. Father of LA anesthesia 4. Father of GA A. August Bier B. Prof. Helmut Weese C. John Snow D. Dr. Heinrich Friedrich Wilhelm Braun 2. Father of Spinal anesthesia3. Father of LA anesthesia4. Father of GA A. August BierB. Prof. Helmut WeeseC. John SnowD. Dr. Heinric A. 1-A, 2-C, 3-D, 4-B B. 1-D, 2-B, 3-C, 4-A1 C. 1-C, 2-A, 3-D, 4-B D. 1-B, 2-A, 3-D, 4-C ---------------------------------------- 11. Which of the following doctors made an important development with the discovery of nitrous oxide? A. Joseph Priestley B. Humphry Davy C. Horace Wells D. JJ Simpson ---------------------------------------- 12. Which of the following changes occurring is true about Plane 1 of the 3rd anesthetic stage? Page 3 3 A. Pupillary dilation B. Decrease Lacrimation C. Increase Lacrimation D. Apnea ---------------------------------------- 13. In the operating room, when a patient under anesthesia exhibits delirium, tachycardia, irregular respiration, and an intact gag reflex, which stage of anesthesia is the patient in? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 ---------------------------------------- Correct Answers Question Correct Answer Question 1 2 Question 2 1 Question 3 1 Question 4 2 Question 5 3 Question 6 1 Question 7 2 Question 8 3 Question 9 4 Question 10 4 Question 11 1 Question 12 3 Question 13 2 Solution for Question 1: Correct Option B - V: As the patient has poor vital parameters and is actively bleeding due to his ruptured aortic aneurysm, he requires emergent surgery. He has a poor prognosis. A moribund patient not expected to survive without surgery is categorised as ASA class V. Adult examples of ASA class V include ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleeding with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organs/system dysfunction. Page 4 4 In the pediatric population, any massive trauma, intracranial haemorrhage with mass effect, a patient requiring ECMO, respiratory failure or arrest, malignant hypertension, decompensated congestive heart failure, hepatic encephalopathy, ischemic bowel or multiple organs/system dysfunction is under ASA class V Incorrect Options: Option A - III: A patient with the severe systemic disease is categorised as ASA class 3. Substantive functional limitations are present. For example, poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (> 3 months) of MI, CVA, TIA, or CAD/stents. Option C - IV: A patient with severe systemic disease that constantly threatens life is categorised as ASA class 4. Examples include recent (0.7 mg/dL: Preoperative serum creatinine levels of more than 2.0mg/dl (180mcgmol/L) are associated with an increased risk of perioperative cardiac complications. Option D - Age > 40 years: Age is not included in the revised cardiac index. Page 5 5 It is not associated with an increased risk of perioperative cardiac complications. Solution for Question 3: Correct Option A - 3 weeks prior: Preoperative use of antipsychotics and antidepressants puts the patient at risk of developing postoperative delirium and a relapse, significantly affecting the patient's condition. Antipsychotics, antidepressants, and antiepileptics should be continued till the day of surgery. The only exception to this rule is tricyclic antidepressants which should be stopped 3 weeks before surgery. Nortriptyline is a tricyclic antidepressant and hence should be stopped 3 weeks prior. TCAs cause alteration of receptor densities and sensitivities and take at least 3 weeks for it to reverse. Abrupt cessation might cause overactivity of certain receptors like alpha -1 receptors and underactivity of certain receptors like beta-1 and serotonin -2 receptors. The resulting effects will lead to withdrawal symptoms. This is the reason why TCAs should never be stopped abruptly and must be tapered before discontinuation. A note on withdrawal symptoms can be mentioned. TCAs also have alpha-1 antagonist, anticholinergic, and antihistaminic properties. Incorrect Options: Option B - 24 hours prior: Lithium is stopped 24 hours before. Option C - Continued till the day of surgery: All other antidepressants are continued till the days of surgery except tricyclic antidepressants. Option D - 6 weeks prior: Stopping six weeks before surgery is unduly long and will result in a relapse of the condition. Thus they should be stopped three weeks prior. Solution for Question 4: Correct Option: B - 4 hours breast milk: Breast milk would be withheld 4 hours before surgery for this child to reduce the risk of pulmonary aspiration. Incidentally, children are more susceptible to dehydration than adults, so the preoperative fasting guidelines are planned appropriately for age and other biological parameters. Incorrect Options: Option A: 2 hours for breast milk Option C: 6 hours for breast milk Option D: 8 hours for breast milk Page 6 6 Solution for Question 5: Correct Option C - General anesthesia: The anesthetic technique of choice for emergency repair of the ruptured globe in patients is general anesthesia—despite the increased risk of aspiration pneumonia. The patient is considered to have a full stomach if the injury occurred within 8 hours after the last meal, even if the patient did not eat for several hours before the surgery. Although Retrobulbar block, Subtenon block, and Peribulbar block minimize the risk of aspiration pneumonia, it is still contraindicated in patients with penetrating eye injuries because injecting local anesthetic behind the globe increases intraocular pressure and may lead to the expulsion of intraocular contents. Incorrect Options: Option A - Retrobulbar block: It is utilized during intraocular surgery. This method involves injecting a local anesthetic into the retrobulbar space, the region behind the eyeball. Option B - Subtenon block: The virtual space between the capsule and the sclera is referred to as the sub-tenon or episcleral space. Local anesthetic is injected into this area, where it diffuses posteriorly into the retro-orbital space to block the traveling sensory and motor neurons, causing analgesia and akinesia. Option D - Peribulbar block: One regional anesthesia technique used in ophthalmic surgery to provide anesthesia and akinesia is peribulbar block. The peribulbar block is given by injecting the local anesthetic into the extraconal compartment of the eye. It has a reduced risk of optic nerve injury. Solution for Question 6: Correct Option A - Acromegaly, enlarged tongue: The patient presents with typical physical features of acromegaly, such as thickened skin, spade-like hands, prominent supra-orbital ridges, increased hat size, and an enlarged tongue. Acromegaly is caused by the hypersecretion of Growth Hormones after puberty in adults. The presenting features, such as vomiting, blurred vision, and headache, are due to the local effects of pituitary adenomas. Acromegaly occurs after puberty because of the over-secretion of growth hormones after epiphyseal closure. The Modified Mallampatti score is an assessment of the size of the tongue relative to the oropharyngeal opening in order to predict a difficult airway. Since this patient has an enlarged tongue, only the hard palate will be visible so the Mallampatti score is 4. This indicates that it will be difficult to secure the airway when the patient needs one. Page 7 7 Incorrect Options: Option B - Gigantism, enlarged goiter : In gigantism, physical changes occur before puberty The enlarged goiter is not the factor for the oral cavity assessment as in the MPC. Option C - Gigantism, enlarged tongue: In gigantism, physical changes occur before puberty. Option D - Acromegaly, enlarged goiter: The enlarged goiter is not the factor for the oral cavity assess ment as in the MPC. Solution for Question 7: Correct Option B - Status epilepticus, Mallampati classification grade 3: Status epilepticus: Individual seizures lasting more than 5 minutes or more than 1 seizure within 5 minutes. As the soft, hard palate and base of the uvula are visible during airways assessment, the modified mallampati grade is 3 in this case. The management in this patient is to secure airways, maintain vitals, terminate seizures, and treat the underlying cause. Incorrect Options: Option A - Tonic-clonic seizures, Mallampati classification grade 3: GTCS: Has a tonic and clonic phase and the patient will return to baseline within 2 minutes. Soft palate, hard palate, and uvula base are visible in grade 3. Option C - Tonic-clonic seizures, Mallampati classification grade 4: If only the hard palate is visible, the n the MPC grade is 4. Option D - Status epilepticus, Mallampati classification grade 4: MMP grade 4 is the visibility of only the hard palate. Solution for Question 8: Based on the given findings: Facial trauma = 1 point Inter Incisor Distance > 3 finger breadths = 1 point Thyroid To Mouth Distance of 2 finger breadths = 0 points Mallampati Class III = 1 point The patient can touch his chest with his chin = 1 point In the Lemon Airway Classification system, points are assigned based on several parameters to predict the ease of intubation. The parameters are: Look externally Page 8 8 facial trauma = 1 point Evaluate 3-3-2 rule Inter Incisor Distance > 3 finger breadths = 1 point, Thyroid To Mouth Distance < 3 finger breadths = 0 points Mallampati Class Class III = 1 point Obstruction or lack thereof ability to extend the neck = 0 points Neck mobility ability to touch the chest with the chin = 1 point Adding these points together, the total Lemon Airway Classification score for this patient is: Therefore, the correct answer is C. 4 points. Solution for Question 9: Correct Option D - Introduction of thiopentone: Since Lundy introduced it in 1934, thiopentone has become the most widely used induction agent because of the rapid hypnotic effect, highly predictable effect, lack of vascular irritation, and general overall safety. Incorrect Options: Option B - Guedel airway: In 1933 Guedel designed a rubber pharyngeal airway with a metal insert to prevent occlusion if bitten. The 'Guedel airway' has stood the test for nearly 90 years. Option A - Introduced cuff in ET tube: Together with Waters, he was among the pioneers of cuffed