-Dr Manjit Shrestha

AIM
• System is to assess and communicate a patient’s pre-anesthesia medical co-
morbidities.
• The classification system alone does not predict the perioperative risks, but used
with other factors (e.g., type of surgery, frailty, level of deconditioning)

Q. Disease that is severe constant

threat to life, categorizes patient as
a) ASA Class II
b) ASA Class III
c) ASA Class IV
d) ASA Class V
 Preoperative assessment of oral cavity for endotracheal intubation in an adult is done by?
a) Mallampati score
b) Cormack Lehane
c) ASA grading
d) AHA grading

AHA HEART FAILURE CLASSIFICATION

Stage A Patients at risk for heart failure who have not yet developed structural heart changes
(i.e. those with diabetes, those with coronary disease without prior infarct)

Stage B Patients with structural heart disease (i.e. reduced ejection fraction, left ventricular
hypertrophy, chamber enlargement) who have not yet developed symptoms of heart
failure
Stage C Patients who have developed clinical heart failure

Stage Patients with refractory heart failure requiring advanced intervention (i.e. biventricular
pacemakers, left ventricular assist device, transplantation)
NPO prior to surgery MEDICATIONS
ADULTS Anti-HTN Continued till day of surgery

8 hrs. Full fatty meals Hypoglycemic Minor / Moderate- Omit last dose
agents Major- Omit last dose and start Insulin /
6 hrs. Semisolid foods glucose
2 hrs. Clear fluids Thyroid Continued
PEDIATRICS Anticoagulants Aspirin – continued
Clopidogrel – Stop 7 days prior
8 hrs. Full fatty meals LMWH – 12- 24hrs prior
6 hrs. Formulae milk / semisolid foods UFH – 6 hrs prior
Warfarin : 3-4 days prior
4hrs. Breast milk
OCPs NEED NOT BE STOPPED (Progesterone only)
2 hrs. Clear Combined pills  4 weeks prior
HCT 6-8 weeks prior
Antipsychotics, antidepressants , antiepileptics continued on day
of surgery EXCEPT
TCA 3 weeks prior
Lithium Stop 24-48hrs prior
 Role of Glycopyrrolate before GA?
a) Decrease laryngeal secretion
b) Muscle relaxation
c) Prevents aspiration
d) Provides analgesia

Pre-operative Medications
Anxiolytics Benzodiazepines (Midazolam, Diazepam, lorazepam)

Pain / Analgesia Opioids / NSAIDs

Anti-aspiration Ondansetron / Metoclopromimde
prophylaxis

Anticholinergics Decrease secretion – Glycopyrrolate

Sedation – Scopolamine
Decrease reflexes/ vagolytics - Atropine
 Five mandatory monitors-
I. ECG – Lead II (arrhythmia) and V5 (MI)
II. NiBP / Invasive blood pressure
monitoring
III. Pulse oximetry
IV. Capnography (EtCO2)
V. Temperature
 Sites for temperature  CVP monitor  Swan-Ganz catheter
monitoring-  Tip of catheter  Pulmonary artery
 Pulmonary artery catheter between SVC and catheter
(most sensitive but not Right atrium  Measures left atrial
commonly used)  Monitors right atrial pressure of heart
 Lower 1/3rd of esophagus (Most pressure of heart
common site)
 TM
 Nasopharynx
  BI SPECTRAL INDEX
 Depth of anesthesia is measured by ?
- Monitor depth of anesthesia
a. BiSpectral index (BIS)
- Three EEG electrodes in forehead
b. MAC
c. Post tetanic potentiation - 0 (coma) to 100 (full awareness)

d. Train of four - Desirable 40 to 60

 EtCO2 level is increased in all

condition ,except?
a) Fever
b) Shivering
c) Hypoventilation
d) Hypothermia
1.Stage of analgesia or disorientation
 INHALATION  LOC
COMPONENTS OF GA:
2.Stage of excitement or delirium
 Hypnosis
 LOC  Regular respiration
 Excitement, BP increased,
 Amnesia
 Pupil partially dilated
 Analgesia
 Muscle Relaxation/ attenuation of
3.Surgical Anesthesia autonomic reflex
 Plane I  EYE : Fixed
 Plane II  Loss of corneal / laryngeal reflex
 Plane III  Pupil dilate, Light reflex lost
 Plane IV  Intercostal paralysis, Shallow breathing, Dilated pupil

4.Medullary paralysis
 Death
Father of Anesthesiology John Snow

N2O Joseph priestly (1772)

Chloroform John Snow (1831)

