lOMoAR cPSD| 33812165

ANAESTHESIA
MoPH EXAM
PRACTICE
-MODULE-
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TOPI C 1: LOCALANESTHETI C ANAESTHESI A 1

• Remember that w hile most local anaest het ics cause

TOPI C 1: LOCAL ANESTHETI C
vasdilatation,
Cocaine is one of t he rare examples of local
1. True about EMLA:
anaesthetic which causes vasoconstriction’
A. Can be used for intubation
• Pocaine, Chlorprocaine and Lidocaine all cause varodilation.Q
B. Mixture of local anesthesia
C. Faster acting
6. Longest acting L.A
D. Used in children
A. Bupivacaine
B& D
B. Tetracaine
C. Xylocaine
• EMLA ( Eutectic mixture of 2.5% Lidocaine base and 2.5% . D. Procaine
Prilocaine base) is a topial anaesthetic B
formulation, widely used for cut aneous analgesia
through intact skin.
7. Nerve Fibre affected by local anesthesia first
• The preparation should be applied under an occlusive
A. Type A
bandage for 45-60 minutes to obtain
B. TypeB
effective cutaneous anaesthesia.
C. Type C
• Uses :
D. Type
to decrease pain a/ w percutaneous insertion of I : V. needles
C
and cannulas.
- Skin grafting procedures.
- in neonates or in needle phobics. Susceptibility Most Intermediate Least
- Newborn circumcision. to susceptible susceptible

Hypoxia B A C
2. Which of the following is not an amide:
A. Lidocaine Pressure A B C
B. Procaine
Local C B A
C. Prilocaine Anesthetics
D. Etidocaine
B
8. Shortest acting local anaesthetic agent is:
A. Procaine
Amide linked Local anaesthetics B. Leidocaine
Lidocaine C. Tetracaine
Bupivacaine D. Bupivacaine
Dibucaine A
Prilocaine
Ropivacaine
Procaine
Ester linked local anaesthetics Durat ion of act ion of v arious anaest het ic agent s in
Cocaine descending order are :
Procaine
Dibu cain e ( Cin ch ocain e) > Tet racaine ( am et hocain e) >
Chlorprocaine
Bupivacaine > Lidocaine > Procaine
Tet racaine
Amongst the choices provided procaine is the shortest acting.
Benzocaine
Other commonly asked questions on local anaesthesea :
3. Which one of the follow ing local anesthetics belongs
to the ester group?
A. Procaine

B. Bupivacaine • Safest LA agent – Prilocaine

C. Lignocaine • Longest acting LA – Dibucaine ( Cinchocaine)
D. Mepivacaine • Shortest acting LA – Chlorprocaine
A • Best L.A. for Regional block – Bupivacaine
• Only naturally occurring LA-Cocaine
5. . W hich of the follow ing local anaesthet ics • Only LA agent which causes vasoconstriction – Cocaine
causes vasoconstriction: (Rest are vasodilators)
A. Procaine
B. Lidocaine 9. All of the follow ing are example of amide linked local
C. Cocaine anaesthetics except:
D. Chlorprocaine A. Lidocaine
C B. Procaine
C. Bupivacaine
Cocaine
D. Mepivacaine
B
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TOPI C 1: LOCALANESTHETI C ANAESTHESI A 2

- Restoration of haemodynamics with I VF & cardiac

12. . About lidocatne, all are true except:
massage if required.
A. LA effect
- Prevention of metabolic acidosis with sodium bicarbonate.
B. Cardiac arrhythmia
- Prevention or early treatment of seizure activity
C. Ester
with Benzodiazepines.
D. Acts on mucous membrances
- Inotropic support with Atropine, Epinephrine, Dopamine
C
& Calcium chloride.
Defibrillation, Antiarrythmic agents like Amiodarone.

• Lidocaine is AMI DE linked LA

16. . True about local anaesthetic agents
good for both surface application and injections.
A. Duration depends on protein binding
• Lidocaine has little effect on contractility and conductivity,
B. Potency depends upon lipid solubility
it abbreviates ERP, and is used as ANTI- ARRHYTHMI C.
C. LA with low PK is more active
Overdose of lidocaine can cause-cardiac arrhythmias, -
D. Higher dose produces more block
Decrased BP, convulsion, resp.arrest, coma etc.
E. Signal transduction blockade
ALL
13. . True statements about local anaesthesia:
A. I t inhibits the generation of action potential.
• Local anaesthetics are chemical compounds which are capable
B. Un myelinat ed t h in f iber are most suscept ible t h an
of reversibly inhibit ing the propagation of impulses in
myelinated large fibers.
nerve cells.
C. Toxicity is reduced by addition of vasoconstrictor.
• Three major factors determine the conduction-blocking profile
D. Blocks all modalities of sensation at the same time
of a LA in an isolated nerve preparation :
A
Lipid solubility, protein binding & PK.

LA agents which are highly lipid-soluble are able to penetrate the

• Local anesthesia (LA) produce conduction blockade of neural
neuronal membrane & gain access to their site of action
impulses by preventing passage of sodium ions through ion
more readily than less lipid-soluble agents & is reflected
selective sodium channels in nerve membranes thus inhibiting
biologically in their increased potency.
generation of Action potential. I t do not alter the resting t
Duration of action of LA appear to be influenced primarily by their
ransmembrane potential or threshold potential.
protein-binding capacity, agents with the longest duration of
• Myelin increases conduction velocity and makes the nerve
action ( Bupivacaine & Ropivacaine) are highly protein
membrane more susceptible to LA.
bound.
• Large myelinated fibers are more sensitive to LA than small
unmyelinated f ibers.
• LA with PK closer to physiological PH will have more
• Preganglionic type ‘B’ fibers are more readily blocked by LA
rapid onset than those with higher PK.
than any fiber.
• Onset of conduction block by LA depends on the dose or
• In practice, the sequence of nerve block by LA are :
concentration of LA.
Autonomic -> Sensony -» Motor
• The physiological changes during laryngoscopy & intubation are
• Addition of vasoconstrictors like adrenaline to LA
:
- Produces : decreased absorption and reduces toxicity
CVS :
- Prolongs analgesic activity.
Hypertension, Tachycardia & dysrhythemias & bradycardia in
children.
14. . Local anaesthesia acts by
Respiratory :
A. Na+ channel inhibition
I n cr eased air w ay r eact iv i t y & lar yn gospasm &
B. Ca+ channel inhibition
bronchospasm.
C. Mg* 4 channel inhibition
CNS : Stimulates CNS activity with Increased in EEG activity,
D. K+ channel inhibition
CMR (cerebral metabolic rate), cerebral blood flow , & thus
A
I CP & I OP.
Abdomen : I ncreased in intraabdominal pressure with
increased risk of aspiration in patients with full stomach.
Local anaesthetic drugs exert their effect by binding to
the internal mouth of the sodium channel.
17. . Short acting
L.A:
15. . Drugs used in case of local anesthetic toxicity:
A. Procaine
A. Antiarrhythmic
B. Lignocaine
B. IV fluids
C. Bupivacaine
C. Anticonvulsant
D. Tetracaine
D. O2
A
A

Emmergency treatment of local anaesthetic toxicities are:

Procaine, is a short acting local anaesthetic duration of nerve block
- Facemask oxygenation.
is 30-60 minutes
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TOPI C 2: KETAMI NE ANAESTHESI A 3

Ester linked local aneasthetics produce allergic reaction because

18. . True about local anaesthetic:
A. Cocaine acts by decreasing norepinephrine they are first metabolized to PABA derivative. These
metabolites are responsible for the allergic reaction caused by
B. Act by decreasing sodium entry into the cell
ester linked local anaesthetics.
C. Lignocaine is a amide
Out of the given options only Benzocaines is an ester
D. Dibucaine is drug of choice for epidural anaesthesia
linked local anaesthetic,
B& C

22. . L.A. causing Methaemoglobinemia

A. Procaine
1 9 . Or der of sensit ivit y of ner ve f ibres t o Loca l
B. Prilocaine
anaesthetic in decreasing order:
A. Pain ( C and A-delta), Preganglionic sympathetic B., motor C. Bupivacaine
B. Preganglionic sympathetic B., Pain (C and A- delta), sensory, D. Cocaine
motor B
C. Pain ( C and A- delt a) , sensory, mot or, Preganglionic
sympathetic B
D. Preganglionic sympathetic B. sensory, motor, Pain (C andA- • Prilocaine is an amide linked local anaesthetic.
delta) • Methamoglobinemia may be seen sometimes with use of
B prilocaine.
• One of the degrading products of prilocaine has potential
of causing methamoglobirumia Congenital or acquired
methamoglobinumia are thus contraindications to the use of
Prilocaine
Fiber Sensory Modality Diamete Condu Local Myelinat
Type Classifi Served r (mm) ction Anestheti ion
cation {mis) c TOPI C 2: KETAMI NE
Sensitivit
y
23. . Which of the following increases intracranial tension
Aa Motor 12-20 70-120 + Yes
A. Thiopentone
Aa Type la Proprio 12-20 70-120 ++ Yes
ception B. Ketamine
Aa Typelb Proprio 12-30 70-120 ++ Yes C. Halothane
ception D. Propofol
AP Type II Touch 5-12 30-70 ++ Yes B
pressur
e
Proprio
ception 24. . Which of the follow ing causes hallucination ;
Ay Motor 3-6 15-30 ++ Yes A. Ether
(muscle
spindle) B. Halothane,
A5 Type-III Pain 2-5 12-30 +++ Yes C. Ketamine
Cold D. Thiopentone
tempera
C
ture
Touch
B Pregang <3 3-14 ++++ Some
lionic 25. . Best anaesthesia for status Asthmaticus is
autono A. Thiopentone
mic
fibers B. Ether
C Type IV Pain 0.4-1-2 05-2 ++++ No C. Ketamine
Dorsal Warm D. N2O
root and C
cold
tempera
ture Ketamine
Touch
• Ketamine causes Sympathetic stimulation which leads to
C Postgan 0.3-1.3 07-2.3 ++++ No
Sympat glionic
Bronchodilatation so it is the anaesthetic of choice for
hetic sympat Status Asthmaticus.
hetic • I t is more potent Bronchodilator than Halothane
fibers
• Muscle Relaxant of Choice in Asthma —Pancuronium
• Muscle Relaxant to be avoided in Asthma
21. . Which of the following local anesthetic is most • Metacurine & Succinyl choline ( d/ t secretion of histamine)
likely to produce an allergic reaction
A. Prilocaine 26. Anaesthetic agent causing raised intracranical tension
B. Ropivacaine is:
C. Etidocaine A. Etoruidal
D. Benzocaine
D
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TOPI C 2: KETAMI NE ANAESTHESI A 4

• Ketamine is used as anaesthetic where maintenance

B. Ketamine
of blood pressure is important e.g. in states of shock
C. Ether
D. Nitrous Oxide
Ketamine produces profound analgesia
B

Ketamine
• Ketamine is an analogue of phencyclidine and therefore it
causes hallucinations.
• Ketamine.
• I t causes Dissociative Anaesthesia * .

It causes sympathetic stimulation which leads to

• Cardiac stimulation —increase O2 demand*
• Bronchodilation —
• it is anesthetic of choice for Bronchial Asthma
• Increase all pressure
• B.P.,I.C.T. ,I .O.P.
• I t causes muscular rigidity *
• I t increases salivation so Atropine is always given withit Ketamine
*. • Ketamine causes an increase in all pressure viz
intracranial pressure
Intraocular pressure
27. . An unconscious pt. of head injury comes in casualty.
Blood pressure
Examination show s raised intracranial pressure.
I t does not cause muscle Relaxation
Which anesthetic agent is contra- indicated:
Ketamine induces dissociative anaesthesia : profound
A. Propofol
analgesia , immobility, amnesia with light sleep and felling
B. Ketamine
of dissociation Q from ones own body and the surrounding.
C. Etomidate
D. Thiopentone sodium
I t forms the answer to a set of questions. A quick revision
B therefore :
• Anaeshesia of choice in shock/ hypotension : Ketamine
• Anesthetic associat ed w ith increase in muscle tone :
Ketamine ketamine
• Ketamine causes increase in all pressure of body fluids - • Anaesthetic which does not abolish reflexes : Ketamine
• Increased I CT • Profound analgesia is seen with : Ketamine
• Increased I OT • Anaesthetic which increases cardiac oxygen demand :
• Increased B.P. Ketamine
• Therefore it is not used in raised I CT and I OT as it may • Anaesthetic of choice in Bronchial Asthma : Ketamine
increase the pressure to morbid levels. • Anaesthetic which is associated with emergence delerium
• Ket am ine, li ke Ph encyclidine, is prim arily a non- and hallucinations : ketamine
competitive antagonist of the NMDA receptor ,which
opens in response to binding of the neurotransmitter glu Anaesthet ic causing increased CT Anaesthet ic which increase
t am at e. Th is N M DA r ecept or m edia t es t he I OT
analgesic ( reduction of pain ) effects of ketamine at low • Ketamine • ketamine
doses • Halothane • Nitrous oxide
• Ketamine causes bronchodilation • Scoline
• I t is primarily used for the induction and maintenance of general • Cyclopropane
anesthesia, usually in combination with some sedative drug. Anaest het ics causing decreased I CT Anaest het ic w hich
decreased IOT
• Other uses include sedation in intensive care, analgesia • Theopentone • Morphine
• Droperidol • Thiopentone
( particularly in emergency medicine), and treatment of
• Althesin • Halothane
bronchospasm.
• Ketamine
29. . Dissociative anesthesia is
• The injection of a therapeutic dose of Ketamine produces
A. Ketamine
dissociative anaesthesia
B. Halothane
• Ket amine is a phenycyclidine analogue, it produces
C. SCH
Hallucinations
D. d-TC
A
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TOPI C 2: KETAMI NE ANAESTHESI A 5

maintained i.e. - Systemic vascular resistance should be

30. . Maximum analgesic action is seen with:
increased pulmonary vascular resistance should be
A. Catecholamine
decreased.
B. Propofol
C. Ketamine
• This will help to reduce t he shunt in cyanot ic heart
D. Thiopentone
diseases.
C
• Therefore the goal of anaesthetic management in patients
with cyanotic heart disease is to maintain
intravascular volume or systemic vascular resistance.
Ketamine
Ketamine is a rapidly acting parenteral anaesthetic, causing
• Anaesthetic drugs and procedures w hich increase
Sedation and Profound analgesia besides other features.
Analgesia is a marked feature and extends int o the systemic vascular resistance and decrease pulmonary
postoperative period. vascular resistance should be preferred.

32. . Which drug of anaesthetics causes hallucination: Ketamine (intramuscular or intravenous) is commonly used
A. Ketamine as an induction agent in cyanotic heart disease because it
B. Trilene maintains or increases systemic vascular resistance and it does
C. Halothane not appear to increase pulmonary vascular resistance (PVR) in
D. Trichloroethylene children.
A So the use of ketamine will decreased right to left shunting.

“ Dreaming, Hallucinat ions and delerium are seen w it h • Halothane’s safety in patients with cyanotic heart disease
ketamine” - and good cardiac reserve is well established
• Patients with milder degrees of Right to left shunting can
37. . With regard to Ketamine, all of the following are also tolerate inhalational induction with halothane
true except - because Halothane tends to maintain systemic vascular
A. I t is a direct myocardial depressant resistance (systemic arterial vasodilation is minimal
B. Emergence phenomena are more likely if anticholinergic with halothane).
premedication is used • But Remember, that halothane induction is not used in very
C. I t may induce cardiac dysarrythmias in patients receiving
young patients (because it is pungent and it is slow acting).
tricyclic antidepressants
• Halothane is also not preferred for patients with low CO.
D. Has no effect on intracranial pressure
D
Important facts which should always be taken care of while
anaesthetizing a patient with right to left shunt.
• The right to left shunting tends to slow the uptake of
38. . A 5 year old child is suffering from cyanotic heart
inhalational anaesthetics.
disease. He is planned for corrective surgery. The
• I n contrast it may accelarate the onset of intravenous
induction agent of the choice w ould by -
A. Thiopentone agent s.
B. Ketamine Nitrous oxide is usually used with inhalational induction (does
C. Halothane not increase PVR)
D. Midazolam
B 41. . Which of the following increases cerebral
oxygen consumption
A. Propofol
• Cyanotic heart disease have predominantly Right to left shunt B. Ketamine
i.e. blood flows directly from right ventricle to left ventricle C. Thiopentone
bypassing the pulmonary circulation. D. Alfentanyl
• This produces cyanosis as the systemic blood coming to B
the right ventricle cannot be oxygenated by the lung.
• Not e t h at in r ight t o left shunt ing , t he f ixed
component is determined by the severity of the right • This has been discussed so many times that ketamine
ventricular obstruction while t he variable component increases cerebral oxygen consumption. I t increases the
depend upon dif ference bet w een syst emic vascular intracranial tension too.
resistance (SVR) and pulmonary vascular resistance (PVR)
• Thiopentone and propofol decrease cerebral oxygen
consumption.
• I f the right ventricular obstruction remains same greater the
Alfentanyl is an opioid and opioids in general reduce cerebral
systemic vascular resistance the lesser the shunt,
oxygen consumpt ion, cerebral blood f low an d
• So in right to left shunts a favourable ratio of systemic
intracranial pressure.
vascular resistance to pulmonary resistance should be
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TOPI C3: SUCCI NYLCHOLI NE ANAESTHESI A 6

TOPI C 3: SUCCI NYLCHOLI NE

44. . Malignant hyperthermia is seen with

A. Gallamine
B. Lignocaine
C. Succinylcholine (Sch)
D. Bupivacaine
C

4 7 . Administ ration of Scoline produces dangerous

• Drug causing malignant hyperthermia hyperkalemia in:
1) Sucinyl choline ( Most common) A. Paraplegia
2) Halothane B. Fracture Femur
3) Lidocaine C. Raise intracranial pressure
4) Mepivacaine D. Acute renal failure
5) Methoxyflurane A
6) Gallamine
7) Ethylene
8) Ethyl chloride
9) Trichlorethylene

45. . Post anaesthetic muscle soreness is caused by

A. Gallamine
B. d-Tubocurarine
C. Suxamethonium
D. Xylocaine
C

• Suxamethonium causes muscle pain -

• This pain is influenced by age, sex and physical fitness. Paraplegia
i) Pain is more common in women • “ Hyperkalemia caused by Scoline is insignificant exceptafter—
ii) More common in middle age than extreme age. >
iii) Less common in muscularly f it • paraplegia
• The longer the interval b/ w injection of barbiturate and • burns &
• t et anus”
suxamethonium the more intense the pain.
• Other adverse effect of Scoline:
1. Malignant Hyperthermia
Prevention of muscle pain caused by suxamethonium
2. Muscle Fasciculations
1) Precurairzation - Nondepolarizing relaxants are given 3
minutes before suxamethonium injection 48. . Hyperkalemia due to Scoline is seen in all except:
2) lignocaine injection before suxamethonium A. Muscular Dystrophy
B. Crush injury
Other adverse effects of Suxamethonium - C. Abdominal Sepsis
1) Hyperkalemia D. Burns
2) Raised intraocular pressure none
3) Malignant hyperpyrexia
4) Dystrophia myotonica
5) CVS - Bradycardia and cardiac arrest None of the above
• Hyperkalemia d/ f Scoline is seen in follow ing
46. Regarding myasthenia, what is true about sensitivity conditions:
to curare and succinylcboline Curare - Succinylcholine: • Trauma
• Burns
A. Decreased Increased
• Muscle disease such as myopathy
B. Decreased Normal
• Motor neuron disease
C. Increased Increased
• Muscular Dystrophy
D. Increased Decreased
• denervation
D • Spinal Cord t ransection
• Tetanus
In myaesthenia gravis the muscles affected by myaesthenia • Congenital cerebral palsy
gravis are hypersensitive to non depolarizing relaxants like • Chronic Arterial insufficiency
curare but they are resistant to succinyl choline and • Severe I ntra Abdominal infection
decamethonium (depolarizing blockers)
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TOPI C3: SUCCI NYLCHOLI NE ANAESTHESI A 7

Suxamethonium –ADVERSE EFFECTS Succinyl choline is short acting muscle relaxant as it is rapidly
• Side effects include fasciculations, muscle pains, acute metabolized by pseudocholinestrase secreted both by liver and
rhabdomyolysis with hyperkalemia, transient ocular plasma.
hypert ension, and changes in cardiac rhyt hm In liver failure , this enzyme is reduced ,so succinylcholine
including bradycardia, cardiac arrest, and ventricular concentration is increase during liver failure and is also
dysrhythmias. maintained for greater periods.
• In children with unrecognized neuromuscular diseases, a single
The duration of paralysis produced by succinylcholine is
injection of suxamethonium can lead to massive release of
increased during liver failure but this does not require
potassium from skeletal muscles with cardiac arrest.
• Suxamethonium does not produce unconsciousness or
Succinylcholine to be contraindicated in liver failure.
anesthesia, and its effects may cause considerable
psychological distress while simultaneously making it Condit ions w here succinyl choline use is contra
impossible for a patient to communicate. indicated due to hyperkalemia caused by succinyl choline are-
• For these reasons, administration of the drug to a (a) ) Tetanus (h) Massive trauma
conscious patient is strongly contraindicated , except (b) ) Stroke (i) Prolonged body immobilization
in necessary emergency situations. (c) Closed head injury (j ) GB. syndrome
(d) Myopathy (k) Spinal cord injury
49. . I n a young patient w ho had extensive soft t issue (e) Burn (L) Paraplegia
and muscle injury, w hich of these muscle relaxants used (f) Acidosis (M) Severe intraabdominal infection
for endot racheal int ubat ion might lead t o cardiac
arrest: 52. . A six- year old boy is scheduled for examination of
A. Atracurium. the eye under anaesthesia. The father informed that
B. Suxamethonium.
for t he past six months t he child is developing
C. Vecuronium.
progressive weakness of both legs. His elder sibling had
died at age of 14 years. Which drug would you
D. Pancuronium
definitely avoid during the anaesthetic management
B
?
A. succinylcholine
B. thiopentone
Hyper kalem ia pr odu ced du e t o su xam et h oniu m is C. nitrous oxide
aggravated in muscular diseases. The hyperkalemia so D. vecuronium
produced causes cardiac arrest. A

Weakness of the legs indicate that the boy is suffering from

myopathy { most probably Duchenes muscular dystrophy).

Succinyl choline use is contra indicted in myopathy due to

increased risk of hyperkalamia.

5 0 . W hich muscle relaxant increases int ra cranial

pressure?
A. Mivacurium
B. Atracurium
C. Suxamethonium
D. Vecuronium
C

Succinylcholine (or Suxamethonium) causes increase in -

(a) Intracranial pressure 53. . A young boy undergoes eye surgery under day case
(b) ) Intraocular pressure anesthesia w ith succinyl choline and propofol and
(c) ) Intragastric pressure after 8 hours he starts walking and develops muscle
pain. What is the likely cause?
51. . The use of succinylcholine is not contraindicated in A. Early mobilization
A. tetanus B. Due to the effects of eye surgery
B. closed head injury C. Succinyl choline
C. cerebral stroke D. Propofol
D. hepatic failure C
D
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TOPI C3: SUCCI NYLCHOLI NE ANAESTHESI A 8

Muscle pain or Myalgia is a common adverse effect of succinyl Phase I block :• results from persistant depolarizatin of
choline muscle end plate.
I t is common in women and young to middle aged adults and • preceded by muscle fasciculation
in those who are ambulant shortly after surgery • pot en t iat ed by isof lu r an e,
The young adult in question has recieved succinylcholine and antichlinesterase, magnesium an lithium.
is now ambulant after surgery. Phase I Iblock: • results from desensitization of receptor
He is classically presenting with myalgia secondary to Ach
to succinyl choline use. • resemble block produced by TC and is
partially reversed by anticholinesterases.
Myalgia ( Muscle Pain after succinyl chnline
• The incidence of muscle pain after administration of succinyl 56. . Muscle pain after anaesthesia is caused by:
choline varies from 0.2 % to 89% A. Vecuronium
B. D tubocurare
I t occurs more frequently in : C. Suxamethonium
• Women / young to middle aged adults D. All
• After minor surgery ( day case) C

I n those who are ambulatory shortly after surgery

( rather than bedridden patients) • Mu scle pain af t er an aest h esia i s cau sed by
• Pain is believed to be secondary to damage produced in muscle SUXAMETHONI UM- pain is influenced by age, sex and
by unsynchronized contraction of adjacent muscle fibres just physical fitness.
prior to the onset of paralysis.
• Myalgia may be prevented ( or attenuated) by a small dose Important side effects of suxamethonium
of non depolarizing neuro muscular block few minutes before - Prolonged Apnea
succinylcholine administration - I ncreased K+
- I ncreased I OP
54. . Agent causing malignant hyperthermia - Muscle pain
A. Succinyl Choline - Malignant hyperpyrexia
B. Dantroline - Dystrophia Myotonica
C. gallamine Bradycardia, cardiac arrest P-K reaction.
D. Ketamine
A 57. . Drugs metabolized by cholinesterase:
A. Succinycholine
B. Mivacurium
Malignant hyperthermia is an autosomal dominant genetic disorder C. Esmolol
of skeletal muscle that occurs in susceptible individuals. I t is D. Remifentanyl
precipitated by drug administeration, particularly: E. Ketamine
1. Succinyl choline A
2. Halothane
3. Fluoranes : sevofluorane, isofluorane etc
4. Amide local analgesics eg lignocaine 58. . True about scoline are following except:
5. Phenothiazines A. Fasciculations
6. Tricyclic antidepressant B. ICT increases
7. Monoamine oxidase inhibitors C. Non Depolarising neuro muscular blocker
D. Short acting muscle relaxant
The drug of choice for t reatment of malignant hyperthermia A& B
is Dantrolene

55. . Fasciculation are known to be caused by: 59 . Myaest henics are resistant to follow ing muscle
A. Suxamethonium relaxant:
B. Vecuronium A. Suxamethonium
C. Pancuronium B. Pancurium
D. Atracumium C. Atracuronium
A D. Vecuronium
A

Suxamethonium • Myasthenic patients are resistant to decamethonium and

Suxamethanium or other depolarizing blockers depolarize muscle suxamethonium.
end plates by opening Na+ channels and initially produce Muscles affected by myasthenia gravis are hypersensitive to
non depolarizing muscle relaxants.
twitching and fasciculations because in the focally
innervat ed mammalian muscle st imulat ion ist ransient.
60. Which of the following is the neuromuscular blocking
Neuro muscular blockage by depolarizing agents can be divided into
agent with the shortest onset of action?
two phases:
A. Mivocurium
B. Vecuronium
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TOPI C3: SUCCI NYLCHOLI NE ANAESTHESI A 9

C. Rapacuronium
D. Succinylcholine
D

* Shortest acting muscle relaxant ( both depolarizing and

non depolarizing) -
• Shortest acting non depolarizing muscle relaxant
Succinylcholine --> Mivacurium

Muscle relaxants Onset (min.) Duration (min.)

Succinyl choline 1-1.5 3-6
Mivacurium 2-4 12-20
Rocuronium 1-2 25-40
Vecuronium 2-4 30-60
Atracurium 2-4 20-35
Cisatracurium 3-6 20-40
Piperacuronium 2-4 50-100
d-Tubocurarine 4-6 30-60 • Su ccin y lch olin e r eleases a m et abolit e —>
Pancuronium 4-6 40-80 Succinvlmonocholine
This met abolit e causes excitat ion of t he cholinergic
Doxacurium 4-8 60-120
receptors in the sinoatrial node, resulting in bradycardia.
61. . All of the following statements are incorrect about • Children are particularly susceptible to succinylcholine
the treatment of prolonged suxamethonium apnoea due induced bradycardia.
to plasma cholinesterase deficiency ( after a single dose • In adults bradycardia is commonly seen when second dose
of suxamethonium) except- of succinylcholine is administered.
A. Reversal with incremental doses of neostigmine Pr event ion a ga inst succinvlchol ine induced

B. Continue anaesthesia and mechanical ven t i lat ion t ill bradvcardia.

recovery “ Intravenous atropine is often given prophylactically in
C. Transfusion of fresh frozen plasma children an d alw ays bef ore a second dose of
D. Plasmapheresis succinychotine”.
B
63. . Phase I I block is seen in
A. Halothane
Suxamethonium is a very short acting muscle relaxant. B. Ether
I t has very rapid onset of action and very short duration of C. D-tubocurare
action D. Suxamethonium
Reason D
Rapid onset of action
---> I t is highly lipid soluble
Short duration of action Suxamethonium
---> I t is rapidly metabolized by pseudocholinesterase • Suxamethonium causes Biphasic Block.
But sometimes suxamethonium intake is associated w ith • With dose more than 500mg.
prolonged apnoea. The reason are - • Phase I block ---> Features of classical depolarization
- Atypical serum cholinesterase block
- Low level of serum cholinesterase • Phase I I block - - - > Result s f rom desensit ization of
- Dehydration and electrolyte imabalance r ecept or t o act y lch olin e an d
resembles competitive block and
An overdose of relaxant drug partially antagonized by anticholinesterase.
Excessive formation of succinylcholine monocholine phase I I
block
Th er e ar e t w o ph ases t o t h e blocki n g ef f ect of
- M a na gem en t of pr olonged a p nea a f t er
suxamethonium
suxamethonium.
Phase 1 block
- Th e best m an agem en t in t h is case i s t o pr ovide
The f irst is due to the prolonged st imulation of the
mechanical ventilation , maint ain anaest hesia and
acetylcholine receptor results first in disorganized muscle
continue monitoring till muscle function returns to normal.
contractions ( fasciculations, considered to be a side effect),
- Transfusion of fresh frozen plasma is beneficial ( I t
as the acetylcholine receptors are stimulated . On st
will provide pseudocholinesterase)
imulation, the acetylcholine receptor becomes a general ion
channel, so there is a high flux of potassium out of the cell,
62. . Bradycardia is common after injection of -
A. Midazolam and of sodium into the cell, resulting in an endplate
potential less than the action potential. So, after the initial
B. Succinyl choline
C. Dopamine f iring, the cell remains refractory.
D. Isoprenaline
B • Phase 1 blockade is potent iated by anticholinesterases
and antagonized by competitive blockers.
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TOPI C 4: SPI NAL ANAESTHESI A ANAESTHESI A 10

Phase 2 block The manifestation of total spinal analgesia are-

• I f the duration of blockade is prolonged however, or if the 1. Marked hypotension
concentration of the blocker is excessive, then phaset w o 2. Apnoea
blockade occurs in w hich t he pharmacological 3. Dilated pupils
characteristic is that of a compet itive inhibition.
Phase 2 blockade is antagonized by anticholinesterases, and Management
potent iated by competitive blockers. Patient should be immediately intubated and 100% O 2
should be given I .V. fluids and vasopressors should be given
Why does Acetylcholine cause Hyperkalemia
• Th e side ef f ect of h yper kalaem ia is becau se t h e 65. . I n high spinal anaesthesia what is seen
acetylcholine receptor is propped open, allowing continued flow A. Hypertension and Bradycardia
of potassium ions into the extracellular fluid. B. Hypertension and Tachycardia
• A t ypica l incr ea se of pot a ssium ion ser um C. Hypotension and Bradycardia
concentration on administration of suxamethonium is 0.5 D. Hypotension and Tachycardia
mmol per litre, whereas the normal range of potassium is C
3.5 to 5 mmol per litre: a significant increase which results
in the other side-effects of ventricular fibrillation due to reduced
to action potential initiation in the heart. Hypotension and Bradycardia
• Phase 1 block potentiated by anticholinesterases and Effect of spinal block on cardiovascular system
antagonized by competitive blockers.
• Phase 2 block antagonized by anticholinesterases and
potentiated by competitive blockers.

