TOPIC 1: LOCAL ANESTHETIC ANAESTHESIA 1

TOPIC 1: LOCAL ANESTHETIC • Remember that while most local anaesthetics cause
vasdilatation,
1. True about EMLA: Cocaine is one of the rare examples of local
A. Can be used for intubation anaesthetic which causes vasoconstriction’
B. Mixture of local anesthesia • Pocaine, Chlorprocaine and Lidocaine all cause varodilation.Q
C. Faster acting
D. Used in children 6. Longest acting L.A
B&D A. Bupivacaine
..........(PGI - DEC 2006) 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 cutaneous analgesia ..........(AIPGMEE - 1994)
through intact skin.
• The preparation should be applied under an occlusive 7. Nerve Fibre affected by local anesthesia first
bandage for 45-60 minutes to obtain A. Type A
effective cutaneous anaesthesia. B. TypeB
• Uses : C. Type C
to decrease pain a/w percutaneous insertion of I:V. needles D. Type
and cannulas. C
- Skin grafting procedures. .........(AIPGMEE - 1995)
- in neonates or in needle phobics.
- Newborn circumcision. Susceptibility Most Intermediate Least
to susceptible susceptible
2. Which of the following is not an amide:
A. Lidocaine Hypoxia B A C
B. Procaine Pressure A B C
C. Prilocaine
D. Etidocaine Local C B A
B Anesthetics
..........(AIIMS PGMEE NOV - 2003)
Amide linked Local anaesthetics 8. Shortest acting local anaesthetic agent is:
Lidocaine A. Procaine
Bupivacaine B. Leidocaine
Dibucaine C. Tetracaine
Prilocaine D. Bupivacaine
Ropivacaine A
Ester linked local anaesthetics ..........(AIPGMEE - 1997)
Cocaine
Procaine Procaine
Chlorprocaine Duration of action of v arious anaesthetic agents in
Tetracaine descending order are :
Benzocaine Dibucaine (Cinchocaine)>Tetracaine (amethocaine) >
Bupivacaine > Lidocaine > Procaine
3. Which one of the following local anesthetics belongs Amongst the choices provided procaine is the shortest acting.
to the ester group?
A. Procaine Other commonly asked questions on local anaesthesea :
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
..........(AIPGMEE - 2006), AIPGMEE - 2007 • Only naturally occurring LA-Cocaine
• Only LA agent which causes vasoconstriction – Cocaine
5. Which of the following local anaesthetics causes (Rest are vasodilators)
vasoconstriction:
A. Procaine 9. All of the following are example of amide linked local
B. Lidocaine anaesthetics except:
C. Cocaine A. Lidocaine
D. Chlorprocaine B. Procaine
C C. Bupivacaine
..........(AIPGMEE - 1999), AIPGMEE – 1998 D. Mepivacaine
PGI - 1997 – Dec, AIIMS PGMEE - DEC 1997 B
Cocaine ..........(AIPGMEE - 1998)