(Labor analgesia to Queen
Victoria)
1st Anesthesiologist of Nepal B. B. Singh
Antibiotics Alexander Fleming
Antisepsis Joseph Lister
Bacteriology Leeuwenhoek
Blood Group Landsteiner
CT Godfrey Hounsfield
Epidemiology John Snow
Immunology Edward Jenner
Medicine Hippocrates
Modern Anatomy Andreas Vesalius
Modern Surgery Ambroise Pare
Paediatrics George Armstrong
Radiology Roentgen
 Q. Color of O2 cylinder?
A. Grey body with white shoulder
B. Black body with white shoulder
C. Black body with grey shoulder
D. White body with black shoulder

 Q. Most common cylinder

attached to anesthesia machine ?
A. Type A
B. Type C
C. Type D
D. Type E
 Nitrous oxide: Blue shoulder  Color of nitrous oxide cylinder is?
a) Blue
 Cyclopropane: Orange b) Blue body white shoulder
c) White
 Oxygen: Black body with white
d) Black
shoulder[NMC]
 Air: Gray body with Black and white
shoulder
 Thiopentone: Yellow
 Carbon dioxide: Grey shoulder
 Halothane: Purple (red)
 Helium: Brown shoulder
 N2: Black grey body with black and
white shoulder
 Entonox: Blue body white shoulder
The pin index safety system (PISS) is a
precise configuration of pins and holes that
facilitate the connection between a specific
medical gas cylinder and the delivery
system of these gases
 Q. Dead space is increased by all except?
a) Anticholinergic drugs
b) Standing
c) Hyperextension of neck
d) Endotracheal intubation
Ans: D
 Q. Physiological dead space consists of?
a) Alveolar dead space
b) Anatomical + Alveolar dead space
c) Anatomical – Alveolar dead space
d) Apparatus+ Alveolar dead space
Ans: B

 Q. Dead space is increased by all except?  Q. Regarding Tracheostomy, which is true?

a) Large NIV mask a) Increases apparatus dead space
b) ETT b) Decreases alveolar dead space
c) COPD c) Increases alveolar ventilation
d) None d) Decreases anatomical dead space
Ans: B Ans: D
 DEAD SPACE INCREASED
Standing
Neck Extension, jaw protusion
Bronchodilators (anticholinergics)
Large NIV masks, Large circuit components
COPD, rarely bronchiectasis
IPPV and PEEP
DEAD SPACE DECREASED
Supine
Neck flexion
Bronchoconstrictors
Artificial air ways (ETT, tracheostomy)
Hyperventilation, Bronchospasms
Massive pleural effusion
 Anatomical dead space
 Portion of the airways (such as the mouth and trachea to
the bronchioles) which conducts gas to the alveoli
 The normal value for dead space volume (in mL) is
approximately the lean mass of the body (in pounds)
 1/3rd of the resting tidal volume (450-500 mL).

 Alveolar dead space

 Sum of the volumes of those alveoli which have
little or no blood flowing through their adjacent
pulmonary capillaries,
 i.e., alveoli that are ventilated but not perfused,
and where, as a result, no gas exchange can occur.
 Negligible in healthy individuals, but can increase
dramatically in some lung diseases due to
ventilation-perfusion mismatch.
 Central nervous system (CNS) depressive state that is reversible and
provides
analgesia
sedation and decreased anxiety
amnesia and impaired consciousness
relaxation of skeletal muscle
prevention of reflexes

 can be divided into

1) intravenous anesthesia
2) inhaled anesthesia
 Causes a rapid induction of anesthesia when the anesthetic enters the blood, a portion of it binds
to plasma proteins (bound) while the rest are unbound
 the binding ability of the IV anesthetic is dependent on numerous factors, such as
 drug ionization
 lipid solubility

 the anesthetic enters the brain at a rate that depends on

 arterial concentration of unbound drug
 lipid solubility
 degree of ionization

 the higher the arterial concentration of the unbound drug, lipid solubility, and nonionized
molecules
 the faster the anesthetic enters the brain

 eventually, the anesthetic leaves the CNS (redistribution), resulting in

 recovery from the IV anesthetic
 Q. Thiopentone does not cause?
 A. Analgesia B. Rapid action
 C. Poor muscle relaxation D. Initial restlessness

Q. Which of the following is true about Thiopentone?

A. Acidic B. Good muscle relaxant
C. Produces analgesia D. Depth of anesthesia can be increased rapidly
with rapid recovery

Q. Pentothal sodium should be injected preferably into:

A. Veins in antecubital fossa B. Neck veins
C. Veins over the outer aspect of forearm D. Femoral vein

 Accidental intra-arterial injection of Thiopentone causes:

 A. Vasodilation B. Vasovagal
 C. Necrosis of wall D. Vasospasm
 Q. Not a contraindication of Thiopentone:
A. Asthmatics B. Aortic stenosis
C. Hyperkalemic periodic paralysis D. Patient on blocker