Vessels Heart
Drug interactions
1. Potentiation of the neuromuscular blockade caused by the Vasodilation of arterioles, resistance Decrease inotropic Action
aminoglycoside antibiotics , and tetracyclines. vessels and venous capacitance Decrease chronotropic Action
2. . Do n ot pot en t iat e t h e ef f ect s of t h e h alogen at vessels (This causes Hypotension)
Increase effective Refractory period
ed hydrocarbon anesthetics -halothane
Decrease automaticity decrease
3. Lit hium in t her apeut ic concent r at ions used in t he level of catecholamine
t reatment of manic disorders can slow the onset and increase
(This causes Bradycardia)
the duration of action of succinylcholine.

TOPI C 4: SPI NAL ANAESTHESI A

64. A patient was administered epidural anaesthesia with 15

ml of 1 .5% lignocaine with adrenaline for hernia surgery.
He developed hypotension and respiratory depression
within 3 minutes after administration of block. The
commonest cause would be.
A. Allergy to drug administered.
B. Systemic toxicity to drug administered.
C. Patient got vasovagal shock.
D. Drug has entered the sub arachnoid space
D

Sometimes during epidural analgesia, due to inadvertent

suparachnoid injection ( i.e. the injection enters the
subarachnoid space) a condition termed ‘total spinal
analgesia” is produced. I t is produced because large dose
of drug which is used in epidural anaesthesia enters the
subarachnoid space.
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TOPI C 4: SPI NAL ANAESTHESI A ANAESTHESI A 11

66 . Follow ing spinal subarachnoid block a pat ient

develops hypotension. This can be managed by the
follow ing means except.
A. Lowering the head end
B. Administration of 1000 ml of Ringers lacate before the
block
C. Vasopressor drug like methoxamine
D. Use of ionotrope like dopamine
A

For spinal subarchnoid block, the anaesthetic agent is injected

into the subarchnoid space.
The subarchnoid space contains CSF.
I f the head end is lowered , the anaesthetic drug will
move towards the cephalic direction (being heavier than
CSF). This will increase the level of spinal block and may
lead to cardiac & ventilatory failure.
(Sympathetic supply of heart comes from T3 to T4; phrenic
nerve supplying diaphragm arise from C3 to C5)

“ Hyperbaric solution of bupivacaine are injected as a ‘single

shot’ into the cerebrospinal f luid, to produce rapidly an
intense blockade, usually within 5 minutes.
Autonomic sympathetic blockade results in hypotension,
necessitating prior intravenous f luid loading and tit
ration of vasoconstrictor drugs.
I f the hyperbaric solution is allow ed to ascend too
high, severe hypotension and ventilatory failure occur.
This factor limits the use of spinal anaesthesia to surgery
below the segmental level of T10 .”

67. . Centrineuraxial ( spinal and epidural) anaesthesia

is not contraindicated in-
A. Platelets < 80,000
B. Patient on aspirin
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TOPI C 4: SPI NAL ANAESTHESI A ANAESTHESI A 12

C. Patient on oral anticoagulants Caudal anaesthesia may be used for perenial operations.
D. Raised intracranial pressure I t is not indicated in Lower segment caesarian section.
B Further it is associated with potential risk of penetrating
the fetal head in obstetric practice.

Centrineuraxial anesthesia is not associated with increased

risk with most antiplatelet agents (eg. aspirin Q & NSAJDs).
Cont raindications of Centrineuraxial ( Spinal / Epidural)
Anesthesia

69. . A patient undergoing caesarean section following

pr olonged l a bour under suba r a ch noid block
developed carpopedal spasm. Lignocaine was used as
anesthetic agent. The most likely diagnosis is:
A. Amniotic f luid embolism
B. Lignocaine toxicity
C. Hypocalcemia
D. Hypokalemia
C

Du r in g pr olon ged labou r , pain f r om episodic u t erin e

contractions produces an increase in minute ventilation.
Absolute Contraindications
Hyperventilation thus produced results in development of
- Patient’s refusal
- Patient’s inability to maintain stillness during the needle puncture hypocarbia and respiratory alkalosis.
(eg. dementia, psychosis) Resulting acute respiratory alkalosis causes intracellular shift
- Raised intra cranial pressure of K+ , Na+ & PO 4
" and reduces free Ca+ 2 by increasing
(papilledema, cerebral edema, tumors in posterior fossa, t he prot ein bound f ract ion and preci pi tat es
suspected subarachnoid Hemorrhage) hypocalcemia.
- Severe hypovolemia
- Severe stenotic valvular heart disease, the patient may be Respiratory alkalosis secondary to hvperventilation following
unable to compensate for vasodilation because of a fixed prolonged labour may result in :
cardiac output.
- Marked skin sepsis & marked spinal deformity Neurological Symptoms Symptoms
- Marked coagulopathy, blood dyscariasis or full anticoagulant symptoms secondary to secondary to
hypophosphatemia
therapy secondary to hypocalcemia
cerebral Muscle weakness
Paraesthesias
Relative contraindications vasoconstriction Carpopedal
- Un coperative patient (may be performed in conjuction with Dizziness Visual spasm
GA) symptoms Tetany
- Pre existing neurological deficit (eg demyelinating lesions). Syncope Seizure
- All severe & marked diseases in lesser degree i.e. spinal
deformity, sepsis etc. Lignocaine toxity is likely to cause hypercalcemia by
- Pre eclamptic toxaemia - epidural block has been used with releasing Ca into the blood and hence corpopedal
great benefit in this condition, but a platelet count of less
spasm as a manifestation is unlikely.
than 100 xlO9 L”1 usually preclude epidural or subarachnoid
70. Concentration of Lidocaine used in spinal anaesthesia
block. A. 5%
- Mildly impaired coagulation B. 3%
- Patients with platelet < 80000 / ml C. 2%
D. 1%
68. . A Low er Segment Caesarean section ( LSCS) can be A
carried out under all the follow ing techniques of
anaesthesia except:
A. General anaesthesia Lignococine
B. Spinal anaesthesia
5% 4% 0.5%
C. Caudal anaesthesia
D. Combined Spinal Epidural anaesthesia Spinal Topically in Eye Epidural
C Anesthesia Anesthesia
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TOPI C 4: SPI NAL ANAESTHESI A ANAESTHESI A 13

71. . Post Spinal Headache can last for • Severe Hypovolemia

A. upto 10 min • Raised I CT
B. upto 10 hours • Infection at site of injection
C. 7-10 days Severe stenotic valvular Heart disease & fixed cardiac output
D. upto 10 months states
C
75. . Spinal anaesthesea should be injected into the
space between:
A. T12 – L1
Post spinal Headache starts in 1st 3 days and lasts for 1-
B. L1-L2
2 weeks
C. L3 – L4
D. L5 – S1
72 . Best w ay t o prevent hypotension during spinal
C
anesthesia
A. preloading with crystalloids
B. Mephentermine
C. Dopamine The LA is injected in the subarachnoid space between L 2_ 3orL

D. Tredelenbug’s position _ , i.e. below the lower end of spinal cord.

3 4
A • The primary site of action is the nerve root in the cauda equina
rather than the spinal cord.
• The level of anaesthesia depends on volume and speed of
Hypot en sion follow ing spinal an aest hesia is due t o injection, specific gravity of drug solution & posture of the
blockage of sympathetic vasoconstrictor outflow patient.
to blood vessels, venous pooling and decreased return • Duration of spinal anaesthesia depends on drug used and
to heart. Prevention is by preloading with crystalloids. its concentration. e

73. . Post sipnal headache is due to

A. Meningitis • Autonomic pre- ganglionic fibres are more sensitive and
B. Encephaletics somatic motor fibres less sensitve than somatic sensory fibres.
C. CSF leak (Sympathetic block occurs before para-sympathetic and
D. Increased I CT somatic block).
C
76. . Which is the true statement regarding post-
dural anesthetic headache:
A. Blood patch is the f irst line of treatment
‘Headache is due to seepage of CSF and can be minimized
B. Occurs due to low CSF pressrue
by use of smaller bore needle’
C. Increased incidence with early mobilization of patient.
D. Use of small guage needle prevents hea
74. . I n all of the following conditions neuraxial
A
blockade is absolutely contraindicated, except:
A. Patient refusal
B. Coagulopathy
C. Severe hypovolemia 77. . True about epidural anaesthesia in pregnancy:
D. Pre-existing neurological deficits A. Given through subarachnoid space.
D B. Increases cardiac output.
C. Decreases venous return.
D. Venous pooling.
E. Decreased placental circulation
• Neuraxial block is combined name given to spinal, Epidural
C
and Caudal Blocks.
Principal site of action for neuroaxial block is Nerve root
• In epidural anesthesia, the anesthetic drug is injected in
Absolute contra indications are - a potential space within the bony cavity of the spinal canal and
outside the dural sac.
• Patient Refusal
• Bleeding Diathesis
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TOPI C 4: SPI NAL ANAESTHESI A ANAESTHESI A 14

I n spinal anest hesia, only the drug is injected in the DEFI NI TI VE

subarachnoid space. - Full hydration maintenance
- Simple analgesics
• CVS changes that occurs after epidural anaesthesia : - Maintain supine position
Epidural Anesthesia - Continuous drip of Hartman’s solution in extradural space
• Loss of sympathetic vasomotor tone with a catheter
• Vasodilatation Epidural blood patch with 10-20ml of venous blood.
• Peripheral pooling of blood
• Reduced venous return 80. . Trendelenberg position produces decrease in all
• Reduced cardiac output of the following except-
A. Vital capacity
Hypotension B. Functional residual capacity
• I n the absence of hypotension, neither epidurals nor spinal C. Compliance
have any effect on the progress of labor nor do they D. Respiratory rate
affect uterine blood flow . D
Brief episode of hypotension do not appear to affect the
clinical condition of the neonates, the duration seems
more important than the degree.
Hypotension during epidural is usually said to occur if blood Trendelenburg position or head down posit ion causes a
pressure falls 20-30 mm Hg below the preepidural level or cephalad shift in the abdominal viscera and the
systolic pressure drops below 100 Hg. diaphragm.

78. Vasopressor of choice in hypotension produced during

sub- arachroid block:
A. Ephedrine
B. Mephentermine
C. Adrenaline
D. Dopamine
E. Steroids
C& D

79. . Post dural puncture headache, true about

A. Common in elderly
B. Small bore needle prevents it
C. Early ambulation increases incidence
D. Occurs immediately after spinal anaesthesia
E. Blood patch is the f irst line of treatment
B This effects the lung volume in the following way
Functional residual capacity -----> Decreases
Total lung volume -----> Decreases
Postdural puncture headache ( PDPH) may occur after Vital capacity -----> Decreases
deliberate or accidental dural puncture, or even after
Lung compliance -----> Decreases
uncomplicated block.
• Typically it comes on within an hour or two of the Although these changes are usually well tolerated by healthy
anaesthesia & may be delayed for some days & may last for patients, it may cause hypoxemia in obese patients and
weeks or even months. patients with preexisting lung disease.
• Pain usually occurs in the occipital region & a/ w pain & st
iffness in neck.
I t is worsened by sitting up & relived by lying down or by abdominal
compression.

Factors affecting PDPH :

• I ncreasing
- Younger age
- Females> male
• Larger needle
- Dural fibres cut transversely The above ment ioned ch anges also lead t o increased
- Pregnant females ventilation/ perfusion mismatching and atelactasis.
- Multiple punctures There is also increased likelihood of regurgitation.

• Treatment: 81. . Site of action in epidural analgesia

PROPHYLACTI C A. Cortex
- Avoided in pts with h/ o frequent severe headache B. SubstantiaGelatinosa
- Use of smaller sized needle C. Ventral horn
- Whitacre needle or sprotte needle should be used D. Sensory nerve ending
- Prevention of dehydration, B
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TOPI C 5: ANAESTHESI A COMPLI CATI ONS ANAESTHESI A 15

• The epidural space is situated between the dura mater and

the vertebral canal . I t extends from the cranium to the
sacrum and contains loose connective tissue, fat, lymph
vessels, blood vessels and nerves. Drugs can be administered
into the epidural space.
• They diffuse across the dura and the subarachnoid spa
ce a nd b ind t o r ecept or s loca t ed in t he substantia
gelatinosa in the dorsal horn of the spinal cord. They also
exert an effect on the nerve roots outside the dura mater, are
absorbed systemically from the epidural blood vessels an d m 84. . Mendelson syndrome is due to:
ay be dist r ibut ed t h rou gh t hesubarachnoid space in the A. Aspiration pneumonitis
cerebrospinal fluid (CSF). B. Chemical pneumonitis
C. Oesophagitis
D. Oesophageal spasm
Substantia Gelatinosa
A

• Mendelson’ s syndrome is acid aspir ation syndrome.

Aspiration of acid gastric contents cause a chemical trauma
to bronchial and alveolar epithelia i.e. acute exudative
pneumonitis
Mendelson’s syndrome usually occur with material (gastric acid)
at a PH of 2.5 or below , but known to occur with fluid of a
neutral PH as well.

85. . Diffusion hypoxia is seen during:

A. Induction of anaesthesia
B. Recovering anaesthesia
C. Preoperatively
D. Postoperatively
B
TOPI C 5: ANAESTHESI A COMPLI CATI ONS
Diffusion hypoxia is seen during recovering anaesthesia. I t is
8 2 . W hich d oes not ca use br onchospa sm a f t er seen with N2O.
anaesthesia Mechanism
A. Regurgitation After prolonged N O2anaesthesia when discontinued N2O having
B. Aspiration low Solubility rapidly diffuses to alveoli and dilutes alveolar air
C. Postintubation PP of oxygen in alveoli is reduced: Resulting hypoxia is called
D. Halothane DIFFUSION HYPOXIA
D
86. . I ncubator heat is delivered by except:
A. Conduction
Halothane causes dilatation of Bronchi and is preferred in B. Convection
Asthma C. Radiation
Causes of Bronchospam D. Evaporation
The patients lower airways are excessively responsive to the D
following –
1) Surgical stimulation
a) Intubation under light aneasthesia • Incubator heat is delivered by radiation and convection. Some
b) Carinal stimulation by a tube that is too long incubators have humidifiers which will produce an ambient
2) Respiratory infection relative humidity within the canopy of 90% or m or e (
3) Pulmonary edema com par ed w i t h 30 —40 % h u n id i t y w i t h ou t humidifier).
4) ) Sever e r edu ct ion in lu n g volu m e
as in t en sion pneumothorax, Drugs.

8 3 . M ism a t ched blood t r a nsf usion m a nif est s

intraoperatively as:
A. Rise in B. P.
B. Excessive bleeding
C. Dyspnoea
D. Hematuria
B

Mismatched blood transfusion manifests intraoperatively as

EXCESSIVE BLEEDING.
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TOPI C 5: ANAESTHESI A COMPLI CATI ONS ANAESTHESI A 16

• Sodium Nitroprusside can sometimes cause toxicity due to

At such humidity infants evaporative heat loss is very low. Also
its conversion to cyanide and thiocyanate, when its infused
sometimes wall of the incubator is doubled which also helps
for longer duration.
to prevent evaporative loss of heat from infant.
• “ Toxic accumulation of cyanide leading to severe lactic acidosis,
In infant heat loss through conduction is very small as infants
can occur usually if sodium nitroprusside is infused at a rate
are not usually in direct contact with structure of high
greater than 5 microgm/ kg.”
thermal capacity.
• Short-term side-effects of nitroprusside are d/ t excessive
vasodilation with hypotension and its consequences
87. . During intra operative anesthesia mismatched
blood by transfusion is manifested by:
92. . The most common cause of morbidity and mortality
A. Hypotension
in patients undergoing major vascular surgery is:
B. Increase Bleeding
A. Renal complications
C. Bonchospasm
B. Thrombo embolic phenomenon
D. Movement of limbs
C. Coagulopathies
E. Rash
D. Cardiac complications
A & B, C
Ans d

* Mismatched blood t r ansfusion in anaest het ic patient

93. . The most common rhythm disturbance during early
present as :
postoperative period is:
Immediate rapid severe and progressive hypotension.
A. Bradycarida
Tachycardia
B. Ventricular fibrillation
General oozing from wound.
C. Tachycardia
Urticarial rash.
D. Complete heart block
Bronchospasm, raising airway pressures on intermittent positive
Ans c
pressure ventilation. Later jaundice and oliguria in 5-10%
of these patient.
The most common acute post-operative arrhythmias
were junctional ectopic tachycardia
88. . Cause of post- operative hypertension
A. Pre-operative hypertension
B. inadequate analgesia
94. . Most common cause of postoperative renal failure:
A. Decreased renal perfusion
C. Phaeochromocytoma
D. Hypoxaemia B. Toxicity of anesthetic drugs
E. Hypercarbia C. Toxicity of antibiotics
All D. ——
A

89. . True about aspiration pneumonia

A. Affected by volume of aspiration • Most common cause of postoperative renal failure
B. Affected by PH of aspiration fluid is decreased renal perfusion due to hypovolemia.
C. Increased incidence during induction Hypovolemia usually results from inadequate intraoperative
D. Inflammation f luid replacement, continuing fluid sequestration by tissues
E. I nfection { third spacing) or wound drainage or postoperative bleeding.
All
9 5 . W hich of t he f ollow ing does not repr esent a
significant anaesthetic problem in the morbidly obese
• Factors affecting Acid aspiration pneumonia: patient?
- Aspirate volume > 25ml A. Difficulties in endotracheal intubation
- PH of aspirate < 2.5 B. Suboptimal arterial oxygen tension
- Aspiration of partially digested food C. Increased metabolism of volatile agents
• Conscious level of patients ( e.g. alcoholics, drug D. Decreased cardiac output relative to total body mass
abusers, seizures, strokes or general anaesthesia) D
- Mecha nical impediment s ( e. g. nasoga st r ic or
endotracheal tubes)
• Pur e a cid a spir a t ion pr oducing a spir a t ion
pneumonitis or chemical pneumonitis (inflam-mation) &
aspiration of oropharyngeal secretion produces severe
bacterial pneumonitis.

91. . Sodium nitroprusside infusion may result in:

A. Hypertension
B. Pulmonary oedema
C. Cyanide toxicity
D. Heart block
C

• Sodium Nitroprusside is an effective antihypertensive agent

(dilates both arteries and veins)
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TOPI C 6: HALOTHANE ANAESTHESI A 17

Problems faced by obese pat ient du r in g an aest hesia • Hemodynamic monitoring - I t is done by
Perioperative
These patients are often difficult to intubate as a result Central venous or pulmonary artery pressure monitoring.
of limited mobility of temperomandibular and atlantoccipital The most sensitive hemodynamic correlates are derived
j oint s, a narrowed airw ay and a short ened distance between from pulmonary artery pressure monitoring -
mandible and sternal fat pads. Ischemia is frequently but not always associated with an
I ncreased risk of developing aspiration pneumonia, abrupt increase in pulmonary capillary wedge pressure.
t h er ef o r e r ou t in e t / t w i t h H 2 a nt a gonist s an d
metoclopromide is given. The most common hemodynamic abnormalities observed dur
ing isch em ic episodes ar e hyper t ension and
I ntraoperative tachycardia.
Volatile anaesthetics are metabolized more rapidly while
the action of nonvolatile agents are prolonged. 97. . Sallick’s manouvere is used
Risk of aspiration A. To reduce dead space
Difficulties in regional anaesthesia B. To prevent alveolar collapse
C. To prevent gastric aspiration
Postoperative D. To facilitate assisted respiration
Respir a t or y f a i lur e is t he m a j or pr oblem C
postoperatively
There is risk of postoperative hypoxia, so extubation should be • Sallick’s manoeuvre is application of backward pressure
delayed until the effects of neuromuscular blocker is completely on Cricoid cartilage to prevent gastric aspiration.
reversed.
TOPI C 6: HALOTHANE
Cardiovascular changes in obesity
• High Blood volume 98. . Hepatoxic anaesthetic agent is:
• High Cardiac output A. Ketamine
• Hypertension (Systemic and pulmonary) B. Ether
• High Workload on heart C. Nitrous Oxide
• High Stroke volume D. Halothane
• Cardiomegaly D
Respiratory changes in an obese patient
• Decrease in vital capacity and functional residual capacity
• Hypoxemia • Halothane is hepatoxic. I t is “ contraindicated” in liver
• Decrease compliance diseases.
• Decrease respiratory drive • Other I mportant side effects of Halothane
These patients require high FiO 2 t o achieve adequate

oxygenation, the ratio of Nitrous Oxide by O 2is kept at 2/ • Arrythmia (Max Arrythmogenic)*
3 Malignant Hyperthermia*
Gastrointestinal changes in obesity
Hiatal hernia 99. . Least analgesic gas used is
Gastroesophageal reflux A. N20
Poor gastric emptying B. Ether
Hyper acidic gastric fluid C. Halothane
D. Cyclopropane
9 6 . The most sensitive and pract ical t echnique for
C
detection of myocardial ischemia in the perioperative
period is -
• Halothane is a potent anaesthetic but poor analgesic
A. Magnetic Resonance Spectroscopy
All the other agents mentioned in the question are good
B. Radio labeled lactate determination
analgesics
C. Direct measurement of end diastolic pressure
Nitrous Oxide - I t is good analgesic but poor anaesthetic.
D. Regional wall motion abnormality detected with the help
Ether - I t is potent anaesthetic as well as good analgesic
of 2D transoesophagealechocardiography
Cyclopropane - I t is a good anaesthetic and a good analgesic
D
100. Which one of the following agents sensitizes the
Two dimensional t ransesophageal echocardiography is the most
myocardium to catecholamines?
sensitive method to detect myocardial ischemia in the
A. Isoflurane
perioperative period.
B. Ether
C. Halothane
D. Propofol
C

Halot hane sen sit ize t h e h eart t o adren alin e ( bot h

exogenous as well as endogenous, more prominently
exogenous) producing severe ventricular arrhythmias‘.
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TOPI C 6: HALOTHANE ANAESTHESI A 18

101. Repeated use of halothane causes: 104. Anesthesia agent with least analgesic property
A. Hepatitis A. N2O
B. Halothane
B. Encephalitis. .
C. Ether
C. Pancreatitis
D. Propane
D. Bronchitis
B
A

Halothane is a potent anaesthetic but provides poor analgesia.

Hepatitis
Massive hepatic necrosis has been seen following halothane Best/Maximum Trilene
anesthesia. analgesia
Subclinical ‘Halothane Hepatitis1 with lesser degree of liver
impairment , and a hepatocellular pattern of elevat ed
Profound Analgesia Ketarnine
transferases may also occur. Only analgesia N2O
The most susceptible ones are middle-aged females and obese. Analgesic Halothane

102. Anatomical dead space is increased by all of the 105. Post operative jaundice is because of use of:
A. Isoflurane
following except:
B. NO
A. Atropine
C. Melhoxyflurane
B. Halothane
D. Halothane
C. Massive pleural effusion
D
D. Inspiration
C
• Post operative jaundice can be cause by halothane. I t can
Anatomical dead space means those areas in the tracheo-
cause massive hepatic necrosis, subclinical one is called
bronchial t ree, where the gaseous exchange between the
‘Halothane hepatitis.’
lung and capillaries is not possible.
This area starts from the nasal cavity and includes, larynx, Note : Other causes of post. Operative jaundice
t r ach ea, bronch ii and ends in t he t ermin al bronchiole. - Phenothiaziges
- MAO inhibitors
Pleural effusion, normally tends to compress on the alveoli and - Blood. Transfusion
thus interferes with the physiological dead space (space - Sepsis
where gaseous exchange is occurring). Coincidental viral infection.
However, with a massive effusion, atleast some of the structure
comprising the anatomical dead space may be compressed 106. True about halothane:
thereby decreasing the anatomical dead space. A. 1% Thymol is used as preservative.
B. I t sensitizes heart to catecholamines at 1 MAC.
103. All of the following are true except: C. 20% metabolized.
A. Halothane is good as an analgesic agent D. I t is not usually given in same patient within 3 months.
B. Halothane sensitises the heart to action of catacholamines E. I t forms compound-A with sodalime,
C. Halothane relaxes brochi & is preferred in anaes thetics B
D. Halothane may cause Liver cell necrosis
A
• Halothane is a volatile, liquid with sweet odour, nonirritant and
noninflammable anaesthetic.
Halothane is good as an analgesic agent • I t contains 0.01% thymol for stability and decomposed by
• Halothane is a potent anaesthetic but not a good analgesic light, but is stable when stored in amber-lime and the vapour is
absorbed by rubber.
or muscle relaxant.
• An estimated 15-20% of absorbed halothane undergoes
• Halothane sensitizes the heart to arrythmogenic action of
metabolism.
Adrenaline
• Sevoflurane reacts w ith soda-lime and thus produces
• Rem em ber dr u gs w h ich sen sit izes t h e h eat t o
compound-i.e., pentafluoroisopropenyl fluromethyl ether.
arrythmogenic action of adrenaline include
• Pet h idin e is r ecom men ded in t h e man agemen t of
- Halothane
Halothane shakes.
- Methoxyflurance • Halothane may persist in the liver for as long as 12 days after
- Trichloroethylene administration.
-
Cyclopropane
107. True about halothane:
- Chloroform A. Causes bronchodilation
- Halothane causes bronchodilation. Thus it is preferred in B. Anti-arrhythmic
asthmatics (also Ketamine) C. Ted cardiac index
• Massive hepatic necrosis is follow ing halothane D. Uterine contraction occurs
anaesthesia has been reported E. Causes hepatitis
A& E
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TOPI C7: THI OPENTONE ANAESTHESI A 19

108. True about Halothane: While I ntra arterial injection causes Vasospasm
A. Non-irritant intravenous injection causes Vasodilatation.
B. Antiarrhythmic
C. I t antagonises bronchospasm 113. Thiopentone is contraindicated in:
D. Vasodilator A. Acute intermitent porphyria
A &C B. Induction of GA
C. CHF
D. GI disease
• Halothane is a colourless, relatively non-irritant vapour. A
I t is non-flammable non-explosive when mixed with O in any
2
concentrations used clinically.

Effects on organs : • Acute intermitent porphyria

CVS : - Myocardial depression, fall of arterial pressure. • Bar bit u r at es ( Th iopen t one) ppt acu t e in t er mit en t
- Vasodilatation, dilates coronary arteries porphyria
- Bradycardia.
- Increased myocardial excitability, ventricular extrasystoles.
Arrythmia after I .V. infusion of Adrenaline > 10 micro g/ min.

110. Which of the are the following contraindication for

halothane used:
A. Male sex
B. Middle age
C. Recent halothane use
D. Associated liver pathology
E. Obesity Safe drugs in porphyria

C& D
Local Anaesthesia Drugs used in anaesthesia
Amethocaine Adrenaline
111. . Which of the follow ing fluorinated anaesthetics
corrodes metal in vaporizers and breathing systems? Bupivacaine Atropine
A. Sevoflurane Lignocaine 2 Cyclopropane
B. Enflurane Prilocaine Epinephrine
C. Isoflurane Procaine Ether
D. Halothane Tetracaine Isoflurane
D Neostigmine
Nitrous oxide
Pancuronium
• Halothane causes corrosion of metals in vaporizers and Phentolamine
breathing system Propofol
Suxamethonium
TOPI C 7: THI OPENTONE Safe anticonvulsants in porphyria

112. I ntra arterial injection of thiopentone causes: Anticonvulsants

A. Hypotension Clobazam
B. Necrosis of vessel wall Clonazepam
C. Vasodilation Gabapentin
D. Vasospasm Sodium
D valporate
Valporate3
Vigabatrin
Vasospasm
When thiopentone is given intra arterial it results in ppt of
Safe drugs in porphyria
solid crystals of Thiopentone Analgesics
 Alfentanil
These solid crystal block small vascular channels at Arteriolar Aspirin
and capillary levels Buprenorphine
 Codeine Phosphate
Vasospasm Dextromethorphan
(d/ t irritant properties of solid crystals) Dextromoramide
Diamorphine
• Morbidity due to Intra arterial injection of Thiopentone is Dihydrocodeine
also d/ t Fenbufen
– Thrombosis & Endothelial damage Fentanyl
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TOPI C7: THI OPENTONE ANAESTHESI A 20

(b) Prostacycline
(c) )
Flurbiprofen Antidepressants Dexamethaethasone (d)
Ibuprofen Fluoxetine Tolazoline
Indometacin Mianserin ( e) Phenoxybenzamine
Ketoprofen Antipsychotics (f) Urokinase
Meloxicam Chlorpromazine
• Cancel the operation
Methadone Fluphenazine • Possibly continue volatile anesthesia as an effective
Morphine Haloperidol method of securing vasodilatation
Naproxen Olanzapine • Perform a Brachical plexus or stellae ganglion block to
Paracetamol Pipotiazine remove all vasoconstrictor impulses
Pethidine Trifluoperazine • I . V. lignocaine is a vasoditator
– (all local anesthetics are vasoditator except cocaine) and can
Piroxicam
help overcome the vasoconstriction caused by
Sulindac thiopentone.