HELP LINE NO. 9391567707

 TOPIC 1: LOCAL ANESTHETIC ANAESTHESIA 2

12. About lidocatne, all are true except:
A. LA effect
B. Cardiac arrhythmia
C. Ester
D. Acts on mucous membrances
C -
..........(PGI - 1998 - Dec)
• Lidocaine is AMIDE linked LA
good for both surface application and injections.
• Lidocaine has little effect on contractility and conductivity,
it abbreviates ERP, and is used as ANTI- ARRHYTHMIC.
Overdose of lidocaine can cause-cardiac arrhythmias, -
Decrased BP, convulsion, resp.arrest, coma etc.
13. True statements about local anaesthesia:
A. It inhibits the generation of action potential.
B. Unmyelinated thin fiber are most susceptible than
myelinated large fibers.
C. Toxicity is reduced by addition of vasoconstrictor.
D. Blocks all modalities of sensation at the same time
A •
..........(.PGI - DEC 2003)
• Local anesthesia (LA) produce conduction blockade of
neural impulses by preventing passage of sodium ions
through ion selective sodium channels in nerve membranes
thus inhibiting generation of Action potential. It do not
alter the resting transmembrane potential or threshold
potential.
• Myelin increases conduction velocity and makes the nerve
membrane more susceptible to LA.
• Large myelinated fibers are more sensitive to LA than small
unmyelinated fibers.
• Preganglionic type ‘B’ fibers are more readily blocked by
LA than any fiber.
• In practice, the sequence of nerve block by LA are :
Autonomic -> Sensony -» Motor
• Addition of vasoconstrictors like adrenaline to LA
- Produces : decreased absorption and reduces toxicity
- Prolongs analgesic activity.
14. Local anaesthesia acts by
A. Na+ channel inhibition
B. Ca+ channel inhibition
C. Mg*4 channel inhibition
D. K+ channel inhibition
A CMR (cerebral metabolic rate), cerebral blood flow, &
..........(PGI - JUNE 1997)
Local anaesthetic drugs exert their effect by binding to
the internal mouth of the sodium channel.
15. Drugs used in case of local anesthetic toxicity:
A. Antiarrhythmic
B. IV fluids
C. Anticonvulsant
D. O2
A ..........(PGI - June -2000)
..........(PGI - JUNE 2006)
Emmergency treatment of local anaesthetic toxicities are:
- Facemask oxygenation.
- Restoration of haemodynamics with IVF & cardiac
massage if required.
- Prevention of metabolic acidosis with sodium bicarbonate.
- Prevention or early treatment of seizure activity
with Benzodiazepines.
Inotropic support with Atropine, Epinephrine, Dopamine
& Calcium chloride.
Defibrillation, Antiarrythmic agents like Amiodarone.
16. True about local anaesthetic agents
A. Duration depends on protein binding
B. Potency depends upon lipid solubility
C. LA with low PK is more active
D. Higher dose produces more block
E. Signal transduction blockade
ALL
..........(PGI - JUNE 2004)
• Local anaesthetics are chemical compounds which are
capable of reversibly inhibiting the propagation of
impulses in nerve cells.
Three major factors determine the conduction-blocking
profile of a LA in an isolated nerve preparation :
Lipid solubility, protein binding & PK.
LA agents which are highly lipid-soluble are able to penetrate
the neuronal membrane & gain access to their site of
action more readily than less lipid-soluble agents & is
reflected biologically in their increased potency.
Duration of action of LA appear to be influenced primarily by
their protein-binding capacity, agents with the longest
duration of action (Bupivacaine & Ropivacaine) are
highly protein bound.
• LA with PK closer to physiological PH will have more
rapid onset than those with higher PK.
• Onset of conduction block by LA depends on the dose or
concentration of LA.
• The physiological changes during laryngoscopy & intubation
are :
CVS :
Hypertension, Tachycardia & dysrhythemias & bradycardia
in children.
Respiratory :
Increased a irway reactivity & lar yngospasm &
bronchospasm.
CNS : Stimulates CNS activity with Increased in EEG activity,
thus ICP & IOP.
Abdomen : Increased in intraabdominal pressure with
increased risk of aspiration in patients with full stomach.
17. Short acting L.A:
A. Procaine
B. Lignocaine
C. Bupivacaine
D. Tetracaine
A
Procaine, is a short acting local anaesthetic duration of nerve
block is 30-60 minutes