end otracheal tubes. The Waters to-and-fro canister was heavy and cumbersome, so Arthur Guedel began experimenting with various ways of applying cuffs to the tube to provide a complete seal. Page 9 9 Option C - Stages of anaesthesia: Arthur Guedel created one of the first safety systems in anesthesiology, with a chart that explained the stages of anaesthesia with an increasing depth ranging from stages 1 to 4. Solution for Question 10: Correct Option D - 1-B, 2-A, 3-D, 4-C : Father of IV anesthesia Father of Spinal anesthesia Father of LA anesthesia Father of GA Prof. Helmut Weese August Bier Dr. Heinrich Friedrich Wilhelm Braun John Snow Solution for Question 11: Correct Option A - Joseph Priestley: Nitrous oxide, aka Laughing gas, was first discovered by an English chemist Joseph Priestly in 1772. Upon experimenting with heating iron filings dampened with nitric acid, he created nitrous oxide. Incorrect Options: Option B - Humphry Davy: Sir Humphry Davy was a British chemist and inventor from Cornwall who invented the Davy lamp and a very early form of arc lamp. Option C - Horace Wells: Horace Wells was an American dentist who pioneered the use of anesthesia in dentistry, specifically the use of nitrous oxide. Option D - JJ Simpson: Sir James Young Simpson was a Scottish obstetrician and a significant figure in the history of medicine. He was the first physician to demonstrate the anesthetic properties of chloroform on humans and helped to popularise its use in medicine. Solution for Question 12: Correct Option C - Increase Lacrimation: Seen in Plane 1 of 3rd anaesthetic stage Page 10 10 Incorrect Options: Option A - Pupillary dilation: Seen in 2nd anaesthetic stage Option B - Decrease Lacrimation: Seen in Plane 3 of 3rd anaesthetic stage Option D - Apnea: Seen in 4th anaesthetic stage Solution for Question 13: Correct Option B - Stage 2: Stage 2: Stage of Excitement or Delirium Loss of consciousness to the onset of automatic breathing. Disinhibition, Delirium, Hypertension, and Tachycardia occur because of Sympathetic stimulation. Airway manipulation is avoided. Respiration is Rapid, irregular The Eyelash reflex disappeared, but other reflexes were intact (cough, vomiting) Incorrect Options: Option A - Stage 1: Stage 1: Stage of Analgesia or Disorientation From the beginning of induction of general anaesthesia to loss of consciousness. Eyelash reflex lost This stage can be initiated in a preoperative anesthesiology holding area, where the patient is given medication and may begin to feel its effects but has not yet become unconscious. This stage is usually described as the "induction stage." Patients are sedated but conversational. Option C - Stage 3: Stage 3: Stage of Surgical Anesthesia Stage of automatic respiration to paralysis of respiration Divided into 4 planes Plane 1 From the onset of automatic respiration to the cessation of eyeball movement. Eyelid reflex, Conjunctival reflex and Swallowing reflex are lost Marked eyeball movement From the onset of automatic respiration to the cessation of eyeball movement. Eyelid reflex, Conjunctival reflex and Swallowing reflex are lost Marked eyeball movement Plane 2 Cessation of eyeball movement to the beginning of paralysis of the intercostal muscle. Laryngeal reflex lost Secretion of tears increases Respiration is automatic and regular Intermittent cessation of respiration Loss of eyeball movement Cessation of eyeball movement to the beginning of paralysis of the intercostal muscle. Laryngeal reflex lost Page 11 11 Secretion of tears increases Respiration is automatic and regular Intermittent cessation of respiration Loss of eyeball movement Plane 3 Complete relaxation of intercostal & Abdominal muscles Loss of pupillary light reflex This is the true surgical anaesthesia plane Complete relaxation of intercostal & Abdominal muscles Loss of pupillary light reflex This is the true surgical anaesthesia plane Plane 4 Complete intercostals paralysis to diaphragmatic paralysis. Irregular respiration Paradoxical rib cage movements Diaphragm paralysis Complete intercostals paralysis to diaphragmatic paralysis. Irregular respiration Paradoxical rib cage movements Diaphragm paralysis From the onset of automatic respiration to the cessation of eyeball movement. Eyelid reflex, Conjunctival reflex and Swallowing reflex are lost Marked eyeball movement Cessation of eyeball movement to the beginning of paralysis of the intercostal muscle. Laryngeal reflex lost Secretion of tears increases Respiration is automatic and regular Intermittent cessation of respiration Loss of eyeball movement Complete relaxation of intercostal & Abdominal muscles Loss of pupillary light reflex This is the true surgical anaesthesia plane Complete intercostals paralysis to diaphragmatic paralysis. Irregular respiration Paradoxical rib cage movements Diaphragm paralysis Option D - Stage 4: Overdose Respiratory cessation to potential death The skeletal muscle becomes flaccid, has a weak pulse, and Decreased Blood pressure. This stage occurs when too much anaesthetic agent is given relative to the amount of surgical stimulation, worsening an already severe brain or medullary depression. This stage begins with respiratory cessation and ends with potential death. Page 12 12 Page 13 13 Previous Year Questions 1. What is the appropriate preoperative fasting recommendation? A. 4 hours for solids in adults B. 2 hours for liquids in adults C. 2 hours for breast milk in infants D. 4 hours for solids in infants ---------------------------------------- 2. What is the preferred drug for preoperative antibiotic prophylaxis in a patient who is about to undergo cardiac surgery? A. Penicillin G B. Erythromycin C. Azithromycin D. Cefazolin ---------------------------------------- 3. Which investigation yields the most precise prognostic information for predicting the risk of perioperative cardiac complications among the options provided? A. Exercise ECG testing B. Dobutamine stress echocardiography C. Myocardial perfusion scintigraphy D. Coronary angiography ---------------------------------------- 4. When assessing a patient before anesthesia, the oral cavity should be examined. The image provided below displays the examined cavity. It illustrates__ A. Mallampati class IV B. Mallampati Class II C. Mallampati class III D. Mallampati class I ---------------------------------------- 14 5. Which of the following treatments should be avoided in patients with acute intermittent porphyria? A. Thiopentone B. Propofol C. Etomidate D. Ketamine ---------------------------------------- 6. Which surgery should be avoided in a patient with a fibroma and moderate to severe cardiac disease? A. Laparoscopic hysterectomy B. Abdominal hysterectomy C. Total hystertectomy D. Sub total hysterectomy ---------------------------------------- 7. Identify the Mallampati class of this patient A. Class II B. Class I C. Class IV D. Class III ---------------------------------------- 8. In adults, at which level does the spinal cord terminate? A. L3-L4 B. L1-L2 C. T12-L1 D. L2-L3 ---------------------------------------- 9. Glycopyrrolate is used as a pre-anesthetic agent for A. Reducing the secretions B. Sedative effect Page 2 15 C. Skeletal muscle relaxant D. Anxiolytic ---------------------------------------- 10. How is the preoperative evaluation of the oral cavity conducted in adults to facilitate endotracheal intubation? A. Mallampatti score B. Conmack lehane C. ASA grading D. AHA grading ---------------------------------------- 11. What is the most effective approach for verifying the accuracy of intubation during laryngoscopy? A. Capnography B. Air entry on auscultation C. Ultrasonography D. Chest movement ---------------------------------------- 12. What is the recommended position for inserting a Ryle's tube? A. Supine with neck flexed B. Sitting with neck flexed C. Supine with neck extended D. Sitting with neck extended ---------------------------------------- 13. What is the purpose of using glycopyrrolate as a pre-anesthetic agent? A. Reducing the secretions B. Sedative effect C. Skeletal muscle relaxant D. Anxiolytic ---------------------------------------- Correct Answers Question Correct Answer Question 1 2 Question 2 4 Question 3 2 Question 4 3 Page 3 16 Question 5 1 Question 6 3 Question 7 1 Question 8 2 Question 9 1 Question 10 1 Question 11 1 Question 12 2 Question 13 1 Solution for Question 1: Correct Option B: 2 hours for liquids in adults A preoperative fasting period is a time prescribed before any procedure that involves general anesthesia, sedation, or regional anesthesia. During this period, no oral intake of solids or liquids is allowed. This fasting is mandatory for the safety process to protect gastric contents from pulmonary aspiration, which is supposed to happen at any time during the anesthesia. It is considered 6 hours for milk as well as light meals, and 8 hours for fatty foods. The collective fasting recommendation is two hours for clear and light liquids, four hours for breast milk, and six hours for solid foods, infant formula, light meals, and non-human milk. Incorrect options Option A: 4 hours for solids in adults Eight hours of preoperative fasting is recommended for solid food in adults. Option C: 2 hours for breast milk in infants Page 4 17 Four hours of preoperative fasting is recommended for breast milk. Option D: 4 hours for solids in infants It is recommended 6 hours for solid foods in preoperative fasting before anesthesia. It should be kept in mind that cereal and baby food are solid foods. Solution for Question 2: Correct Option D - Cefazolin: Cefazolin is a first-generation cephalosporin antibiotic commonly used for preoperative antibiotic prophylaxis in patients undergoing cardiac surgery. It works by inhibiting the growth and multiplication of bacteria that can cause surgical infections. Studies have shown that administering cefazolin before surgery can significantly reduce the risk of surgical infections. This is why it is the drug of choice for preoperative antibiotic prophylaxis in patients undergoing cardiac surgery. It is important to note that antibiotics should only be used when