 Q. Not a property of Thiopentone:

 A. Antithyroid B. Anticonvulsant
 C. Antanalgesic D. Antiallergic

Q. A 32 year female with a history of epilepsy is to be operated for neck swelling.

The agent which can be used safely is:

A. Enflurane B. Thiopentone
C. Methohexital D. Atracurium
 Ultrashort acting, d/t fast redistribution from brain
 Highly alkaline yellow amorphous
 MOA: GABA stimulatory, ACh inhibitory
 4-5mg/kg
 Thiopentone because of its high lipid solubility crosses the placenta quickest and the fetal
concentration is rapidly increased to attain equilibrium with maternal concentration in 5 minutes
 Decreases cerebral metabolism, CEREBRAL PROTECTION
 Used in raised ICP, head injury, status epilepticus

 Redistribution causes SHORT t1/2 

 The elimination half life of Thiopentone is 10.4 hours but consciousness is regained after 6-8 minutes due to
redistribution which means drug from highly vascular areas like brain is redistributed to less vascular areas
like fat and muscle
 CONTRAINDICATION:
 Acute intermittent porphyria, Barbiturate allergy (Hypersensitivity), Asthma, Airway Obstruction (Status
asthmaticus), Shock
 Thiopentone sodium causes" reverse coronary steal phenom-ena" or " Robbin-hood
phenomena". (Opposite of isoflurane)
 Dose of Propofol for induction in anesthesia is:
 A. 1 mg/kg B. 2 mg/kg
 C. 5 mg/kg D. 9 mg/kg

Q. Which of the following agent is used for day care surgery?

A. Midazolam B. Propofol
C. Alfentanil D. Thiopentone

Q. Propofol vial once opened should be used within:

A. 6 hours B. 24 hours
C. 48 hours D. 1 week
 Propofol is oil based preparation containing soybean
oil, egg lecithin and glycerol, so painful on injection!!! S/E-
 2mg/kg APNEA
 Onset: 15sec, DOA: 2-8 min
PAIN
HYPOTENSION
 RAPID & SMOOTH RECOVERY
BRADYCARDIA
 Antiemetic & antipruritic, Bronchodilator
PROPOFOL INFUSION
 NO MUSCLE RELAXATION, NO ANALGESIA SYNDROME
 SEDATION in ICU, DAY CARE SURGERY (>4mg/kg/hr. for more than
 DOC for malignant hyperthermia (IVA) 48hrs,steroids,neurology
problems)
Cardiomyopathy,
 Contraindicated
 Pregnancy and children of less then 3 yrs. old age
Rhabdomyolysis,
 Egg allergy Metabolic acidosis
 Airway obstruction
 Shock
  Q. Not a action of ketamine on CNS:
a) Inhibition of cortex
b) Inhibition of thalamus
c) Inhibition of limbic system
d) Inhibition of dorsal horn cells of spinal cord

Q. Highest analgesic effect is a feature of ?

A. Ketamine B. Thiopentone C. Propofol D. Etomidate

Q. Patient with history of recurrent convulsions should not be given ?

A. Propofol B. Ketamine C. Bupivacaine D. Etomidate
 Q. Which of the following IV anesthetic agent is the drug of choice in shock
individuals:
 A. Thiopentone sodium B. Propofol
 C. Ketamine D. Midazolam

Q. Most common type of hallucinations after ketamine:

A. Visual B. Auditory
C. Tactile D. None of the above

Q. Agent of choice for decreasing hallucinations after ketamine:

A. Thiopentone B. Propofol
C. Morphine D. Midazolam
 Ketamine is preferred agent for induction in all except:
 A. Tetralogy of Fallot B. Constrictive pericarditis
 C. Congestive heart failure D. Ventricular septal defect (VSD)
 Dissociative Anaesthesia
 MOA: NMDA receptor antagonist
 Onset: `60sec (IV), 3-4 mins (IM) DOA: 15mins
 2 mg/kg (IV) , 5-10 mg/kg (IM)
 Routes:IV, IM, ORAL and intrathecal (spinal) routes, Inhalational (Children)
 INCREASES ICP & IOP, Hallucination
 MYOCARDIAL DEPRESSION
 INDICATIONS: AGENT OF CHOICE:
 ASTHMATICS (Bronchodilation), maintains airway reflexes
 SHOCK (SM stimulation )
 Constrictive pericarditis, Cardiac tamponade

 CONTRA:
 Head injury
 HTN, Hyperthyroidism
 Vascular aneurysm, Ophthalmic surgery
 Q. Most of the IV anesthetics produce myocardial depression . One with most cardiovascular
stable is?
 A. Thiopentone B. Etomidate
 C. Propofol D. ketamine