HELP LINE NO. 9391567707

 TOPIC 2: KETAMINE ANAESTHESIA 3

18. True about local anaesthetic: Ester linked local aneasthetics produce allergic reaction
A. Cocaine acts by decreasing norepinephrine because they are first metabolized to PABA derivative.
B. Act by decreasing sodium entry into the cell These metabolites are responsible for the allergic reaction
C. Lignocaine is a amide caused by ester linked local anaesthetics.
D. Dibucaine is drug of choice for epidural anaesthesia Out of the given options only Benzocaines is an ester
B&C linked local anaesthetic,
..........(PGI - June -2001)
22. L.A. causing Methaemoglobinemia
19. Order of sensitivity of nerve fibres to Local A. Procaine
anaesthetic in decreasing order: B. Prilocaine
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-delta), sensory, motor, Preganglionic ..........(AIPGMEE - 1994)
sympathetic B
D. Preganglionic sympathetic B. sensory, motor, Pain (C and • Prilocaine is an amide linked local anaesthetic.
A-delta) • Methamoglobinemia may be seen sometimes with use of
B
prilocaine.
..........(AIIMS PGMEE - MAY 2008)
• One of the degrading products of prilocaine has potential
of causing methamoglobirumia Congenital or acquired
Fiber Sensory Modality Diamete Condu Local Myelinat methamoglobinumia are thus contraindications to the use
Type Classifi Served r (mm) ction Anestheti ion of Prilocaine
cation {mis) c
Sensitivit
y TOPIC 2: KETAMINE
Aa Motor 12-20 70-120 + Yes
Aa T ype la Proprio 12-20 70-120 ++ Yes 23. Which of the following increases intracranial tension
ception A. Thiopentone
Aa T ypelb Proprio 12-30 70-120 ++ Yes B. Ketamine
ception
C. Halothane
AP T ype II T ouch 5-12 30-70 ++ Yes
pressur
D. Propofol
e B
Proprio ..........(AIIMS PGMEE - SEP 1996)
ception
Ay Motor 3-6 15-30 ++ Yes
(muscle 24. Which of the following causes hallucination ;
spindle) A. Ether
A5 T ype-III Pain 2-5 12-30 +++ Yes B. Halothane,
Cold C. Ketamine
tempera
ture D. Thiopentone
T ouch C
B Pregang <3 3-14 ++++ Some ......(AIIMS PGMEE - SEP 1996), AIIMS PGMEE - DEC 1997
lionic
autono
mic 25. Best anaesthesia for status Asthmaticus is
fibers A. Thiopentone
C T ype IV Pain 0.4-1-2 05-2 ++++ No B. Ether
Dorsal Warm
root and
C. Ketamine
cold D. N2O
tempera C
ture
T ouch
..........(AIIMS PGMEE - FEB - 1997)
C Postgan 0.3-1.3 07-2.3 ++++ No
Sympat glionic Ketamine
hetic sympat • Ketamine causes Sympathetic stimulation which leads to
hetic
fibers Bronchodilatation so it is the anaesthetic of choice
for Status Asthmaticus.
• It is more potent Bronchodilator than Halothane
21. Which of the following local anesthetic is most likely • Muscle Relaxant of Choice in Asthma —Pancuronium
to produce an allergic reaction • Muscle Relaxant to be avoided in Asthma
A. Prilocaine • Metacurine & Succinyl choline (d/t secretion of histamine)
B. Ropivacaine
C. Etidocaine 26. Anaesthetic agent causing raised intracranical tension
D. Benzocaine is:
D A. Etoruidal
..........(AIIMS PGMEE - MAY 2004)

HELP LINE NO. 9391567707

 TOPIC 2: KETAMINE ANAESTHESIA 4

B. Ketamine • Ketamine is used as anaesthetic where maintenance

C. Ether of blood pressure is important e.g. in states of shock
D. Nitrous Oxide
B Ketamine produces profound analgesia
..........(AIIMS PGMEE - JUNE - 1997)

Ketamine
• Ketamine is an analogue of phencyclidine and therefore it
causes hallucinations.
• Ketamine.
• It 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.
• It causes muscular rigidity*
Ketamine
• It increases salivation so Atropine is always given with
• Ketamine causes an increase in all pressure viz
it*. intracranial pressure
Intraocular pressure
27. An unconscious pt. of head injury comes in casualty. Blood pressure
Examination shows raised intracranial pressure. It 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
B. Ketamine felling of dissociation Q from ones own body and the
C. Etomidate surrounding.
D. Thiopentone sodium
B It forms the answer to a set of questions. A quick revision
..........(AIIMS PGMEE JUNE - 1999) therefore :
AIPGMEE - 2000 , AIPGMEE – 1998 • Anaeshesia of choice in shock/hypotension : Ketamine
PGI - JUNE 1997, PGI - June –1999 • Anesthetic associated with increase in muscle tone :
AIIMS PGMEE - MAY 2006, AIIMS PGMEE - DEC 1998 ketamine
• Anaesthetic which does not abolish reflexes : Ketamine
Ketamine • Profound analgesia is seen with : Ketamine
• Ketamine causes increase in all pressure of body fluids - • Anaesthetic which increases cardiac oxygen demand :
• Increased ICT Ketamine
• Increased IOT • Anaesthetic of choice in Bronchial Asthma : Ketamine
• Increased B.P. • Anaesthetic which is associated with emergence delerium
• Therefore it is not used in raised ICT and IOT as it may and hallucinations : ketamine
increase the pressure to morbid levels.
• K etamine, like Phencyclidine, is primarily a non- Anaesthetic causing increased CT Anaesthetic which increase
IOT
competitive antagonist of the NMDA receptor,which
• Ketamine • ketamine
opens in response to binding of the neurotransmitter
• Halothane • Nitrous oxide
glutamate . This NMDA receptor mediates the
• Scoline
analgesic (reduction of pain ) effects of ketamine at
• Cyclopropane
low doses
Anaesthetics causing decreased ICT Anaesthetic which
• Ketamine causes bronchodilation decreased IOT
• It is primarily used for the induction and maintenance of • Theopentone • Morphine
general anesthesia, usually in combination with some • Droperidol • Thiopentone
sedative drug. • Althesin • Halothane