114. I ntraarterial Thiopentone injection causes 116. During surgery for aortic arch aneurysm under deep
A. Cardiac arrest hypothermic circulatory arrest which of the following
B. Respiratory arrest anaesthetic agent administered prior to circulatory
C. Convulsion arrest that also provides cerebral protection ?
D. Pain A. Etomidate
D B. Thiopental Sodium
C. Propofal
D. Ketamine
B
Signs and symptoms of intra art erial inj ect ion of
thiopentone
a) I mmediate - • During the surgery for aortic arch all the blood supply tot
i) Pain h e br ain has t o be st opped so t h at pr oper ar ch
ii) White hand with cyanosed f ingers anastomosis can be performed. This carries great risk for the
iii) Patches of skin discolouration brain. So the surgery for aortic arch aneurysm is
iv) Onset of unconsciousness is delayed beyond the usual performed now days using deep hypothermia and
t ime circulatory arrest method .
b) Late • I t is based on the principle that brain can safely tolerate
i) Ulcers or blisters circulatory arrest for periods of upto 45minutes, if the
ii) Edema of forearm and hand temperature is carefully lowered to 15-17°C wide surgery. So
iii) Gangrene - rare during surgery for aortic arch aneurysm temperature is lowered
t ill the temperature of the body is lowered up to 15-17° c and
115. A pt. Selected for surgery w ho was induced with then surgery is performed.
thiopentone i.v. through one of the antecubital veins
complains of severe pain of w hole hand. The next line • During this process we need an anaesthetic agent which
of management is: lowers the metabolic demands of the brain, so that the
A. Give I .V. Ketamine through same needle brain can sustain longer periods of circulatory arrest.
B. Give I .V. propofol through same needle Thiopentone sodium is one such drug, which lowers
C. Leave it alone the metabolic demands of brains and provides it
D. Give I .V. lignocaine through same needle added protection, when its blood supply it reduced
D during surgery.

Give I .V. lignocaine through same needle 117. Which of the following anesthetic agents does not
• I njection . has gone into the Artery which lies adjacent trigger malignant hyperthermia?
to the antecubital vein. A Halothane
• I mmediate symptoms and sign of intra arterial B. Isoflurane
thiopentone C. Suxamethonium
1. Pain during injection D. Thiopentone
2. A white hand with cyanosed fingers d/ t arterial spasmw D
hich may be accompanied or follow ed by art erial
thrombosis ‘Muscle relaxant succinylcholine is t he most commonly
3. Patches of skin discoloration in the limb implicated agent. Halothane and isoflurane have also been
4. Onset of unconsciousness may be delayed beyond the usual, implicated.
time. Barbitur ates ( thiopentone sodium) are safe drugs for gen
er al an aest h esia in pat ien t s su scept ib le f or
Treatment malignanthyperthermia
• Leave the canula in site Malignant Hyperthermia
• Heparin 1000 units is given via cannula in the Artery Malignant hyperthermia is a familial syndrome characterized
• Through Canula in the Artery inject clinically by arise of temperature of at least 2DC/ hour
(a) Papavarine 40 -80 mg in 10- 20 ml of Saline I nheritance
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TOPI C7: THI OPENTONE ANAESTHESI A 21

Au t osom al dom in an t in h er i t an ce w i t h in com plet e * Ketamine is having profound analgesic property.

penetration .Defect in gene on chromosome * Fentanyl is a synthetic opioid having intense analgesia.

Pathology 123. I ntravenous thiopentone, produces

Abnormality of Ryanodine Receptor: calcium releasing ch A. Rash
an nel of sar coplasm ic ret iculum . Sudden r ise in B. Pain
intracellular calcium2 leads to hypermetabolic state. C. Spasm
D. Hypotension
118. Not intravenous Anasthetic agent E. Muscular excitation (locally)
A. Ketamine A& B& D
B. Thiopantone
C. Etomidate • Thiopentone is an ultra short acting barbiturate used for
D. Cyclopropane induction of anaesthesia.
D • The different effects produced by thiopentone are :

Classification of Anaesthe tic agents: CNS & Respiratory system : Sedation, hypnosis, anaesthesia
& respiratory depression.
Inhalation Intravenous - I ncreased cerebral blood f low , decrease I C pressure,
Cerebral metabolism & O consumption leading to cerebral
Gas Liquid Inducing agent Slower Acting 2
protection..
• N2O • Ether • Propofol • Ketamine - CVS : hypotension due to vasodilatation in skin & muscle.
• Halothane • (dissociative Larynx : Increased sensitivity to stimuli producing laryngeal
Methohexitone anesthesia) spasm.
Eye : - pupils f irst dilate then constrict.
• Cyclopropane • Thiopentone • Fentanyl
• Fluranes • Etomidate Droperidol - Loss of eyelash reflex is an excellent sign of adequate induction.
(Neurolept Allergic reaction : Rarely manifests as scarlantiniform rash,
analgesia) angioneurotic edema & photosensitivity.
- Enflurane Injection effects : - The incidence of pain on injection is 1-2%
- Iso flurane when injected into small veins & essentially none when
injected into larger veins.
- Desmoflurane - Perivenous injection produces pain, redness & swelling,
- Sevoflurane haematoma formation, bruising, rarely ulceration.
- Accidental intraarterial injection produces intense arterial
119. Sodium Thiopentone is ultra short acting d/ t spasm & excruciating pain that can be felt from the injection
A. Rapid absorption site to the hand & fingers.
B. Rapid metabolism Musculo skeletal : Besides producing unconsciousness, it can
C. Rapid redistribution cause mild muscular excitatory movements such as
D. Rapic excretion hypertonus, t remor or twitching & respiratory excitatory ef
C fect s in cluding cou gh & h iccu p. Th ese ar e dosedependent
effect s.
121. Uses of thiopentone:
A. Seizure 124. Regarding thiopentone all are true except
B. Truth spell A. Sodium carbonate is added to improve its solubility
C. Reduction of I .C.P. B. Cerebro protective
D. Cerebral protection C. Contraindicated in porphyria
E. Maintanance of Anesthesia D. Induction agent of choice in shock
Ans a,b,c,d,e D

122. Which of the follow ing is not analgesic • Thiopentone is a short acting barbiturate used in the
A. N2O induction of anaesthesia.
B. Thiopentone • Anaesthetic barbiturates are derivatives of Barbituric acid with
C. Methohexitone an oxygen or sulfur at 2 position.
D. Ketamine • Th e t hree bar bit ur at es comm only u sed for clinical
E. Fentanyl anaesthesia are :
B • Sodium thiopental
• Thiamylal
• Methohexital
* N2O (nitrous oxide) is a weak anaesthetic agent having potent Barbiturates are formulated as the sodium salts with 6%
analgesic property. sodium carbonate and reconstituted in water or isotonic
* Thiopentone & Methohexitone, both are barbiturate group saline to produce alkaline solutions with pH of 10- 11.
of in du ct ion agen t w i t h ou t an algesic pr oper t ies. • Once reconstituted these are stable in solutions for upto
Thiopentone having ant- analgesic property only i.e. 1 week.
it decreases the pain threshold.
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TOPI C 8: PAEDI ATRI C ANESTHESI A ANAESTHESI A 22

• Thiopent one is used for the induct ion of anaesthesia because Other drugs used are -
it has a very rapid onset of action. 1) Methohexitone
• The typical induction dose ( 3-5 mg/ kg) of thiopentone produces 2) Propofol
unconsciousness in 10 - 30 seconds with a peak effect in 1 3) Etomidate
minute and duration of anaesthesia of 5-8 minutes. 4) Ketamine
• Action of this drug terminates quickly because of rapid
redistribution. 12 6 . The ideal muscle relaxant used for a neonate
• Thiopentone is highly lipid soluble, t herefore it s undergoing porto- enterostomy for biliary atresia is:
redistribution is very rapid and this accounts for its short A. Atracurium.
duration of action. B. Vecuronium
• Sulphur is added t o increase t he lipid solubilit y of thiopent C. Pancuronium.
one. D. Rocuronium
• Thiopentone is given intravenously. A
• I t produces little to no pain on injection.
• Venoirritation can be reduced by injection into larger non hand
veins and by prior intravenous injectionof lidocaine. In this case a muscle relaxant is required whose metabolism
• I f som et im es t h iopen t on e ina dver t en t ly ent er has nothing to do with liver (because liver is damaged in biliary
intraarterial circulation it causes severe inflammatory and atresia)
potentially necrotic reaction.
• So Atracurium is the muscle relaxant of choice as it is inactivat
Effects on system C.N.S. ed in plasma by spont aneous non enzymat ic degradation. (
• Besides producing a general anaesthesia, barbiturates Hoffman elimination) so its duration of action will not be
reduce the cerebral metabolic rate, as measured by cer affected in patients with hepatic insufficiency.
ebr al oxygen con su m pt i on ( CMR0 ) in a dose2
dependent
manner. 127. I n a 2 months old infant undergoing surgery for biliary
• As a consequence of the decrease in (CMRO ) cerebral2
blood atresia, you would avoid one of the following anaesthetic
flow and intracranial pressure are similarly reduced. A. Thiopentone
• Becau se it m ar kedly low er s cer ebr al m et abolism ,
B. Halothane.
thiopentone has been used as a protectant against cerebral
C. Propofol.
ischemia.
D. Sevoflurane
• Thiopentone also reduces intraocular pressure.
B
• Presumbaly in part due to their CNS depressant activity
barbiturates are effective anticonvulsants.
• Thiopentone in particular is a proven medication in the t/
t of status epilepticus. halothane is known to cause liver toxicity. So Halothane
should be avoided in a patient undergoing surgery for Biliary
C.V.S atresia (as the liver is already damaged)
• Thiopentone produces dose dependent decrease in blood
pressure.
• The effect is primarily due to vasodilation particularly
venodilation.
Respiratory
• Theiopentone is respiratory depressants.
• I t causes dose dependent decrease in minute ventilation and
tidal volume with a smaller and inconsistent decrease in
respiratory rate.

Other adverse effects

• Thiopentone has no clinically significant effect on hepatic, renal
or endocrine systems.
• Thiopentone ( Barbiturates) can induce fatal attacks of 128. Regarding neonatal circumcision, which one of the
porphyria in patients with acute intermittent porphyria and follow ing is true:
are contraindicated in such patients. A. I t should be done without anaesthesia, as it is hazardous
to give anaesthesia.
TOPI C 8: PAEDI ATRI C ANESTHESI A B. I t should be done without anesthesia, as neonates do not
perceive pain as adults.
125. Method of anaesthetic induction in children is by C. I t should be done under local anaesthesia only.
A. Intramuscular D. General anaesthesia should be given t o neonat e for
B. Inhalation circumcision as they also feel pain as adults
C. Intravenous D
D. Oxygen tent
C Circumcision anaesthesia .
“ A general anaesthetic is preferable in children, but in adults
local infilt rative anaesthesia, or regional anaesthesia with a
• In children intravenous induction of anaesthesia is the most caudal or subpubic block is also satisfactory
common method used for induction of anaesthesia.
• The drug most commonly used is thiopentone
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TOPI C 8: PAEDI ATRI C ANESTHESI A ANAESTHESI A 23

• I ts main development has been as a monitoring tool

for use during anaesthesia and intensive care .
• I t is usually presented as a graph of expiratory CO2
plot ted against t ime , or, less commonly, but more
usefully, expired volume. The plot may also show the
inspired CO2, w hich is of interest w hen rebreathing
systems are being used.

129. Which of the following inhalational agents is the

induction agent of choice in children:
A. Methoxyflurane
B. Sevoflurane
C. Desflurane
D. Isoflurane
B • The capnogram is a direct monitor of the inhaled and
exhaled concentration or partial pressure of CO2, and
an indirect monitor of the CO2 partial pressure in the
Faster, pleasant, and smooth in duction with no significant arterial blood. In healthy individuals, the difference bet w een
systemic toxity makes sevoflurane the agent of choice for art erial blood and expired gas CO2 part ial pressures is very
induction, especially in children small, and is probably zero in children. In the presence of most
forms of lung disease, and some forms of congenital heart
130. . A tw o- month- old infant has undergone a major disease (the cyanotic lesions) the difference between arterial
surgical procedure. Regarding postoperative pain blood and expired gas increases and can exceed 1 kPa.
relief which one of the follow ing is recommended:
A. No medication is needed as infant does not feel pain after • During anaesthesia, there is int erplay bet w een t w ocom
surgery due to immaturity of nervous system pon en t s: t h e pat ien t an d t h e an aest h esia administration
B. Only paracetamol suppository is adequate device ( which is usually a breathing circuit and a ventilator or
C. Spinal narcotics via intrathecal route respirator). The crit ical connection between the two
D. Intravenous narcotic infusion is lower dosage components is either an endotracheal tube or a mask, and
Ans c CO2 is typically monitored at this junction. Capnography
directly reflects the elimination of CO2 by the lungs to the
anaesthesia device. I ndirectly, it reflect s t h e product ion of
• Bupivacaine has, until recently, been the drug of choice for CO2 by t issues an d t he circulatory transport of CO2 to the
postoperative epidural infusions in children. Despite a lungs.
reasonable safety profile, bupivacaine is currently being
replaced by many anest hesiologist s w ith new local 1 3 2 . All of t he follow ing agent s can be given for
anesthetics: levobupivacaine and ropivacaine . These induction of anaesthesia in children except:
local anesthetics are associated with less risk for cardiac and A. Halothane
central nervous system toxicity and are also less likelyto B. Servoflurane
result in unwanted postoperative motor blockade C. Morphine
D. Nitrous oxide
131. A non ventilated preterm baby in incubator is under C
observation. Which is the best way to monitor the baby’s
breathing and detect apnea? Morphine
A. Capnography Morphine should not be used in infants specially those
B. I mpedence pulmonometry less than 6 months of age.
C. Chest movement monitoring Morphine is also not commonly recommended in older children(3-
D. Infrared End Tidal CO 2mesurement 10 years) of age
A

• Capnography is the monitoring of the concentration or Most commonly used method for inducing gaseous anaesthesia
partial pressure of carbon dioxide ( CO2 ) in the is with O2, with or without N2 O and either halothane or
respiratory gases. sevoflurane.
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TOPI C 9: VENTI LATOR ANAESTHESI A 24

• What happens w hen such a person holds his

breath.
• Soon his blood O level will fall (hypoxia) but his blood CO
2 2
level will be normal or below normal (as he was hypocapnic
due to hyperventilation)
• His blood O2 level will continue to fall, but his CO2 level

will still be not high enough to st imulate the brain for

respiratory drive.
• The person will continue to hold his breath and his
• Halothane is well tolerated in children , in which ther O2 level may fall to lethal levels without any respiratory
isk of h alo t h an e in du ced h epat i t is on r epeat ed drive ( his brain is still unaware that he is in danger
administration is small. of dying from hypoxia.)
• Enflurane and isoflurane are more pungent and not
recommended 137. I n volume cycled ventilation the inspiratory flow
• Sevoflurane, if available is the agent of choice rate is set at
A. 140-160L/ min
• Nitrous oxide is particularly useful because of the speed B. 110-130 L/ min
of indu ct ion, absence of cardiovascular and respiratory C. 60-100 L/ min
depression, its rapid onset and offset, and its powerful analgesic D. 30-50 L/ min
action. Ans : C
13 5 . Upper respiratory tract infection is a common • Ventilators are devices which are used to provide warm and
problem in children. All the follow ing anesthetic humidified gas to the airway opening according to specific
complications can occur in children with respiratory volume pressure and time patterns. The ventilator serves as
infections, except: energy source only during inspiration replacing the
A. Bacteremia
muscles of chest wall and diaphragm.
B. Halothane granuloma
• Expiration is passive driven by the recoil of the lung and chest
C. Increased mucosal bleeding wall.
D. Laryngospasm
B There are various modes of mechanical ventilation such as
(1) Assist control mode ventilation
• Due to local infection there is hyperemia of the local area & (2) Continuous positive airway pressure
trauma can result in mucosal bleeding (3) Pressure control ventilation
• Due to local edema & inflammation laryngospasm can be a (4) Pressure support ventilation
complication (5) Open lung ventilation
• Systemic infection can lead to Bacteremia • These various modes of ventilation specifies the mannerin
which ventilator breaths are t riggered, cycled and limited.
TOPI C 9: VENTI LATOR Lets see the meaning of these terms.
Trigger- I t defines what the ventilator senses to initiate
136. After Hyperventilating for some time holding the an assisted cycle.
breath is dangerous because: I n volume- assist cont rol, t he patient can receive
A. Decrease CO2 shift the O2 dissociation curve to the left controlled or assisted breaths – all identical
B. Alkalosis can lead to tetany
C. I t can lead to CO2 Narcosis
D. Due to lack of st imulation by CO2, anoxia can go into
dangerous levels

Due to lack of stimulation by CO2, anoxia can go into dangerous

levels
• In our body its not O2, but CO2 that maintains the
respiratory drive ( though main function of respiration is
to maintain adequate oxygen level in the body)
• Thusits not hypoxia but hypercarbia that is required • One has to be careful with triggering devices: if the t riggeris
to inform the brain that respiration is inadequate. t oo sen si t ive t h e pat ien t “ over t r igger s” an d
• I f normally a person holds his breath he will soon hyperventilates, if it is not sensitive enough, the patient
have decrease O2 level ( hypoxia) and increase CO 2 becomes dysynchronous.
level ( hypercarbia)
• Hypercarbia will stimulate the brain and increase the Cycle- Refers t o the factors that determine the end of
respiratory drive, forcing the person to take breath. inspiration
• What happens when a person hyperventilates ? For e.g., in volume cycle ventilation inspiration ends
• decreased PaCO2 of blood when a specified volume is delivered to the patient
• normal O2 saturation (despite hyperventilation arterial Limiting factors- are operator specified values such as
O2 saturation remains same as blood is almost fully airway pressure that are monitored by transducer’s
saturated at normal ventilation rate ) internal to the ventilatory circuit.
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TOPI C 9: VENTI LATOR ANAESTHESI A 25

• Volume cycle ventilation and Assist control mode of Pressure support ventilation (PSV)
ventilation. • For the spontaneously breathing patient, pressure
Every breath whether t riggered by patient or t imer is a volume support ventilation ( PSV) has been advocated to limit
cycled breath and the inspiratory f low rate is maintained at 60 barot rauma and t o decrease the w ork of breathing.
L/ min • Pressure support differs from A/ C and I MV in that a level
of support pressure is set ( not TV) to assist every
Methods of Ventilatory Support spontaneous effort.
Continuous mandatory ventilation • Airway pressure support is maintained until the patient’s
inspiratory f low falls below a certain cutoff (eg, 25% of peak
• Breaths are delivered at preset intervals, regardless of patient
f low). With some ventilators, there is the ability to set a ba
effort.
• This mode is used most often in the paralyzed or apneic patient ck- up I M V r at e should spont a neous respirations
because it can increase the work of breathing if cease.
respiratory effort is present.
• Continuous mandatory ventilation ( CMV) has given way • PSV is frequently the mode of choice in pat ients whose
to assist -control ( A/ C) mode because A/ C with the apneic respiratory failure is not severe and who have an adequate
patient is tantamount to CMV. Many ventilators do not have respiratory drive. I t can result in improved patient
a true CMV mode and offer A/ C instead. comfort, reduced cardiovascular effects, r educed
r isk of ba r ot r a um a , a nd im pr oved distribution of
Assist -control ventilation gas.
• The ventilator delivers preset breaths in coordination
with the respiratory effort of the patient . Noninvasive ventilation
• With each inspiratory effort, the ventilator delivers a full assisted • The application of mechanical ventilatory support through
tidal volume. a mask in place of endotracheal intubation is
• Spont a neous br ea t hin g i nde pe nde nt of t he becoming increasingly accepted and used in the
ventilator between A/ C breaths is not allowed. emergency department . Considering this modality for
• As might be expected, this mode is better tolerated than pat ient s w ith mild- t o-moder at e respir at ory failure is
CMV in patients with intact respiratory effort. appropriate. The patient must be mentally alert enough
to follow commands. Clinical situations in which it has
Intermittent mandatory ventilation proven useful include acute exacerbation of chronic
• Wit h intermittent mandatory ventilation ( I MV) , obstructive pulmonary disease ( COPD) or asthma,
breaths are delivered at a preset int erval, and decompensated congestive heart failure ( CHF) w ith
spontaneous breathing is allowed between ventilator- mild- to- moderate pulmonary edema, and pulmonary
administered breaths. edema from hypervolemia.
• Spont a neous br ea t hing occur s against t he • I t is most commonly applied as continuous positive
resistance of the airway tubing and ventilator airway pressure ( CPAP) and biphasic positive airway
valves, which may be formidable. This mode has given pressure ( BiPAP).
w ay t o synchr onous int erm i t t ent ma nda t or y • BiPAP is commonly misunderstood to be a form of pressure
ventilation ( SI MV). support vent ilation t r iggered by patient breaths; in
actuality, BiPAP is a form of CPAP that alternates
Synchronous intermittent mandatory ventilation between high and low positive airw ay pressures,
• Th e vent i la t or deliver s pr eset br ea t hs in coordinat permitting inspiration ( and expiration) throughout.
ion w ith the respiratory effort of t he patient .
Spontaneous breathing is allow ed bet ween breaths. • I ndications For Mechanical Ventilation
Synchronization attempts to limit barotrauma that may occur Clinical criteria
with I MV when a preset breath is delivered to a patient who • Apnea or hypopnea
is already maximally inhaled (breath stacking) or is forcefully • Respiratory distress with altered mentation
exhaling. • Clinically apparent increasing w ork of breathing
• The initial choice of ventilation mode (eg, SIMV, A/ C) is unrelieved by other interventions
institution and practitioner dependent. A/ C ventilation, as • Obtundation and need for airway protection
in CMV, is a full support mode in that the ventilator performs Other criteria
most, if not all, of the work of breathing. These modes are • Controlled hyperventilation (eg, in head injury).
beneficial for patient s who require a high m in u t e ven t • Severe circulatory shock
i lat ion . Fu l l su ppor t r edu ces oxygen consumpt ion and Laboratory Criteria for Mechanical Ventilation
CO2 product ion of t he respir at ory muscles. A potential
drawback of A/ C ventilation in the patient with obstructive Blood gases PaO2 <55 mm Hg
airway disease is worsening of air trapping and breath stacking. PaCO2 >50 mm Hg and pH <7.32
Pulmonary function tests Vital capacity <10 mL/kg
• When full respiratory support is necessary for the
pa r a lyzed p a t ient f ollow ing neu r om uscula r Negative inspiratory force <25
blockade, no difference exists in minute ventilation or cm H2O
airway pressures with any of the above modes of FEV1 < 10mL/KG
ventilation.
Guidelines for Ventilator Settings
• I n the apneic patient , A/ C with a respiratory rate Mode of ventilation
• The mode of ventilation should be tailored to the needs
( RR) of 10 and a TV of 500 m L delivers the same minute
ventilation as SIMV with the same parameters. of the patient. In the emergent situation, the practitioner
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TOPI C 9: VENTI LATOR ANAESTHESI A 26

may need to order initial settings quickly. SI MV and A/ C are • One obvious beneficial effect of PEEP is to shift lung water from
versatile modes that can be used for initial settings. the alveoli to the perivascular interstitial space. I t does not
• In patients with a good respiratory drive and mild- decrease the total amount of extravascular lung water. This is
to- moderate respiratory failure , PSV is a good initial of clear benefit in cases of cardiogenic as well as
choice. noncardiogenic pulmonary edema. An additional benefit of
PEEP in cases of CHF is to decrease venous ret urn t o t
Tidal volume he r ight side of t he hear t by increasing intrathoracic
• Observations of the adverse effects of barotrauma and pressure.
volutrauma have led to recommendations of lower tidal volumes
than in years past, when tidal volumes of 10-15 mL/ kg were • Applying physiologic PEEP of 3 - 5 cm H2 O is common
routinely used. to prevent decreases in functional residual capacity in
• An initial TV of 5-8 mL/ kg of ideal body weight is generally those with normal lungs. The reasoning for increasing levels
indicated, with the lowest values recommended in the presence of PEEP in critically ill patients is to provide acceptable
of obstructive airway disease and ARDS. The goal is to adjust
oxygenation and to reduce the FiO2 to nontoxic levels (FiO2
the TV so that plateau pressures are less than 35 cm H2 O.
< 0.5). The level of PEEP must be balanced such that
excessive intrathoracic pressure ( with a resultant decrease in
Respiratory rate
venous return and risk of barotrauma) does not occur.
• A respiratory rate (RR) of 8-12 breaths per minute is
recommended for patients not requiring hyperventilation
for t he t reat ment of t oxic or met abolic acidosis, or Sensitivity
intracranial injury. High rates allow less t ime for exhalation, • With assisted ventilation, the sensitivity typically is set
increase mean airway pressure, and cause air trapping in at - 1 to - 2 cm H2 O. The development of iPEEP
patients with obstructive airway disease. The initial rate increases the difficulty in generating a negative
ma y be as low as 5 - 6 br eat hs per minut e in inspiratory force sufficient to overcome iPEEP and
asthmatic patients when using a permissive hypercapnic the set sensitivity. Newer ventilators offer the ability to
technique. sense by inspiratory flow instead of negative force. Flow
sensing, if available, may lower the work of breathing
Supplemental oxygen therapy associated with ventilator triggering.
• The lowest FiO2 that produces an arterial oxygen
saturation ( SaO2 ) greater than 90 % and a PaO2 I nitial ventilator settings in various disease states.
greater than 60 mm Hg is recommended. No data indicate
that prolonged use of an FiO2 less than 0.4 damages Tidal volume RR I/E ratio PEEP FIO2
parenchymal cells. Normal lungs 8 mL/kg 10-12 1:2 4 1.0
Inspiration/ expiration ratio Asthma/copd 6 mL/kg 5-8 1:4 4 1.0
• The normal inspiration/ expiration ( I / E) ratio to start ARDS 6 mL/kg 10-12 1:2 4-15 1.0
is 1:2 . This is reduced to 1:4 or 1:5 in the presence Hypovolemia 8 mL/kg 10-12 1:2 0-4 1.0
of obstructive airway disease in order to avoid air- trapping
(breath stacking) and auto-PEEP or intrinsic PEEP (iPEEP). Use 138. Laryngeal mask Airway ( LMA) is used for;
of inverse I / E may be appropriate in certain patients with A. Maintenance of the airway
complex compliance problems in the setting of ARDS. B. Facilitating laryngeal surgery
C. Prevention of aspiration
I nspiratory flow rates D. Removing oral secretions
• I nspiratory flow rates are a function of the TV, I / E A
ratio, and RR and may be controlled internally by the
ventilator via these other settings. I f flow rates are set Laryngeal mask is used for maintenance of airway in patients
explicitly, 60 L/ min is typically used. This may be in whom t racheal intubation is difficult or impossible.
increased to 100 L/ min to deliver TVs quickly and I t is a cuffed mask designed to fit closely over the
allow for prolonged expiration in the presence of laryngeal aperture . I t forms a seal around the larynx.
obstructive airway disease.

Positive end-expiratory pressure

• PEEP has several beneficial effects and may be clinically
underutilized. Research underway is examining the utility
of high ( > 10 cm H2 O) PEEP in disease stat es
ranging from COPD/ asthma to ARDS . PEEP has been
found to reduce the risk of atelectasis trauma and increase
the number of “ open” alveoli participating in ventilation,
thus minimizing V/ Q mismatches. However, note that in
disease states such as ARDS, the degree to which alveoli
function has been compromised varies tremendously within - Laryngeal mask airway is also called as Bain Mask (after
t h e lu n gs and t h er e is no single “idea l” PEEP the name of its inventor)
appropriate for all alveoli; rather, a compromise PEEP - I t provides relatively safe anaesthesia for adults and
must be selected. children in place of t racheal intubation.
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TOPI C 9: VENTI LATOR ANAESTHESI A 27

Contraindications Oropharyngeal abscess or mass.

• Full stomach patients
• Hiatus hernia
• Pregnancy (where chances of aspiration are high).
• Patients who are vulnerable to go in bronchospasm.

I t should be remembered that it is only an adjunct to airway

management but not a substitute for t racheal intubation.
Moreover it does not protect the airway from pulmonary
aspiration.
140. The follow ing modes of ventilation may be used for
139. The laryngeal mask airway used for securing the airway weaning off patients from mechanical ventilation except:
of a patient in all of the following conditions except: A. Controlled Mechanical ventilation (CMV).
A. In a difficult intubation. B. Synchronized intermittent mandatory ventilation ( SIMV).
B. In cardiopulmonary resuscitation. C. Pressure support ventilation (PSV).
C. In a child undergoing an elective/ routine eye surgery. D. Assist -control ventilation (ACV)
D. In a patient with a large tumour in the oral cavity A
D
In controlled mode ventilation ( CMV) patients own effort
Oropharyngeal abscess or mass is a contraindication to the is nil.
use of laryngeal mask airw ay. ( LMA) Only ventilator is delivering the present t idal volume. This mode
therefore will play no role in weaning a patient from mechanical
ventilation.