clinically indicated and that the surgeon and medical team should determine the specific timing and duration of antibiotic therapy based on the individual patient's needs and risk factors. Incorrect Options: Option A - Penicillin G: Penicillin G is a penicillin antibiotic that is effective against a wide range of bacteria. However, it is not typically used as a preoperative antibiotic prophylaxis for cardiac surgery because it has a narrow spectrum of activity and is ineffective against all the bacteria that can cause surgical infections. Option B - Erythromycin: Erythromycin is a macrolide antibiotic often used to treat respiratory tract infe ctions and some sexually transmitted diseases. However, it is not typically used for preoperative antibi otic prophylaxis in cardiac surgery because it is less effective than other antibiotics for preventing surgi cal infections. Option C - Azithromycin: Azithromycin is also a macrolide antibiotic frequently used to treat respiratory tract infections, skin infections, and other bacterial infections. However, it is not commonly used for pre operative antibiotic prophylaxis in cardiac surgery because it is ineffective against all the bacteria that c an cause surgical infections. Solution for Question 3: Correct Option B - Dobutamine stress echocardiography: Dobutamine stress echocardiography is a cardiac imaging test that assesses the heart's function and blood flow during physical stress induced by dobutamine, a medication that increases heart rate and contractility. This test provides valuable information about the heart's response to stress, allowing for the detection of any underlying coronary artery disease (CAD) or impaired cardiac function. It allows for the evaluation of both cardiac structure and function, as well as the detection of any inducible ischemia or impaired contractility. This makes it a more accurate predictor of perioperative cardiac complications compared to exercise ECG testing. Page 5 18 Incorrect Options: Option A - Exercise ECG testing: While exercise ECG testing is commonly used to evaluate cardiac function and detect CAD, it may not provide as accurate prognostic information in predicting perioperative cardiac complications compared to dobutamine stress echocardiography. Exercise ECG testing primarily assesses the electrical activity of the heart during exercise and may miss underlying structural or functional abnormalities. Option C - Myocardial perfusion scintigraphy: Myocardial perfusion scintigraphy, also known as nuclear stress testing, involves injecting a radioactive tracer into the bloodstream to assess blood flow to the heart. While this test provides valuable information about perfusion abnormalities, it may not provide as accurate prognostic information for predicting perioperative cardiac complications compared to dobutamine stress echocardiography. It primarily evaluates blood flow rather than cardiac function. Option D - Coronary angiography: Coronary angiography is an invasive procedure that involves injecting contrast dye into the coronary arteries to visualize any blockages or narrowings. While coronary angiography is the gold standard for diagnosing coronary artery disease, it is not typically used as a prognostic tool for predicting perioperative cardiac complications. It provides anatomical information about the coronary arteries rather than functional or physiological data. Solution for Question 4: Correct Option C - Mallampati class III: The Mallampati classification is a scoring system for airway assessment. It relates the amount of mouth opening in a patient with the tongue size to determine the estimated space available during endotracheal intubation and laryngoscopy. Mallampati class I Faucial Pillars (P), Uvula (U), soft palate (S), and hard palate (H) are all visible. Mallampati Class II Uvula, Soft palate, and hard palate are visible> faucial Pillars are not visible. Mallampati Class III Base of the Uvula Soft Palate (S) and hard palate (H) are visible Mallampati Class IV Only Hard palate (H) is visible The picture shows Mallampati Class III as only the base of the uvula is visible. Page 6 19 Solution for Question 5: Correct Option A - Thiopentone: Acute intermittent porphyria (AIP) is a rare genetic disorder characterized by a deficiency of the enzyme porphobilinogen deaminase, which is involved in heme synthesis. AIP can lead to the accumulation of porphyrin precursors, which can cause acute attacks with various symptoms, including severe abdominal pain, neurological symptoms, and psychiatric manifestations. Among the options provided, Thiopentone is contraindicated in patients with acute intermittent porphyria. Thiopentone is a barbiturate anesthetic agent that can potentially trigger an acute porphyria attack. The administration of barbiturates, including Thiopentone, can induce hepatic enzyme activity, which can disrupt heme synthesis and trigger the accumulation of porphyrin precursors, worsening the symptoms of AIP. Incorrect Options: Option B - Propofol: On the other hand, Propofol, Etomidate, and Ketamine are considered safer option s for anesthesia in patients with acute intermittent porphyria. These agents do not significantly affect he me synthesis or induce hepatic enzyme activity, making them less likely to precipitate an acute attack i n patients with AIP. Option C - Etomidate: On the other hand, Propofol, Etomidate, and Ketamine are considered safer opti ons for anesthesia in patients with acute intermittent porphyria. These agents do not significantly affect heme synthesis or induce hepatic enzyme activity, making them less likely to precipitate an acute attac k in patients with AIP. Option D - Ketamine: On the other hand, Propofol, Etomidate, and Ketamine are considered safer optio ns for anesthesia in patients with acute intermittent porphyria. These agents do not significantly affect h eme synthesis or induce hepatic enzyme activity, making them less likely to precipitate an acute attack in patients with AIP. Page 7 20 Solution for Question 6: Correct Option C - Total hysterectomy: Total hysterectomy involves the removal of the uterus and cervix. In a patient with moderate to severe cardiac disease, total hysterectomy is contraindicated. Total hysterectomy can increase surgical stress on the cardiovascular system, potentially causing complications in patients with compromised cardiac function. Incorrect Options: Option A - Laparoscopic hysterectomy: Laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus. It is generally considered a suitable option for patients with cardiac disease because it involves smaller incisions, less blood loss, and faster recovery compared to open surgery. However, the patient's individual cardiac status should be evaluated, and the decision should be made in consultation with a cardiac specialist. Option B - Abdominal hysterectomy: Abdominal hysterectomy is a surgical procedure where the uterus is removed through an abdominal incision. While it is a more invasive procedure compared to laparoscopic hysterectomy, it can still be performed in patients with moderate to severe cardiac disease after careful evaluation of their cardiac status and consideration of the risks and benefits. Option D - Subtotal hysterectomy: Subtotal hysterectomy, also known as supracervical hysterectomy, involves the removal of the uterus while preserving the cervix. Subtotal hysterectomy may be a preferred option for patients with moderate to severe cardiac disease because it is less invasive compared to total hysterectomy. However, the decision should still be made after careful evaluation of the patient's cardiac status and consultation with a cardiac specialist. In summary, in a patient with a fibroma and moderate to severe cardiac disease, the surgery that is co ntraindicated is Total hysterectomy. Solution for Question 7: Option A: Class II In the diagram given in the question, there is a complete visualization of the soft palate but only the tip of the uvula is not seen. Hence, the type of Mallampatti classification seen is class II. Hence, option A is the correct answer for the question given. Option B: In class I Mallampatti classification, there is a complete visualization of the soft palate and uvula. Option C: In class IV Page 8 21 The soft palate is not seen when we look at it. Option D: In class III There is a visualization of only the base of the uvula. Solution for Question 8: Correct Option B - L1-L2: In adults, the spinal cord typically ends at the level of the first lumbar vertebra (L1) or the second lumbar vertebra (L2). This termination point is known as the conus medullaris. It's important to note that the spinal cord does not extend down to the end of the vertebral column. Instead, beyond the conus medullaris, the spinal cord tapers into a bundle of nerve roots called the cauda equina. Incorrect Options: Option A - L3-L4: This option is commonly seen as the termination level of the dural sac, which contain s the cerebrospinal fluid (CSF) surrounding the spinal cord and nerve roots. However, the actual termin ation of the spinal cord itself is typically higher, around L1-L2, as mentioned above. Option C - T12-L1: The thoracic spinal cord extends down to approximately the level of T12, and the co nus medullaris is located in the lumbar region rather than the thoracic region. Therefore, T12-L1 is not t he correct level at which the spinal cord ends in adults. Option D - L2-L3: Similar to option a), this level is commonly associated with the termination of the dur al sac, not the spinal cord itself. The spinal cord typically terminates slightly higher at the level of L1-L2. Solution for Question 9: Correct Option A: Reducing the secretions Glycopyrrolate is an anticholinergic medication that is commonly used as a pre-anesthetic agent in surgical procedures. Its primary role is to reduce excessive secretions in the respiratory tract and other areas of the body during anesthesia. By blocking the effects of acetylcholine, it inhibits the production of saliva, sweat, and other respiratory and gastrointestinal secretions. This helps to maintain a clear airway and prevent