• Other uses include sedation in intensive care, analgesia 29. Dissociative anesthesia is
(particularly in emergency medicine), and treatment of A. Ketamine
bronchospasm. B. Halothane
• Ketamine C. SCH
• The injection of a therapeutic dose of Ketamine produces D. d-TC
dissociative anaesthesia A
• Ketamine is a phenycyclidine analogue, it produces ..........(AIPGMEE - 1996)
Hallucinations AIIMS PGMEE - NOV 2006

HELP LINE NO. 9391567707

 TOPIC 2: KETAMINE
30. Maximum analgesic action is seen with:
A. Catecholamine
B. Propofol
C. Ketamine
D. Thiopentone
C diseases.
..........(AIPGMEE - 1997) , PGI - 2001 - Dec
Ketamine
Ketamine is a rapidly acting parenteral anaesthetic, causing
Sedation and Profound analgesia besides other features.
Analgesia is a marked feature and extends into the
postoperative period.
32. Which drug of anaesthetics causes hallucination:
A. Ketamine
B. Trilene
C. Halothane
D. Trichloroethylene
A
..........(AIPGMEE - 1998)
“Dreaming, Hallucinations and delerium are seen with
ketamine” -
37. With regard to Ketamine, all of the following are
true except -
A. It is a direct myocardial depressant
B. Emergence phenomena are more likely if anticholinergic
premedication is used
C. It may induce cardiac dysarrythmias in patients receiving
tricyclic antidepressants
D. Has no effect on intracranial pressure
D
..........(AIIMS PGMEE - NOV 2005)
38. A 5 year old child is suffering from cyanotic heart
disease. He is planned for corrective surgery. The
induction agent of the choice would by -
A. Thiopentone
B. Ketamine
C. Halothane
D. Midazolam
B
41. Which of the following increases cerebral oxygen
..........(AIIMS PGMEE - NOV 2005)
• Cyanotic heart disease have predominantly Right to left
shunt i.e. blood flows directly from right ventricle to left
ventricle bypassing the pulmonary circulation.
• This produces cyanosis as the systemic blood coming to
the right ventricle cannot be oxygenated by the lung.
• Note that in right to left shunting , the fixed
component is determined by the severity of the right
ventricular obstruction while the variable component
depend upon difference between systemic vascular
resistance (SVR) and pulmonary vascular resistance (PVR)
• If the right ventricular obstruction remains same greater
the systemic vascular resistance the lesser the shunt,
• So in right to left shunts a favourable ratio of systemic
vascular resistance to pulmonary resistance should be
HELP LINE NO. 9391567707
ANAESTHESIA 5
maintained i.e. - Systemic vascular resistance should be
increased pulmonary vascular resistance should be
decreased.
• This will help to reduce the shunt in cyanotic heart
• Therefore the goal of anaesthetic management in patients
with cyanotic heart disease is to maintain
intravascular volume or systemic vascular resistance.
• Anaesthetic drugs and procedures which increase
systemic vascular resistance and decrease pulmonary
vascular resistance should be preferred.
Ketamine (intramuscular or intravenous) is commonly used
as an induction agent in cyanotic heart disease because it
maintains or increases systemic vascular resistance and it
does not appear to increase pulmonary vascular resistance
(PVR) in children.
So the use of ketamine will decreased right to left shunting.
• Halothane’s safety in patients with cyanotic heart disease
and good cardiac reserve is well established
• Patients with milder degrees of Right to left shunting can
also tolerate inhalational induction with halothane
because Halothane tends to maintain systemic vascular
resistance (systemic arterial vasodilation is minimal
with halothane).
• But Remember, that halothane induction is not used in
very young patients (because it is pungent and it is slow
acting).
• Halothane is also not preferred for patients with low CO.
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
inhalational anaesthetics.
• In contrast it may accelarate the onset of intravenous
agents.
Nitrous oxide is usually used with inhalational induction (does
not increase PVR)
consumption
A. Propofol
B. Ketamine
C. Thiopentone
D. Alfentanyl
B
..........(AIIMS PGMEE - NOV 2007)
• This has been discussed so many times that ketamine
increases cerebral oxygen consumption. It increases
the intracranial tension too.
• Thiopentone and propofol decrease cerebral oxygen
consumption.
Alfentanyl is an opioid and opioids in general reduce cerebral
oxygen consumption, cerebral blood flow and
intracranial pressure.
 TOPIC 3: SUCCINYLCHOLINE ANAESTHESIA 6