ETOMIDATE:
Most cardiovascular stable
DOC for Aneurysm surgery/ cardiac
disease
0.3mg/kg
Adrenal cortex suppression
 Primarily used for maintenance of anesthesia

Potency
 the index of potency is the inverse of the Minimum Alveolar Concentration
(Potency = 1/MAC)
 MAC is the concentration of inhaled anesthetic needed to prevent movement in
50% of patients in response to a noxious stimuli (e.g., surgical incision)
 E.g,
 high potency inhaled anesthetic has a low MAC
 the more lipid soluble the inhaled anesthetic is, the more potent it is; thus,
the lower the MAC
 the goal of inhalation anesthesia is to maintain an optimal brain partial
pressure (Pbr)
 the movement of the anesthetic from one body compartment to the next is
based on the drug partial pressure gradient
 the inhaled anesthetic drug would move from the alveolar partial pressure (Palv) → arterial
partial pressure(Pa) → Pbr
 eventually this steady state is achieved so that Palv = Pa = Pbr
 the speed of achieving this steady state is determined by a number of factors, such as

 Blood solubility
 Alveolar wash-in replacing normal lung gases with the inhaled anesthetic
 Cardiac output
 Tissue type's effect on the anesthetic
 Blood solubility

 Determined by the blood/gas partition coefficient (B/G)

 this is the concentration ratio of the inhaled anesthetic in the blood phase to
the gas phase when equilibrium is achieved

 Anesthetics with low blood solubility

 equilibrium is achieved rapidly

 quickly saturates the blood
 results in a rapid induction and recovery
  Q. Blood gas partition coefficient of anesthetic agent tells about:
A. Duration of action B. Potency of agent
C. Time lag of induction of anesthesia D. All of the above
 Ans: c

Q. The gas with greatest solubility in blood:

A. Nitrous oxide B. Nitrogen Potency of inhaled
C. Oxygen D. Hydrogen anesthetic agents is
Ans: A estimated by the minimum
alveolar concentration
(MAC) that produces a lack
of reflex response to skin
Q. Most potent inhaled anesthetic is:
A. Halothane B. Isoflurane
incision in 50% individuals
C. Sevoflurane D. Desflurane
Ans: A

POTENCY
HALOTHANE > ENFLURANE > ISOFLURANE > DESFLURANE
 Q. Anesthetic agent with least blood gas partition B/G coefficient
coefficient? Induction is fastest with least B/G coefficient
a) Desflurane
b) Nitrous oxide
c) Halothane
d) Ether
 Ans: A

Q. Mendelson Syndrome is due to?

a) Nosocomial pneumonia
b) Aspiration pneumonitis
c) Esophagitis
d) Esophageal spasm
Ans: B

Mendelson's syndrome is chemical pneumonitis or aspiration

pneumonitis CAUSED by a
Aspiration during anesthesia, especially during pregnancy.
Aspiration contents may include gastric juice, blood, bile, water or an
association of them.
 Minimum alveolar concentration is decreased by all, except:
 A. Pregnancy B. Hypothermia
 C. Acute alcohol intoxication D. Hypothyroidism
 Ans: D

MAC is decreased in:

• Pregnancy
• Hypothermia and hyperthermia up to 42°C
• Anaemia
• Intravenous anaesthesia
• Local anaesthesia
• Acute alcohol intoxication
• Increased age hyponatremia hypoxia (p02 < 40)' hypercalcemia, hypermagnesemia.

MAC is increased by:

a. Hyperthermia> 42°C.
b. Barometric pressure.
c. Chronic alcohol intoxication.
MAC is not affected by hypo- and hyperthyroidism and is same for males and females.
Q. Method of anesthetic induction in child is:
A. IM B. Inhalation
C. Intravenous D. Oxygen tent
Ans: B