Laryngeal Mask Airway

I t is a special type of airway useful in difficult intubation.
I t is placed blindly in the oropharynx and the cuff is 14 1 . I n apat ient w ith fixed respiratory obst ruction
inflated with large volume of air inflated cuff seals the Helium is used along with Oxygen instead of plain
lateral and posterior pharyngeal walls and patient can be oxygen because
ventilated through ventilation parts. A. It decreases oxygenation
B. It decreases turbulence
I ndications C. It decreases the dead space
1) As an alternative to intubation where difficult intubation D. It provides analgesia
is anticipated. D
2) Securing airway in emergency where intubation and mask
ventilation is not possible. I t increases oxygenation
3) As a elect ive m et hod for m in or su r ger ies w h er e • Helium is given as Heliox [ HeO2] , a mixture of 20% to
anaesthetist wants to avoid intubation.

4) As a conduit for bronchoscopes, small size tubes, gum 80 % He and 80% to 20% O 2 [ usually 80% He with
elastic bougies. 20% O ] . I t has about 1/ 3rd the density of O or air.
2 2
Advantages • Because helium is highly diffusible , the use of the mixture
Easy to insert (even paramedical staff can insert). greatly reduces the work of breathing in a patient with
Does not require any laryngoscope and muscle relaxants Does narrowed airways and thus lead to improved aerosol
not require any specific position of cervical spine so can be delivery and increased oxygenat ion in severe
used in cervical injuries asthma.
• I t may also reduce the risk of barotrauma.
Disadvantages • Airw ay resist ance is dict at ed by t he diamet er of t he airways
• I t does not prevent aspiration so should not be used and by the density of the inspired gas. Therefore when
for full stomach patients. nitrogen ( of air) is replaced by helium, airw ay
• High incidence of laryngospasm and bronchospasm resistance is reduced due to the lower density of
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TOPI C 9: VENTI LATOR ANAESTHESI A 28

the inspired gas. This means that when one breathes I t ’s value’ is increased when there are :
Heliox, airw ay resist ance is less, and t herefore t he - Increased CO 2 production e.g. in malignant hyperpyrexia.

mechanical energy required to ventilate the lungs, - Depression of r espir at ory cent er w it h con com it ant
or the Work of Breathing ( WOB) is decreased . reduction of total ventilation and ExCO . 2
- Reduction of effective ventilation induced by paralysis,
• Heliox is used mainly in the alleviation of many medical neurologic disease, high spinal anaest hesia ,
conditions that involve a decrease in airway diameter weakened respiratory musculature or respiratory
( and consequently increased airw ay resistance) , disease.
such as upper airway obstruction, asthma, chronic
obstructive pulmonary disease ( COPD) , bronchiolitis Abnormally low end- tidal values ( < 35 mm of Hg) most
and croup. Patients with these conditions may suffer a often reflect hyperventilation but may be also be caused by
range of symptoms including dyspnea (breathlessness), increased dead space with normal PaCO i.e. alveolar 2 gas
hypoxemia (below-normal oxygen content in the arterial emanating from a lung region w ith no
blood) and eventually a weakening of the respiratory blood flow ( and no local CO 2 relative to PaCO2. So,
muscles due to exhaustion, which can lead to respiratory in pul. embolism it is decreased).
failure and require intubation and mechanical ventilation -
Heliox may reduce all these effects, making it easier for
144. The physiological dead space is decreased by:
the patient to breathe, and as it will reduce work of
A. Upright position
breathing, Heliox can help to prevent this respiratory
B. Positive pressure ventilation
failure. Heliox has also found utility in the weaning of
patients off mechanical ventilation, and in the nebulization C. Neck f lexion
of inhalable drugs. D. Emphysema
A
• I t decreases turbulence. In COPD, Helium is used along with
O2 to decrease the viscosity of gaseous mixture which The PaCO2 will be greater than or equal to end-ridal PaCO2
increases its linearity & decreases resistance in pathway. ( PET CO 2 ) u n less t h e pat ien t in spir es or r eceives
exogen ou s car bon dioxide ( e. g. , f r o m per i t on eal
insufflation). The difference between PETCO ) 2 is because
of dead space ventilation. The most common reason for
an acute increase in dead space ventilation is decreased
cardiac output. Measurement of this difference-which is
simple, readily obtainable, and fairly inexpensive- yields
reliable information relative to the degree of dead space
ventilation. Clinical situations that change pulmonary blood
flow sufficiently to increase dead space ventilation can be
det ect ed by com par in g PET CO w i t2 h t em per at u r e
corrected PaCO 2. Yamanaka and Sue52 found that t he
142. All are true about PEEP except: PETCO2 in ventilated patients varied linearly with the dead
A. Useful in situations where PO2 is low space t o t idal volume ratio ( VD/ VT) and that PETCO 2
B. Decreased Cardiac output correlated poorly with PaCO . Thus, in the critically ill,
2
C. Impaired renal function mechanically vent ilat ed patient , and in anest het ized
D. Decreased I CT patients, monitoring PETCO gives far more information
2
D about ventilatory efficiency or dead space ventilation than
it does about the absolute value of PaCO . 2
• When PEEP (Positive End Expiratory Pressure) is applied, there
is rise in cerebral venous and intracranial pressures in
145. Placement of a double lumen tube for lung surgery
parallel with the increase in mean intrathroacic pressure.
is best confirmed by -
• Cardiac output and venous return is reduced Rt. Atrial pressure
A. Et CO2
- rises.
B. Airway pressure measurement
• Useful in conditions where PO is low
2
and also easier if PCO2
C. Clinically by auscultation
is lowered.
D. Bronchoscopy
143. End- tidal CO2 is increased to maximum level in: D
A. Pulmonary. Embolism
B. Malignant hyperthermia
C. Extubation
D. Blockage of secretion
B

• The PCO2 value at the end of exhalation is referred to as

End-tidal PCO 2 ( PETCO 2).
The normal end-expiratory CO 2 partial pressure ranges
between 35 and 45 mm of Hg.
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TOPI C 10: ATRACURI UM ANAESTHESI A 29

• During thoracic surgery there is a need for one lung to be What is the use of end tidal CO determination ( Et CO ) in

deflated and or isolated. This offers the surgeon easier intubuation ?.

2 2
and better acess within the designated hemothorax. • The EtCO2 can be used to confirm the position of the
I n order to achieve this double lumen endobronchial endotracheal tube , ( whether the tube is in
t ubes are used t hat allow t he anaest hetist t o oesophagus or trachea)
2

selectively deflate one lung w hile maintaining • The persistent detection of CO by a capnograph is the

standard ventilation of the other.

Components of Double lumen tube

• Double lumen endobronchial tube has two separate colour
coded lumen each with its own bevel.
• One lumen ends in the t rachea and the other lumen ends
in either the left or right main bronchus
• Each lumen has its own cuff (t racheal an bronchial cuffs) and
colour coded pilot balloons.
• The proximal end of t hese tubes is connect ed to a breathing
system.

Mechanism of action
• Because of the differing anatomy of the main bronchi and their
branches, both right and left versions of any particular double
lumen tube must exist.
• Once correct ly posit ioned t he anaesthet ist canselectively
ventilate one lung, so for operations requiring that the
right lung is deflated , a left sided double lumen tube would
be used that enables selective ventilation of the left lung alone
and vice versa.

• Th e posit ion of t h e t u bes sh ou ld b e ch ecked by

auscultation immediately after intubutation and after
positioning the patient for operation.
• The auscultat orv met hod for checking the correct placement
of tube is hist a clinical method for ensuring correct placement
of the tube and the confirmation of correct placement of the
tube should be the done by flexible fibreoptic
bronchoscopy.
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TOPI C 10: ATRACURI UM ANAESTHESI A 30

best confirmat ion of tracheal placement of an

endotracheal tube ( EtCO2).
Capnography can detect whether the tube is in t rachea
or oesophagus but can not differentiate bet w een
tracheal intubation and endobronchial intubation
because in both these cases t here will be persistent
detection of CO r

146. . The most common cause of hypoxia during

one lung ventilation is -
A. Malposition of the double lumen tube
B. Increased shunt fraction
C. Collapse of one lung
D. Soiling of lung by secretions
B

Malpositioning of the double lumen endo-bronchial tube

used to be the most common cause of hypoxia during
one lung ventilation.
However during last 2 decades, with the use of f iber-
opt ic br on ch oscopes or br on ch ial bl ocker s, t h is
complication has declined and no longer remains the
most common cause of hypoxemia in these procedures.
The common cause is pulmonary AV shunt in the non-
ventilated lung and the ventilated lung.

How does this shunt develops during one lung

ventilation
• I ntentional collapse of the lung on the operative side
facilitates most t hor acic procedures but complicates
anaesthetic management.

Since the collapsed lung continues to be perfused

and is deliberately no longer ventilated, the patient
develops a large right to left intrapulmonary shunt (20-
30% ) .
Mixing of the unoxygenated blood from the still ventilated
dependent lung widens the P -a (alveolar to arterial) O A 2
gradient and can result in hypoxemia.

TOPI C 10 : ATRACURI UM

147. Which of the following is the muscle relaxant of

choice in renal failure?
A. Rapacurium
B. Pancuronium
C. Atracurium
D. Rocuronium
C
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TOPI C 10: ATRACURI UM ANAESTHESI A 31

‘The unique feature of Atracurium is inactivation in plasma Atracurium gets inactivated in plasma by spontaneous
by spont aneous nonenzymat ic degradat ion ( Hoffman non- enzymatic Hoffman’s elemination.
elemination) consequently its duration of action is not altered I t is short acting and reversal is mostly not required
in patients with renal / hepatic insufficiency, or hypodynamic
circulation. Hemodynamically it is almost neupal The concept of Balanced anaesthesia was introduced by
Lundy and consist of
Preferred relaxants Thiopental For Induction
I n renal failure : Vecuronium or Atracurium.
N2O For Amnesia
I n hepatic failure : Atracurium.
I n Myasthenia gravis : if relaxants are essential, one-tenth Mepiridine (or other opioid) For Analgesia
of the normal dose of atracurium Curare For Muscle relaxation
I n short cases: atracurium, rapacurium, or mivacurium.
Atracurium:
I n obstetrics any relaxant except gallamine.
Gets inactivated in plasma by spontaneous non-
I n a r t er ia l sur ger y: t o m ain t ain ar t er ial pr essu r e
enzymatic Hoffman’s elimination.
pancuronium.
Short acting
To deliberately reduce BP: tubocurarine.
Reversal is mostly not required
For r a pid sequen ce induct ion: w i t h ou t u sin g
suxamethonium, Rocuronium or rapacurium. Vecuronium:
Recover y is gen er ally spon t an eou s not needing
148. An elderly male on ventilator has received atracurium neostigmine reversal unless repeated doses are given.
infusion for 3 days. He now develops epilept ic • Longterm administration of vecuronium to patients in I CU has
fits.Probable cause for his epilepsy is: resulted in prolonged neuro muscular blockade (upto sever al
A. Allergy to drug days) d/ t a ccum ula t ion of 3 - H ydr ox ymetabolite,
B. Accumulation of Atracurium or development of polyneuropathy.
C. Accumulation of Laudanosine
D. Ventilator failure • Gallamine:
C Long acting
Needs reversal
Laudanosine is a metabolite of Atracurium and has CNS st • Pancuronium:
imulating properties. Long acting
Laudonosine may produce convulsions from its CNS st Needs reversal
imulating action, when high plasma concentration of
Laudanosine are reached. 152. Hoffman’s elimination is seen with:
In clinical practice, in the operating room and ICU setting, such A. Gallamine
high concentrations are usually not reached, but the patient B. Atracurium
in question has been on atracurium for 3 consequestive days C. Succinyl choline
before he develops epilepsy and hence high plasma D. Tubocurare
concentration of Laudanosine could well be a probable cause B
for epilepsy.
153. Muscle relaxant used I n renal failure:
149. Shortest acting non- depolarising skeletal muscle
A. Ketamine
relaxant is:
B. Atracurium
A. Mivacurium
C. Pancuronium
B. Vecuronium
C. Atracurium D. Fentanyl
D. Succinyl choline B
A
Muscle relaxant of choice in renal failure is Atracurium. I t is
Mivacurium also suitable :
• Shortest acting depolarization agent is succinyl choline — For liver disease.
(duration = 3 to 6mm) — For patients with atypical cholinesterase.
• Shortest acting non-depolarization agent is – Mivacurium — For organophosphorous poisoning,
(duration = 12-20 min) - Myasthenia Gravis.

150. . At the end of a balanced anaesthesia technique 156. A 21- year- old lady with a history of hypersensitivity
w ith non- depolarizing muscle relaxant, a patient to Neostigmine is posted for an elective caesarean
recovered spontaneously from the effect of muscle section under general anesthesia. The best muscle
relaxant w ithout any reversal. Which is the most relaxant of choice in this patient should be
probable relaxant the patient had received. A. Pancuronium
A. Pancuronium B. Atracurium
B. Gallamine C. Rocuronium
C. Atracurium D. Vecuronium
D. Vecuronium B
C
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TOPI C11: I NTUBATI ON ANAESTHESI A 32

Neost igmine is given for reversal of act ion of non- Using upper incisors as lever to lift the laryngoscope will cause
depolarizing muscle relaxants damage to the upper incisors ( in fact it will break the upper
incisors)
Neostigmine is an anticholinesterase. I ts action prevents
t he met abolism of a cet ylcboline by t h e en zym e
During endotracheal intubation a small pillow should be placed
acetylcholinesterase. This increases the concentration
under the occiput to flex the neck and extend the atlanto-
of Acetylcholine in t he synaptic clef t and leads t o
occipital joint. This straightens the path from upper
development of action potential.
incisors to the larynx.
This causes the muscles paralysed by the muscle rerlaxants
to return back to their normal contractile state.
I n bot h st r aight blade laryngoscope and curved blade
laryngoscope the tip of the laryngoscope is inserted firmly into
Neostigmine is usually required after long acting muscle
the vallecula and is used to lift the base of epiglottis.
relaxants have been used, to hasten recovery at the end of
operation.
Among the muscle relaxants given in the option Atracurium has
159. The narrowest part of larynx in infants is at the cricoid
the shortest duration of action and so it usually does not level. I n administering anesthesia this may lead to all
require neostigmine for the reversal of its action. except.
A. Choosing a smaller size endotracheal tube.
Mivacurium is the short est act ing competitive blocker B. Trauma to the subglottic region.
therefore it does not need reversal. C. Post operative stridor
D. Laryngeal oedema
TOPI C 11: I NTUBATI ON D

157. Endotracheal intubation is contraindicated in: The narrowest part of larynx in infants is at the cricoid level
A. Fracture mandible ( below the vocal cords), hence endotracheal tube which
B. Short neck passes through the vocal cords may not pass through
C. CSF rhinorrhoea the cricoid -hence a smaller size of tube is chosen.
D. Fracture cervical spine
C Because cricoid (subglottic area) area is the narrowest - it may
get traumatized during intubation.

CSF rhinorrohoea

“ Endotracheal intubation can be done in patients with fracture

of cervical spine. I t may be difficult and may require
fibreoptic intubation”.
Postoperative stridor after extubation occurs due to mucosal
edema in subglottic area resulting after intubation. Laryngeal
edema is unlikely because small size of tube used in infants
does not cause trauma to larynx, however it may cause
trauma to subglottic area leading to subglottic edema.

160. . Which of the follow ing is not an indication for

endotracheal intubation?
A. Maintenance of a patent airway
B. To provide positive pressure ventilation
C. Pulmonary toilet
158. During laryngoscopy and endo- tracheal intubation D. Pneumo thorax
which of the maneuver is not performed: D
A. Flexion of the neck.
B. Extension of Head at the atlanto-occipital joint.
C. The laryngoscope is lift ed upwards levering over the upper
Pneumothorax requires urgent needle thoracocentesis and/
incisors.
or I ntercostal drainage .
D. In a straight blade laryngoscope, the epiglottis is lif ted by Pneumothorax is a known complication of endotracheal
the t ip intubation and mechanical ventilation and is certainly not an
indication for the same.
C
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TOPI C11: I NTUBATI ON ANAESTHESI A 33

INDICATIONS FOR ENDOTRACHERAL I NTUBATI ON 162. True about endotracheal intubation is:
I ndicat ions for Endot r achea ! I nt uba t ion in t he A. I t reduces the normal anatomical dead space
operating room include : B. I t produces resistance to respiration
• The need to deliver positive pressure ventilation C. Sub-glottic oedema is the most common complication
• Protection of the respiratory t ract from aspiration of gastric D. All of the above
content s A
• Surgical procedure involving the head and neck or in non-
supine positions that preclude manual airway support • Endotracheal intubation decreases the normal anatomical
dead space (150ml) to as less as 25ml, and thus providesa
• Almost all situations involving neuromuscular paralysis distinct advantage.
• Surgical procedures involving the cranium, thor ax, or • Endotr acheal int ubat ion increases the resist ance t o
abdomen respiration.
• Procedures that may involve intracranial hypertension To keep resistance at a minimum , use of widest internal
diameter endotrachal tube that will f ill in the larynx is
Some non-operative indicat ions are: recommended.
• Profound disturbance in consciousness with the inability • Subglotic edema, though a complication, is not the most
to protect the airways common one.
• Tracheobronchial toilet ( pulmonary toilet)
• Severe pulmonary or multisystem injury associated with 163. True about endotracheal cuff:
respiratory failure, such as sepsis, airway obstruction A. Low-volume, high pressure
hypoxemia, and hypercarbia B. Low-volume, low pressure
C. High-volume, low pressure
161. Malampatti Grading is for: D. High volume, high pressure
A. To assess mobility of cervical spine E. Equal volume and pressure
B. To assess mobility if atlantotaxial joint A& C
C. For assessment of free rotation of neck before intubation.
D. Inspection of oral cavity before intubation Large volume, low pressure endotracheal tube cuffs are
D claimed to have less deleterious effect on tracheal mucosa
than high pressure , low volume cuffs
I nspection of oral cavity before intubation
Malampatti grading is to assess the ‘size of tongue’, ‘pharyngeal
pillars’, ‘uvula’ etc. prior to endotracheal intubation.

Malampatti grading for assessment of air way :

Grade Structures visible on opening mouth
I Faucial pillars / soft palate / uvula
II I Faucial pillars / soft palate / uvula masked by base of
tounge III Only soft palate
I V Hard palate

164. I ndications of tracheostomy are:

A. Flail chest
B. Head injury
C. Tetanus
D. Cardiac tamponade
E. Foreign body
A, B, C & E

Indications for tracheostomy

To relieve upper airway obstruction
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TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 34

• Foreign body 165. True about Laryngoscopy & intubation except

• Trauma A. Hypertension
• Acute infection - acute epiglottitis, diphtheria B. Tachycardia
• Glottic oedema C. Decreased I CT
• Bilateral abductor paralysis of the vocal cords D. Decreased Intra ocular pressure
• Tumours of the larynx E. Increased lower oesophageal sphincter tone
• Congenital web or atresia Ans c,d,e
To improve respiratory function
• Fulminating bronchopneumonia Application of cricoid pressure reduces LES tone and may cause
• Chronic bronchitis and emphysema the esophagus to be displaced to the side rather than to be
• Chest injury and flail chest compressed. Compression in the backward and upward
Respiratory paralysis direction improves laryngoscopy.
• Unconscious head injury
• Bulbar poliomyelitis
rise in intraocular pressure during laryngoscopy and
• Tetanus
intubation is a matter of concern in patients of acute glaucoma
Advantages of t racheostomy over endotracheal intubation
• Reduces patient discomfort
• Reduces need for sedation Topical anesthesia of oropharynx with lidocaine aerosol
• Improves ability to maintain oral and bronchial hygiene ( 6 ml of 4% for 5 min) prevented hypert ension and
• Reduces risk of glottic trauma tachycardia during laryngoscopy
• Reduces dead space and reduces w ork of breathing
• Au gmen t s process of w eaning from vent ilat ory TOPI C 12 : MUSCLE RELAXANT
support
167. Train of four fade is a characteristic feature of:
Tracheostomy technique A. Depolarizing block
• Patient positioned supine with sandbag between scapulae B. Non depolarizing block
• Transverse cervical skin incision 1 cm above sternal notch C. Both depolarizing and non-depolarizing block
• Incision should extend to the sternomastoid muscles D. Malignant hyperthermia
• Dissect through fascial planes and retract anterior jugular B
veins
• Retract the strap muscles
Train of four fade isa characteristic of a non-depolarizing
• Divide thyroid isthmus and oversew to prevent bleeding
block
• Place cricoid hook on 2 nd tracheal ring
• Stoma fashioned betw een 3 rd and 4 th tracheal rings
• Anterior portion of tracheal ring removed What is a Train of Four Stimulation and Fade
• No advantage in creating a tracheal flap • Train-of-four stimulation denotes administration of four
• Endo-tracheal tube withdrawn to sub-glottis successive 200| is stimuli in 2 seconds (2 Hz)
• Tracheostomy tube inserted using obturator • The pattern seen with a depolarizing block differs from
• When confirmed that in correct position t he ET tube that of a non- depolarizing block
removed With a non depolarizing block t here is progressive
• Tube secured with tapes depression of height with each twitch ( fade)
With a depolarizing block there is equal depression of all four
twitches

Complications of tracheostomy
I mmediate
• Haemorrhage
• Surgical trauma - oesophagus, recurrent laryngeal nerve Train-of- Four
• Pneumothorax
I ntermediate With 2-Hz stimulation, the mechanical or electrical response
• Tracheal erosion decreases lit tle after the fourth stimulus, and the degree
• Tube displacement of fade is similar to that found at 50 Hz. 43 Thus, applying train-
• Tube obstruction of-Four st imulation at 2 Hz provides more sensitivity than
• Subcutaneous emphysema single twitch and approximately the same sensitivity as
• Aspiration & lung abscess tetanic st imulation at 50 Hz. I n addition, this relatively low
Late frequency allows the response to be evaluated manually
• Persistent t racheo-cutaneous fistula
• Laryngeal and tracheal stenosis
• Tracheomalacia
• Tracheo-oesophageal f istula
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TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 35

or visually. Moreover, the presence of a small number of

impulses ( four) eliminates the problem of posttet anic
facilitation. Train-of-four stimulation can be repeated every
12 to 15 seconds. There is a fairly close relationship bet
w een single- t w i t ch depression and t r ain - of - f our
response, 116 and no control is required for the latter. During
recovery, the second twitch reappears at 80 to 90% single- twitch
block, the third at 70-80% , and when blockade is 65-70% , all
four twitches become visible.117 Then, the train-of-four ratio, the
height of the fourth twitch to that of the first twitch, is
linearly related to first twitch height.

When blockade is < 70% . When single-tw itch height has recovered
to 100% , the train-of-four ratio is approximately 70% .

Posttetanic count ( PTC). During profound blockade, no

response is seen t o t r ain- of - four ( TOF) or tet anus.
However, because there is posttetanic facilitation, some twitches
can be seen after tetanic st imulation. I n this example, the
PTC is 9.

168. Phase - I I blocker is:

A. D - TC
B. Cocaine
C. Scoline
D. Vencuronium
C

• Phase - I I blocker is scoline

Depolarising muscle relaxants have dual mechanism of
action ( NM Blockade) :
— Phase - I : Persistent depolarisation of muscle end plate
and is rapid onset.
— Phase - I I : Slow onset, desensitization of the receptor to
acetvlcholine
• Decamethonium and suxamethonium have these actions. D
- TC, Vecuronium are non-depolarising, competitively block
at NM junction on nicotinic (NM)cholinergic receptors,

Succinylcholine Tubocuraine
Phase I Phase II
Administration of Antagonistic Augmented Additive
tubocuraine
Administration of Additive Augmented Antagonistic
Succinylcholine
Effect of neostigmine Augmented1 Antagonistic Antagonistic
Initial excitatory effect Fasciculations None None
on skeletal muscle
Response to a tetanic Sustained2 Unsustained Unsustained
stimulus
Posttetanic facilitation No Yes Yes
Rate of recovery 4-8 min > 20 min3 30-60 min3
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TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 36

169. Drug causing anaphylactoid reaction:

A. Propotol
B. Alcuronium
C. Thiopentone
D. Glycopyrrolate
B

• Development of t rue allergy or antibody formation may of

course occur in days or weeks following exposure to any
of non depolarising muscle relaxants ( i.e. ALCURONIUM)
• They also cause TACHYPHYLAXI S.

170. Neostigmine is used for reversing the adverse effect

of:
A. d - TC + pancuronium
B. d TC only
C. Alcuronium only
D. Ketamine
complicationA

• By interfering with the breakdow n of acetylcholine ,

neostigmine indirectly stimulates both nicotinic and
muscarinic receptors.
• Unlike physostigmine , neostigmine has a quarternary
nitrogen; hence, it is more polar and does not enter
the CNS. its effect on skeletal muscle is greater than
that of physostigmine, and it can stimulate contractility before
it paralyzes.
• Neostigmine has short duration of action , usually thirty
minutes to two hours.

• Neostigmine binds to the anionic site of cholinesterase.

The drug blocks the active site of acetylcholinesterase so
the enzyme can no longer break down the acetylcholine
molecules before they reach the postsynaptic membrane
receptors. This allows for the threshold to be reached so
a new impulse can be triggered in the next neuron.

• I n myasthenia gravis there are too few acetylcholine

receptors so w it h the acetylcholinesterase blocked,
acetylcholine can bind to the few receptors and trigger a
muscular contraction.

• I t is used to improve muscle tone in people with

myasthenia gravis and routinely, in anesthesia at t he
end of anoperation, to reverse the effects of non-
depolarizing m uscle r el a x a nt s such a s r ocu r
onium a nd vecuronium.
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TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 37

• I t can also be used for urinary retention resulting from

general anaesthesia and to treat curariform drug • Shortest acting competitive(non Mivacurium (duration
toxicity. depolarizing) neuromuscular of action 12-18
blocker minutes)
• Another indication for use is the Ogilvie syndrome which is
a pseudoobstruction of the colon in critically ill patients. • Fastest acting non-depolarizing Rocuronium
blocker
• Historically, it has been used as a test for early pregnancy.
I n a non-pregnant female whose menstrual period is • Shortest and fastest acting Succinylcholine
delayed, administ r ation of neost igmine can provoke neuromuscular blocker (overall)
menstrual bleeding. Modern tests which rely on detecting hCG • Longest acting neuromuscular Pancuronium
in urine have rendered this application obsolete. blocker
• Neost igmin e w il l cau se slow ing of t h e h ear t r at e
(bradycardia), for this reason it is usually given along • Histamine release is d-TC maximum tendency,
with a parasympatholytic drug such as atropine or caused by Succinylcholine, Mivacurium,
glycopyrrolate. • Virtually no histamic Pancuronium
release
171. True about Non- depolarizing muscle relax ants: • Maximal vagal block and Pancuronium
A. Competitive inhibitor of acetylcholine T achycardia
B. Metabolised by pseudocholinesterase • Vagal stimulation is caused Succinylcholine
by
C. Mg2+ predisposes the block
D. Ca2+ antagonizes the block • Maximal ganglion blockade d-TC
is caused by
E. Hypothermia prolongs the block
• Ganglion stimulation is Sucinylcholine
A, C, D & E
caused by

* Ch ar act er ist ics f eat u r es of N ondepol a r izing 173. Muscle relaxant excreted exclusively by kidney is:
neuromuscular blocking drugs: A. Scoline
- They are competitive blockers & compete with Ach for B. Atracurium
t h e en d plat e r ecept or s bu t w i t hout ca using C. Vecuronium
depolarization. D. Gallamine
D
- Acts by preventing the access of Ach to the cholinergic
receptor, which are responsible for muscular tone &
Gallamine
contraction.
- Do not cause muscular fasciculation.
- Relatively slow onset ( 1-5 min).
- Am on g all t h e n on - depo lar izin g r elaxan t s, on ly
Mivacurium is metabolized by pseudocholinesterase. ’
- Reversed by neostigmine & other anticholinesterases.
- Effects reduced by adrenaline & Ach.
- The relaxed muscles still responsive to other (mechanical
• Most commonly used muscle relaxant Vecuronium
for routine surgery
• Most potent skeletal muscle relaxant Doxacurium
• Least potent skeletal muscle relaxant Succinycholine
• Least potent non-depolarizing skeletal Rocuronium
muscle relaxant

& electrical ) stimuli.

- Block is potentiated by volatile agents, Mg 2+ & • Rapacuronium is the shortest ating drug.
hypokalemia. • Rapacuronium has been wit hdrawn f rom t he market
- Ca2+ enhances the release of Ach from the motor nerve because it produ ces intense bronchospasm in a
terminal & enhances excitation-contraction coupling in muscles significant number of patients.
thus partially antagonizing the block • Alcuronium is a relatively short acting muscle relaxant.
- mild cooling antagonizing the block, but greater cooling
( < 33° c) potentiates the block.
- Acidosis increases duration & degree of the block.

172. Shortest acting NDMR:

A. Succinyl choline
B. Rapacuronium
C. Atracurium
D. Pancuronium
B
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• TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 38

• “ Urinary Excretion of Gallamine is > 95% .

• I ts billiary excretion is < 1% ”.
• Gallamine
• I t is nephrotoxic so C/ I in Renal Failure * .
• I t crosses placenta so C/ I in Pregnancy* .

• M.R. undergone Hoffman’s elimination —-Atracurium

• M.R. of choice in Renal failure & Hepatic failure
• Atracurium

• At racurium is a neuromuscular- blocking drug or

skeletal muscle relaxant in t he cat egory of non- depolar
isin g neur om uscu lar blocking agent s, u sedadjunctively in
anaesthesia to facilitate endotracheal intubation and to
provide skeletal muscle relaxation during surgery or
mechanical ventilation.
• Side effects owing to histamine liberation are rash,
reflex increase in heart rate, low blood pressure and
bronchospasm.