TOPIC 3: SUCCINYLCHOLINE

44. Malignant hyperthermia is seen with

A. Gallamine
B. Lignocaine
C. Succinylcholine (Sch)
D. Bupivacaine
C
..........(AIIMS PGMEE - MAY - 1993)

• Drug causing malignant hyperthermia 47. Administration of Scoline produces dangerous

1) Sucinyl choline (Most common) hyperkalemia in:
2) Halothane A. Paraplegia
3) Lidocaine B. Fracture Femur
4) Mepivacaine C. Raise intracranial pressure
5) Methoxyflurane D. Acute renal failure
6) Gallamine A
7) Ethylene ..........(AIIMS PGMEE JUNE - 1999)
8) Ethyl chloride
9) Trichlorethylene

45. Post anaesthetic muscle soreness is caused by

A. Gallamine
B. d-Tubocurarine
C. Suxamethonium
D. Xylocaine
C
..........(.AIIMS PGMEE - NOV - 1993)

• Suxamethonium causes muscle pain -

• This pain is influenced by age, sex and physical fitness.
i) Pain is more common in women
Paraplegia
ii) More common in middle age than extreme age.
• “Hyperkalemia caused by Scoline is insignificant except
iii) Less common in muscularly fit
after—>
• The longer the interval b/w injection of barbiturate and • paraplegia
suxamethonium the more intense the pain. • burns &
• tetanus”
Prevention of muscle pain caused by suxamethonium • Other adverse effect of Scoline:
1) Precurairzation - Nondepolarizing relaxants are given 3 1. Malignant Hyperthermia
minutes before suxamethonium injection 2. Muscle Fasciculations
2) lignocaine injection before suxamethonium
48. Hyperkalemia due to Scoline is seen in all except:
Other adverse effects of Suxamethonium - A. Muscular Dystrophy
1) Hyperkalemia B. Crush injury
2) Raised intraocular pressure C. Abdominal Sepsis
3) Malignant hyperpyrexia D. Burns
4) Dystrophia myotonica none
..........(AIIMS PGMEE JUNE - 2000)
5) CVS - Bradycardia and cardiac arrest
None of the above
46. Regarding myasthenia, what is true about sensitivity • Hyperkalemia d/f Scoline is seen in following
to curare and succinylcboline Curare - Succinylcholine: conditions:
A. Decreased Increased • Trauma
B. Decreased Normal • Burns
C. Increased Increased • Muscle disease such as myopathy
D. Increased Decreased • Motor neuron disease
D • Muscular Dystrophy
..........(AIIMS PGMEE - NOV - 1993) • denervation
• Spinal Cord transection
In myaesthenia gravis the muscles affected by myaesthenia • Tetanus
gravis are hypersensitive to non depolarizing relaxants • Congenital cerebral palsy
like curare but they are resistant to succinyl choline • Chronic Arterial insufficiency
and decamethonium (depolarizing blockers) • Severe Intra Abdominal infection

HELP LINE NO. 9391567707

 TOPIC 3: SUCCINYLCHOLINE
Suxamethonium –ADVERSE EFFECTS
• Side effects include fasciculations, muscle pains, acute
rhabdomyolysis with hyperkalemia, transient ocular
hypertension, and changes in cardiac rhythm
including bradycardia, cardiac arrest, and ventricular
dysrhythmias.
• In children with unrecognized neuromuscular diseases, a
single injection of suxamethonium can lead to massive
release of potassium from skeletal muscles with cardiac
arrest.
• Suxamethonium does not produce unconsciousness or
anesthesia, and its effects may cause considerable
psychological distress while simultaneously making it
impossible for a patient to communicate.
• For these reasons, administration of the drug to a
conscious patient is strongly contraindicated , except
in necessary emergency situations.
49. In a young patient who had extensive soft tissue
and muscle injury, which of these muscle relaxants
used for endotracheal intubation might lead to
cardiac arrest:
A. Atracurium.
B. Suxamethonium.
C. Vecuronium.
D. Pancuronium
B definitely avoid during the anaesthetic management
..........(.AIIMS PGMEE MAY - 2003)
Hyperkalemia produced due to suxamethonium is
aggravated in muscular diseases. The hyperkalemia so
produced causes cardiac arrest.
50. Which muscle relaxant increases intra cranial
pressure?
A. Mivacurium
B. Atracurium
C. Suxamethonium
D. Vecuronium
C
..........(AIIMS PGMEE NOV - 2002)
Succinylcholine (or Suxamethonium) causes increase in -
(a) Intracranial pressure
(b) Intraocular pressure
(c) Intragastric pressure
51. The use of succinylcholine is not contraindicated in
A. tetanus
B. closed head injury
C. cerebral stroke
D. hepatic failure
D C
..........(AIIMS PGMEE NOV - 2002)
HELP LINE NO. 9391567707
ANAESTHESIA 7
Succinyl choline is short acting muscle relaxant as it is rapidly
metabolized by pseudocholinestrase secreted both by liver
and plasma.
In liver failure ,this enzyme is reduced ,so succinylcholine
concentration is increase during liver failure and is also
maintained for greater periods.
The duration of paralysis produced by succinylcholine is
increased during liver failure but this does not require
Succinylcholine to be contraindicated in liver failure.
Conditions where succinyl choline use is contra
indicated due to hyperkalemia caused by succinyl choline
are-
(a) Tetanus (h) Massive trauma
(b) Stroke (i) Prolonged body immobilization
(c) Closed head injury (j) GB. syndrome
(d) Myopathy (k) Spinal cord injury
(e) Burn (L) Paraplegia
(f) Acidosis (M) Severe intraabdominal infection
52. A six-year old boy is scheduled for examination of
the eye under anaesthesia. The father informed that
for the past six months the child is developing
progressive weakness of both legs. His elder sibling
had died at age of 14 years. Which drug would you
?
A. succinylcholine
B. thiopentone
C. nitrous oxide
D. vecuronium
A
..........(AIIMS PGMEE NOV - 2002)
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.
53. A young boy undergoes eye surgery under day case
anesthesia with succinyl choline and propofol and
after 8 hours he starts walking and develops muscle
pain. What is the likely cause?
A. Early mobilization
B. Due to the effects of eye surgery
C. Succinyl choline
D. Propofol
..........(AIPGMEE - 2007)
 TOPIC 3: SUCCINYLCHOLINE ANAESTHESIA 8