complications such as aspiration pneumonia. Incorrect Options Option B: Sedative effect Glycopyrrolate is not primarily used for its sedative effects. While it may have some mild sedative properties, its main purpose is to reduce secretions rather than induce sedation. Option C: Skeletal muscle relaxant Glycopyrrolate is not a skeletal muscle relaxant. It does not directly affect muscle relaxation or neuromuscular transmission. Option D: Anxiolytic Page 9 22 Glycopyrrolate is not used primarily for its anxiolytic properties. Its main function is to reduce secretions rather than alleviate anxiety or provide calming effects. Solution for Question 10: Correct Option A: Mallampatti score The Mallampatti score is a classification system used to assess the visibility of the structures in the oral cavity and predict the ease of intubation. It is determined by visualizing the patient's mouth in a sitting position and grading the view of the soft palate, uvula, and tonsillar pillars. It ranges from Class I (full visibility) to Class IV (no visibility). A higher Mallampatti score indicates a more difficult intubation. Incorrect Opitons Option B: Cormack-Lehane The Cormack-Lehane classification is used to assess the view of the vocal cords during laryngoscopy, not specifically the oral cavity. Option C: ASA grading The American Society of Anesthesiologists (ASA) grading system is used to assess a patient's physical status before surgery, but it does not specifically evaluate the oral cavity for intubation. Option D: AHA grading There is no commonly known anesthesia grading system called AHA grading. Solution for Question 11: Correct Option A - Capnography: Capnography is the best method for checking whether the intubation is correct or not during laryngoscopy. Capnography measures the concentration of carbon dioxide (CO2) in exhaled breath. When the endotracheal tube is correctly placed in the trachea, exhaled CO2 will be detected, confirming proper intubation. It provides a reliable and immediate indication of correct tube placement. Incorrect Options: Option B - Air entry on auscultation: While auscultation for air entry is a common method for confirming tube placement, it may not be as reliable as capnography. Option C - Ultrasonography: Ultrasonography can be used to visualize the structures of the airway, but it is not typically used to confirm tube placement during laryngoscopy. Page 10 23 Option D - Chest movement: Chest movement alone is not a reliable indicator of correct intubation and may not provide definitive confirmation. Capnography provides more accurate and immediate feedback. Solution for Question 12: Correct Option B - Sitting with neck flexed: When inserting a Ryle's tube, which is a type of nasogastric tube, the ideal position for the patient is sitting with the neck flexed. This position helps to straighten the nasal passage and facilitate the passage of the tube into the stomach. It allows for a more straightforward and safer insertion process. Incorrect Options: Option A - Supine with neck flexed: This position may make the insertion of the Ryle's tube more challe nging as the neck flexion is limited in the supine position. Option C - Supine with neck extended: This position can cause discomfort and may make the insertion of the Ryle's tube more difficult. The neck extension can obstruct the nasal passage and hinder the pas sage of the tube. Option D - Sitting with neck extended: This position may cause discomfort and can increase the risk of the tube going into the respiratory tract instead of the stomach. Solution for Question 13: Option A: Glycopyrrolate Glycopyrrolate is primarily used as a pre-anesthetic agent for reducing secretions in the respiratory tract and other body systems. It belongs to a class of drugs called anticholinergics, which work by inhibiting the effects of acetylcholine, a neurotransmitter involved in various bodily functions. In the context of anesthesia, excessive secretions in the respiratory tract can interfere with the airway management and ventilation during surgery. By administering glycopyrrolate before anesthesia, the production of respiratory secretions is reduced, improving the visibility of the surgical field and facilitating proper respiratory function. Option B: Sedative effect Glycopyrrolate is not primarily used for its sedative effects. It does not have significant sedative properties and is mainly focused on reducing secretions. Option C: Skeletal muscle relaxant Glycopyrrolate is not used as a skeletal muscle relaxant. It primarily affects the cholinergic system and is not intended for muscle relaxation during anesthesia. Option D: Anxiolytic Glycopyrrolate is not used as an anxiolytic. Its main role is in reducing secretions rather than alleviating anxiety or promoting sedation Page 11 24 Page 12 25 Regional + Spinal Anesthesia 1. In a 45-year-old male with established alcoholic liver disease scheduled for open reduction and internal fixation with plating for proximal fractures of the right radius and ulna under brachial plexus block using local anesthetics, which drug can be administered safely without requiring dose adjustment? (or) Which drug can be administered to a 45-year-old male with alcoholic liver disease, undergoing open reduction and internal fixation, under a brachial plexus block using local anesthetics, without requiring dose adjustment? A. Lignocaine B. Bupivacaine C. Cocaine D. Procaine ---------------------------------------- 2. Which of the following would be a feature of ropivacaine? A. It is the enantiomer of cocaine B. It is contraindicated in labour analgesia C. It is more potent and more lipid soluble than bupivacaine D. Cardiotoxicity is lesser than that of bupivacaine ---------------------------------------- 3. A 48-year-old male with triple vessel disease and longstanding diabetes had developed gangrene in his left foot. What is the best plan for anesthesia? A. Popliteal block B. Sciatic block C. Femoral block D. Saphenous nerve block ---------------------------------------- 4. What contraindication would preclude the administration of a retrobulbar block in a 25-year-old female scheduled for vitrectomy following a traumatic eye injury with haziness and floaters in vision? (or) What is the contraindication for providing a retrobulbar block in a 25-year-old female with traumatic eye injury and vision disturbances? A. History of malignant hyperthermia B. Difficult airway C. Bleeding disorders D. Pregnancy ---------------------------------------- 26 5. A 38-year-old male presents to the emergency department after a road traffic accident. The patient has an open wound on his arm. He is alert and oriented to time and space with a GCS of 15/15. His vital signs are stable and other general physical examination reveals no abnormalities. The patient is shifted to the operation theatre for stitching of the wound. Which of the following anaesthesia can be used in this case? (or) Which of the following anaesthesia is appropriate in 38-year-old male is in the operation theatre for stitching an open wound on his arm after a road traffic accident? A. Patient-controlled analgesia B. Multimodal analgesia C. Intercostal nerve block D. Bier's block ---------------------------------------- 6. Which nerve roots will be anesthetized by the planned nerve block to achieve anesthesia for the ulnar side of the hand, little finger, ring finger, and small muscles of the hand (excluding those of the thenar eminence and the first and second lumbrical muscles) in a 15-year-old boy undergoing tendon repair surgery for a tendon injury on the 5th finger after a street fight? A. C8-T1 B. C5-C6-C7 C. C6-C7-C8 D. C7-C8-T1 ---------------------------------------- 7. A 30-year-old male patient is admitted to the orthopedic ward after internal fixation of a comminuted fracture of the head of the radius. The patient complains of pain immediately after the operation. The anesthesiologist decides to give him a nerve block that involves injecting the anesthetic into the brachial plexus through the supraclavicular fossa. What is the most likely complication of this procedure? (or) What is the most likely nerve block complication involving injecting the anesthetic into the brachial plexus through the supraclavicular fossa? A. Pneumothorax B. Horner Syndrome C. Hypotension D. Systemic Toxicity of Local Anaesthetic ---------------------------------------- 8. A 24-year-old boy presents to the surgical outdoor patient department with a complaint of swelling on his forehead, which is about 2x5 cm in size. On examination, it was a sebaceous cyst. The patient wants to remove that for which he was admitted, and the patient is told that it will be removed under local anesthesia. Alkalization of local anesthetic solutions by the addition of sodium bicarbonate has the following benefits: (or) Page 2 27 The alkalization of local anesthetic solutions by adding sodium bicarbonate has the following benefit: A. Speeds the onset B. Diminish the depth of the blockade C. Decreases systemic toxicity D. Decreases the availability of lipid-soluble forms of local anesthetic ---------------------------------------- 9. After administering 3.25 ml of 0.5% hyperbaric bupivacaine intrathecally for spinal anesthesia in a 40-year-old male with a right inguinal hernia, which nerve fiber should be assessed first? (or) After the subarachnoid injection, the nerve fibre to be tested at the earliest is: A. C fibre B. Dorsal root C. Aδ D. Aα ---------------------------------------- 10. A 20-year-old male was admitted with a history of a road traffic accident and sustained an injury to the right upper limb. This patient was planned for open reduction and internal fixation with plating for both bone fractures in the right forearm under the brachial plexus block. Inj. Lignocaine with adrenaline was used to decrease the bleeding and systemic toxicity. The dose of lignocaine with adrenaline that could be used for this patient to obtain adequate blockade is: (or) What dosage of lignocaine with adrenaline would be suitable for the patient to achieve adequate nerve blockade? A. 7 mg/kg Body weight B. 4.5 mg/kg Body