Q. Inhalational agent of choice for shock patient is:

A. Halothane B. Isoflurane
C. Cyclopropane D. Enflurane
Ans: C
 Most common cause of death after chloroform anesthesia:
 A. Respiratory depression B. ARDS
 C. Ventricular fibrillation D. Malignant hyperthermia
 Ans: C
Q. Which of the following inhalational agent is avoided in Pheochromocytoma?
A. Halothane
B. Sevoflurane
C. Isoflurane
D. None
Ans: A
HALOTHANE
 Preservative : 0.01% thymol
 Least analgesic property
 BRADYCARDIA (Depress baroreceptors), ↓ IOP, ↓ BP, ↑ ICT
 Sensitizes myocardium to dysarthmic effect of catecholamine
 DOC: ASTHMA, HOCM, Uterine relaxation
 CONS:
 5 “H”:
 Malignant hyperthermia, MALIGNANT
 Halothane hepatitis (Trifluoroacetic acid) HYPERTHERMIA
 Hypotension,  Halothane, Sevoflurane,
 Hypercapnia Isoflurane, Desflurane,
 Halothane shakes Enflurane (SIDE)
 PPH (relaxed uterus)  Suxamethonium,
Decamethonium
 N2O
 SEVOFLURANE MAC high (104%)
 DOC: ASTHMA, Children AMNESIA solely
Diffusion hypoxia post surgery
 DESFLURANE
NEEDS 100%
 Day care surgery, SHOCK patients
SIDE EFFECTS:
 ISOFLURANE Bone marrow suppression
 DOC for cardiac ,hepatic & neurosurgery Peripheral neuropathy
 CORONARY STEAL PHENOMENA
 However, preserves hepatic artery
perfusion
 ENFLURANE
 Epileptogenic, myocardial depression
 AVOID in Renal disease, Epilepsy
Nitrous oxide
 low blood solubility → low blood/gas partition
coefficient → rapid induction/recovery
 low lipid solubility → low potency → high MAC

Halothane and Fluranes

 high blood solubility → high blood/gas partition
coefficient → slow induction/recovery
 high lipid solubility → high potency → low MAC
 No analgesia  Halothane
 Profound analgesia  ketamine
 Maximum analgesia Trielene
 Only analgesia  N2O

 CVS effect:
 Halothane=Enflurane > Isoflurane=Desflurane= Sevoflurane
 Q. Alcoholic liver failure patient requires GA for operation. Agent of choice?
 A. Ether B. Halothane
 C. Isoflurane D. Enflurane
 Ans: C

Q. Following RTA, patient suffered splenic rupture. His BP is 90/60mmHg, PR 126/m

and SpO2 is 92%. Induction agent of choice?
A. Remifentanyl B. Thiopental
C. Etomidate D. Succinyl choline
Ans: C

Q. Atropine as pre-anesthetic agent has all effects except?

A. Decrease secretion B. Bronchoconstriction
C. Prevent bradycardia D. Prevent hypotension
Ans: B
 Muscle blockade sequence
Eyelids >jaw> Pharynx> Larynx> abdominal muscles> limb muscle
 Reversal sequence is also same
 SIDE EFFECTS:
 BRADYCARDIA (low dose)
 ↑ ICP
 Onset: 20-30sec (SHORTEST )  ↑ K+
 DEPOLARIZING / NON- COMPETITIVE  ↑ IOP
 DOA: 3-5 mins
 Muscle myalgia
 Malignant Hyperthermia
 1-2mg/kg (Trt: Dantrolene)
 MOA: similar to Ach, non competitive
 TWITCHING,
 FASCICULATIONS
1st in limbs Neck  finger eyes  trunk 
respiratory muscle
 Doesn’t cross placenta
 Doesn’t require reversal of blockade
 0.1mg/kg
 Hepatic metabolism & biliary secretion (AVOIDED IN HEPATIC
INSUFFICIENCY /BILIARY OBSTRUCTION)
 Most cardio stable muscle relaxant (CARDIAC PATIENT)

Rocuronium Gallamine
0.5-1mg/kg Excretion by kidney (80%)
Rapid Sequence Induction AVOID IN RENAL DISEASE &
Painful injection PREGNANCY
 0.5mg/kg SIDE EFFECT:
 Onset: 2-3 min,  Convulsion d/t metabolite
(rare)
 DOA: 10-15 mins
 Histamine release causing
 METABOLISM: hypotension &
 SPONTANEOUS DEGRADATION IN PLASMA bronchospasm
 Hoffman degradation (self destruction of
drug)
 Metabolite LAUDANOSINE, can cause
convulsions
 DOC: Hepatic , Renal failure, Myasthenia gravis,
old age, new born
 ISOMER: CISATRACURIUM 4 times potent and
doesn’t cause histamine release
 Q. Anticholinesterases are used for reversal of NM blockade of all muscle
relaxants below except?
a) Vecuronium
b) Decamethonium
c) d-tubocuranine
d) Rocuronium
 Ans: B
 Prevent sensory nerve impulses from reaching the central nervous system (CNS)
 this is accomplished by blocking the inner portion of the sodium channel which
in turn prevents the propagation of an action potential
 most effective in rapidly firing neurons
 Structure
 a lipophilic group is joined to a hydrophilic group via
 an amide or ester linkage
 biotransformation of amides mainly occur in the liver
 tertiary amine cross membrane in uncharged form and
undergo ionic change in order to bind to sodium channel in charged form
 biotransformation of esters are accomplished by plasma cholinesterase
(pseudocholinesterase)
Order of blockade of nerve fibres by LA
 B fibers > C fibers >Ad sensory fibers > A alpha type Ia, I beta> A beta>
A gamma > A alpha motor.