Muscle pain or Myalgia is a common adverse effect of succinyl Phase I block :• results from persistant depolarizatin of
choline muscle end plate.
It is common in women and young to middle aged adults and • preceded by muscle fasciculation
in those who are ambulant shortly after surgery • potentiated by isoflur ane,
The young adult in question has recieved succinylcholine and antichlinesterase, magnesium an lithium.
is now ambulant after surgery. Phase IIblock:• 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
It occurs more frequently in : C. Suxamethonium
• Women /young to middle aged adults D. All
• After minor surgery (day case) C
..........(PGI - 1999 - Dec)
In those who are ambulatory shortly after surgery
(rather than bedridden patients) • Muscle pain after anaesthesia i s caused by
• Pain is believed to be secondary to damage produced in SUXAMETHONIUM- pain is influenced by age, sex and
muscle by unsynchronized contraction of adjacent muscle physical fitness.
fibres just 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 - Prolonged Apnea
before succinylcholine administration - Increased K+
- Increased IOP
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:
..........(AIPGMEE - 1995) A. Succinycholine
B. Mivacurium
Malignant hyperthermia is an autosomal dominant genetic C. Esmolol
disorder of skeletal muscle that occurs in susceptible D. Remifentanyl
individuals. It is precipitated by drug administeration, E. Ketamine
particularly: A
1. Succinyl choline ..........(PGI - DEC 2004)
2. Halothane
3. Fluoranes : sevofluorane, isofluorane etc 58. True about scoline are following except:
4. Amide local analgesics eg lignocaine A. Fasciculations
5. Phenothiazines B. ICT increases
6. Tricyclic antidepressant C. Non Depolarising neuro muscular blocker
7. Monoamine oxidase inhibitors D. Short acting muscle relaxant
A&B
The drug of choice for treatment of malignant hyperthermia ..........(PGI - JUNE 1997)
is Dantrolene
59. Myaesthenics are resistant to following muscle
55. Fasciculation are known to be caused by: relaxant:
A. Suxamethonium
A. Suxamethonium
B. Pancurium
B. Vecuronium
C. Atracuronium
C. Pancuronium
D. Vecuronium
D. Atracumium
A
A
..........(PGI - June -2000)
..........(AIPGMEE - 1997)
• Myasthenic patients are resistant to decamethonium and
Suxamethonium
suxamethonium.
Suxamethanium or other depolarizing blockers depolarize
Muscles affected by myasthenia gravis are hypersensitive to
muscle end plates by opening Na+ channels and initially
non depolarizing muscle relaxants.
produce twitching and fasciculations because in the
focally innervated mammalian muscle stimulation is
60. Which of the following is the neuromuscular blocking
transient.
agent with the shortest onset of action?
Neuro muscular blockage by depolarizing agents can be divided
A. Mivocurium
into two phases:
B. Vecuronium