weight C. 2 mg/ kg Body weight D. 3 mg/kg Body weight ---------------------------------------- 11. A 30-year-old patient presents in the outpatient department with a complaint of nausea and four episodes of vomiting with extreme drowsiness and slurring of speech. On examination, a doctor noticed he exhibited pallor tachycardia and tachypnea with jerky movements of the limbs. He had a history of mesh repair under spinal anesthesia. Which of the following anesthetic drug over-dosage can cause these symptoms? (or) Which anesthetic drug overdose can cause symptoms of extreme drowsiness, slurred speech, pallor, tachycardia, tachypnea, and jerky limb movements in a patient with a history of mesh repair under spinal anesthesia? A. Articaine B. Mepivacaine Page 3 28 C. Lignocaine D. Bupivacaine ---------------------------------------- 12. After receiving an epidural injection of 12ml of 2% lidocaine, an 18-year-old woman in active labor reports Circumoral numbness and becomes apprehensive. What is the likely diagnosis? (or) What is the presumptive diagnosis when an 18-year-old woman in active labor complains of Circumoral numbness and becomes apprehensive immediately after receiving an epidural injection of 12ml of 2% lidocaine? A. Allergy to drug administered. B. Systemic toxicity to drugs administered C. Vasovagal shock D. Facial paralysis ---------------------------------------- 13. What is the route of absorption of a local anesthetic, from fastest to slowest conduction? A. Endotracheal >Lumbar epidural > Intercostal block > Subcutaneous. B. Endotracheal > Intercostal block > Lumbar epidural > Subcutaneous. C. Subcutaneous> Intercostal block > Lumbar epidural >Endotracheal D. Lumbar epidural > Intercostal block >Endotracheal > Subcutaneous. ---------------------------------------- 14. Which is a true statement regarding EMLA cream? A. It is not a eutectic mixture of local anaesthetic B. Ratio of Lignocaine to Prilocaine is 8:5 C. Ratio of Lignocaine to Prilocaine is 1:1 D. Mucous membrane ---------------------------------------- 15. The rationale for adding dextrose in spinal anaesthesia is to: A. Increase duration of action B. Reduce plasma levels of local anesthetic to prevent toxicity C. Increase specific gravity D. Make the drug Hypobaric. ---------------------------------------- 16. What is the most appropriate anesthetic technique for a 48-year-old man with a diagnosis of ST-segment elevation myocardial infarction (STEMI) who is planning for a non-surgical reperfusion intervention? A. Local anaesthesia B. Caudal Anaesthesia Page 4 29 C. General Anaesthesia D. Epidural Anaesthesia ---------------------------------------- 17. What is the sign of a successful nerve block under stellate ganglion block? A. Flushing of face B. Salt craving C. Irritability D. Hypotension ---------------------------------------- 18. Which of the following is the shortest-acting local anesthetic agent? A. Bupivacaine B. Ropivacaine C. Chloroprocaine D. Tetracaine ---------------------------------------- 19. A 75-year-old man presents in the outpatient department with a humerus fracture after a road track accident. The orthopedic surgeon admitted him; he is posted for open reduction and external fixation. As soon as the patient was administered the local anesthetic agent, he exhibited the symptoms of seizures and sensory and visual changes with a reduced level of consciousness. What is the next step in the management of this patient? (or) What is the next step in the management of a 75-year-old patient who exhibits seizures, sensory and visual changes, and a reduced level of consciousness after being administered a local anesthetic for open reduction and external fixation of a humerus fracture? A. Lignocaine B. Lipid emulsion therapy C. Vasopressin D. Ephedrine ---------------------------------------- 20. What condition can cause symptoms of shortness of breath, lethargy, and tachycardia in a patient after undergoing sebaceous cystectomy under local anesthesia? A. Ropivacaine B. Procaine C. Articaine D. Prilocaine ---------------------------------------- 21. Which local anesthetic can be administered via the intravenous route? A. Bupivacaine Page 5 30 B. Lidocaine C. Ropivacaine D. Tetracaine ---------------------------------------- 22. A 38-year-old male is scheduled for a nerve block procedure, and the anesthesia team is considering the use of adrenaline (epinephrine) to enhance the effects of the local anesthetic. In this context, in which of the following nerve blocks should the administration of adrenaline be avoided to prevent potential complications? (or) In which of the following nerve blocks should adrenaline (epinephrine) not be administered to avoid potential complications? A. Penile nerve block B. Brachial plexus block C. Epidural block D. Subarachnoid block ---------------------------------------- 23. Which of the following local anesthetics is linked by an ester bond? A. Lidocaine B. Bupivacaine C. Cocaine D. Dibucaine ---------------------------------------- 24. What is the typical composition used for achieving analgesia without complete anesthesia during labor? A. Bupivacaine 0.125% + Fentanyl B. Bupivacaine 0.125% + Morphine C. Ropivacaine 0.25% + Fentanyl D. Lidocaine 1% + Meperidine ---------------------------------------- 25. A 50-year-old male patient with a known case of systemic hypertension on treatment posted for hemorrhoidectomy under spinal anaesthesia. The intervertebral space below which we can enter the spinal needle for this patient is: (or) Below which intervertebral space can the spinal needle be inserted for a 50-year-old male with systemic hypertension undergoing hemorrhoidectomy under spinal anesthesia? A. L2 – L3 B. L3 – L4 C. L1 – L2 Page 6 31 D. L5 – S1 ---------------------------------------- 26. What is the name of this needle? A. Tuohy's needle B. Quincke-Babcock needle C. Whitacre needle D. Sprotte needle ---------------------------------------- 27. A 28-year-old patient was given epidural anaesthesia with 15 ml of 1.5% Lignocaine with adrenaline for hernia surgery. He developed hypotension and respiratory arrest and became unconscious within 3 minutes. What is the most probable cause? (or) What is the most probable cause of hypotension, respiratory arrest, and unconsciousness within 3 minutes after administering epidural anesthesia with 15 ml of 1.5% Lignocaine with adrenaline to a 28-year-old patient undergoing hernia surgery? A. Systemic toxicity to lignocaine B. Total spinal block C. Anaphylaxis to lignocaine D. Vasovagal shock ---------------------------------------- 28. A 50-year-old male was a case of a right inguinal hernia and was posted for hernioplasty under spinal anaesthesia. Injection bupivacaine 0.5% hyperbaric solution was given at L3-L4 space. What is the order of sensory blockade expected in this patient? (or) What is the expected order of sensory blockade in a 50-year-old male undergoing inguinal hernioplasty with bupivacaine 0.5% hyperbaric solution injected at the L3-L4 space for spinal anesthesia? A. Temperature – pain – touch – pressure B. Pain – pressure – touch – temperature C. Pressure – touch– pain– temperature D. Touch – pain – pressure – temperature Page 7 32 ---------------------------------------- 29. Which of the following cranial nerve is most commonly involved in post-dural puncture headache? A. 5th cranial nerve B. 6th cranial nerve C. 9th cranial nerve D. 10th cranial nerve ---------------------------------------- 30. An 18-year-old male presents to the clinic. He complained of an occipital headache. The headache developed 2 days ago when he underwent a diagnostic lumbar puncture. Which of the following statement is most appropriate? (or) Which of the following statements is most appropriate for an 18-year-old male presenting with an occipital headache that developed 2 days ago following a diagnostic lumbar puncture? A. Pencil-point spinal needles increase the incidence B. Definitive cure is obtained with an epidural blood patch C. Headache is aggravated by lying down and relieved by sitting D. None of the above ---------------------------------------- 31. Which of the following is not an absolute contraindication of neuraxial anaesthesia? A. Patients refused B. Local infection of site C. Raised Intracranial pressure D. Spinal deformity ---------------------------------------- 32. A 45-year-old female patient undergoes general anaesthesia for radical mastectomy. After one hour of induction, the patient develops hypotension. The anaesthetist immediately starts her on vasopressor support, bringing her blood pressure back to normal. Which support is best to be utilised in such a condition? (or) Which support is best to be utilized for managing hypotension in a 45-year-old female patient undergoing general anesthesia for radical mastectomy, where vasopressor support was initiated to restore blood pressure to normal? A. Ephedrine B. Atropine C. Dobutamine D. Adrenaline ---------------------------------------- Correct Answers Page 8 33 Question Correct Answer Question 1 4 Question 2 4 Question 3 1 Question 4 3 Question 5 4 Question 6 1 Question 7 1 Question 8 1 Question 9 3 Question 10 1 Question 11 3 Question 12 2 Question 13 2 Question 14 3 Question 15 3 Question 16 1 Question 17 1 Question 18 3 Question 19 2 Question 20 4 Question 21 2 Question 22 1 Question 23 3 Question 24 1 Question 25 2 Question 26 1 Question 27 2 Question 28 1 Question 29 2 Question 30 2 Question 31 4 Question 32 1 Solution for Question 1: Page 9 34 Correct Option D - Procaine: This is a case of fracture of the radius and ulna for which the patient is posted for open reduction and internal fixation under the brachial plexus block. Ester local anesthetics undergo hydrolysis by cholinesterase enzyme principally in the plasma and, to a lesser extent, in the liver. So procaine, a local ester anesthetic, can be given in patients with hepatic dysfunction with little dose adjustment. The rate of hydrolysis varies, with chloroprocaine being the most rapid, procaine being intermediate, and tetracaine being the slowest. The exception to hydrolysis of ester local anesthetics in the plasma is