The uptake of local anesthetic from greatest to least is as follows:

 IV> tracheal> intercostal> caudal> paracervical> epidural> brachial >
sciatic > subcutaneous.
 Order of nerve blockade
 small-diameter fibers > large diameter fibers and myelinated fibers >
unmyelinated fibers
 size predominates over myelination

 Order of loss in local anesthesia

 (first) pain → temperature → touch → pressure (last)
 Q. True about using local anesthetic with adrenaline?
 A. Constricts vessels so onset of action is fast
 B. Dilates vessels so onset of action is slow
 C. Should not be given in penile surgery
 D. All of the above
 Ans: C

Q. Lignocaine + adrenaline is not given in which block?

A. Penile B. Brachial plexus
C. Ankle block D. Elbow block
Ans: A

Q. Which of the sensation is blocked first during anesthesia?

A. Heat B. Pain
C. Cold D. Pressure
Ans: C
 SEQUENCE OF BLOCKADE
Autonomic > Sensory (Cold > Heat > Pain> touch > Deep pressure> Proprioception ) >
Motor
 RECOVERY
 Motor > Sensory > Autonomic
 Q. Which of the following agent is an amide?
 A. Procaine B. Tetracaine
 C. Prilocaine D. Cocaine
 Ans: C
 Lignocaine is DOC for ventricular tachycardia.
 S/E in high dose convulsion, hypotension, cardiac arrest, resp. depression.
 Xylocaine is neither vasoconstrictor nor vasodilator (very little vasodilatation
activity may be seen)
 M/A → By blocking Na+ channel.
 Uses - spinal block, epidural block, regional nerve block, ventricular
fibrillation, as local infiltration, to blunt hemodynamic response to intubation.
 Xylocaine 2% is used in dose of 3-5 mg/kg.
 Xylocaine 2% with adrenaline is used in a dose of 5-7 mg/kg.
 Xylocaine with adrenaline should not be used for ring block, penile block.
 Xylocard (Xylocaine without preservative) is the only preparation of xylocaine
used i.v.
 More cardiotoxic than lignocaine.
 Long acting drug. Effect lasts for 6 hrs.
 Hyperbaric solution of B~ is injected as a single shot into CSF to produce
intense (usually within 5min) blockade (spinal/ intra-thecal anesthesia).
 Should not be used in Bier's block (because of its cardiotoxic potential).
 Cardiotoxic: Prolongs QT interval. Bretylium is DOC for bupivacaine induced
ventricular tachycardia.
 Used for skin infiltration, epidural, spinal regional nerve block
 Less placental transfer. Fetomaternal ratio is 0.32 so used in labor/ obstetric
analgesia.
 Produces differential blockade.
LIGNOCAINE Max dose :4-5mg/kg , 7mg/kg (with Adrenaline )
USES:
 XYLOCARD 2% (lignocaine without preservative)
 Ventricular tachycardia
 Ventricular extra systoles
 LA (1-2%)
 SA (5%, 8% heavy)
BUPIVACAINE Longest acting (5-16 hrs.)
Max dose: 2.5mg/kg
Heavy Bupivacaine: DEXTROSE ADDED
CARDIOTOXIC ( Dysrhythmias  Amiodarone)
USES:
 Nerve block 0.5%
 EPA: 0.125% - 0.5%
 SA 0.5% (heavy in 8% dextrose)
 Q. 30year old lady is to undergo surgery under IV regional anesthesia for
her left trigger finger. Which of the following should be avoided ?
 A. Lignocaine
 B. Bupivacaine
 C. Prilocaine
 D. Lignocaine + Ketorolac
 Ans: B