HELP LINE NO. 9391567707

 TOPIC 3: SUCCINYLCHOLINE ANAESTHESIA 9

C. Rapacuronium
D. Succinylcholine
D
..........(AIIMS PGMEE - MAY 2006)

* 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 • Succinylcholine rele ases a metabolite —>
Pancuronium 4-6 40-80 Succinvlmonocholine
Doxacurium 4-8 60-120 This metabolite causes excitation of the cholinergic
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 induced bradycardia.
due to plasma cholinesterase deficiency (after a single • In adults bradycardia is commonly seen when second dose
dose of suxamethonium) except- of succinylcholine is administered.
A. Reversal with incremental doses of neostigmine Prevention against succinvlchol ine induced
B. Continue anaesthesia and mechanical ventilation till bradvcardia.
recovery “Intravenous atropine is often given prophylactically in
C. Transfusion of fresh frozen plasma children an d always before a sec ond dose of
D. Plasmapheresis succinychotine”.
B
..........(AIIMS PGMEE - NOV 2004) 63. Phase II block is seen in
A. Halothane
Suxamethonium is a very short acting muscle relaxant. B. Ether
It has very rapid onset of action and very short duration of C. D-tubocurare
action D. Suxamethonium
Reason D
Rapid onset of action ..........(AIIMS PGMEE - DEC 1998)
---> It is highly lipid soluble
Short duration of action Suxamethonium
---> It is rapidly metabolized by pseudocholinesterase • Suxamethonium causes Biphasic Block.
But sometimes suxamethonium intake is associated with • 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 II block ---> Results from desensitization of
- Dehydration and electrolyte imabalance receptor to a ctylcholine and
resembles competitive block and
An overdose of relaxant drug partially antagonized by anticholinesterase.
Excessive formation of succinylcholine monocholine phase II
block
There are tw o phases to the blocki ng effect of
- Managemen t of prolonged ap nea after
suxamethonium
suxamethonium.
Phase 1 block
- The best man agement in this case i s to provide
The first is due to the prolonged stimulation of the
mechanical ventilation, maintain anaesthesia and
acetylcholine receptor results first in disorganized muscle
continue monitoring till muscle function returns to normal.
contractions (fasciculations, considered to be a side
- Transfusion of fresh frozen plasma is beneficial (It
effect), as the acetylcholine receptors are stimulated .
will provide pseudocholinesterase)
On stimulation, the acetylcholine receptor becomes a
62. Bradycardia is common after injection of - general ion channel, so there is a high flux of potassium
A. Midazolam out of the cell, and of sodium into the cell, resulting
B. Succinyl choline in an endplate potential less than the action potential.
C. Dopamine So, after the initial firing, the cell remains refractory.
D. Isoprenaline
B • Phase 1 blockade is potentiated by anticholinesterases
..........(AIIMS PGMEE - NOV 2005) and antagonized by competitive blockers.

HELP LINE NO. 9391567707

 TOPIC 4: SPINAL ANAESTHESIA
Phase 2 block
• If the duration of blockade is prolonged however, or if
the concentration of the blocker is excessive, then phase
two blockade occurs in which the pharmacological
characteristic is that of a competitive inhibition.
Phase 2 blockade is antagonized by anticholinesterases,
and potentiated by competitive blockers.
Why does Acetylcholine cause Hyperkalemia
• The side effect of hyper kalaemia is because the
acetylcholine receptor is propped open, allowing continued
flow of potassium ions into the extracellular fluid.
• A typical increase of potassium io n serum
concentration on administration of suxamethonium is 0.5
mmol per litre, whereas the normal range of potassium is
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.
• Phase 1 block potentiated by anticholinesterases and
antagonized by competitive blockers.
• Phase 2 block antagonized by anticholinesterases and
potentiated by competitive blockers.
Drug interactions
1. Potentiation of the neuromuscular blockade caused by
the aminoglycoside antibiotics , and tetracyclines.
2. Do not potentiate the effects of the halogenated
hydrocarbon anesthetics -halothane
3. Lithium in therapeutic concentrations used in the
treatment of manic disorders can slow the onset and
increase the duration of action of succinylcholine.
TOPIC 4: SPINAL ANAESTHESIA
64. A patient was administered epidural anaesthesia with
15ml 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 into the subarchnoid space.
..........(.AIIMS PGMEE MAY - 2003)
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. It is produced because large dose
of drug which is used in epidural anaesthesia enters the
subarachnoid space.
HELP LINE NO. 9391567707
ANAESTHESIA 10
The manifestation of total spinal analgesia are-
1. Marked hypotension
2. Apnoea
3. Dilated pupils
Management
Patient should be immediately intubated and 100% O2
should be given I.V. fluids and vasopressors should be given
65. In high spinal anaesthesia what is seen
A. Hypertension and Bradycardia
B. Hypertension and Tachycardia
C. Hypotension and Bradycardia
D. Hypotension and Tachycardia
C
..........(AIIMS PGMEE MAY - 2001)
Hypotension and Bradycardia
Effect of spinal block on cardiovascular system
Vessels Heart
Vasodilation of arterioles, resistance Decrease inotropic Action
vessels and venous capacitance Decrease chronotropic Action
vessels (This causes Hypotension)
Increase effective Refractory period
Decrease automaticity decrease
level of catecholamine
(This causes Bradycardia)
66. Following spinal subarachnoid block a patient
develops hypotension. This can be managed by the
following 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
..........(.AIIMS PGMEE MAY - 2003)
For spinal subarchnoid block, the anaesthetic agent is injected
The subarchnoid space contains CSF.
If 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 fluid, to produce rapidly an
intense blockade, usually within 5 minutes.
Autonomic sympathetic blockade results in hypotension,
necessitating prior intravenous fluid loading and titration
of vasoconstrictor drugs.
If the hyperbaric solution is allowed 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
 TOPIC 4: SPINAL ANAESTHESIA ANAESTHESIA 11