cocaine, which undergoes significant metabolism in the liver. Severe liver disease may slow the clearance of the amino amide local anesthetics, and significant drug levels may accumulate. So dose reduction of amino amide local anesthetics is necessary for hepatic dysfunction. Incorrect Options: Option A - Lignocaine: Lignocaine metabolizes in the liver primarily by oxidative dealkylation, followed by hydrolysis to silicide. Lignocaine, an amino amide local anesthetic drug, needs dose adjustment in chronic liver diseases. Option B - Bupivacaine: Metabolism of bupivacaine includes aromatic hydroxylation, N-dealkylation, amide hydrolysis, and conjugation in the liver. Bupivacaine is an amino amide local anesthetic and needs dose adjustment in patients with chronic hepatic diseases. Option C - Cocaine: The exception to the hydrolysis of ester local anesthetics in the plasma is cocaine. Cocaine undergoes significant metabolism in the liver using hepatic carboxylesterase and is partially excreted unchanged in the urine. Solution for Question 2: Correct Option D - Cardiotoxicity is lesser than that of bupivacaine: One of the notable advantages of ropivacaine compared to bupivacaine is its reduced potential for cardiotoxicity. Bupivacaine has a higher affinity for cardiac sodium channels, which can lead to cardiac arrhythmias and toxicity if absorbed systemically in high doses. Ropivacaine, with its reduced cardiotoxicity, is often chosen when cardiac safety is a concern. Incorrect Options: Option A - It is the enantiomer of cocaine: This statement is not accurate. Ropivacaine is not an enanti omer of cocaine. While both are local anesthetics, they are distinct molecules with different structures a nd properties. Page 10 35 Option B - It is contraindicated in labor analgesia: This statement is not accurate. Ropivacaine is comm only used for labor analgesia through techniques such as epidural or spinal anesthesia. It provides effe ctive pain relief while allowing the mother to remain conscious and participate in the birthing process. Option C - It is more potent and more lipid soluble than bupivacaine: This statement is partially accurat e. Ropivacaine is less lipid-soluble than bupivacaine, which contributes to its lower potential for cardiot oxicity. It is also less potent than bupivacaine, making it a safer choice in terms of cardiac effects. Solution for Question 3: Correct Option A - Popliteal block: Popliteal nerve block provide excellent coverage for foot and ankle surgery, while sparing much of the hamstring muscles. The popliteal nerve block is a form of regional anesthesia utilized for a variety of foot and ankle conditions. This form of anesthesia has become a popular technique to decrease postoperative pain, decrease narcotic use and increase patient satisfaction. There are several approaches for administering a popliteal sciatic nerve block, all with unique advantages and disadvantages. Commonly, a posterior approach is employed with the patient positioned prone. Alternatively, the lateral approach can be used with patient in the supine position. There are several approaches to administering a popliteal sciatic nerve block, all with unique advantages and disadvantages. Commonly, a posterior approach is employed with the patient positioned prone. Alternatively, the lateral approach can be used with patient in the supine position. Saphenous nerve supplies skin over the medial aspect of the leg and ankle joint. This block used in conjunction with sciatic nerve block to provide complete anaesthesia/analgesia below the knee. Femoral nerve innervates hip and thigh. Sciatic nerve block can be used for the procedure involving hip, knee, thigh, lower leg and foot. Solution for Question 4: Correct Option C - Bleeding disorders: Bleeding disorders, such as hemophilia or coagulopathies, can be a contraindication for invasive procedures like retrobulbar blocks. Injecting local anesthetic in the presence of a bleeding disorder can increase the risk of hematoma formation. Incorrect Options: Option A - History of malignant hyperthermia: Malignant hyperthermia is a rare but potentially life-threatening reaction to certain medications (like succinylcholine, halogenated compound, lignocaine) used during general anesthesia. It is not directly related to the administration of a retrobulbar block, which is a regional anesthesia technique for eye surgery. This option is unlikely to be a contraindication for a retrobulbar block. Page 11 36 Option B - Difficult airway: Difficult airway refers to challenges in securing the patient's airway during intubation or ventilation. While a difficult airway may influence the choice of anesthetic techniques, it may not be a direct contraindication for a retrobulbar block. Option D -Pregnancy: Pregnancy is not typically a contraindication for retrobulbar blocks; however, precautions may need to be taken, especially in the later stages of pregnancy. The benefits and risks should be carefully considered. Solution for Question 5: Correct Option D - Bier's block: This is a case of a road traffic accident in which the patient presents with an open wound on his arm. Bier's block is intravenous regional anaesthesia by injecting local anaesthetic intravenously into the tourniquet occluded limb. It is not used for postoperative analgesia. It is indicated in any procedure that needs local anaesthesia, muscle relaxation, or a bloodless region in a limb. It is used for the reduction of bone dislocation or fractures, laceration repair, foreign body removal, drainage of infection, or debridement of burns. Many methods are available for postoperative pain, including systemic analgesics and regional analgesic techniques. The selection of methods is based on the patient's preferences and the risks and benefits of each analgesic modality. Systemic analgesic techniques: Opioids: intravenous patient-controlled analgesia. Non opioids: NSAIDS, Acetaminophen, gabapentinoids like gabapentin and pregabalin, ketamine, tramadol. Opioids: intravenous patient-controlled analgesia. Non opioids: NSAIDS, Acetaminophen, gabapentinoids like gabapentin and pregabalin, ketamine, tramadol. Regional analgesic techniques: Single dose neuraxial opioids, continuous epidural analgesia, peripheral regional analgesia, paravertebral, intercostal blocks, and local infiltration analgesia. Single dose neuraxial opioids, continuous epidural analgesia, peripheral regional analgesia, paravertebral, intercostal blocks, and local infiltration analgesia. Opioids: intravenous patient-controlled analgesia. Non opioids: NSAIDS, Acetaminophen, gabapentinoids like gabapentin and pregabalin, ketamine, tramadol. Single dose neuraxial opioids, continuous epidural analgesia, peripheral regional analgesia, paravertebral, intercostal blocks, and local infiltration analgesia. Incorrect Options: Page 12 37 Option A - Patient controlled-analgesia (PCA): In this method, a PCA pump is attached to the intravenous drip; when a patient has pain, he presses the PCA button and analgesia is delivered instantly. Morphine is the gold standard drug for intravenous infusion PCA. Option B - Multimodal analgesia: The principle of multimodal analgesia is to use multiple strategies and drug classes to manage patient expectations and control postoperative pain. It allows early ambulation and enteral nutrition and attenuates the perioperative stress response. Option C - Intercostal nerve block: It is a type of regional anaesthesia. It provides the best analgesia to patients with rib fractures. It is also an excellent analgesic option for post-surgical pain after chest and upper abdominal surgery. Solution for Question 6: Option A - C8-T1: This is a case of tendon injury in which the patient presents with complaints of pain and swelling in the hand and forearm after a street fight. A nerve block that will anesthetize the patients' ulnar side of the hand, the little finger, and the ring finger, and all the small muscles of the hand, except those of the thenar eminence and the first and second lumbrical muscles, is the ulnar block which involves the C8-T1 nerve roots. The ulnar nerve block is usually used in operations involving the hand's ulnar side (medial side). Incorrect Options: Option B - C5-C6-C7: C5, C6, and C7 supply the major and minor pectoralis via the lateral and medial pectoral nerves, coracobrachialis, brachialis, and biceps brachii via the musculocutaneous nerve. The musculocutaneous nerve provides sensation to the skin of the lateral forearm. Option C - C6-C7-C8: The C6 portion helps control the wrist extensions and thumb side of the hand and forearm. C7 innervates the tricep, wrist extensor, and back of the arm and middle finger. C8 controls the fifth finger and medial side of the arm and forearm. Option D - C7-C8-T1: C7 innervates the tricep, wrist extensor, and back of the arm and middle finger. C8 controls the fifth finger and medial side of the arm and forearm. T1 supplies the superior chest, arm, and forearm region. Page 13 38 Solution for Question 7: Option A: Pneumothorax The patient, in this case, is complaining of postoperative pain; supraclavicular brachial plexus block is an effective way to control postoperative pain after surgery of the arm from mid humerus to the hand, supraclavicular brachial plexus block consists of inserting the needle in the brachial plexus entering from the supraclavicular fossa, and the most common injury is pneumothorax due to the close proximation of pleura. It is a regional anaesthetic technique used instead of general anaesthesia or for postoperative pain in operations involving the arm. Complications include infection, bleeding, neuropathy and, most importantly, pneumothorax. Option B: Horner syndrome Horner syndrome is a complication of interscalene block. The patient presents with complaints of miosis, ptosis, and anhydrosis. Option C: Hypotension Hypotension is a complication commonly associated with spinal anaesthesia. It is caused by decreased systemic vascular resistance (SVR) and cardiac output. Option D: Systemic toxicity of local anesthetic It is a complication associated with bier's block, a form of regional