• M.R. causing maximum Histamine release

• —d-TC*
• M. R. cau sin g m inim um Hist a mine relea se —
Vecuronium*
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TOPI C 12: MUSCLE RELAXANT ANAESTHESI A 39

• M.R. C/ I in Hepatic failure They binds to ach receptors like acetycholine but are incapable
• d-TC, Pancuronium, Scoline* of inducing ion channel opening.
Since acetycholine is prevented from binding to its receptors
no end plate potential develops.
I n t h is w ay t h ey act as compet it ive a nt a gonist of
acetycholine.

• M.R. used in Bronchial Asthma

• Atracurium & Vecuronium

Non depolarizing muscle relaxants are -

Long acting Intermediate Short acting

acting
Tubocurarine Atracurium Mivacurium
Metocurine Cisatracurium Rapacuronium
Doxacurium Vecuronium
Pancuronium Rocuronium
Pipecuronium
Gallamine
Depolarizing muscle relaxant
A summary of the pharmacology of nondepolarizing
These drugs physically resemble Ach and therefore bindto
muscle relaxants.
Ach receptors generating a muscle action potential but
Relaxant Chemical Metabolism Primary Onset 2 Duration3 Histamine Vagal unlike Ach these drugs are not metabolized by
Structure1 Excretion Release4 Blockade5
acetylcholinesterase and their concentration in the
Atracurium B +++ Insignificant ++ ++ + 0
Cisatracurium B +++ Insignificant ++ ++ 0 0
synaptic cleft does not fall as rapidly . This results in
Mivacurium B +++ Insignificant ++ + + 0 continuous prolonged depolarization of muscle end phase.
Doxacurium B Insignificant Renal + +++ 0 0
Pancuronium S + Renal ++ +++ 0 ++
Pipecuronium S + Renal ++ +++ 0 0
Vecuronium S + Bil lary ++ ++ 0 0
Rocuronium S Insignificant Bil lary +++ ++ 0 +

1B, benzylisoquinoline; s, steroidal.

Drug ED95 for Intubation Onset of Duration Maintenance Maintenance

Adductor Pollicis Dose Action for of Dosing by Dosing by
During N2/O2 intubating Intubating Boluses Infusion
(mg/kg)
Anesthesia Dose Dose (mg/kg) (mg/kg/min)
(mg/kg) (min) (min)
Succinylcholine 0.5 1.0 0.5 5-10 0.15 2-15 mg/min
Rocuronium 0.3 0.8 1.5 35-75 0.15 9-12
Mivacurium 0.08 0.2 2.5-3.0 15-20 0.05 4-15
Atracurium 0.2 0.5 2.5-3.0 30-45 0.1 5-12
Cisatracurium 0.05 0.2 2.0-3.0 40-75 0.02 1-2 175. Cardiovascular side effects are minimal with
Vecuronium 0.05 0.12 2.0-3.0 40-90 0.01 1-2 A. Pancuronium
Pancuronium 0.07 0.12 2.0-3.0 60-120 0.01 -
B. Rocuronium
Pipecuronium 0.05 0.1 2.0-3.0 80-120 0.01 -
Doxacurium 0.025 0.07 4.0-5.0 90-150 0.05 -
C. Doxacurium
D. Vecuronium
174. . The neuromuscular blocking action of Curare is E. Mivacurium
brought about by B,C & D
A. Blocking Acetylcholine synthesis
B. Preventing the release of Acetylcholine 176. Which one of the follow ing muscle relaxant hasthe
C. Causing persistent depolarization maximum duration of action?
D. Competitive inhibition A. Atracurium
D B. Vecuronium
C. Rocuronium
Curare are also called non depolarizing muscle relaxants. D. Doxacurium
Non depolarizing muscle relaxants competitively inhibit D
acetylcholine
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TOPI C 13: PROPOFOL ANAESTHESI A 40

179. Which of the following statements about propofol

TOPI C 13: PROPOFOL
is not true?
A. I t is contraindicated in porphyria
B. I t does not t rigger malignant hyperthermia
C. Commercial preparations contains egg
D. I t is a suitable agent for day care surgery
A

Propofol can be used safely in porphyria & malignant

hyperthermia
• Propofol is an oil based preparation containing egg
lecithin
177. The following combination of agents are the most I t is an alkylphenol, 2, 6-Disopropylphenol.
preferred for short day care surgeries I t is highly soluble in lipid but insoluble in water so it is presented
A. Propofol, fentanyl, isoflurane as a 1 or 2 percent emulsion in 10 percent soyabean oil
B. Thiopentone sodium, morphine, halothane with 1.2 percent egg phosphatide as the emulsifying
C. Ketamine, pethidine, halothane agent
D. Propofol, morphine, halothane The addit ion of disodium edet at e ( 0. 005% ) supresses
A bacterial growth.

For day care surgery patients are sent back home the same day. • Propofol is considered the agent of choice for day care
Therefore you need agen t s w hich are rapidly eliminated anaesthesia.
so that no after effects are left. The agents used are- Smoot h induct ion, rapid onset of act ion , easy
- Propofol t it ration to effect, short clinical duration of action and dem
- Alfentanil onst r able ant iemet ic ef f ect make propofol aninduction
- Remifentanil agent of choice for day care anaesthesia.
- N2 0
- Isoflurane • Propofol is non contraindicated in porphyria
- Sevoflurane
Propofol is considered safe in porphyria -
- Desflurane
• Propofol does not trigger Malignant Hyperthermia
‘Propofol is the intravenous induction agent of choice ’
Propofol has been recommended as the agent of choice for
because of its early induction and smooth recovery.
induction is suscept ible individuals for malignant
Patients remain clear headed and have low incidence of
hyperthermia
post operative nausea and vomiting.
182. A 38 year old man is posted for extraction of last molar
tooth under general anaesthesia as a day care case. He
wishes to resume his work after 6 hours. W hich one
of t he follow ing induction agent s is preferred:
A. Thiopentone sodium
B. Ketamine
C. Diazepam
D. Propofol
D

The patient in question wishes to resume his work after

6 hours and hence needs a day care anaesthetic agent that
Day case surgery Agent of choice
has the advantage of rapid recovry and lit tle incidenceof post
Intravenous induction Propofol
agent recovery compilations. Propofol as described above is such
Desflurane >Isoflurane an agent of choice.
Inhalation induction
agent Alfentanyl Remifentanyl
Intravenous opioid
183. True about Propofol
analgesia A. I t suppress adrenocortical hormone
Mivacurium
B. I .M. injection is not painful
C. Hepatic metabolism
Muscle relaxants
D. Di-isopropyl phenol
Agents used in day care anaesthesia include : E. Cerebral protector
1. Propofol B, C, D & E
2. Alfentanyl, Remifentanyl
3. Isoflurane, Sevoflurane, Desflurane * Propofol ( 2, 6 - diisopropyl phenol) is an intravenous
4. Met hohexitone anaesthetic agent.
5. Thiopent one
6. Etomidale
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TOPI C 14: I SOFLURANE ANAESTHESI A 41

* The main disadvantage in t he use of propofol is t he age; maintenance of general anesthesia in adult patients
and pediatric patients older than 2 months of age; and
production of pain on its injection into small veins.
sedation in medical contexts, such as intensive care
This can be decreased by selecting larger veins or by prior
administration of 1% Lidocaine or a potent short-acting
unit ( I CU) sedation for intubated, mechanically
opioid. vent i la t e d a dult s , an d in pr ocedu r es su ch as
* Propofol metabolism in the liver is rapid & extensive. colonoscopy.
• I t provides no analgesia
* Propofol reduces cerebr al metabolic rat e of oxygen
( CMRO2) without reduction of cerebral perfusion
• 20 ml ampoule of 1% propofol emulsion
pressure ( CPP), producing cerebral protection.
• A common hospital-worker slang term for Propofol is “Milk of
• Etomidate is also an anaesthetic agent w hich Amnesia/ Milk of Anesthesiologists
suppresses the secretion of cortisol.

1 8 4 . A 2 0 - year - old pat ient present ed w i t h ea rly

pregnancy for Medical Termination of Pregnancy
( MTP) in day care facility. What will be the anesthetic
induction agent of choice?
A. Thiopentone
B. Ketamine
C. Propofol
D. Diazepam
C

Rapid induction of propofol is due to its high I ipid solubility

and rapid recovery is due to very short distribution.

185. . The follow ing anaesthetic drug causes pain on • The elimination half-life of propofol has been estimated
intravenous adminstration: to be between 2–24 hours. However, its duration of clinical
A. Midazolam effect is much short er because propofol is rapidly
B. Propofol distributed into peripheral tissues , and its effects
C. Ketamine therefore wear off considerably within even a half
D. Thiopentone sodium hour of injection.
B • This, together with its rapid effect ( within minutes of injection)
and the moderate amnesia it induces makes it an ideal
• i t is int r a a rt er ial ( not in t ravenous) in j ect ion of drug for I V sedation .
thiopentone, that causes intense pain. • Aside f r om t h e hypot ension ( m a inly t hr ough va
• I ntraarterial injection of thiopentone induces severe sodilat a t ion) and t ra nsient a pnea f ollow ing
inflammatory and potentially necrotic reaction and induction doses
should be avoided. I ts intravenous injection does not produce • one of propofol’s most frequent side effects is pain on
pain. injection, especially in smaller veins . This pain can be
mitigated by pretreatment with lidocaine.
• I nt ra venous inj ect ion of propofol f requent ly
• Pat ient s t end t o show great varia bilit y in t heir
produces pain.
response t o propofol , at t imes showing profound
sedation with small doses.
186. I nduction agent for Day care Surgery is:
• Propofol has been known to cause an adverse reaction in some
A. Ketamine
patients, known cases include myoclonia and dystonia.
B. Diazepam Note this is extremely rare.
C. Thiopentone • Propofol appears to be safe for use in porphyria , and has
D. Propofol not been known to t rigger malignant hyperpyrexia.
D • A recent ly described r are but serious side effect is
propofol infusion syndrome . This potentially lethal
Propofol metabolic derangement has been reported in critically-
ill patients after a prolonged infusion of high- dose
• “Propofol is used as in inducing agent for day care propofol in combination with catecholamines and/
surgery because residual impairment is less marked and or corticosteroids
incidence of post operative nausea and vomiting is low.”
TOPI C 14: I SOFLURANE
• Day care anaesthesia −−− I soflurane
• Day care analgesic −−− Alfentanyl 187. I n raised intracranial tension, anaesthetic agentused
is
• Propofol is a short- acting intravenous anesthetic agent A. Nitrous oxide (N2O)
used for the induction of general anesthesia in adult patients B. Trichloroethylene
and pediatric patients older than 3 years of C. Enflurane
D. Isoflurane
D
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TOPI C 14: I SOFLURANE ANAESTHESI A 42

“All inhalational agents are cerebral vasodilators this • Isoflurane may cause coronary steal phenomenon , it is
vasodilation causes increase in blood flow which powerful caronary dilator
causes increase in intracranialpressure.”
Among the inhalational agents I soflurane causes the least
increase in cerebral blood f low . Therefore it is most suitable
inhalational agents in increased intracranial pressure.

I soflurane -
- I t has got least effect on heart
- Agent of choice in renal and hepatic failure
- I t has got rapid induction and recovery
- Pupils do not dilate and light reflex in not lost even at
deeper levels.
- I t does not provoke seizures
I t produces profound respiratory depression • I soflur ane is t he preferred agent for neuro surgical
anaesthesia as in Low concentration it does not cause any
188. Which of the following statements about inhalation increase in cerebral blood flow.
anesthetic agents is wrong?
A. Sevoflurane is more potent than isoflurane
B. Sevoflurane is less cardiodepressant than isoflurane
C. Desflurane has lower blood-gas partition coefficient than
sevoflurane
D. Sevoflurane has a higher MAC than isoflurane
A& D

Compared with isoflurane, sevoflurane is less potent

and lacks coronary vasodilating properties’

1 8 9 . W hich a na est het ic a gent ha s t he lea st

cardiovascular effect: • I soflurane is used is day care surgery.
A. Isoflurane
B. Enflurane
C. Tnlene
D. Ketamine
A

I soflurane
• Of the various inhalation agents available, isoflurane has the
advantage of providing stability to cardiac rhythm and t h e
lack of sensit izat ion of h eart t o exogen ous or endogenous • Isoflurane is always administered in conjunction with air
adrenaline and/ or pure oxygen . Often nitrous oxide is also used.
• I t causes less myocardial depression than halothane on
enflurane. Isoflurane for maintainence not induction
I t thus causes the least alternation of cardiovascualar stat • Although its physical properties means that anaesthesia can
us. be induced more rapidly than with halothane , its
pungency can irritate the respiratory system, negating t his
t heoret ical advant age conferred by it s physical properties.

• I t is usually used to maintain a state of general anesthesia that

has been induced w ith another drug, such as thiopentone
or propofol.
• I t vaporizes readily, but is a liquid at room temperature.
• I t is completely non- flammable.
• I soflurane reduces pain sensitivity ( analgesia) and
relaxes muscles

190. Anaesthetic agent of choice in renal failure is:

A. Methoxyflurane
B. Isoflurane
C. Enflurane
D. None of the above
B
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TOPI C 15: OPI OI DS ANAESTHESI A 43

Isoflurane ‘Of the various inhalation agents available, isoflurane has

• Methoxyflurane has a high nephrotoxic potential the advantage of providing stability of cardiac rhythm
• Enflurane is best avoided as nephrotoxic levels of and lack of sensitization of the heart to exogenous and
fluoride ions have been seen just after 3.5 MAC-hours. endogenous adrinaline. ’ -
• Isoflurane, sevoflurane, desflurane and halothane result Isoflurane is stable and unlikely to be toxic.
in lit t le or no increase in fluoride levels and are
preferred. 194. Fluoride content is least:
A. Methoxyflurane
191. A man with alcoholic liver failure requires general B. Enflurane
anesthesia for surgery. Anaesthetic agent of choice is: C. Isoflurane
A. Ether D. Sevoflurane
B. Halothane C
C. Methoxyflurane
D. Isoflurane Among all the fluorinated anesthetic agents mentioned here, isof
D lu r an e is h avin g t h e least f lu or i de con t en t &
methoxyflurane is having the highest amount of fluoride cont
ent .
I soflurane
The higher the f luoride content, the more the side effect
of the drug.
Anaesthesia in chronic alcoholism :
Chronic alcoholism damages the liver but also induces drug
TOPI C 15: OPI OI DS
metablism enzymes so the response to drugs is not always
predictable .
195. Neurolept analgesia all are true except:
A. Can be used along with N2 0 oxygen
Common agent employed include :
B. Causes focal dystonia
• Midazolam is useful for sedation.
C. Fentanyl - droperidol
• Regional analgesia should be considered
D. Causes hypotension
• I soflurane or sevoflurane are suitable anaesthesitc
NONE
agents.
• ‘Neurolept analgesia’ is Fentanyl and droperidol combination and
• The perioperative use of certain narcotic opioids such as
when 65% N2 O + 35% O2 is adminstered it is converted to
morphine and oxycodone should be avoided in patients
‘Neurolept anaesthesia’.
with cirrhosis, because their bioavailability is markedly
• Muscle dystonia, abnormal movements can occur as an
increased and their half-life prolonged.[ 6] By contrast,
extrapyramidal side effect of droperidol .
metabolism of fentanyl does not seem to be affected
• Fall in BP ( due t o a —adrenergic blocking act ion of
by hepatic dysfunction .
droperidol) is generally slight unless hypovolemia is
present or patient’s posture is changed .
• The metabolism of cert ain benzodiazepines ( such as
Heart rate often decreases ( fentanyl stimulates vagus) but
midazolam and diazepam) can also be slowed in patients with
heart is not sensitized to adrenaline.
cirrhosis, whereas oxazepam and temazepam undergo
• Droperidol sometimes cause hypotension.
conjugation without hepatic metabolism and their
clearance rate is, therefore, not affected .
196. Best antagonist of Morphine
A. Pentazocine
• I n pat ient s wit h hepat ic dysfunct ion, t he increased
B. Buprenorphi ne
duration of action of benzodiazepines and narcotics can
C. Naloxone
lead to prolonged depression of the central nervous
D. Nalorphine
system and hepatic encephalopathy ; these agents should, C
therefore, be used with caution in the perioperative setting.
• Of the volatile anesthet ics, isoflurane is generally Naloxone
recommended as it undergoes the least amount of
hepatic metabolism and does not impair hepatic bloodf • T/ t of choice for morphine poisoning is Naloxone ( 6 mg.IV)
low . repeated every 3 min till respiration picks up)
• By contrast , halot hane undergoes significant hepat ic
• I t is preferred due to no agonist ic act ion and no
metabolism and reduces hepatic blood f low . Halothane
respiratory depression.
anesthesia carries with it a significant risk of drug-induced • Nalorphine is given only when Naloxone not available
hepatitis
1 9 7 . W hich of t he follow ing opioids is not given
192. Least Cardiotoxic anaesthetic agent intrathecally
A. Enfluranc A. Remifentanil
B. Isoflurane B. Morphine
C. Sevoflurane C. Sufentanil
D. Halothane D. Fentanyl
B A
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TOPI C 15: OPI OI DS ANAESTHESI A 44

Remifentanil is not used intrathecatly because glycine in the drug 201. Which one of the following is the description used
vehicle can cause temporary motor paralysis. I t is generally for the term allodynia during pain management?
given by continuous, intravenous infusion , Opioids such A. Absence of pain perception
as Mor ph in e, Diamor ph in e, Pet hiden (Meperidene), B. Complete lack of pain sensation
Fentanyl and Sufentanil may all be used intra thecally C. Unpleasant sensation with or without a st imulus
D. Perception of an ordinarily nonnoxious sitmulus as severe
pain
198. Drug with Ceiling effect D
A. Morphine
B. Buprenorphine
C. Fentanyl Terms used in pain management
D. Mfentanyl Allodynia Perception of an ordinarily nonnoxious
B stimulus as pain
Analgesia Absence of pain perception
Anaesthesia Absence of all sensations
Buprenorphine is most potent opoid used for epidural
Analgesia. Dysesthesia Unpleasant or abnormal sensation with or
without a stimulus
Because of its ceiling effect and poor bioavailability,
buprenorphine is safer in overdose than opioid full agonists Hypalgesia Diminished response to noxious
stimulation
• Advantages of buprenorphine in the t reatment of chronic Hyperalgesia Increased response to noxious stimulation
pain are, from a clinical perspective, its relatively long half- Hyperaesthesia Increased response to mild stimulation
life, the option of sublingual and transdermal application Hyperpathia Presence of hyperaesthesia, allodynia and
and the excellent safet y profile ( ceiling effect for hyperalgesia usually associated with
respiratory depression, lack of immunosuppressive overreaction and persistence of sensation
effect, low pharmacokinetic interaction potential, after the stimulus
no accumulation in renal impairment Hypoaesthesia Reduced cutaneous sensation (e.g. light
touch, pressure or temperature)
199. 0 .5 mg Buprenorphine equivalent of: Neuralgia Pain in the distribution of a nerve or a
A. 10 mg tramadol group of nerves.
B. 6 mg morphine Paresthesia Abnormal sensation perceived without an
C. 75mg of pentazocine apparent stimulus
C Radiculopathy Functional abnormality of one or more
roots
• The potency of opioids in mg, relat ive t o lOmg of
morphine are: 20 2 . A 52 year old male diagnosed as triple vessel coronary
Pentazocine = 30 mg artery disease with poor left ventricular function.
Nalbuphine = 10 mg Coronary artery bypass grafting surgery w as
Butorphanol = 2 mg decided. During maintenance of anaesthesia w hich
Buprenorphine = 0.2 mg one of t he f ollow ing a gent s should bepreferred?
Dezocine = 10 mg A. IV Opioids
Meptazinol = 100 mg B. Isoflurane
Pethidine (Meperidine) = 75 mg C. Halothane
Fentanyl = 0.1 mg D. Nitrous oxide
Sufentanil = 0.01 mg A
Alfentanil = 1 mg
Met hadone = 10 mg Maintenance anaesthesia in patients w ith coronaryheart
Tramadol = 100 mg disease.
So, 0.5 mg of Buprenorphine = 25 mg of Morphine = 250mg - Isoflurane is the most common maintenance anaesthesia used
of Tramadol = 75mg of Pentazocine. in these cases, but doubts have been raised regarding its
safety in patients with coronary artery disease.
200. Which one of the common side effects is seen with
fentanyl? - I soflurane causes vasodilat at ion of coronary
A. Chest wall rigidly arteries, so it is feared that it can cause coronary steal
B. Tachycardia phenomenon.
C. Pain in abdomen - I soflurane also causes minimal cardiac depression.
D. Hypertension Many anaestheists believe that opioids are better in these
A cases, opioids do not have any direct depressant on heart
and are also helpful in cases of heart failure.
Opioids ( part icularly Fentanyl, Sufent anil and
Alfentanil) can induce chest w all rigidity severe The major disadvantage with the use of opioids is patient
enough to prevent adequate ventilation. awareness and respiratory depression.
This centrally medicated muscle contraction is most frequent after The prospective clinical trials on isoflurane have not been
large drug boluses and is effectively treated with able to prove that it causes coronary steal.
neuromuscular blocking drugs.
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TOPI C16: BUPI VACAI NE ANAESTHESI A

Coronary heart disease patients is 205. Cholinesterase metabolizes following except:
Pts with poor Left ventricular function A. Propanidid
“ Maintenance anaesthesia of choice is — I .V. opioids B. Procaine
Pts with good Left ventricular function
C. Acetyl choline
Maintenance anaesthesia of choice is — I soflurane
D. Bupivacaine
Advantages of I soflurane in patients with CHD D

• They reduce myocardial O 2 requirement

• Protective role in reperfusion injuries Disadvantages of

I soflurane in patients with CHD Bupivacaine is not metabolized by cholinesterase. Rest of the
• Negative inotropic effect
dr ugs are met abolized by cholinest er ase & causes
• Cause coronary vasodilatation that can lead to coronary
hydrolysis.
steal
• Tachycardia and hypotension
207. Which of the following is long acting local anesthetic
Advantage of i.v. opioids in patients with CHD > 2 hrs
• They do not have any direct depressant effect on heart A. Bupivacaine
• There is no effect on Contractility Automaticity Conduction
B. Prilocaine
sensitivity to catecholamines
C. Etidocaine
Due to these advantage, i.v. opioids have become the mainstay
of anaesthesia in pts with poor left ventricular function. D. Lignocaine
A& C
Disadvantages of i.v. opioids
• Patient awareness Procaine 30-60
• Prolonged respiratory depression, postoperatively
• Opioids also fail to consistently control the hypertensive Lignocaine 60-120
response to stimulation.
T etracaine 180-480
203. Which one of the following is the shortest acting Bupivacaine 180-600
intravenous analgesic:
A. Remifantanil. Repivacaine 180-360
B. Fentanyl. Etidocaine 240-480
C. Alfentanil.
D. Sufentanil • Bupivacaine
A
Metabolism Hepatic
All of these are included in short acting narcotic analgesics.
This shortest acting among them is Remifentanil. Half life 3.5 hours (adults)
Onset Duration 8.1 hours (neonates)
Remifentanil 30s - 60s 5-5 minutes Excretion Renal, 4-10%
Alfentanil 0.5 m 5-10 minutes
* Prilocaine is having intermediate duration of action like lignocaine.
Fentanyl 1-4 m in 30 min
Sufentanil 1-4 m in 30 min
208. . Bupivacaine
TOPI C 16: BUPI VACAI NE A. Less cardiotoxic than prilocine
B. I t is an amide
204. The topical use of follow ing local anesthetic is not
C. The max dose tolerable is 8 mg/ kg/ body wt
recommended
D. Duration more than 2 hrs
A. Lignocaine
B. Bupivacaine B& D
C. Cocaine
D. Dibucaine • Bupivacaine is an amide type local anaesthetic drug.
B – I t is reputed to be four times as potent as both Mepivacaine
& Lignocaine.
Local anaesthetics * I t is more cardiotoxic than other local anaesthetics & is made
Used as surface Can not be used as surface worse by hypoxia, hypercapnia & by pregnancy. So, it is
anaesthetics anaesthetics not used for I .V. regional anaesthesia ( Bier’s block)
(a) Cocaine (a) Bupivacaine .
(b) Lidocaine (b) Procaine * I t causes more sensory than motor block & its duration
(c) Dibucaine (c) Mepivacaine of effect is between 5 & 16 hr.
(d) T etracaine Maximum safe dose that can be used is 2 mg/ kg.
(e) Benzocaine
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ANAESTHESI A
209. . Levo- bupivacaine is administered by w hich of TOPI C 17: PI N I NDEX
; follow ing routes
A. Nasogastric
B. Epidural
C. Intra- venous
D. Intra-theccal
E. Oral
B

• Commercial bupivacaine is a racemic mixture of both ‘R’ &

‘S’ isomers.
Levobupivacaine is as effective as racemic one & being ‘S’
isomer has the potential for reduced toxicity.

I t can be used by the following routes.:

212. . Pin index system is a safety feature adopted
- I ntrathecal
in anaesthesia. Machines to prevent:
- Epidural A. Incorrect attachment of anaesthesia machines.
- Peripheral nerve blocks B. Incorrect attachment of anaesthesia face masks.
• Bupivacaine is more prone to induce cardiac arrythymia & C. Incorrect inhalation agent delivery.
should not be used for I V regional anaesthesia. D. Incorrect gas cylinder attachment
D
210. Which one of the following local anaesthetics is highly
cardio- toxic: To understand this and the next question you are requiredto
have a preliminary knowledge of Boyle anaesthesia
A. Lignocaine
machine.
B. Procaine
Boyle anaest hesia machine is a cont inuous f low type of machine
C. Mepivacaine used for administration of inhalational anaesthesia.
D. Bupivacaine I t is equipped with tw o oxygen cylinders, tw o nitrous
D oxide cylinders, one carbondioxide cylinder and one
cyclopropane cylinder.
211. . A 30 - year- old lady is to undergo surgery under
intravenous regional anesthesia for her left ‘t rigger These cylinders are locked to Boyle apparatus in metal yoke
w ith two pins and fiting holes on the cylinder head.
finger’. Which of the following should not be used
Each cylinder has a particular pin code and unless the
for this patient
correct cylinder valve is attached the pins and holes will not
A. Lignocaine coincide. Thus it is practically impossible to f it any cylinder to
B. Bupivacaine wrong yokes.
C. Prilocaine
D. Lignocaine + Ketorolac
B

I ntravenous regional anaesthesia or Bier’s block is used for

producing intense surgical anaesthesia for short surgical
procedures of the forearm and hand.
An esmarch bandage or an orthopaedic pneumatic splint
is used to compress the arm or the forearm.

The anaesthetic is inserted on the dorsum of the hand through an 213. The Pin index code of Nitrous oxide is:
A. 2,5.
intravenous catheter.
B. 1, 5.
This techqnique is most commonly used for carpal tunnel
C. 3, 5.
release. D. 2,6
C
Local aneasthetics used are –Lidocaine ,Prilocaine
Local anaest hetic cont r aindica t ed - Bupivacaine Pin index for the following gases are-
{ because of its potential side effects). • Nitrous oxide -> 3 and 5
• Oxygen -> 2 and 5
Bupivacaine prolongs QTC and cause vent ricular • Cyclopropane -> 3 and 6
tachycardia or cardiac depression. • Carbondioxide -> 1 and 6
I nternational colour code for cylinders
The site of action of drug in this technique is peripheral
• Oxygen* -> black with white shoulders
nerve ending.
• Nitrous oxide* -> Blue

HELP LI NE NO. 9391567707

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MI NORTOPI CS ANAESTHESIA 43

• Carbon dioxide* -> Gray • NO is a colourles, odourless, heavier t han air, non-
2
• Cyclopropane* -> Orange inflammable gas supplied under pressure in steel cylinders
• Colour of cylinder is blue
214. For High Pressure Storage of compressed gases, • Pressure of cylinder is 750 I b/ sq. inch (Psi)
Cynlinders are made up of: • Pin-index is 3, 5
A. Molybdenum steel MAC- value between 100% and 105%
B. I ron + molybedenum
C. Cooper + steel
D. I ron
A

Molybdenum steel
“ Cylinders are made of molybdenum steel”

• Comparison of different medical gases commonly used are

:
Gas Colour Of Pin Index State In Pressure Volume Filling
Cylinder Cylinder Density
Oxygen White 2,5 Gas 1900 660l ' 68%
Psig
Nitrous Blue 3,5 Gas
Oxide Liquid < 745 Psig 1590
98°f

215. . An anaesthetist orders a new attenant to bring 218. All of the following are used to maintain proper
oxygen flow to the patient except:
the oxygen cylinder. He w ill ask the attendant to
A. Placement of nitrogen f lowmet er dow nstream of t he
identify the correct cylinder by following color code:
A. Black cylinders with white shoulders oxygen f lowmeter
B. Black cylinders with grey shoulders- B. A proportionater between N2 and O2 control valve
C. White cylinders with black shoulders C. Different pin index for nitrogen and oxygen
D. Grey cylinder with white shoulders D. Calibrated oxygen concentration analyses
A C

• Pin index safety system for cylinders prevents incorrect

Gas Colour of Cylinder cylinder attachments.
Oxygen Black body, white
shoulder I t is a safeguard in t r odu ced t o elim inat e cylinder
interchanging and the possibilit y of accident ly pla
Air Grey body, black and cing t he in correct gas on a yoke designed t o accomodate
white shoulder another gas.
N2O Blue I t has nothing to do with hypoxia.
Entonox (O2 and N2O Blue body, white and The systems used to prevent
mixture in equal blue quartered shoulder hypoxia:-
volume) Low oxygen pressure alarm It detects oxygen supply failure at
the common gas inlet that activates
Cyclopropane Orange a gas whistle or electric alarm
Carbondioxide Grey Minimum oxygen/nitrous oxide Prevent delivery of less than 21 %
ratio controller device (hypoxic oxygen
Thiopentone Yellow guard)
Oxygen must enter the common Prevent hypoxia in event of
Halothane Amber (Purple - Red) manifold down-stream to other proximal gas leak
gases
217. True about N2O cylinder Oxygen concentration monitor Prevents administration of hypoxic
A. Pressure is 2200 PSI and alarm gas mixtures in event of a low
B. Blue in colour pressure system leak; precisely
regulate oxygen concentration
C. Gas in liquid form
D. Pin index 3.5
TOPI C 18: MAC
E. I t is flammable
B,D
219. Partition coefficient of gas:
A. Measure of potency
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MI NORTOPI CS ANAESTHESIA 44

B. Directly proportional to potency response to a painful stimulus (surgical incision) in 50%

C. Measures solubility individuals. I t is accepted as a valid measure of potency of
D. All of the above inhalational GAs because it remain fairly constant for a
given species even under varying conditions.
C
222. Characteristic of an ideal gas is:
A. Volume is directly proportional to change in pressure
• Blood/ Gas partition co-efficient is the ratio ( at equillibrium)
B. Volume is inversely proportional to change in temperature
of concentration in blood to that in Gas.
• I t measures the solubility of the gas. C. At absolute temp, volume of gas is 1
D. Obeys charles, boyles and avagadro’s laws
The MAC ( minium alveolar concentration) measures t he
potency of inhalational anaesthetics.
D
The MAC of a no. of GAS shows excellent correlation
• An ideal gas obeys charle’s, boyle’s and avogadro’s law.
with their oil/ gas partition co-efficient.
Boyle’s Law : - Volume (V) is inversely proportional to the
pressure.
For a highly soluble gas-alveolar concentration can rise
SLOWLY w here as a low solu ble gas- t he alveolar concent Charles’s Law : - Volume of a given mass of gas is proportional
rat ion r ises RAPI DLY so, t here is an inverse relationship. to its^ absolute Temperature if pressure remains constant.