Agent Duration of
action
 Q. Longest acting local anaesthetic is: Procaine and 0.25-0.5 hours
 A. Lignocaine chloroprocaine
lidocaine, mepivacaine, 0.5-1.5 hours
 B. Chloroprocaine and prilocaine,
 C. Bupivacaine tetracaine 2-3 hours
 D. Ropivacaine bupivacaine 2-4 hours
 Ans: C Etidocaine and 2-3 hours
ropivacaine
 Life-threatening genetic abnormality of skeletal muscles char/by sympathetic
stimulation tachycardia, tachypnea, ↑BMR, hyperkalemia, muscle rigidity,
hypertension, DIC, and fever.
 Seen in children of muscular dystrophy.
 Masseter m/s rigidity is the earliest definitive sign and hypercapnia is the earliest
biochemical change.
 SCH causes MH in immediate post op period (within hours).
 ↑se in End tidal CO, (ET CO2).
 T/t: Cooling of body, hyperventilation with O2
 SPECIFIC ANTIDOTE : Dantrolene - sodium (Bromocriptine is also useful).
Dantrolene sodium interferes with the release of Ca++ ions from SR (sarcoplasmic
reticulum) → Inhibit ryanodine receptors → Decrease intracellular Ca
COMPLICATIONS OF SPINAL
 Hypotension (Most common)
 Bradycardia ( Most common
arrhythmia)
 Apnea, Cardiac arrest
 Nausea & Vomiting
 6th nerve involved (Longest course)
 Urinary retention (most common Post
OP)
 PDPH (12-24hrs) : CSF leakage
 Q. SA is given over which space? Adult : L3-L4
 A. L3-L4 B. L4-L5 Children : L4-L5
 C. L1-L2 D.L5-S1
 Ans: A Spinal cord level ends at
 L1 ADULTS
 L3 Infants
Q. Which of the following needle is used in Epidural anesthesia?
A. Whitacre B. Quincke
C. Sprotte D. Tuohy
Ans: D Dura cutting : Quincke, Pitkin
Dura Separate: Whitacre, Sprotte

Q. All of the following about Epidural anesthesia are correct, except?

A. Segmental blockage
B. Duration of anesthesia can be prolonged with repeated boluses
C. Free flow of CSF
D. Large doses of anesthetic agents required
Ans: C
 Q. Post spinal headache is caused due to?
 A. Trauma to dura
 B. Loss of CSF
 C. Due to anesthetic drugs
 D. Difficult posture
 Ans: B

Q.All of the following structures are pierced during SA, except?

A. Ligamentum flavum
B. Supraspinous ligament
C. Arachnoid matter
D. Posterior longitudinal ligament
Ans: D
 Q. What is seen in high spinal anaesthesia?
 A. Hypotension & Bradycardia
 B. Hypotension & Tachycardia
 C. Hypertension & Bradycardia
 D. Hypertension & Tachycardia
 Ans: A

Q. Following spinal subarachnoid block, patient develops hypotension.

This can be managed by except?
A. Reverse Trendelenburg position
B. Administration of 100mL of Ringer’s Lactate before block
C. Vasopressor drug like ephedrine
D. use of inotrope like dopamine
Ans: A
 Q. 5year old child, the size of ET tube?
 A. 5.1mm ID B. 6. 1mm ID
 C. 7.1mm ID D. 2.1 mm ID
 Ans: A

SIZES:
 Premature: 2.5
 0-6 months: 3-3.5
 6 months- 1 yr : 3.5- 4
 1-6 yr: Age/3 +3.5
 >6 child : Age/4 +4.5
 Q. Drug avoided in Head injury?
 A. Oxygen B. Normal Saline
 C. Antibiotics D. Morphine

Q. Which of the following is contraindicated in endotracheal intubation ?

a) Head elevation
b) Pre-oxygenation with 100% oxygen
c) Neck Flexion at Atlanto-Occipital joint
d) Introduction of blade towards right side of oropharynx
 Q. During CPR, Chest
compression to
respiration is ?
 A. 100:2
 B. 30:2
 C. 15:2
 D. 3:1
 Ans: B
Q. Concentration of Epinephrine at CPR?
A. 1:1000
B. 1:10000
C. 1:100
D. 1: 2000
Ans: A
 Q. Use of Entonox for pain relief during surgical dressing. It contains?
 A. 10% O2 and 90% of halothane
 B. 75% O2 and 25% of NO2
 C. 40% O2 and 60% of NO2
 D. 50% O2 and 50% of NO2
 Ans: D

 Q. In ICU , following right subclavian vein cannulation for CV line, patient

developed respiratory distress, dyspnea, hypotension & tachycardia. Chest
examination shows diminished air entry in and decreased breath sound on
auscultation & hyper resonance on percussion over the right chest. Diagnosis is?
 A. Acute MI
 B. Pulmonary edema
 C. Air embolism
 D. Pneumothorax
 Ans: D
 Q. After contrast media injection in radiology department a patient
develop severe hypotension, bronchospasm and cyanosis. Which of
the following should be used for treatment:
 A. Atropine
 B. Aminophylline
 C. Dopamine
 D. Adrenaline
 Ans: D
 IMMEDIATE COMPLICATIONS OF INTUBATION ARE:
a. Tube displacement leading to hypoxia.
 Complication to larynx from b. Reflex disturbances leading to cardiac arrhythmias and
prolonged endotracheal intubation laryngospasm.
are all, except: c. Injury to lips, gums, teeth, pharynx, epiglottis.
 A. Ulceration d. Laryngeal injury by cuff leading to ulceration &
 B. Stenosis necrosis.
 C. Necrosis B. POSTOPERATIVE COMPLICATIONS:
 D. Abductor paralysis a. Sore throat.
b. Laryngeal edema (usually present after 1 to 2 hours).
 Ans: D
c. Surgical emphysema.
d. Laryngeal nerve palsies.
C. DELAYED COMPLICATIONS:
a. Vocal cord granuloma.
b. Tracheal and laryngeal stenosis.
c. Laryngeal and tracheal web.
d. Tracheal collapse
Pressure necrosis leading to ulceration & finally granulosa
and stenosis usually occur after prolonged intubation but
laryngeal nerve palsies can occur even with intubation for
smallest period
 Tracheostomy is done in?
 A. Tetanus B. Flail chest
 C. Cardiac tamponade D. Fracture femur & pelvis
 Ans: A