anaesthesia. Bier's block is given by giving anaesthetic into the venous system while applying the tourniquet to prevent the systemic distribution of anaesthetic. Solution for Question 8: Correct Option A - Speeds the onset: The pH of a commercial preparation of local anesthetic ranges from 3.9 to 6.5. The pKa of local anesthetics used clinically is near eight, so only a tiny fraction of local anesthetics exist in the lipid-soluble form. Alkalization increases the percentage of local anesthetic existing in the lipid-soluble form(uncharged) that is available to diffuse across the lipid-soluble barriers (Nerve sheath). Adding sodium bicarbonate will speed the onset of peripheral nerve and epidural block by 3 to 5 minutes. Incorrect Options: Option B - Diminish the depth of the blockade: It enhances the depth of sensory and motor blockades. It increases the spread of epidural blockade. Option C - Decreases systemic toxicity: Local anesthetics are generally safe when limited to the site of therapy. If local anesthetic reaches the systemic circulation, it causes toxicity. Page 14 39 Option D - Decreases the availability of the lipid-soluble form of local anesthetic.: It increases the availability of lipid-soluble forms of local anesthetic. Alkalization increases the percentage of local anesthetic existing in the lipid-soluble form(uncharged) that is available to diffuse across the lipid-soluble barriers (Nerve sheath). Solution for Question 9: Correct Option C - Aδ: These are small, myelinated fibers that transmit fast pain signals and temperature sensations. They can be tested relatively early after a subarachnoid injection. Incorrect Options: Option A - C fibre: C fibres have low conduction velocity. There are unmyelinated fibres that are small in diameter. Option B - Dorsal root ganglia: Dorsal root ganglia contain cell bodies with sensory nerves that carry sensory information to the spinal cord. The dorsal root ganglia is a nodular structure located in the posterior root of spinal nerves. Option D - Aα: Aα are primary receptors of the Golgi tendon organ and muscle spindles. They include type la and lb sensory receptors and are large myelinated fibres. Solution for Question 10: Correct Option A - 7 mg/kg Body weight: Lignocaine belongs to the amino amide group. It is a short-acting local anesthetic. The safe dose of lignocaine with epinephrine is 7mg/kg body weight. The safe dosage without epinephrine is 4mg/kg body weight. Incorrect Options: Option B - 4.5 mg/kg Body weight: A safe dosage of lignocaine without epinephrine is about 4mg/kg body weight. 4.5mg/kg is a significantly lower dosage with epinephrine. Option C - 2 mg/ kg Body weight: It is the approximate dosage of bupivacaine without epinephrine. It is the approximate dosage of levobupivacaine with epinephrine. Page 15 40 Option D - 3 mg/kg Body weight: It is a safe dosage of levobupivacaine and ropivacaine. This value is less for lignocaine. Solution for Question 11: Correct Option C - Lignocaine: The above-given sign and symptoms, which include nausea, vomiting, drowsiness, slurred speech, tachycardia, and tachypneic with a jerky movement, indicates the diagnosis of Methemoglobinemia. Methemoglobinemia is a rare but potentially life-threatening complication. It occurs due to the administration of certain drugs like Prilocaine, Benzocaine, and Lidocaine (Lignocaine) when administered with Benzocaine, which causes the oxidation of hemoglobin to methemoglobin. Lignocaine is one of those drugs which causes methemoglobinemia. It can occur in injected and topical forms. It can be fatal too. Incorrect Options: Option A - Articaine: It is a local amide anesthetic. Its predominant adverse effect is limb weakness. Option B - Mepivacaine: It is a local anesthetic of the amide type. It causes abdominal pain and weakness of muscles. Option D - Bupivacaine: It belongs to the amide group of local anesthetics. It does not cause Methemoglobinemia. Solution for Question 12: Correct Option B - Systemic toxicity to drugs administered : Epidural anesthesia involves the injection of local anesthetics into the epidural space to provide pain relief during labor. In this scenario, the patient's complaint of lip numbness and apprehension immediately following the epidural injection suggests signs of systemic toxicity to the administered drug (lidocaine). Systemic toxicity can occur if the local anesthetic is inadvertently injected into a blood vessel, leading to rapid absorption into the bloodstream. Initial symptoms of local anesthetic systemic toxicity (LAST) can include circumoral numbness, metallic taste, agitation, tinnitus, hallucinations, GTCS, and apprehension. Page 16 41 Recognizing and managing systemic toxicity is crucial to prevent severe complications, such as seizures and cardiovascular collapse. Incorrect Options: Option A - Allergy to the drug administered: Allergic reactions to local anesthetics are rare. The rapid onset of symptoms is more indicative of systemic toxicity. Option C - Vasovagal Shock: Vasovagal reactions are characterized by bradycardia and hypotension. The symptoms described are not typical of vasovagal shock. Option D - Facial paralysis: The symptoms described are not consistent with facial paralysis but are more suggestive of systemic toxicity to the local anesthetic. Solution for Question 13: Correct Option B - Endotracheal > Intercostal block > Lumbar epidural > Subcutaneous: When it comes to anaesthesia, the absorption of drugs is maximum via the endotracheal; inhalation anaesthesia can only be given through the trachea. The rate of systemic absorption of local anaesthetics is most significant with intercostal nerve blocks followed by caudal, lumbar epidural, brachial plexus block, and then femoral and sciatic nerve blocks. Incorrect Options: Option A - Endotracheal >Lumbar epidural > Intercostal block > Subcutaneous: Intercostal nerve blocks work more efficiently than lumbar epidural. In the Intercostal nerve block, the local anaesthetic agent reaches the circulation within 8-9 minutes. Option C - Subcutaneous> Intercostal block > Lumbar epidural >Endotracheal : Subcutaneous sites provide the least absorption to the local anaesthetic agents. Subcutaneous sites are best for local anaesthesia when a laceration or wound on the skin is stitched or managed. Option D - Lumbar epidural > Intercostal block >Endotracheal > Subcutaneous: The intercostal block is more effective than the lumbar epidural. It provides excellent analgesia, especially in rib fractures or trauma to any thoracic site. Solution for Question 14: Correct Option C - Ratio of Lignocaine to Prilocaine is 1:1: EMLA cream (Eutectic Mixture of Local Anesthetics) contains two active ingredients: lidocaine and prilocaine. Page 17 42 The cream is formulated with a 1:1 ratio of lidocaine to prilocaine. This means that both lidocaine and prilocaine are present in equal proportions, each constituting 2.5% of the cream. The equal ratio is important for achieving a balanced combination of the two local anesthetics, providing effective anesthesia for the intended procedures. Lidocaine and prilocaine are both amide-type local anesthetics that work by blocking sodium channels in nerve cell membranes, thereby preventing the generation and conduction of nerve impulses. Incorrect Options: Option A - It is not a eutectic mixture of local anaesthetic: EMLA cream is a eutectic mixture of local anaesthetics. It contains two active substances, lidocaine and prilocaine. Option B - Ratio of Lignocaine to Prilocaine is 8:5: EMLA cream, which consists of a 1:1 Mixture of 2.5 % Lidocaine and 2.5% prilocaine. The requirement to make EMLA is 5% concentration each. Option D - Mucous membrane: EMLA cream is primarily designed for use on intact skin and is commonly applied before procedures such as venipuncture and minor skin surgeries to reduce pain and discomfort. It is not typically used on mucous membranes. Solution for Question 15: Correct Option C - Increase specific gravity: The rationale for adding dextrose to Bupivacaine is to increase specific gravity. Baricity is defined as the ratio of the density of the local anaesthetic to the density of CSF. The significance of baricity is actually the ability to influence the distribution of local anaesthetic spread based on gravity. Adding dextrose makes local anaesthetic hyperbaric and prevents uncontrolled ascending of local anaesthetics because of the more predictable spread and less interpatient variability. The local anaesthetic solutions are made hyperbaric by the addition of glucose or hypobaric by the addition of sterile water. A hyperbaric solution of local anaesthetic is denser (heavier) than CSF, whereas a hypobaric solution is less dense (lighter) than CSF. Hyperbaric solutions tend to move to the most dependent area of the spine. With the patient in a head-down position, a hyperbaric solution spreads cephalad, and a hypobaric anaesthetic solution moves caudally. A head-up position causes a hyperbaric solution to settle caudally and a hypobaric solution to ascend cephalad. An isobaric solution tends to remain at the level of injection. Incorrect Options: Option A - Increase the duration of action: Page 18 43 By adding dextrose, make local anaesthetic hyperbaric and prevent uncontrolled ascending of local anaesthetics. It will not increase the duration of action. Option B - Reduce plasma levels of a local anaesthetic to prevent toxicity: Adding 8% dextrose in Bupivacaine 0.5% will increase the specific gravity of the solution and make it hyperbaric. It will not reduce the plasma level of the local anaesthetic. Option D - Make the drug Hypobaric: The local anaesthetic solutions are made hyperbaric by the addition of glucose or hypobaric by the addition of sterile water. Adding 8% dextrose in Bupivacaine 0.5% will make the solution hyperbaric Solution for Question 16: Correct Option A - Local Anesthesia: In the above case, the signs and symptoms, such as substernal chest pain, which radiates to the left arm in a hypertensive and diabetic patient with ST-elevation and raised troponin level, are suggestive of ST-elevation myocardial infarction. As