220. All of the following factors decrease the Minimum 223. The potency of an I nhalational anesthetic depends on:
A. Blood gas partition co-efficient
Alveolar Concent rat ion ( MAC) of an inhalat ion
B. Oil-gas partition co-efficient
anaesthetic agent except.
C. Gas pressure
A. Hypothermia
D. Blood pressure
B. Hyponatremia
C. Hypocalcemia B
D. Anemia
C • The physical property of anaesthetic that correlates best with
anaesthetic potency is the lipid solubility (i.e., oil-gas part it
Minimum alveolar concentration ion co-efficient ) , whereas t he best est imat e ofanaesthetic
- I s t he con cent r at ion of anaest het ic gas needed t o eliminate potency is the minimum alveolar concentration (MAC) (at 1 atm)
movements among 50% of patients challenged by of an agent that produces immobility in 50% of those subjects
standardized skin incision. The MAC is usually expressed as exposed to a noxious stimulus.
percentage of gas in a mixture required to achieve the effect . The MAC of a number of GAs part ion coefficient shows excellent
correlation with their oil-gas. partition coefficient The blood-
Factors causing decrease in MAC. gas partition coefficient is the r atio of the concentration of
1. Hypothermia anaesthetic in blood to that in the gas phase. I t is an index
2. Anaemia of solubility of the GA in blood. The uptake of anaesthetics
3. Hyponatremia depends on blood-gas coefficient.
4. Pregnancy
5. Hypoxemia 2 24 . Low est concent ration of Anaest hetic agent in
6. Cholinesterase inhibitors pulmonary alveoli needed to produce immobility in
7. Reserpine, a methyldopa response to painful stimulus in 50 % individual is termed
8. Severe hypotension as:
A. Minimal alveolar concentration
Factors causing increase in MAC: B. Maximum alveolar concentration
1. Hyperthermia C. Maximum analgesic concentration
2. Hyperthyroidism D. Minimum analgesic concentration
3. Alcoholism A
4. Hypernatremia
Rem em ber , n u m er ically MAC is sm a l l f or pot ent Minimal alveolar concentration
anaesthetics, such as halothane and large for less potent • Minimal alveolar concentration (MAC)
anaesthetics such as nitrous oxide. “ is the lowest concentration of the anaesthetic in
Therefore the inverse of MAC is an index of potency of pulmonary alveoli needed to produce immobility in response
the anaesthetic. to a painful stimulus in 50% individuals.
I t is accepted as a valid measure of pot ency of
221. I ndex of potency of general anaesthesia inhalational general anesthetics.”
A. Minimum alveolar concentration
B. Diffusion coefficient Meyer-Overton hypothesis
C. Dead space concentration • The MAC of a volatile substance is inversely proportional to
D. Alveolar blood concentration its lipid solubility ( oil:gas coefficient) , in most cases.
A • This is the Meyer-Overton hypothesis. MAC is inversely
related to potency i.e. high mac equals low potency.
• MAC is the lowest concentration of the anaesthetic in
pulmonary alveoli needed t o produce immobilit y in
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MI NORTOPI CS ANAESTHESIA 45

TOPI C 19: MC GI LL CI RCUI T

228 . I n Magil circuit, Airflow is:

A. Equal to Minute Alveolar Ventilation
B. Half of the Minute Volume
C. Equal to Minute Volume
D. Twice the Minute Volume
C

• I n gen er al an aest h esia, r ecover y an d em ergen cy

resuscitation procedures involve the use of a breathing syst
Mapleson D
em. The pr inciple of anaest het ic syst ems is t oefficiently
(Coaxial Bain)
eliminate exhaled carbon dioxide, without greatly increasing
• This system is mainly used with spontaneous respiration.
dead space or resistance.
• The Fresh Gas Flow is close to the patient and the APL
• In 1954 Mapleson classified breathing systems based on
their efficiency in eliminating carbon dioxide during valve is placed away from the patient . The risk of
rebreathing in this circuit will be high especially in patients
spontaneous respiration .
who have a short expiratory pause or do not have an
• The breat hing syst ems are classified in order of
expiratory pause ( infant s). To overcome this problem a high
increased requirement of fresh gas flow ( FGF) to pr
FGF of 2 - 4 times of the patient’s Minute Volume is required. I
event r e br ea t hing dur ing spont a neous
f Mapleson D is used with controlled or assisted ventilation
respiration.
a high FGF is required to prevent all rebreathing. In practice
• System A requires 0.8 - 1 times, B and C require 1.5-2 times
some rebreathing is tolerated and in an adult an FGF of 6
and D, E and F require 2-4 times of the patient’s minute
- 7 litres/ minute will maintain a normal arterial C02 tension.
volume.

Equal to Minute alveolar Ventilation

‘Mapleson system A is also known as Magill system’ :
This is t he most efficient syst em w it h spont aneous
respiration

Mapleson E
(I nfant T-piece, and Ayres T-Piece without Bag)
• This system is primarily for use in neonates and paediatrics,
A flow of about 5 L/ min ( equal to minute ventilation)is where low resistance is of great importance . There
required in young healthy patients to f lush Co from
2
the is no APL valve ( to reduce resistance) and a high FGF, 2 -4
system) times of the patient’s Minute Volume (with a minimum flow
of 3 litres/ minutes) is required to eliminate rebreathing risk
Mapleson B during spontaneous ventilation.
• In this system the Reservoir bag, fresh gas supply
and APL valve are closer to the patient . This will cause
mixing of inspiratory and expiratory gases and therefore a
higher f low rate (1.5 - 2 times of the patient’s minute
volume, i.e. 12 - 16 lit res/ min) is required to prevent
rebreathing during spontaneous respiration. Due to the
risk of rebreathing and reduced delivery of oxygen
rich gases to the patient this system is no longer
used.

• This system is recommended for up to 22kg (approximate tidal

volume of 140ml).
• This system recommends that total fresh gas flow should be
about twice the minute volume of the patient ( and volume of
the reservoir tube equal to about 1/ 3rd of the t idal
volume)
• Mapleson C The main advantage of a ‘T’ piece is the absence of Resistance
(Waters Bag, Bagging System (Adult, Direct and Paediatric) and to Expiration a factor of crucial importance to children.
Resuscitation Bag)
This system is similar to Mapleson B , however, the bag is Jackson Rees m ade a great improvement t o T- Pieces
positioned very close to the patient. This system is used for (Mapleson E) by adding an open tail 0.5 litre reservoir
manual ventilation during resuscitation. A flow rate of bag to the end of expiratory ( reservoir) limb .
1.5 - 2 t imes of the Minute Volume is required to avoid
rebreathing
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MI NORTOPI CS ANAESTHESIA 46

This allows manual ventilation and the application of Positive End • Mapleson C
Expiratory Pressure ( PEEP) to help maintain open airways. Used in postoperative recovery room
• Mepleson D
Mapleson F Most efficient in assisted and controlled ventilation
• Jackson Rees Modification (Infant T-piece, and Ayres T- Piece • Mepleson E
with open end Bag) Used in infants and children (flow rate = 2x minute volume)
Jackson Rees m ade a great improvement t o T- Pieces I t is as efficient as Mepleson D in assisted and controlled
(Mapleson E) by adding an open tail 0.5 litre reservoir ventilation
bag to the end of expiratory ( reservoir) limb . Also known as Ayre ‘s tube.
This allows manual ventilation and the application of Positive End
Expiratory Pressure ( PEEP) to help maintain open airways. 22 7 . The most appropriate circuit for ventilating a
• For controlled ventilation, normocapnia can be maintained with spontaneously breathing infant during anaesthesia is:
a FGF of 1000ml + 100ml/ kg body weight. A. Jackson Rees’ modification of Ayres’ T Piece.
B. Mapleson A or Magill’s circuit.
C. Mapleson C or Waters’ to and fro canister.
D. Bains circuit
A

The most appropriate circuit advocated/ or use in infants

is the Ayre’s T piece ( Mapleson E).
Type E is basically a circuit for spontaneous respiration,
as it does not contain a breathing bag .

Efficiency of system with spontaneous Respiration :

A>D& E>C>B

Efficiency of systems with IPPV :

D & E>B >C>A

225. Regarding rebreathing prevention valve, incorrect

is
A. Should be as far as possible from the patient
B. Should be light
C. Suitably designed
D. Installed at expiratory end of the tube
A Being incomplete it was classically modified by Jackson
Rees who added a bag for monitoring and IPPV.
Jackson’s Rees modification of Ayre’s T piece has thus
226. All of the following are suitable anaesthetic circuits become the most appropriate circuit for ventilating
for both controlled and assisted ventilation except a spontaneously breathing infant.
A. MaplesonA
B. MaplesonB&C
C. MaplesonD
D. MaplesonE
A

Mapleson A syst em is most useful in spont aneous

respiration and least useful in assisted and controlled
ventilation.
• Ef f iciency of t he syst em s w i t h spont a neous
respiration
A> D&E> C> B
• Efficiency of systems w it h I PPV ( assist ed and
controlled ventilation)
D&E> B> C> A Effica cy of Mapleson’s syst em s for spont aneous
respiration
Mapleson A system - A> D&E> C> B
Also known as Magill system Although the most efficacious system for spontaneous
Most satisfactory with spontaneous respiration respiration is Mapleson A, in the context of infants and small
Flow of about 5 L/ min is maintained children ,Ayre’s T tube with Jackson Rees modification becomes
the answer of choice.
• Mapleson B ‘The main advantage of the T piece technique is the absence
Not in common clinical use of resistance to expiration, a factor of crucial importance in small
children.’
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MI NORTOPI CS ANAESTHESIA 47

229. . A 25 year old male is undergoing incision and determines the induction and recovery, induction and
drainage of abscess under general anaesthesia with recovery w ill be fast w ith agent w ith less B/ G partition
spont a neous r espir a t ion. The m ost ef ficient coefficient and induction and recovery with be slow er
anaesthetic circuiit is: w it h agents w ith high B/ G partition coefficients.
A. Maplelson A
B. Mapleson B Agent Blood gas partition
C. Mapleson C coefficient
D. Mapleson Desflurane 0.42
A Cyclopropane 0.44
Nitrous oxide 0.47
CO2 will be exhaled into B. tube or directly vented through
an open pop off valve Sevoflurane 0.69
Before inhalation occurs if the fresh gas flow exceeds alveolar minut Isoflurane 1.38
e volume the inflow of f resh gas will force t he remaining
alveolar gas in B. tube to exit from valve and inspiration will only Enflurane 1'.8
contain fresh gas. Halothane 2.4
Because a fresh gas flow equal to minute volume is sufficient to
Chloroform 8
prevent rebreathing of exhaled air ,Mapleson A is the
most efficient circuit for spontaneous ventilation Trielene 9
Ether 12
Methoxyflurane 15

I t can be concluded from the table that induction will be fastest

with desflurane with B/ G coefficient of 0.42 and slowest w ith
methoxyflurane w ith B/ G coefficient of 15.

232. . Which one of the follow ing anaesthetic agents

causes a rise in the I ntracranial pressure:
230. Magill circuit air flow is: A. Sevoflurane.
A. Equal to minute volume B. Thiopentone sodium.
B. Twice to minute volume C. Lignocaine.
C. Half to minute volume D. Propofol
D. Equal to alveolar volume A
A

Equal to minute volume ‘I ntracranial pressure increases at high inspired

- Magil system is synonymous with Mapelson system A concentrations of sevoflurane ‘
- This is the most satisfactory syst em for spontaneous
respiration I n the given options only sevoflurane causes rise in
- Gas flow here needs to be maintained at flow rates of 5- intracranial pressure w hile other cause fall in I .C.P.
6 l/ min which is approximately equal to the minute volume.
Increased Decreased IOP Increased BP Bronchodilat Branchospas
IOP ors tnodics
TOPI C 20: SEVOFLURANE
• Ketamine ■ Halothane • Ketamine (Preferred in (Contraindica
asthmatics) ted in
231. Which one of the follow ing is the fastest acting Asthmatics)
inhalational agent? • N2O • Morphine • Pentazocin • Ketamine • Ether
A. Halothane. (most dilators)
• Etomidate ■ Decreased BP • • Halothane • N2O
B. Isoflurane.
Pancuronium
C. Ether.
• Thiopental • Halothane • • Thiopentone
D. Sevoflurane Promethazine
D • • Morphine
Hexamathonium
The fastest induction is seen with sevoflurane • Trimethaphan • d-Tc

Blood Gas Partition Coefficient ( B/ G Coff.)

This is the most important factor determining the uptake 233. Which of the following volatile anaesthetic agents should
of agent and so the speed of induction and recovery. be preferred for induction of anaesthesia in children ?
A. Enflurane
Agents will low blood gas partition coefficient will have B. Isoflurane
high alveolar concentration e.g., nitrous oxide w it h C. Sevoflurane
blood gas part i t ion coeff icient of 0 . 47 means D. Desflurane
concentration ( or partial pressure) in blood is 47% of alveolar C
concent r at ion. Since alveolar concent r ation
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MI NORTOPI CS ANAESTHESIA 48

I nduction in Pediatric Patient A. Sevoflurane

B. Methoxyflurane
Inhalation Intravenous Intramuscular C. Desflurane
(reserved method) D. Isoflurane
(Preferred
A
method)
Sevoflurane Rapid acting Ketamine Children become very anxious at the mere sight of a needle
Barbiturate so intravenous induction is difficult in children.
(Thiopental) So inhalational anaesthetics are used to induce anaesthesia
propofol in children.
followed, by non Sevoflurane is commonly used to induce anaesthesia in
depolarizing MR children.
(Halothane can also be used)
234. True about sevoflurane:
A. Isopropyl ether
Desflurane and isoflurance can also induce aneasthesia but
B. MAC is 2%
they are not used because of the following side effects.
C. Good to use in old age
- They are pungent
D. Blood gas partition coefficient is more
- Cause coughing
E. Formation of compound ‘A with Baralyme
- Breath holding
A,B,C & E
- Produce laryngospasm

235. A 6 month old child is suffering from patent ductus Agents used if i.v. induction is done in children
arteriosus ( PDA) with congestive cardiac failure. Thiopentone
Ligation of ductus arteriosus was decided for surgical
management. The most appropriat e inhalational Used in children are -» non depolarizing muscle relaxants (e.g.)
a na est het ic a gent of choice w i t h m inim a lha Rapacuronium
em odyna m ic a l t er a t ion f r o induct ion of Rocuronium
anaesthesia is - Atracurium
A. Sevoflurane Miva curium
B. Isoflurane Sometimes succinyl choline can also be used
C. Enfiurane
D. Halothane TOPI C 21 : AI RWAY
A
237. Oxygen delivery is regulated by all, EXCEPT
A. Oxygen tent
• Sevoflurane is t he agent of choice for inhalational B. Nasal catheter
induction of anaesthesia in pediatric procedures. C. Venti mask
• I t is an excellent choice for smooth and rapid inhalational D. Polymask
induction in pediatric procedures because B
- I t has sweet odour, so induction is smooth ..........( AI I MS PGMEE - NOV - 1993)
- Rapid increase in alveolar anaest hetic concentr at ion
(therefore rapid onset of action) O2 is delivered through the following devices
I ts low blood solubility results in rapid fall in alveolar anaest 1) Nasal catheter
het ic concent r ation upon discont inuat ion and results in 2) BI B mask
quicker emergence when compared to other inhalational agents. 3) Polymask
4) Vent mask
Cardiovascular effects of sevoflurane 5) Oxygen tent
• Sevoflurane has minimal effect on cardiovascular system, 6) Oxygen apparatus
it causes minimal hemodynamic alterations therefore it can be
easily used as an induction agen in patients with PDA.

The cardiovascular effects are

- Minimal cardiac depression
- Slight decrease in systemic vascular resistance
- Minimal decrease in cardiac output

Halothane and isoflurane are usually avoided in children

because they have a pungent adour and so the induction
is not smooth. 238. I n a patient w ith multiple injuries, first thing to be
done is:
236. A 6 - year- old child is posted for elective urology surgery A. Patency of airway
under general anesthesia. He refuses to allowt he a B. Maintenance of B. P
nest he siologist a n I V a ccess. The best inha lat C. Immobilize cervical spine
iona l a gent of choice f or induct ion ofanesthesia is D. Lateral position with mouth gag
A
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MI NORTOPI CS ANAESTHESIA 49

• In a patient with multiple injuries, first thing to be done is A. Nasal Cannula

B. Venturi mask
the care of the airway.
- The first step in cardio-pulmonary resuscitation is AIRWAY MAI C. O2 by T-piece
NTAI NANCE D. Edinburgh mask
- The intention for CPR is maintain O perfusion until definite B
2
interventions instituted.
- The elements of CPR TOPI C 22: CPR

• Maintainance of airway ( A) 242. I n a patient w ith cardiorespiratory arrest, basic life

• Breathing ( B) support is given to support which of the following
• Circulation ( C) systems:
A. Respiratory system
240. Laryngeal mask airway is indicated I n: B. Cardiovascular system
A. To prevent aspiration of stomach contents C. Renal system
B. Short surgical procedure D. Gastrointestinal system
C. Where endotracheal intubation is contra-indicated E. CNS
D. Difficult airway A
E. Facilitate endotracheal intubation
B& D

243. During cardiac resuscitation, the following can occur

except:
A. Rupture of Lungs
B. Rupture of liver
C. Rupture of Stomach
D. Rupture of Spleen
The Laryngeal mask airway is an alternative airway device used E. Disseminated intravascular coagulation occurs
for anesthesia and airway support. it consists of an inflatable None
silicone mask and rubber connecting tube. it is inserted blindly
into the pharynx, forming a low-pressure seal around the 244. I n a 10 year old child presented anaphylactic shock,
laryngeal inlet and permitting gentle positive pressure drug of choice is:
ventilation. all parts are latex-free. A. I / V adrenaline
B. S.C. adrenaline
The laryngeal mask airway is an appropriate airway choice when C. Anti histamine
mask ventilat ion can be used but endotracheal intubation is D. Corticosteroids
not necessary. A
contraindications:
Non-fasted patients Status epilepticus is said to occur when a seizure lasts beyond
Morbidly obese patients 30 minutes or seizures are repetitive, prolonged & the
Obstructive or abnormal lesions of the oropharynx patient remains unconscious in between the seizures.
Best drug to use in status epilepticus is lorazepam
Advantages: in a dose of 0.l mg/ kg b.w by I .V. route. This may be
- Allows rapid access repeated after 5 minutes. Lorazepam effect lasts longer
- Does not require laryngoscope than diazepam. I f lorazepam is not available, immediately
- Relaxants not needed diazepam is given in a dose of 0.3 mg/ kg by I V route.
- Provides airway for spontaneous or controlled ventilation Seizures may recur after 15-30 minutes since half life of
- Tolerated at lighter anesthetic planes diazepam is short . Hence, diazepam should be followed
Disadvantges: by phenytoin in a dose of 10-15 mg/ kg IV. I f the fits are
Does not fully protect against aspiration in the non – fasted patient not controlled even with this, 20 mg/ kg of phenobarbitone
standard LMA does not allow high positive pressure ventilation may be given I .V, at a rate of 1 mg/ kg/ minute.
Requires re - sterilization

241. Which one of the following device provides fixed

performance oxygen therapy:
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245. True about adrenaline in CPR: C. Need for inotropic support

A. Can be given intratracheally D. Rate of intravenous f luid replacement
B. I .V. route better than intracardiac E. Assess need for plasma transfusion
C. Intracardiac route better than IV A
D. Converts coarse f ibrillation into fine ones
E. The dose used is 2ml. containing 1 in 1000 concentration
NO ANSWER CVP is a useful means of assessing the circulating blood volume
and therefore appropriate for rate of intravenous f luid
replacement.
• So, CVP has importance in — assessing need for blood and
• During CPR, adrenaline is given every 3 –5 min – this reflects plasma transfusion.
its half-life. When switching from the non-shockable to the
• CVP is not a good guide for daily fluid requirements e.g. A pt.
shockable side of the algorithm, the next dose of adrenaline will can easily be waterloaded or dehydrated in presence of a
be given before the f irst or the second shock depending on normal CVP.
when adrenaline was last given
248. . I n an injured patient with hypovoiemia
intravenous fluid administered is guided by:
A. Central venous pressure.
B. Blood pressure.
C. Urine output.
D. Pulse rate
A, B, C & D

• In a hypovolemic patient, the adequacy of IVF replacement

can be assessed by :
- Clinical pulse, BP
- Urine output
- Invasive CVP and PCWP
246. The outcome follow ing resuscitation of a cardiac arrest
• Normal PCWP = 8-12 mm Hg
is worsened if during resuscitation patient is given -
Pulmonary artery pressure = 25 mm Hg-Systolic ; 10 mm
A. Ringer’s lactate
Hg- Diastolic.
B. Colloids
C. 5% Dextrose
I nterpretation of CVP and PCWP in various
D. Whole blood transfusion
conditions :
C
CONDITION CVP PCWP
• While performing cardiopulmonary resuscitation for cardias
Hypovolemic shock Low Low
arrest, therapy with hyperglycemic intravenous fluid
should be avoided. Right heart failure High N
• Ther apy with intr avenous glucose solutions result s in worse Left heart failure N High
neurological outcome.
Cardiogenic shock (Rt and Lt heart N/High High
• Increase in blood and thus brain glucose during global cerebral
failure)
ischemia will profoundly affect outcome of the patient
• In high risk patients, intravenous glucose solutions should be Cardiac tamponade High High
avoided or used j udiciously and blood glu cose con Pulmonary embolism N/High High
cen t r at io n s sh ou ld be m ain t ain ed w i t h in t h e
normoglycemic range until the patients have passed the period 249. ‘C w ave in JVP tracing seen in:
of high risk for hemodynamic compromise. A. Ventricular systole
• Most critically ill patient s do not need acute glucose B. Ventricular diastole
supplementations. C. Atrial systole
• In patients who require glucose, however we recommend D. Protodiastole
administering it in a manner (e.g. mini drip devices, infusion A
pumps) that will avoid large infusions at the t ime of an ischemic
event. • The different waves of JVP :
• Specifically, glucose containing solutions should not be used ‘a’ w ave : Positive, produced by venous distention due to right
in intravenous lines that will facilitate volume expansion atrial contraction and is dominant wave in JVP.
and drug administrations during t / t of shock or
cardiac arrest. ‘c’ w ave : Positive, produced by the bulging of the tricuspid valve
int o t he r ight at r ium during Rt . vent ricular
TOPI C 23: CVP isovolumetric systole.

247. I mportance of CVP measurements is: ‘x’ descent : due t o both at r ial relaxat ion and to the dow
A. Need for blood transfusion nward displacement of t he t ricuspid valve during ventricular
B. Assess amnount of f luid to be given systole.
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MI NORTOPI CS ANAESTHESIA 51

f ibreoptics for det ermination of mixed venous O2

saturation, and miniaturized electronics located on the
catheter for measurement of pulmonary flow.

25 1 . W hile int roducing the Sw an- ganz cat heter, its

placement in the pulmonary artery can be identified by
the following pressure tracing -
A. Diastolic pressure is lower in PA than in RV.
B. Diastolic pressure is higher in PA than in RV
C. PA pressure t racing has diacrotic notch from closure of
pulmonary valve
D. RV pressure tracing for plateau and sharp drop in early
diastole
B

Pulmonary artery catherization

As the catheter passes via Superior Low pressure waves (mean of 3-8
venacava mmHg)
to right atrium (Right A trial
pressure)
V wave : Positive ; produced by increasing volume of blood
Now the catheter enters Right Tall pressure waves
in the Rt . atrium during ventricular systole when the tricuspid ventricle through tricuspid valve (RV are displayed (15-25 systolic and
valve is closed. pressure) 0-l0 diastolic)
‘y; decent : Produced mainly by the opening of the tricuspid valve
Catheter advances Systolic pressure
and the subsequent rapid inflow of blood into the right
into pulmonary artery remains same as in
atrium.
through the pulmonary right ventricle but the diastolic
valve (Pulmonary Artery pressure
250. Swan Ganz catheter measure: pressure) increases (10-20 mm Hg)
A. PCWP Dicrotic notch caused bv closure of
B. CO. pulmonary
C. Mixed venous 02 saturation valve can also be noted
D. Pulm. capillary pressure Now the catheter advances into A dampened pressure
A a branch of pulmonary waveform
artery (where it wedges) mean pressure of
• Swan-Ganz pulmonary artery catheter is the mainstay for Pulmonary capillary 4 -12mmHg
assessment of cardiac function in the crit ical care and wedge pressure
perioperative settings. I t is used to measure : This reflects the left atrial
- direct pressure of Rt. atrium, Rt. ventricle and pulmonary artery Pressure.
( PAWP).
- indirect pressure in Ieft. atrium. TOPI C 24: I NTRAOPERATI VE MANAGEMENT
- cardiac output by indicator dilution
- Rt. ventricular ejection fraction, 2 52 . W hich of the follow ing agent s is not used t o
provide induced hypotension during surgery?
A Sodium nitroprusside
B. Hydralazine
C. Mephenterrnine
D. Esmolol
C

Mephent ermine act s direct ly on bot h a an d bet a

receptors to cause cardiac stimulation and vasoconstriction.
I t increases the cardiac output and both systolic and
diastolic BP.
I t is used not to induce but to prevent hypotension.

Hvpotensive Anaesthesia :
This is a technique of deliberately reducing the systolic blood
pressure to 8O-9OmrnHg or mean arterial pressure to 50-
65mmHg in order to reduce the intra operative bleeding.

• Recent refinements have included the addition of fast - response The clinical criteria is to reduce the blood pressure by one third
thermistors, high fidelity pressure transducers, of preoperative value.
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MI NORTOPI CS ANAESTHESIA 52

Techniques include the follow ing : • Using this property, carbon dioxide concentration can
be measured directly and continuously throughout the
Vasodilators Inhaled Other respiratory cycle.
Sodium Anaesthetics Spinal tepidural • The gradient observed during end tidal CO2 measurement
nitroprusside Isoflurane (Agent of block in healthy individuals is
Nitroglycerine choice) Halothane Ganglion blockers
Enfiurane (Trimethophan) a End tidal CO < alveolar CO < arterial CO\
2 2
blocker
(phenotolaraine) p
blocker
(Esmolol/prop
analol) a+P blocker
(Lobetalol) Calcium
channal blocker
Prostaglandin PG5

253. Which of the following is not used in controlling

heart rate intraoperatively.
A. Propanolol/ Metoprolol
B. Verapamil
C. Esmolol Why is End tidal CO less than alveolar CO ?
D. Procainamide 2 r

A • Because the end tidal carbon di oxide is always diluted

with alveolar dead space gas from unperfused alveoli. These
Non select ive long acting b blockers are avoided for alveoli do not take part in gas exchange and so contain no
controlling arrythmias (or heart rate) during surgery . carbon di oxide.

Why is alveolar CO2 less than arterial CO 2?

254. Use of I ntraarterial cannula in major surgery • Because the blood from the unvetilated alveoli and lung
A. Measurement of direct intra arterial BP parenchyma (both have higher CO contents)
2
mixes with the
B. Sample for ABG blood from ventilated alveoli .
C. Drug injection
D. BT • In healthy adults with normal lungs end tidal CO 2 is 3 to
A,B,C & D .6 kPa less than arterial CO 2.
• This difference is reduced if the lungs are ventilated with
2 55 . All t he follow ing drugs are recommended fort large tidal volumes.
r ea t m ent of bet a block er induced ex cessive
bradycardia and/ or decrease in cardiac output , Uses of End tidal CO2 ( Et CO,) . Capnographv
except: • To detect correct placement in t racheal intubation.
A. Dopamine Persistent detection of CO2 by a caphograph is best
B. Dobutamine confirmation of tracheal placement of endotracheal
C. Glucagon tube. I f the tracheal tube goes into the oesophagus no,
D. Calcium chloride or very litt le CO is
2
detected.
B
• To diagnose lung embolism as a sudden decrease in end
tidal carbon di oxide, assuming that the arterial blood pressure
remain stable.
256. . Which of the follow ing is not a cardiovascular
monitoring technique - • To diagnose malignant hyperpyrexia as a gradual
A. Transesophageal echocardiography increase in end tidal carbon di oxide.
B. Central venous pressure monitoring • As a disconnection alarm for a ventilator or breathing system.
There is sudden absence of end tidal CO .
C. Pulmonary artery catheterization 2

D. Capnography
Cardiovascular monitoring techniques.
D
Non invasive mathods
(1) ) ECG
(2) ) Blood pressure
Capnography is a respiratory monitor system (not a
(3) ) Transesophageal echocardiography
cardiovascular)
Capnography -
I nvasive
• I t is the det erminat ion of End t idal CO 2 ( Et COj )
( 1) Invasive blood pressure
concentration to confirm adequate ventilation.
• I t is useful during all anaesthetic procedures
TOPI C 25: DESFLURANE
Principal of End tidal CO 2 determination ( capnography)
257. Rapid induction of anaesthesia occurs w ith whichof
• Gases with molecules that contain at least two dissimilar
the following inhalational anesthetics?
at oms absorb radiation in t he infr ared region of t he
A. isoflurane
spect rum.
B. halothane
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MI NORTOPI CS ANAESTHESIA 53

C. desflurane Metabolism of Desflurane - Desflurane undergoes minimal

D. sevoflurane metabolism in humans t herefore serum and urine
C inorganic fluoride levels following anaesthesia are essentially
unchanged from preanaesthetic levels.