INDICATION OF TRACHEOSTOMY
Elective procedure when prolonged ventilation is required.
As a emergency procedure for failed intubation.
Upper airways obstruction
Laryngeal edema, foreign body, bilateral vocal cord palsy,
Tracheal ste-nosis, laryngeal trauma, laryngeal and tracheal web.
Difficult intubation
where neck movement is restricted like Cervical spondylosis, Rheumatoid arthritis, teta-nus
or when neck movement can be life threatening (C1-C2 dislocation).
 Importance of CVP measurement is to assess the need for:
 A. Titration of infusion rate
 B. Plasma transfusion
 C. Blood transfusion
 D. Inotropic support
 Ans: A

Q. Conditions or drugs which causes rise in CVP include all except:

A. IPPV
B. Heart failure
C. Nitroprusside
D. Valsalva maneuver
Ans: C
 Pulmonary capillary wedge pressure denotes pressure of?
 A. Right atrium B. Left atrium
 C. Left ventricle D. Pulmonary artery
 Ans: B

Q. Minimum pressure in left atrium for development of pulmonary edema

A. 15 mmHg B. 18 mmHg
C. 30 mmHg D. 9 mmHg
Ans: C
 Q. While on a teaching sabbatical in Uruguay, a pathologist
examined the excised liver of an 18-year-old otherwise
healthy female who passed away due to massive hepatic
necrosis 5 days after she underwent general anesthesia to
repair a fractured femur. Which of the following is a general
anesthetic most likely responsible for her death?
a. Bupivacaine
b. Lidocaine
c. Midazolam
d. Halothane
 Interpret the following data.
 Ph = 7.40
 PCO2 = 20 mm Hg PO2 = 90 mm Hg,
 HCO3 = 8 meq / lit
 Na = 136 meq / lit. K= 4 meq / lit
 What is your diagnosis?

A. Uncompensated metabolic acidosis

 B. Uncompensated. Respiratory acidosis.
 C. Compensated Respiratory acidosis
 D. Compensated metabolic acidosis
 Interpret the following data.
HCO3 = 8 meq / lit, Ph = 7.20
PCO2 = 80 mm Hg, PO2 = 90 mm Hg,

 What is your diagnosis?

 A Mix metabolic acidosis & respiratory acidosis
 B Mix metabolic alkalosis & respiratory acidosis
 C Mix metabolic acidosis & respiratory alkalosis
 D Mix metabolic alkalosis & respiratory alkalosis
 Interpret the following data
HCO3 = 10 meq / lit, Ph = 7.40
PCO2 = 20 mm Hg, PO2 = 90 mm Hg,
A Mix metabolic acidosis & respiratory acidosis
B Mix metabolic alkalosis & respiratory acidosis
C Mix metabolic acidosis & respiratory alkalosis
D Mix metabolic alkalosis & respiratory alkalosis
 Interpret the following data.
 HCO3 = 38 meq / lit, Ph = 7.50

PCO2 = 20 mm Hg, PO2 = 90 mm Hg,

A Mix metabolic acidosis & respiratory acidosis

B Mix metabolic alkalosis & respiratory acidosis
C Mix metabolic acidosis & respiratory alkalosis
D Mix metabolic alkalosis & respiratory
alkalosis
 Calculate the anion gap Na = 135, K = 5, PO2 = 90, HCO3 =
10, Cl = 104, PCO2 = 45
 A. 21
 B. 16
 C. 36
 D. None of the above

 [AG = (Na) – [(Cl + HCO3)]

 Interpret the following data: paCO2 = 40, paO2= 90, Na= 135, K=5,
HCO3= 23, Cl= 110, Calculate the anion gap. In which of the following
conditions. The above anion gap can occur
a. RTA
b. Lactic acidosis
c. Multiple myeloma
d. Salicylate poisoning
THANKS!!!