the duration of STEMI is less than 12 hours, the best non-surgical intervention for reperfusion is a percutaneous coronary intervention which is performed under Local anaesthesia. For patients with STEMI, immediate coronary angiography with PCI is recommended (primary PCI). Percutaneous Coronary Intervention and other peripheral angiographic techniques usually do not require general anaesthesia. A local anaesthetic should be injected into the skin where the catheter will be inserted. Incorrect Options: Option B - Caudal Anesthesia: Anesthesia is produced by injecting a local anesthetic into the caudal canal, the sacral portion of the spinal canal. Caudal anesthesia provides anesthesia and analgesia for pain relief below the umbilicus. It may be the sole anesthetic or combined with general anesthesia It is also known as caudal epidural anesthesia or a caudal block. Option C - General Anesthesia: General anesthesia (GA) is the state produced when a patient receives medications for amnesia, analgesia, muscle relaxation, and sedation. An anesthetized patient can be thought of as being in a controlled reversible state of unconsciousness. General anesthesia depresses the central nervous system to a sufficient degree to permit the performance of surgery and other noxious or unpleasant procedures. Option D - Epidural Anesthesia: Page 19 44 Epidural anesthesia is a regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia or pain relief, rather than anesthesia, which leads to total loss of feeling. Epidural blocks the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body. During childbirth, epidural injections are commonly used to provide pain relief (analgesia). Solution for Question 17: The signs and symptoms of the patient are severe and prolonged. The pain started after RTA that occurred one month back. These signs point towards complex regional pain syndrome. Stellate ganglion block is preferred in these patients to relieve pain symptoms. Sympathetic fibres from the head, neck, heart, and upper extremities arise from the 1st thoracic segment and ascend in the sympathetic chain to synapse in the inferior, middle, and superior cervical ganglion. The formation of the stellate ganglion is done by the fusion of the first thoracic and inferior cervical ganglion. It receives input from the paravertebral sympathetic chain and provides sympathetic efferent to the upper extremities, head, neck, and heart. The infiltration of local anaesthetic has been used to treat various disorders, but it is primarily performed in the setting of reflex sympathetic dystrophy. It may also be used in vasospastic disorders of the upper extremity. Relations: It is anterior to the transverse process, medial to the scalene muscles, and lateral to the trachea, thyroid, esophagus, internal jugular vein, and carotid artery. An abnormal connection between the sensory and sympathetic nervous systems can lead to sympathetic-mediated pain It is anterior to the transverse process, medial to the scalene muscles, and lateral to the trachea, thyroid, esophagus, internal jugular vein, and carotid artery. An abnormal connection between the sensory and sympathetic nervous systems can lead to sympathetic-mediated pain Approaches Paratracheal (most commonly used) Oblique Posterior Paratracheal (most commonly used) Oblique Posterior Techniques: The therapeutic effects of a sympathetic block may result in the interruption of this neuronal connection. Many techniques have been described to inhibit the stellate ganglion, which may account for the efficacy and variability in response. Historically, stellate ganglion inhibition was performed blindly by the palpation of the prominent anterior tubercle of the transverse process of C6 (Chassaignac's tubercle). Still, this technique was associated with a significant risk of injury to the surrounding vascular and soft tissue structures. Fluoroscopic-guided stellate ganglion blocks improve the delineation of bony anatomy but not soft tissue. Image-guided stellate ganglion blocks by computed tomography (CT) and magnetic resonance imaging offer better visualization but are neither cost nor time efficient. Furthermore, CT exposes the patient and the provider to increased radiation. An Page 20 45 ultrasound-guided blockade of the stellate ganglion has gained popularity, which offers precise anatomical targeting while minimizing unintentional puncture of vital structures and reducing local anaesthetic volume. This method was initially described by placing the needle in the region of the transverse process of C6. It was later refined with needle placement at C6 beneath the prevertebral fascia over the longus Colli muscle. The therapeutic effects of a sympathetic block may result in the interruption of this neuronal connection. Many techniques have been described to inhibit the stellate ganglion, which may account for the efficacy and variability in response. Historically, stellate ganglion inhibition was performed blindly by the palpation of the prominent anterior tubercle of the transverse process of C6 (Chassaignac's tubercle). Still, this technique was associated with a significant risk of injury to the surrounding vascular and soft tissue structures. Fluoroscopic-guided stellate ganglion blocks improve the delineation of bony anatomy but not soft tissue. Image-guided stellate ganglion blocks by computed tomography (CT) and magnetic resonance imaging offer better visualization but are neither cost nor time efficient. Furthermore, CT exposes the patient and the provider to increased radiation. An ultrasound-guided blockade of the stellate ganglion has gained popularity, which offers precise anatomical targeting while minimizing unintentional puncture of vital structures and reducing local anaesthetic volume. This method was initially described by placing the needle in the region of the transverse process of C6. It was later refined with needle placement at C6 beneath the prevertebral fascia over the longus Colli muscle. Signs of successful stellate ganglion block An increase in skin temperature of the ipsilateral arm and onset of Horner's syndrome (ipsilateral ptosis, meiosis, anhidrosis of the neck and face, exophthalmos, nasal congestion) shows the correct placement of the needle. These are side effects of the block rather than complications. Conjunctival congestion Ipsilateral nasal stuffiness Tympanic membrane congestion Flushing An increase in skin temperature of the ipsilateral arm and onset of Horner's syndrome (ipsilateral ptosis, meiosis, anhidrosis of the neck and face, exophthalmos, nasal congestion) shows the correct placement of the needle. These are side effects of the block rather than complications. Conjunctival congestion Ipsilateral nasal stuffiness Tympanic membrane congestion Flushing Complications Intravascular and subarachnoid/epidural injection of local anaesthetic Hematoma Pneumothorax(highest incidence in posterior approach) Brachial plexus block Hoarseness of voice due to recurrent laryngeal nerve block Oesophageal puncture leads to osteomyelitis or mediastinitis (if left-sided approach): Intravascular and subarachnoid/epidural injection of local anaesthetic Hematoma Pneumothorax(highest incidence in posterior approach) Brachial plexus block Hoarseness of voice due to recurrent laryngeal nerve block Oesophageal puncture leads to osteomyelitis or mediastinitis (if left-sided approach): Relations: Page 21 46 It is anterior to the transverse process, medial to the scalene muscles, and lateral to the trachea, thyroid, esophagus, internal jugular vein, and carotid artery. An abnormal connection between the sensory and sympathetic nervous systems can lead to sympathetic-mediated pain Approaches Paratracheal (most commonly used) Oblique Posterior Paratracheal (most commonly used) Techniques: The therapeutic effects of a sympathetic block may result in the interruption of this neuronal connection. Many techniques have been described to inhibit the stellate ganglion, which may account for the efficacy and variability in response. Historically, stellate ganglion inhibition was performed blindly by the palpation of the prominent anterior tubercle of the transverse process of C6 (Chassaignac's tubercle). Still, this technique was associated with a significant risk of injury to the surrounding vascular and soft tissue structures. Fluoroscopic-guided stellate ganglion blocks improve the delineation of bony anatomy but not soft tissue. Image-guided stellate ganglion blocks by computed tomography (CT) and magnetic resonance imaging offer better visualization but are neither cost nor time efficient. Furthermore, CT exposes the patient and the provider to increased radiation. An ultrasound-guided blockade of the stellate ganglion has gained popularity, which offers precise anatomical targeting while minimizing unintentional puncture of vital structures and reducing local anaesthetic volume. This method was initially described by placing the needle in the region of the transverse process of C6. It was later refined with needle placement at C6 beneath the prevertebral fascia over the longus Colli muscle. Signs of successful stellate ganglion block An increase in skin temperature of the ipsilateral arm and onset of Horner's syndrome (ipsilateral ptosis, meiosis, anhidrosis of the neck and face, exophthalmos, nasal congestion) shows the correct placement of the needle. These are side effects of the block rather than complications. Conjunctival congestion Ipsilateral nasal stuffiness Tympanic membrane congestion Flushing An increase in skin temperature of the ipsilateral arm and onset of Horner's syndrome (ipsilateral ptosis , meiosis, anhidrosis of the neck and face, exophthalmos, nasal congestion) shows the correct placem ent of the needle. These are side effects of the block rather than complications. Complications Intravascular and subarachnoid/epidural injection of local anaesthetic Hematoma Pneumothorax(highest incidence in posterior approach) Page 22 47 Brachial plexus block Hoarseness of voice due to recurrent laryngeal nerve block Oesophageal puncture le

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