Cardiovascular effects of Desflurane

• Rapid induction of anaesthesia is seen with both Desflurane& The cardiovascular effects of desflurance appear to be similar
Sevoflurane but Desflurane is the anwer as it causes m to that of isoflurane i.e., it also causes minimal cardiac
or e r a pid induct ion of a na est hesia t hen depression like isoflurane.
Sevoflurane. The specific effects are: -
• The speed of induction by inhalational anaethestics in Blood pressure ----> decrease
descending order is: Heart rate ----> No change or increase
(a) Nitrous oxide Systemic vascular resistance -----> Decrease
( b) Desflurane Cardiac output -----> No change or decrease
( c) Sevoflurane
(d) Isoflurane 260. A 70 - year- old male is posted for a surgery, which is
( e) Halothane likely to last for 4- 6 hours. The best inhalational agent
• Rat e of indu ct ion of anaest hesia by inhalat ional of choice for maintenance of anesthesia in such a case
anaesthetics is inversly proportional to its blood gas is
partition coefficient i.e. the agents with low blood gas partition A. Methoxyflurane
coefficient eg. Nitrous oxide will have faster rate of induction. B. Ether
C. Trichloroethylene
258. Which of the following ihalational agents has the D. Desflurane
minimum blood gas solubility coefficient? D
A. Isoflurane
B. Sevoflurane
C. Desflurane In a geriatric patient the normal physiological functions are
D. Nitrous oxide already compromised so pros and cons of an
C anaesthetic must be carefully weighed against before giving
an anaesthetic.
Blood gas partition coe fficient in ascending order
Methoxyflurane-
Agent Blood gas partition - I t is highly nephrotoxic and this limits its use.
coefficient - In old patients the G.F.R. is already low so any nephrotoxic
agent shold be avoided.
• Desflurane .42
• Nitrous oxide .47 Ether-
• Sevoflurane .68 - Ether was very popular in the past but it is not used now because
of its inflammable and unpleasant properties.
• Isoflurane 1.4
• Enflurane 1.9 Trichlorethylene
• Halothane 2.3 - I t forms explosive mixtures and should not be used in closed
circuit
259. Which one of the following statements regarding Desflurane-
desflurane is correct? - Desflurane is a recently developed, f luorinated congener of
A. It causes severe myocardial depression isoflurane which is quiet safe like isoflurane.
B. It is a structural analogue of isoflurane - I t can serve as a good alternative to isoflurane for
C. It has very high blood and tissue-gas partition coefficients routine surgery as well as prolonged operations
D. It is metabolically unstable ( Here operation is long and lasts for 4-6 hrs).
B
Properties of Desflurane-
- No renal and hepatic toxicity has no arrythmogenic action
Desflurane’s st ruct ure is very similar t o t hat of - Coronory circulation is mantained
isoflurane - Very low solubility in blood and t issues because of which
I t is a recently developed all fluorinated congener of induction and recovery are very fast.
isoflurane (The only difference is substitution of a fluorine - Agent of choice for induction of anaesthesia in Geriatric
atom for isoflurane’s chlorine atom). patients —> Etomidate, thiopentone
I ts special properties are I t is highly volatile - I n h alat ion al agen t of ch oice f or m ain t en an ce of
anaesthesia in Geriatric patient - I soflurane.
Extremely low oil gas partition coefficient Very low solubility in
blood and tissues i.e., very low blood and t issue-gas partition TOPI C 26: MUSCULAR DYSTROPHY/ MYASTHENI A
coefficients Because of these unique properties it’s
induction and recovery are very fast. 261. A 5 year old boy suffering from Duchenne Muscular
Du e t o t h is sh or t act ion i t is com m on ly u sed as Dystrophy and Polymyositis has been fasting for 8 hour
anaesthesia for out patient departments. a nd has t o under go t endon lengt hening
procedure, which Anaesthetics should be used
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MI NORTOPI CS ANAESTHESIA 54

A. I n du ct ion by I . V. scol in e an d N2 O h alot h an e f or dysarrhythmias, conduction abnormalities and finally

maintenance cardiac arrest. The most likely cause is:
B. Induction by I .V. propofol, N2O and O2for maintenance A. Hypercalcemia
C. Induction by I .V. thiopentone and HL.O and halothane for B. Hyperkalemia
maintenance C. Anaphylaxis
D. Inhalational N2O, halothane and O2 for maintenance D. Hypermagnesemia
B B
..........(.AI IMS PGMEE JUNE - 2000). AI PGMEE - 2003
I t has been repeated several times before that succinylcholine
• I n this boy with duchene muscular dystrophy, there is
causes hyperkalem ia in par aplegic pat ient s. Th is
high risk of malignant hyperthermia
hyperkalemia is responsible for cardiac complications such as
• The earliest signs are masseter muscle rigidity
( MMR), Tachycardia, and hypercarbia due to increased dysarrythmias, conduction abnormalities and cardiac arrest.
CO2 production
“ Suxamethonium may be dangerous in the period b/ w about
Malignant Hyper t h er mia ( MHS) is a ph ar macogenet ic 3 days and 6 months or perhaps longer after onset of
predisposition leading to adverse reactions to commonly paraplegia. I t releases more potassium than usual from mu
u sed a na est het ic dr ugs ( e. g. ha lot ha ne, scles and t he ext r em e hyper kalemia can cau searrythmias
succinycholine) . Patients respond to these drugs by
or cardiac arrest.”
excessive release of intracellular calcium which t riggers a
potentially lethal muscle hypermetabolism Central Core
Disease ( CCD) is a chronic muscle weakness and 264. I n myasthcnia gravis, which druges should not be
degeneration due to leakage of intracellular calcium used:
stores. Both conditions share a common genetic cause: A. Gallamine
Mutations in the muscle calcium release channel RYR1. B. Noestigmine
C. Aminoglycosides
D. Metronidazole
E. Ampicillin
A& C

• The muscles affected by MG are hypersensitive to non-

depolarizing muscle relaxants.
Even myasthenics successfully treated w ith steroids
and not requiring anticholinesterases may still show
this hypersensitivity. So they should be avoided, but small
doses of short -acting relaxants like Mivacurium, with
monitoring of the neuromuscular block may be used.

Induction by I .V. propofol, N O and O for maintenance

2 2
• This boy has chances of developing malignant hyperthermia • Myasthenics are resistant to the effects of depolarizing
because muscular diseases ( duchene muscular dystrophy and muscle relaxants like Suxamethonium and Decamethonium.
polymyositis) predispose to malignant hyperthermia.
• Dr u gs l ike Am in oglycoside an t ib iot ics ( neom ycin ,st
Predisposing conditions rept om ycin, gent am icin ) , t et r acyclin e, qu in id in e,
• Arthrogryposis multiplex congenita* procainamide, penicillamine and beta-blockers can worsen MG
• Osteogenesis imperfecta*
and so avoided.
• Congenital ptosis
Ampicillin & Metronidazole are not contraindicated in MG.
• Strabismus
• Hernia, kyphoscoliosis
• Cleft palate TOPI C 27: PREANESTHETI C MEDI CATI ON
• Duchenne muscular dystrophy*
265. Most potent antiemetic agent used in preoperative
Drugs which precipitate malignant hyperthermia period:
• Anaesthetic ——> Succinylcholine* , ( MC) Halothane* A. Glycopyrrolate
• Monoamine oxidase inhibitor B. Hyoscine
• Phenothiazines
C. Atropine
• Amide local anaesthetics
D. Metochlorpromide
• TCA’s
B
2 6 2 . The administ ra t ion of succinylocholine t o a
pa r a plegic pa t ient led t o t he a p pea r a nce of
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MI NORTOPI CS ANAESTHESIA 55

Hyoscine • I t is also an antiemetic ( prevents vomiting), antivertigo

(prevents dizziness), and antispasmodic (reduces smooth
m u scle con t r act ion s; alt h ou gh a der iv at e called
butylscopolamine, that does not cross the blood-brain barrier,
is used preferably).
• I t can be used as a pre- anest het ic sedat ion, as an
antiarrhythmic during anesthesia, and for the prevention of
motion sickness.
• Tr a nsder m a l pa t ches, , ar e a va i l a ble f or t he
prevention of symptoms of travel sickness.

• Scopolamine, also known as hyoscine

• I t act s as a compet it ive ant agonist at musca rinic
acetylcholine receptor ( M1); it is thus classified as an
266. Atropine as preanesthesia has all effects except
anticholinergic or as an anti-muscarinic drug.
A. decrease secretion
Scopolamine hydrobromide.
B. Bronchoconstriction.
– I t can be used as a depressant of the central nervous system,
C. prevent bradycardia
though it can cause excitement, restlessness, hallucinations, or
D. prevebt hypotension
delirium in the presence of pain, mydriasis (pupillary dilation),
B
and cycloplegia (paralysis of the eye muscles).
– When combined with morphine, it produces amnesia
Atropine is a bronchodialator and reduces air way resistance
and a tranquilized state known as twilight sleep. Although
specially COPD and Asthma patients.
originally used in obstetrics, it is now considered dangerous for
that purpose. Sometimes side effects of scopolamine can be
2 6 7 . Dr ugs com m only used in pr e- a na est het ic
mistaken for symptoms of cancer because of the nausea and
medication:
anisocoria associated with brain tumors. However,
A. Diazepam
scopolamine induced anisocoria clears up usually within 3
B. Scopolamine
days.
C. Morphine
D. Succinylcholine
• I t is used in ophthalmology to deliberately cause cycloplegia and
E. Atracuronium
mydriasis so that certain diagnostic procedures may be
A, B, & C
performed. I t is also used in t he treatment of
iridocyclitis.
• Scopolamine is the other name of Hyoscine hydrobromide
w h ich is ant icholiner gic dru g used as premedicant
Succinylcholine & Atracurium are skeletal muscle relaxants used
in intubation & maintenance of anaesthesia.

268. Preanesthetic medication is used to:

A. Decrease does of anesthetic
• In otolaryngology it has been used to dry the upper airway( B. Decrease BP
anti-sialogogue action) prior to instrumentation of the airway C. Prevent aspiration
D. Produce amnesia for peri-operative events
E. Relieve anxiety
A, D & E

• Preanesthetic medication (PAM) refers to the use of drags

before anaesthesia to make it more pleasant and safe.

The aims are :

- To relief anxiety apprehension and to facilitate smooth
induction.
- Amnesia of pre and post operative events.
- Su pplem en t an algesic act ion of anaest h et ics an d
potentiate them so that less anaesthetic is needed.
- DECREASE -Secretions and vagal stimulation caused by
anaesthetics.
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MI NORTOPI CS ANAESTHESIA 56

- Antiemetic effects extending to the postoperative period.

- DECREASE -Acidity* and volume of gastric juice so that it is
less damaging if aspirated.

• The different drugs that are used as PAM are :

Opiods-Morphine
Antianxiety drugs-Diazepam
Sedat ive - Hypnot ics-Barbitur at es Ant icholinergics -
Atropine or hyoscine Neuroleptics-chlorpromazine
H2 blockers-Ranitidine/ Famotidine
Ant iem et ics- Met oclor pr am ide, Dom per idon e, or
Ondansetron.
Left parasternal long axis view with air shadow in the aorta
TOPI C 28: AI R EMBOLI SM

269. Quantitative estimation of air embolism is done by

A. ECG
B. End tidal CO2 estimation
C. Pulmonary capillary wedge pressure
D. Doppler study
B

270. 5 year old child going for sitting craniotomy, while

positioning in O.T. developed end tidal CO2- Zero mm
Hg, PO2- 80mm Hg implies that: ‘
A. Venous air embolism Treatment
B. Left lung collapse • irrigate operative site with fluid
C. Endotracheal tube in Oesophagus • apply occlusive material to bone edges
D. Endotracheal tube blocked with secretions • gently compress internal jugular veins
A • head dow n position
• aspirate air through right atrial catheter (best if tip is atSVC-
Venous air embolism RA junction)
• discontinue N 2O
• The cranial sinuses have negative air pressure . • inotropes may be needed
– So, it is possible that if the pt. is in wrong position while • BEW ARE: PEEP, by reversing RA- LA pr essure
operation, the sinuses may suck some air d/ t their negative gradient, may lead to paradoxical air emboli via PFO
pressure which can cause venous embolism
• The given value for the gases can occur only in Venous air 2 7 1 . About dia gnosing a i r em b olism w i t h
embolism. transesophageal echocardiography, w hich of the follow
ing is false:
Venous Air Embolism ( VAE) A. I t can quantify the volume of air embolised
• consider whenever head > 5 cm above heart B. I t is a very sensitive investigation
• t ransected veins in cut edge of bone or dura may not C. Cont inuous monit or ing is needed t o det ect venous
collapse embolism
• air -> RV -> pulmonary circulation D. Interferes with doppler when used together
• decreased pulmonary blood f low , pulmonary edema, A
bronchoconstriction, cardiovascular collapse, hypoxemia
• paradoxical (air) embolism A “ four-chamber” view. The right atrium is in the upper left
• coronary or cerebral circulations corner of the picture.
• via patent foramen ovale (PFO) (20-30% of adults have The central venous catheter can be seen as a small dot in
probe-patent foramen ovale) detection the center of the atrium

• precordial Doppler ultrasound near right upper st

ernal border is most sensitive non- invasive
monitor ( detects 0.25 ml)
• t r a ns- esopha gea l echoca rdiogr a phy is m ore
sensitive, but more invasive and cumbersome
• sudden decrease in ETCO , incease in ETN
2 2

• gasping, hypotension, dysrhythmias, cyanosis, “ mill-wheel”

murmur
• Apical four chamber view with air shadows in both right
and left ventricle
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MI NORTOPI CS ANAESTHESIA 57

four-chamber view recorded during dissection of a vascular tumor. Oxygen

Air bubbles are visible as a “snow- storm” appearance • I ncrease in oxygen causes a low amplitude, fast
in the right atrium . Note that no air is crossing into the left frequency EEG pattern char act erist ics of cerebral
atrium excitation.
• Decreased brain oxygenation initially causes increased
cerebral excitability as a result of peripheral
chemoreceptor st imulation and its attendant effects on brains
reticular activating system.

I f hypoxia persists and overwhelms compensatory system

diffuse EEG slowing occurs eventually, leading to EEG
silence as anoxia appears.

Carbon dioxide
• Hypocarbia causes slowing of the E.E.G.
• Small increase in pCO2 ( 5-20% above normal) causes
decreased cer ebr al excit abili t y an d an in cr eased
electroshock seizure threshold.
• Higher levels of CO 2 ( 30% above normal) result in
TOPI C 29: HYPOTHERMI A increased cerebral excitability and epilept if orm
discharges.
272. Hypothermia is used in all except: • High levels ( 50% above norm al) pr oduce E. E. G.
A. Neonatal asphyxia depressions.
B. Cardiac surgery
C. Hyperthermia Effects of anaesthetic drugs on electroencephalograms
D. Arrythmia • Most anaesthetics produce a biphasic pattern on the
D E. E. G. con sist in g of an init ial act ivat ion ( at
subanaesthetic doses) follows by dose dependent
• There is substantial protection against ischemia and hypoxia depression.
is provided by. just 1—3° C hypothermia
Hypothermia reduces the t issue metabolic rate about I nhalational anaesthetics
8% / °C. • Halothane produces a typical biphasic pattern.
• I t decr eases t h e cer ebr al m et abolic r at e an d is • Isoflurane is the only volatile anaesthetic that produces
cerebroprotective during episode of cerebral ischemia. isoelectric E.E.G.
• Desflurane and sevoflurane produces a burst suppression
The protection afforded by mild hypothermia is so great that reduced pattern at high does but not electrical silence.
core temperature — 34° C is probably indicated in : Nitrous oxide increases both frequency and amplitude.
- Carotid artery surgery
- tieurosurgery I ntravenous agent
- Procedures where tissue ischemia can be anticipated • Benzodizeapenes produce a typical biphasic pattern
- Traumatic brain injury ARDS on E.E.G.
• Barbiturates, etomidate and propofol produces a
273. Hypothermia is used in: t ypica l bipha sic pa t t er n a nd a r e t he only int
A. Hyperpyrexia ravenous agents capable of producing burst
B. Prolonged surgeries suppression and electrical silence at high dose.
C. Massive blood transfusion • Opioids produce monophasic dose dependent
D. Hypertension depression of the E.E.G.
A& B Ketamine produces an unusual activation consisting of
rhythmic high amplitude theta activity followed by very high
amplitude gamma and low amplitude beta activities.
274. Which of the following in anaesthesia will produce
decreased EEG activities Electroencephalographic changes during anaesthesia
A. Hypothermia Activation Depression
B. Early hypoxia •
• Inhalational agent Inhalational agents (1-2 MAC)
C. Ketamine •
(subanaesthetic) • Barbiturates
D. N2O Barbiturates (small doses)• • Opioids
A Benzodiazepenes (small • Propofol
doses) • Etomidate
Effect of various conditions on E.E.G. Body temperature • Etomidate (small doses)• • Hypocapnia
• Hypothermia causes progressive slowing of the brain Nitrous oxide • Marked hypercapnia
activity. • Hypothermia
• Ketamine
At core temper ature below 35° C complet e elect rical
silence occurs with profound hypothermia. • Mild hypercapnia
• Sensory stimulation
• Hypoxia (early) • Hypoxia (late) ischemia
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TOPI C 30: NI TRI C OXI DE TOPI C 31: POSTOPERATI VE COMPLI CATI ONS

275. . Which of the following inhaled gases is used to 27 8 . Which of t he follow ing agents is used for t he
decrease pulmonary artery pressure in adult s & treatment of postoperative shivering?
infants A Thiopentone
A. nitrous oxide B. Suxamethonium
C. Atropine
B. nitrogen dioxide
D. Pethidine
C. nitric oxide
D
D. nitrogen
C
Treatment of postoperative shivering involves the use
of Tramadol, pethidine or pentazocine and oxygen
inhalation.
Nitric oxide causes decrease in pulmonary artery
• Shivering occurs as a protective mechanism as inhalational
pressure in both adults and infants.
agents, spinal/ epidural blocks cause vasodilatation leading
I t is t he m ost eff ect ive agent u sed t o decrease in
to heat loss.
pulmonary artery hypert ension. I t is an endothelium
• Shivering can be abolished by inhibition of hypothalamus.
derived vasodilator
• Most commonly shivering is seen after halothane.

276. At the end of anaesthesia after discontinuation of Treatment of shivering

nitrous oxide and removal of endotracheal tube, 10 Oxygen inhalation: O consumption may increase upto 4 times
2
0 % oxygen is administered to t he patient to prevent: (400% ) during shivering and hence oxygen inhalat ion during
A. Diffusion Hypoxia shivering is mandatory. . . :
B. Second gas effect
C. Hyperoxia Drugs:
D. Bronchospasm Tramadol is the drug of choice
A . Pethidine/ pentazocine may be used.

2 7 9 . A 2 5 yea r old m ale w i t h roa dside accident

N O has low blood solubility. So when N O is discontinued
2 2
underw ent debridement and reduction of fractured
after prolonged anaesthesia, due to its low blood solubility
both bones right forearm under axillary block. On the
it rapidly diffuses into the alveoli and dilutes the alveolar
second postoperative day the patient complained of
air.
persistent numbness and paresthesia in the right
This causes excess of N2 O in alveoli so the partial pressure
forearm and hand) The commonest cause of this
of oxygen in the alveoli is reduced. neurological dysfunction could be all of the follow ing
except:
• This results in hypoxia and it is known as diffusion hypoxia A. Crush injury to the hand and lacerated nerves
I f the cardiac reserve is normal diffusion hypoxia is not of much B. A t ight cast or dressing
significance but if cardiac reserve is low, diffusion hypoxia can C. Systemic toxicity of local anaesthetics
be very dangerous. D. Tounriqet pressure
C
• Prevention: -

I t can be prevented by continuing 100% O 2

inhalation for a Systemic toxicitv of LA include
few minutes after discontinuing N O 2 • CNS toxicity
• Cardiovascular system
Diffusion hypoxia is not significant with other anaesthetics • Methemoglobinemia
because t he y are adm inist ered a t very low • Allergies
concentrations ( 2 - 4 % ) and so they cannot dilute alveolar But the involvement of the peripheral nerve is characterized
air by more than 1-2% by parathesies, numbness, hypaesthesia, pain are
indication of local peripheral nerve injury.
277. . Which of the follow ing statements is true
regarding Nitric oxide: 2 8 0 . W hen a pa t ient develops supr a vent r icula r
A. Used in pulmonary hypertension t a chyca r dia w i t h hypot ension un der gener a l
B. Decreases the dose of anaesthetics anaesthesia, all of the following treatments may be
C. Sympathomimetic action instituted except:
D. Causes systemic hypotension A. Carotid sinus massage
E. Used as a vasoconstrictor B. Adenosine 3-12 mg IV
Ans a,c C. Direct current cardioversion
D. Verapamil 5 mg IV
• I t is reasonable to expect that inhalation of(NO) could be D
beneficial as a long-term therapy for pulmonary arterial
hypertension ( PAH) Verapamil should not be used in presence of SVT with
adver se fact ors such as h ypot ension. I t can cause
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prolonged hypot ension and depression of vent ricular function, • TC causes hypotension by :
- Ganglion blockade.
especially in the presence of anaesthetic agents that cause
- Histamine release.
myocardial depression.
- decreased venous return.
Supraventicular tachycardia (SVT) can occur at any time during the • I t cause vagal ganglionic blockade - so t ed HR.
preoperative period in susceptible patients. Duration of action is 30— 60 minutes.
• Vagal manoeuvers in the form of carotid sinus massage can
terminate supraventicular arrythmias in about 80% of cases and
TOPI C 33: VECURONI UM
thus these should be tried init ially.
I f attempts to increase vagal tone and terminate the SVT by 284. . Which of the follow ing statement is not
carotid sinus message are unsuccessful, the treatment of correct for Vecuronium ?
choice is adenosine by fast IV injection. This is safe and eff ect A. I t has high incidence of cardiovascular side effects.
ive du r in g haem odyn am ic in t abilit y because adenosine B. I t has short duration of neuro muscular block
has duration of action of less than 60 seconds.I t blocks AV C. In usual doses the dose adjustment is not required in kidney
conduction without compromising ventricular function. disease
Adenosine should not be given to patients wi th asthma D. I t has high lipophilic property
or AV conduction block. A

• I f adenosine is unavailable and the pat ient is

normotensive, I V verapamil can be given . However, Properties of Vecuronium.
verapamil can cause prolonged hypotension and depression (1) I t is non depolarising muscle relaxant
of vent ricular function, especially in t he presence of (2) I t is highly lipophilic
anaesthetic agents that cause myocardial depression. (3) I t has dual excretory pathway i. e.,I tis excreted through
• Cardioversion is indicated if the SVT is associated with both liver and kidney.
hypotension or other adverse risk factors Kidney accounts for of the elimination of Vecuronium
so in renal failure, Vecuronium persists for a longer duration.
TOPI C 32: TUBOCURARI NE Still Vecuronium is not contraindicted in renal failure.
The advantage of Vecuronium is that its side effects are very
281. d- TC ( d- Tubocurarine) is a few .
A. Ganglion blocker I t does not have any cardiovascular side effects.
B. Depolarizing blocker
C. Competitive neuromuscular block 285. Skeletal muscle relaxant having no CVS side effects:
D. a + c both A. Vecuronium
D B. Doxacurium
C. Pancuronium
D. Rocuronium
282. Which one of the following antibacterials should
E. Mivacurium
not be used w ith d- tubocurarine?
A. Norfloxacin
A, B & D
B. Streptomycin
C. Doxycycline
286. Bradycardia during anaesthesia seen in
A. Pancuronium
D. Cefotaxime
B. Vecuronium
B
C. Atracurium
D. Propofol
E. Succinylcholine
Use of St r ep t om ycin alon g w i t h com pet i t ive n on
B, C , D & E
depolarizing blockers like d- tubocurarine can potentiate its
action and produce prolonged apnea .
• Pancuronium causes a moderate increase in heart rate.
St reptomycin should t herefore not be used w it h d-
• Vecuronium is about 20 t imes weaker as a vagolytic
tubocurarine.
substance than pancuronium.
• Bradycardia seen after adminstration of vecuronium &
Streptomycin and Neomyein have higher propensity
atracurium.
than other aminoglyco sides. Tobramycin is least likely
• Propofol produces bradycardia due to central vagal
to produce these effects .
activity.
283. True about d TC is: Succinylcholine produces bradycardia & cardiac arrest on
A. Excreted unchanged by kidney the second on even after the first injection.
B. Causes hypotension by ganglion blocking action
C. Vagolytic action
TOPI C 34: ABG
D. Effect lasts for 2-3 hours
B 287. . Heparin interferes w ith w hich of the follow
ing results of ABG:
A. PO2
Tubocurarine is partly metabolized in body. The unchanged
B. PCo2.
drug is excreted in urine as well as in bile.
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C. PH. • Stage of Anaesthesia are as follow s *

D. HCO3. • Stage I —> Analgesia
E. An ion gap • Stage I I —> Delirium or excitement, partially dilated pupil
C • Stage I I I —> Stage of Surgical Anaesthesia
I t is divided in 4 stages
1. Moving eye to fixed age
288. . Pulse oxymetry detects inaccurately in presence of: 2. Corneal & laryngeal reflex lost
A. Hyperbilirubinemia 3. Light reflex lost
B. Nail polish 4. Intercotsal paralysis,
C. Methernoglobinemia Abdominal respiration,
Pupils widely dilated*
D. Skin pigmentation
• Stage I V —> Stage of Medullary Paralysis
B, C & D

TOPI C 36: ATROPI NE

* Pulse oxymeter is accurate in detecting oxygen saturation, but
291. I n belladona poisoning, antidote is:
there are many sources of error:
- Different Hemoglobins: A. Physostigmine
B. Neostigmine
Methemoglobin : I t absorbs light at equal wave lengths used by C. Ami histamine
pulse oxymeters, so there might be erroneously high values D. Atropine
of saturation. A
Carboxyhemoglobin:
Pulse oxymeters overread by the presence of HbCO. • Belladona poisoning may occur due to drug overdose or
Fetal hemoglobin: Only very high level can cause some consumption of seeds & berries of belladona/ datura plant.
inaccuracy. Children are highly susceptible. Manifestations are due to
Hemoglobin S: Controversial. exaggerated pharmacological actions.
- Bilirubin :
Severe hyperbilirubinemia does not affect pulse oxymetry Physostigmine 1-3 mg. S.C or i.v. antagonizes both central
readings.
& peripheral effects. I t may be repeated 4-6 hourly.
- Malposition of sensor
Neostigmine is less satisfactory.
- Poor peripheral pulsation
- Skin pigmentat ion : Pulse oxymet er readings are
erroneously high in patients with dark skin color. 292. Atropine is used in following except:
- Dyes: Like methylene blue, indocyanine green can cause large A. Glaucoma
t ransient decrease in sat uration without actual decrease in B. Mushroom poisoning
the same. C. Malathion poisoning
- Optical interferance : Sunlight, operating room light, infrared D. Organophosphorous poisoning
heating lamps results in erratic readings. A
- Electrical interferance :
Electrical interferance from an electrosurgical unit can cause • Topical instillation of atrepine cause mydriasis, abolition of light
the oxymeter to give an incorrect pulse count. reflex & cycloplegia lasting 7-10 days. This results in
- Nail polish & coverings : photophobia & blurring of near vision. The ciliary muscles
Black, blue & green (but not red or purple) nail polish may cause recover somewhat earlier than sphincter pupillae. The
significantly lower saturation readings. intraocular tension tends to rise, especially in narrow angle
glaucoma; conventional systemic doses produce minor ocular
TOPI C 35: ANAESTHESI A STAGES
effects.
289. Visual analogue scale ( VAS) most widely used to
Atropine is also used to awtegonise muscarinic effects of drugs
measure
A. Sleep & poisons. I t is the specific antidote for anti ChE & early
B. Sedation mushroom poisoning. I t is also given to block muscarinic
C. Pain intensity action of neostigmine used for rnyasthenia gravis,
D. Depth of Anaesthesia decurarization or cobra envenomation.
C
TOPI C 37: CALCI UM CHANNEL BLOCKERS

290. Stages of Anaesthesia were established by: 293. Drugs which interfere with anesthesia are:
A. Ether A. Calcium channel blocker nifedipine
B. Nitrous Oxide B. Beta blockers
C. Cyclopropane C. Aminoglycosides
D. Chloroform D. Steroid administration
A E. D-tubocurarine
A, B, & C

Ether
• Guedel’s staging of Anaesthesia was given for Ether
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294. Ca2 + channel blockers I n anesthesia. True is: Brief clonic seizures occur with the use of enflurane. Therefore
A. Needs to be decreased as they augment hypotension & enflurane is contraindicated.
muscle relaxation
B. withheld because they lower LES pressure Enflurane
C. Should be given in normal doses as they prevent MI & - Though it can give rise to fluoride as a metabolite, the
angina quantity is insufficient to cause renal toxicity.
D. All of the above - Bronchodilat ion and ut erine relaxat ion is similar t o
C halothane but it is better skeletal muscle relaxant
- I t stimulates salivary and respiratory secretions slightly, but
they generally do not pose any problem.
- I t does not sensitize the heart to adrenaline (Arrythmias
• Calcium channel blockers ( CCB) at therapentic doses have no
significant role in the release of normal Ach or on the strength of are rare)
normal neuromuscular (NM) transmission/ There have been a - Fall in B.P. is similar to that caused by halothane as it also
decreases peripheral resistance to some extent.
few reports, however, that CCB may block of NM
transmission induced by non-depolarising relaxants.
• CCBs relaxes the smooth muscles of esophagus thus causing
TOPI C 39: ETOMI DATE
lowering of LES, but there is no such indication of stoppage
of this drug during anaesthesia for the same complications. 297. Which of the following statements is not true about
• The use of CCBs have several important implication for etomidate?
anaesthetic management. A. It is an intravenous anesthetic
B. It precipitates coronary insufficiency
They are : C. It inhibits cortisol synthesis
D. It causes pain at site of injection
(i) Along with inhalational and narcotic anesthetics, nifedipine
causes decreased systemic vascular resistance, BP, and B
contractility may be additive and alongwith verapamil, they
decrease the AV conduction times and additively decrease BP,
systemic vascular resistance and contractility. Et omidat e does n ot precipit at e coronar y insufficiency.
Cardiovascular & respiratory depression do not occur with
(ii) Verapamil and presumably the other CCBs have been found
to decrease anesthetic requirement by 25% . etomidate.
(iii) Because slow channel activation of Ca2+ is necessary to cause Etomidate:
spasm of of cerebral and coronary vessels, broncho- Pot ent ult rashort act ing non bar bit urat e®
constriction and normal platelet aggregation, these drugs may intravenous anaesthetic.
have a role in treating ischemia of the CNS and CVS,
bronchoconstriction and untoward clotting disorders 298. I nduction agent that may cause adrenal cortex
perioperatively. suppression is:
A. Ketamine
TOPI C 38: ENFLURANE B. Etomidate
C. Propofol
295. Which of the following is contraindicated in epilepsy D. Thiopentione
A. Isoflurane B
B. Halothane
C. Enflurane • I nduction doses of etomidate transiently inhibit
D. Ether enzymes involved in cortisol and aldosterone
C synthesis.
Long t erm infusions lead t o adr enocort ical
suppression.
• Enflurane precipitates generalized tonic clott ic • I t is suitable for day care anaesthesia but less preferred than
seizures therefore it is contraindicated in epileptics. propofol
I ts use is contraindicated in porphyria6, adrenal insufficiency.
• Other questions on Enflurane
It slighty st imulates salivary and respiratoxy secretions TOPI C 40: GALLAMI NE
It causes fall in B.P. due to decrease in peripheral resistance.
It does not sensitize the heart to adrenaline (Arrythmias are 299. Muscle relaxant contraindicated in Renal failure is:
rare). A. Atracurium
I t causes bronchodilation B. D-tubocurare
I t is contraindicated in renal failure. C. Vecuronium
D. Gallamine
2 9 6 . W hich of t he f ollow ing inhalat ional agent is D
contraindicated in a patient with history of epilepsy;
A. Isoflurance
B. Enflurane
• Gallamine is a muscle relaxant C/ I in Renal failure as it is
C. Halothane
almost exclusively excreted by kidney.
D. Sevoflurane
B
• Gallamine (as gallamine triethiodide) is a non-depolarising
muscle relaxant. I t acts by combining with the cholinergic
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B. Dose needs to be altered in renal failure

receptor sites in muscle and competitively blocking the
C. I t is very lit tle affected by pH and heat
t ransmit t er act ion of acet ylcholine. Gallamine has a
D. Loading dose before continuous infusion
parasympatholytic effect on the cardiac vagus nerve which
B
causes tachycardia and occasionally hypertension. Very high
doses cause histamine release.
• Gallamine is commonly used to stabilize muscle
contractions during surgical procedures . Effect of lidocaine on refractory period
i) I n normal cells - I t decreases refractory period
Gallamine ii) I n depolarized cells - I t increases the refractory period
- Gallamine is excreted entirely unchanged in the Kidney, iii) AV Nodal refractory period –
so it is contraindicated in patients with Renal failure – I t has no effect on AV nodal refractory period
• The important point about lidocaine is t hat it has no
Preferred relaxants: electrophysiologycal effects on normal cardiac tissue while
• In hepatic failure: Atracurium it has marked electrophysiologial effect on depolarized
• I n Myaesthenia Gravis : one tenth of normal of Atracurium t issue.
(ifrelaxants are essential).
• In Obstretrics : any relaxant except Gallamine 304. Lignocaine in high doses produces
• In Arterial surgery (to maintain BP): Pancuronium A. Convulsion
To deliberately reduce blood pressure : Tubocurarine B. Respiratory depression
C. Hypotension
TOPI C 41: LAPROSCOPY D. Cardiac arrest
E. Hypothermia
301. Which gas is most commonly used in laparoscopy: A,B,C & D
A. O2
B. CO,
C. N2O • The maximum safe dose of Lignocaine for a 70 kg man with
D. N, adrenaline (epinephrine)- 500mg i.e. 7 mg/ kg;
B without adrenaline ( epinephrine)- 200 mg i.e. 3 mg/
kg body weight.

CO2 Higher doses produces toxicities like :

• The gas used is CO2 , as it is common to the human body CNS : St imulat ion follow ed by depression, restlessness,
and can be removed by the respiratory system if it absorbs hysterical behaviour, vertigo, t remor, convulsions, and
through t issue. respiratory failure.
• I t is also non- flammable, which is important due to the fact
that electrosurgical devices are commonly used in CVS : Hypotension, primary cardiac failure, feeble pulse,
laparoscopic procedures. cardiovascular collapse, bradycardia, pallor & sweating.

Respiratory depression : Apnoea from medullarly depression

or respiratory muscle paralysis.
Allergic :
Rare, bronchospasm, urticaria or angioneurotic oedema.

* Factors influencing local anaesthetic toxicity : . - Quantity

of’solution
- Concentration- of drug
- Presence or absence of adrenaline
- Vascularity of site of injection
- Rate of absorption of drug
- Rate of destruction of drug Hypersensitivtty of patient
- Age, physical status & weight, of patient

TOPI C 43: MALI GNANT HYPERTHERMI A

302. The gas used create pneumoperationeum is:
A. CO2 305. Hyperthermia is caused by:
B. N2 A. Anticholinergics
C. O2 B. MAO inhibitors
D. Room air C. Lithium
E. N2O D. Chlorpromazine
A, C, & D E. Carbimazole
NONE

TOPI C 42: LI DOCAI NE 306. Malignant hyperthermia is caused by:

A. Halothane
303. All are true about Lidocaine, except B. Cyclopropane
A. Prolongs refractory period
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MI NORTOPI CS ANAESTHESIA 63

C. Suxamethonium • Methoxyflurane has a high nephrotoxic potential and its

D. Ether use has been discontinued.
A& C • Ef lu r an e is also n eph r ot oxic, t h ou gh lesser t h an
Methoxyflurane and is also not recommended.
• Isoflurane, sevoflurane and halothane result in lit tle or no
increase in f luoride levels and are preferred.
Halothane & Suxamethonium
• C/ f of Malignant Hyperthermia :
TOPI C 45: MI VACURI UM
• Heat production exceeds the heat loss in the body to
cause a rise of temperature of at least 2 c/ h.
309. Mivacurium false is
• I t is characterized by
A. Hypertension
• Hypercapnia
B. Increasing the dose produces rapid onset of action
• Hyperventilation
C. Bronchospasm
• Hyperkalemia*
D. Flushing RADI OLOGY
• Metabolic Acidolis*
A
• Arrhythmia
• Diffuse intravascular coagulation
• Mivacurium belongs to non depolarizing blocker or
• Pyrexia
competitive skeletal muscle relaxants.
•
• This class of drugs acts by competitively inhibiting the
• There is – increased hemolysis*
NM receptors and thus causing relaxation.
- increased Creatine phosphtinase*
• Th e act ion of t h ese dr u gs can be r ever sed by
- increased Transaminase anticholinesterase like neostigmine.
• Management : • Mivacurium is the only nondepolarising neuromuscular
• Early withdrawal of the volatile anaesthetic agent is of blocker that is metabolised by plasma cholinesterase.
utmost importance • Mivacurium is the shortest acting non depolarizing
• Cool the patient muscle relaxant.
• Acidosis corrected • The usual intubuting dose is 1.5—2 mg/ kg.
• Administer Dantrolene • Mivacurium causes histamine, release but it generally
• Correction of Hyperkalemia does not cause serious side effects except for small degree
• Promote diuresis of hypotension. But when mivacurium is given in large
• Give Dexamethasone doses to increase the onset of action it causes
increased release of histamine w hich leads t o
TOPI C 44: METHOXYFLURANE hypotension, flushing and bronchospasm.
• Mivacurium causes histamine release due to direct action
307. Nephrotoxic anaesthetic agent is: on mast cells.
A. Halothane • On increasing the dose, the onset of action is increased.
B. Isoflurane
C. Methoxyflurane 310. Shortest acting non depolarising muscle relaxant:
D. Nitrous Oxide A. Vecuronium
C
B. Atracurium
..........(AI IMS PGMEE - JUNE - 1997), AI PGMEE - 1998
C. Succinylcholine
Methoxyflurane D. Mivacurium
• Methoxyflurane has the highest fluoride content so it D
is highly Nephrotoxic
• There is high output renal failure and high chances of
Oxalate stone. Shortest acting non depolarising muscle relaxant is ------- >
• I ts minimum alveolar concentration ( MAC) is 0.2 , hence Mivacurium
it is extremely potent.
Longest acting non depolarising muscle relaxant is ------- >
Pipecuronium*
• I t has a high lipid solubility ( oil:gas coefficient around
Most potent N.D muscle relaxant ------------------ > Doxacurium*
950 ) giving it a very slow onset/ offset, thus undesirable for
anesthetic purposes. Least potent N.D muscle relaxant ----------------- > Gallamine*
• Methoxyflurane has a high nephrotoxic potential and its Shortest acting depolarising M.R. ----> Succinylcholine*
use has been discontinued. Overall shortest acting M.R. ----> Succinylcholine*
• Ef lu r an e i s also n eph r ot oxic, t h ou g h lesser t h an • Most potent N.D muscle relaxant
Methoxyflurane and is also not recommended. – Doxacurium
I soflurane, sevoflurane and halothane result in lit tle or no • Least potent N.D muscle relaxant
increase in f luoride levels and are preferred. – Gallamine

308. Nephrotoxicity is caused by:

TOPI C 46: OXYGEN CONCNTRATOR
A. Seroflurane
B. Methoxyflurane
C. Isoflurane
311. True about oxygen concentrator:
D. Halothane A. Zeolite activation
B B. Delivers O2
C. Requires power supply
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MI NORTOPI CS ANAESTHESIA 64

Hematological advantages of Membrane oxygenators vs Bubble

D. Gives O2 at 100 %
oxygenators.
A, B & C
i) Less t rauma to red blood cells
ii) Less trauma to platelets
• Oxygen concentrators are devices that extracts O2 from
iii) Less t rauma to white blood cells
atmospheric air for which a zeolite molecular sieve is used.
iv) Less protein denaturation.
– The atmospheric air is exposed to the zeolite sieve at a certain
Due to these advantages membrane oxygenators have
pressure which selectively retains the N2 & other constituents of
largely replaced bubble oxygenators .
air & thus O2 of about 95% can be achieved.
The oxygenators which were used in past Vertical screens Disc
oxygenators
312. Which of the following produces the least damage
to blood elements -
TOPI C 47: PERI BULBAR BLOCK
A. Disc oxygenator
B. Membrane oxygenator
313. Complication of peribulbar block:
C. Bubble oxygenator
A. Retrobulbular haemorrhage
D. Screen oxygenator
B. Globe rupture
B
C. Optic neuritis
D. Local anaesthetic solution can migrate to brain
E. Vasovagal syncope
Oxygenators are devices used in cardiopulmonary bypass
ALL
surgeries.
Currently only two types of oxygenators i.e. membrane and bubble
oxygenators are in use.
314. I n general, the last muscle to be rendered akinetic
Membrane oxygenators (Pump oxygenerators) are more
with a retrobulbar anesthetic block is:
commonly used because they have improved the efficiency
A. Superior rectus
of gas exchange while minimizing the trauma to the blood
B. Superior oblique
elements.
C. Inferior oblique
D. Levator palpebral superioris
B

Retrobulbar anaesthesia -
• Retrobulbar block is regional anaesthesia for eye surgery.
• In this technique local anaesthetic is injected behindt
he eye int o t he cone for med by ex t raocular
muscles.
• Retrobulbar injection is given with a special needle which
is having a rounded tip.
This lid penetrates the lower lid at the junction of the
middle and lateral one third of the orbit (usually. 5 cm medial
to the lateral canthus).

• Choice of local aneasthetic varies, but lidocaine 2% and

bupivacaine .75% are most common.
Membr ane oxygenat ors imit at e t he nat ur al lung by • To enhance the retrobulbar spread of local anaesthetic
interspersing a thin membrane between gas and blood phases. Hyaluronidase, a hydrolyzer of connect ive t issue
This eliminat es gaseous microemboli format ion and polysaccharide is frequently added.
minimizes blood t rauma.
• A properly placed retrobulbar injection is effective within
seconds and blocks all extraocular muscles except the superior
oblique muscle, affect s t he ciliary ganglion (resulting in
pupillary dilatation) and anesthetizes the entire globe.

A successful retrobulbar block is accompanied by anaesthesia,

akinesia, and abolishment of the oculocephalic reflex (i.e.
a blocked eye does not move during head turning).

Complications of retrobulbur anaesthesia -

• Retrobulbar hemorrhage
• Globe perforation
• Optic nerve atrophy
• Frank convulsion
• Oculocardiac reflex
• Acute neurogenic pulmonary edema
• Trigeminal nerve block
• Respiratory arrest
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TOPI C 48: PORPHYRI A

3 1 5 . Dr ugs cont ra indicat ed in a cut e int er mit t ent

porphyria:
A. Thiopentone
B. Etomidate
C. Ketamine
D. Propofol
E. Midazolam
A& B

Drugs Recommendati
on
Inhaled anaesthetics Safe
Nitrous oxide & volatile anaesthetics
Intravenous anaesthetics
Propofol, ketamine, Midazolam Safe
Thiopental, thiamylal, methohexital & Unsafe
Etomidate
Analgesics
Aspirin, Morphine Safe
Ketorolac, phenacetin & pentazocine Unsafe • onset of Horner’s syndrome indicates a successful stellate
Muscle relaxants block.
Succinylcholine, pancuronium, Safe
atracurium, vecuronium
Anticholinergics
Atropine & glycopyrrolate Safe • Stellate ganglion block ( cervicothoracic sympathetic
Anticholinestenase block)
Neostigmine safe Indications
Pain syndromes
316. The drug which is not suitable for patients with acute Complex regional pain syndrome type I and I I
porphyria for intravenous induction is: Refractory angina
A. Thiopentone sodium Phantom limb pain
B. Propofol Herpes zoster
C. Midazolam Shoulder/ hand syndrome
D. Etomidate Angina
NONE Vascular insufficiency
Raynaud’s syndrome
TOPI C 49: STELLATE GANGLI ON BLOCK Scleroderma
Frostbite
317. A pt. in the I CU w as on invasive monitoring with intra Obliterative vascular disease
arterial cannulation through the right radial artery. For Vasospasm
the last 3 days later he developed swelling and Trauma
discoloration of the right hand. The next line of Emboli
management is: Contraindications
A. Brachial block – Coagulopathy
B. Stellate ganglion block Recent myocardial infarction
C. Application of lignocaine jelly over the site Pathological bradycardia
D. Radial nerve block on the same side Glaucoma
B
• Chassaignac’s tubercle
This is the anterior tubercle of the t ransverse process of the
Stellate ganglion block sixth cervical vertebra, which lies lateral to and at a slightly
higher level than the posterior tubercle, and against which the
carotid artery may be compressed by the f inger.
• Anatomy
The stellate ganglion refers to the ganglion formed by the • Stellate ganglion blocks have been traditionally performed
fusion of the inferior cervical and the f irst thoracic blindly by palpating the t ransverse process of C6 and infiltrating
ganglion as they meet anterior to the vertebral body of C7. I t a large volume ( as much as 20 mL) of local anest het ic.
is present in 80% of subjects. I t usually lieson or above the This technique is dependent on enough volume reaching
neck of the f irst rib. the stellate ganglion to result in an effective block.
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• Pain due to arterial insufficiency can be treated with a stellate 3 2 0 . The f ollow ing a r e used f or t r ea t m ent of
ganglion block, but this would have no effect on someone with postoperative nausea and vomiting following squint
venous insufficiency. surgery in children except:
A. Ketamine.
318. lnterscalene approach to brachial plexus block does B. Ondansetron.
not provide optimal surgical anaesthesia in the area C. Propofol.
of distribution of w hich of the follow ing nerve D. Dexamethasone
A. Musculocutaneous A
B. Ulnar
C. Radial Ketamine is not used for t reat ment of post operative nausea
D. Median and vomiting. I n fact ket amine use is itself associat ed w
B it h nausea and vom it in g an d requir esprophylaxis.
‘Nausea and vomiting occur and require prophylaxis’
“ Blockage of inferior trunk of brachial plexus may be incomplete
requiring specific blockage ofulnar nerve at the elbow” TOPI C 51: ASPI RI N

Brachial Plexus Block 321. . A pt. Who has on Aspirin for a long period was
Interscalene Axillary Approach Supra clavicular & selected for an elective surgery what should be done:
Approach Infraclavicular A. Infusion of platelet concentrate
approaches B. Infusion of fresh frozen plasma
Most intense at C5 - C7 Most intense block in More even distribution C. Stop Aspirin for 7 days
dermatomes and least C7-T, of local anaesthesia &
D. Go ahead with surgery maintaining adequate hemostasis
intense at C8- T , (ulnar (ulnar can be used for
nerve area) nerve).distribution least procedures on arm, C
Most optimal for intense in C5-C6 forearm and hand
Procedures on dermatome Stop Aspirin for 7 days
shoulder, arm and Most optimal for
forearm procedures from elbow
• Aspirin inhibits TxA2 Synthesis by platelet’s even
to hand
in small doses.
TOPI C 50: STRABI SMUS SURGERY
This inhibits platelet aggregation
319. A 5 Yr old child is scheduled for strabismus( squint)
cor r ect ion . I nduct ion of a na e st hesia is
uneventful.After conjunctival incision as the surgeon Bleeding time prolonged nearly twice
grasps the medial rectus, the anesthesiologists looks
at the cardiac monitor .Why do you think he did that
?. Effect lasts for about a week
A. he wanted to check the depth of anesthesia (Turn over time for platelet is 7 days)
B. he wanted to be sure that the BP did not fall
C. he wanted to see if there was an oculocardiac
reflex

D. He w an t ed t o make sure t her e w as no vent r icu lar if Aspirin is stopped for a week before Surgery
dysrhythmias which normally accompany incision =
C all platelet’s will be renewed
=
bleeding time will become normal.
The anaesthesiologist looked at the cardiac monitor to check for
oculocardiac reflex. The Oculocardiac reflex is induced by • Other measures will not help as Aspirin is irreversible
(a) Pressure on the eyeball inhibitor of Tx.A2 .
(b) Traction on the extra ocular muscle
(c) Orbital haematoma TOPI C 52: BOYLE’S APPARATUS
(d) Ocular trauma
(e) Eye pain 322. True about Boyle’s apparatus:
A. Continuous flow machine
I t is a trigeminovagal reflex. B. Liquid anesthetic vapours not used
The afferent pathway is through Trigeminal nerve and C. Resistance very high
the efferent pathway is through Vagus nerve. D. Resistance low
A& D
Manifestations-,
• Bradycardia ( most common) • Boyles apparatus was first developed for use in 1917. I t w
• Cardiac arrythmias as one of t he most common t ypes of anaest het ic equipment
• Nodal rhythum used in operating theatre.
• Ectopic beats • I t operates on the continuous flow principle whereby gas
• Ventricular fibrillation flows all the time during the inspiratory and expiratory phase of
• Asystole patient respiration, being temporarily stored during
expiration in a reservoir bag.
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• The basic principles of gas anaesthesia have been known for section. Which of the follow ing is the anaesthesia
over a hundred years and are still used. An anaesthetising agent technique of choice -
is delivered to the patient via flow controllers and mix A. Spinal anaesthesia
controllers. B. Epidural anaesthesia
C. General anaesthesia
Normally a mixture of N O and O would act as a carrier for D. Local anaesthesia with nerve blocks
2 2
the main agent ( i.e. Halothane). C
Most gas apparatus used today is based on the Boyles
apparatus, and although dated, it is still used in many hospitals.
In coarctation of Aorta, Aorta narrows any where along its
• In Boyles apparatus, the resistance offered by the bottles is course.
overcome by the pressure of gases from the cylinders. After The most common site for coarctation of Aorta is
leaving the bottles, the gases accumulate in the reservoir bag. • Just distal to origin of left subclavian artery
The rubber tubing connecting this bag with the mask • Near the insertion of ligamentum arteriosus
is of wide bore , thus minimal resistance to inspiration is So, the common clinical presentation in coarctation of Aorta
presented to the patient. is
• Hypotension, ischemia, distal to the obstruction,
TOPI C 53: CARBON MONOXI DE (circulation is usually diminished in obdominal organs and
pulses are absent in lower extremities)
323. The gas which produces systemic toxicity w ithout • Hypertension proximal to the site of obstruction
causing local irritation is: ( the B. P. in upper extrenities and head and neck is
A. Ammonia increased)
B. Carbon monoxide
C. Hydrocyanic acid Effect of coarctation of Aorta on Pregnancy.
D. Sulfur dioxide Coarctation of Aorta may lead to compromise of placental
D circulation, because the placental circulation is derived
from uterine artery, which is a branch of internal iliac artery
Carbon monoxide (all the vessels originating distal to coarctation will
Carbon monoxide is a colorless, tasteless, non- irritative gas, have diminished perfusion)
which is produced due to incomplete combustion of carbon. • So, the fetal circulation is in a compromised stat e in coarctation
of Aorta.
TOPI C 54: CHLORAL HYDRATE
Anaesthetic considerations that should be taken into
324. Which is safest to be used in asthmatic patients: account in case of coarctation of Aorta.
A. Nitrazepam • In coarctation of Aorta, any decrease in cardiac output or
B. Phenobarbitone cardiac return is deleterious to the fetus because the placental
C. Chloral hydrate circulation is already compromised on account of
D. All hypnotics are safe coarctation.
• So any anaest hetic procedure or drug w hich causes
E. Morphine
hypotension should be avoided in these patients.
C
Regional anaest het ic procedures such as spinal
anaesthesia and epidural anaesthesia should be avoided
• Benzodiazepines at usual hypnotic doses don’t affect
in these patients because hypotension is the most
respiration or cardiovascular functions. They are now popularly
common side effect of these procedures.
used as preanaesthetic medications because they produce
Th e consequ ence of decr eased ven ous ret ur n and
tranquility and smoothen induction with little respiratory
decreased systemic vascular resistance as a result of
depression.
t hese procedures w ould be hazadrous t o t he
patient.
• Benzodiazepines are saf e in asthm at ics but t h ese
tranquilisers (also Nitrazepam), sedatives, opiates, should be
TOPI C 57 : ETHER
absolutely avoided in severely ill with asthma, as risk of
developing depression of alveolar ventilation is great and
3 27 . All of t he follow ing are t he disadvant ages of
respiratory arrest may occur. anesthetic ether, except:
• Barbiturates cause respiratory and circulatory A. Induction is slow.
depression. B. I rritant nature of ether increases salivary and bronchial
Chloral hydrate, promethazine, diphenhydramine can be used secretions.
satisfactorily. C. Cautery cannot be used
D. Affects blood pressure and is liable to produce arrhythmias
TOPI C 55: COARCTATI ON OF AORTA D
325. A 30 year old w oman with coarctation of aorta is BP & respiration are generally well maintained because of reflex
admitted to the labour room for elective caesarean st imulation and high sympathetic tone- kdt Cardiac arryt
hmias occur r arely w it h et her an d t here is no sen sit
izat io n of t h e m yocar diu m t o cir cu lat in gcatecholamines
–
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Induction with ether is very slow (blood gas coefficient • Endotracheal tube one-half size smaller than usual to maximize
12.0) and very unpleasant the chances of easy intubation
Slow induction and recovery • Firm pressure over cricoid cartilage prior to induction
Ether stimulates salivary and bronchial secretions and so ( Sellick’s maneuver) e applied to make oesophagus
atropine premedication is given collapsed and prevent regurgitation
I t should not be used when diathermy is needed in the • Thiopentone is used as induction agent
airways, because of risk of f ire or explosion • The patient is not artificially ventilated to avoid f illing
of stomach with gas and thereby increasing the risk of emesis
TOPI C 58: FAT EMBOLI SM • I f intubation fails, spontaneous ventilation should be
allowed to return and awake intubation performed
328. Factors favouring fat embolism in a patient with • After surgery , patient should remain intubated until airway
major trauma: reflexes and consciousness has been regained.
A. Mobility of #
B. Hypovolemic shock TOPI C 61: TORNI QUET
C. Resp. failure
D. Diabetes 331. Tourniquet pressure in low er limb surgery:
A& D A. 50 mmHg above systolic
B. 100 mm Hg above systolic
TOPI C 59: OPI OI DS C. 200 mm Hg above systolic
D. Same as systolic BP
329. Best anaesthetic agent for outpatient anaesthesia E. Less than systolic BP
is B
A. Fentanyl
B. Morphine * Tourniquet pressure is about 100 mm of Hg above the systolic
C. Alfentanil blood pressure. The pressure for upper limb is = SBP+ 50mm
D. Pethidine of Hg & for lower limb is = 2 X SBP.
C
TOPI C 62: TRI LENE
In outpatient anaesthesia the patients are sent back home
t h e same day. Th erefor e agent s w hich ar e r apidly 332. Which is not compatible with Soda lime:
eleminated are used so that no after effects are left The agents A. Halothane
used are – B. Ether
• Propofol C. N2O
• Alfentanil D. Trilene
• Remifentanil D
• 90% Ca(OH)2*
• N2 O
• Isoflurane

• Sevofiurane Trilene • 5% Sodium

Hydroxide*
• Desflurane • Soda lime is a mixture of * —>
•1% Potassium
Hydoroxide*
TOPI C 60: RAPI D SEQUENCE ANAESTHESI A • Silicates*

330. During rapid sequence induction of anaesthesia:

A. Sellick’s maneuver is not required
B. Pre-oxygenation is mandatory
C. Suxamethonium is contraindicated
D. Patient is mechanically ventilated before endotracheal
intubation

Rapid sequence I nduction

This induct ion t echnique is used in patient w it h risk of
aspiration pneumonia ( mendelson’ s syndrome) eg.
hiatus hernia or any emergency operation with full
stomach.
In this technique patient is intubated immediately after induction
to avoid vomiting, reguritation and aspiration of gastric content.
Characteristic features -
• Patient is always preoxygenated prior to induction • Soda lime is used to absorb CO2 . When it absorbs CO2
• Prior Curarization with nondepolarization MR to prevent it produces heat . All volatile anaesthetic agents are
increase in intra abdominal pressure that accompanies use of decomposed by the heat produced as a result of absortion
succinyl choline. of CO2 by Soda lime.
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• Thermal decomposition of trilene ( trichlor ethylene) and

Sevoflurane results in toxic compounds therefore neither of • Xenon was discovered in 1898 and found to be the only
them should be used with sodalime. noble gas to be anaesthetic under normobaric conditions.
• For anaesthetic purposes, it was found very close to the
• Function of soda lime ‘ideal agent”.
Soda lime is used in breathing systems to absorb
expired CO2 during anaesthesia. Advantages of Xenon anaesthesia
• I t can be incorporated in a Mapleson C system or a circle • Inert probably nontoxic with no metabolism
system. Exhaled gases are circled back to the canister, • Unlikely to be involved in any biochemical events in the

where CO 2 absorption takes place and water and heat body, can be eliminated via lungs.

are produced. The warmed and humidified gas joins the • Minimal cardiovascular effects.
fresh gas flow to be delivered to the patient. • Low blood solubility.
• Rapid induction and recovery ( low est blood gas
The reaction: partition coefficient)
• Does not trigger malignant hyperthermia
CO + H O leads to H CO • Environmental friendly
2 2 2 3
2H 2CO3 + 2NaOH leads to Na 2CO3 + 4H2O + Heat • Non explosive

2Ca(OH) 2 + Na2CO3 leads to 2CaCO 3 + 2NaOH + Heat

Disadvantages
• In soda lime absorption, the carbon dioxide first reacts C
with w ater to form carbonic acid , which then reacts with
sodium hydroxide to form a soluble carbonate. The soluble
sodium carbonat e t hen react s w it h calcium hydroxide to
form an insoluble carbonate and replenishes the sodium
hydroxide. Heat and w ater are produced during the
reaction. Exhaustion of its activity is indicated by dyes; the
most common one changes from pink to whit e

• indicated by dyes; the most common one changes from pink

to white.

Size of granules

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).

• Carbon monoxide production has occurred w hen

volatile agents containing the CHF2 moiety ( enflurane/
isoflurane/ desflurane) are passed over soda lime that has
become desiccated or dried out.

TOPI C 63: XENON

333 . Which of the follow ing is not true about Xenon

anaesthesia
A. Non explosive
B. Minimal cardiovascular side effects
C. Slow induction and slow recovery
D. Low blood gas solubility
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• High cost
• Low potency
• No commercially available anaesthesia equipment