C. Patient on oral anticoagulants Caudal anaesthesia may be used for perenial operations.
D. Raised intracranial pressure It is not indicated in Lower segment caesarian section.
B Further it is associated with potential risk of penetrating
..........(AIPGMEE - 2007) the fetal head in obstetric practice.

Centrineuraxial anesthesia is not associated with increased

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

69. A patient undergoing caesarean section following

prolonged l abour under subarach noid block
developed carpopedal spasm. Lignocaine was used
as anesthetic agent. The most likely diagnosis is:
A. Amniotic fluid embolism
B. Lignocaine toxicity
C. Hypocalcemia
D. Hypokalemia
C
..........(AIPGMEE - 2004)

Absolute Contraindications During prolonged labour, pain from episodic uterine

- Patient’s refusal contractions produces an increase in minute ventilation.
- Patient’s inability to maintain stillness during the needle Hyperventilation thus produced results in development of
puncture (eg. dementia, psychosis) hypocarbia and respiratory alkalosis.
- Raised intra cranial pressure Resulting acute respiratory alkalosis causes intracellular shift
(papilledema, cerebral edema, tumors in posterior fossa, of K+, Na+ & PO4" and reduces free Ca +2 by increasing
suspected subarachnoid Hemorrhage) the protein bound fraction and precipitates
- Severe hypovolemia hypocalcemia.
- Severe stenotic valvular heart disease, the patient may
be unable to compensate for vasodilation because of a Respiratory alkalosis secondary to hvperventilation following
fixed cardiac output. prolonged labour may result in :
- Marked skin sepsis & marked spinal deformity
- Marked coagulopathy, blood dyscariasis or full anticoagulant Neurological Symptoms Symptoms
therapy symptoms secondary to secondary to
hypophosphatemia
secondary to hypocalcemia
Relative contraindications cerebral Muscle weakness
Paraesthesias
- Un coperative patient (may be performed in conjuction vasoconstriction Carpopedal
with GA)
Dizziness Visual spasm
- Pre existing neurological deficit (eg demyelinating lesions).
symptoms Tetany
- All severe & marked diseases in lesser degree i.e. spinal
Syncope Seizure
deformity, sepsis etc.
- Pre eclamptic toxaemia - epidural block has been used Lignocaine toxity is likely to cause hypercalcemia by
with great benefit in this condition, but a platelet count releasing Ca into the blood and hence corpopedal
of less than 100 xlO9 L”1 usually preclude epidural or spasm as a manifestation is unlikely.
subarachnoid block.
- Mildly impaired coagulation 70. Concentration of Lidocaine used in spinal anaesthesia
- Patients with platelet <80000 /ml A. 5%
B. 3%
C. 2%
68. A Lower Segment Caesarean section (LSCS) can be
D. 1%
carried out under all the following techniques of
A
anaesthesia except:
..........(AIPGMEE - 1994)
A. General anaesthesia
B. Spinal anaesthesia Lignococine
C. Caudal anaesthesia
D. Combined Spinal Epidural anaesthesia 5% 4% 0.5%
C Spinal Topically in Eye Epidural
..........(.AIPGMEE - 2005) Anesthesia Anesthesia

HELP LINE NO. 9391567707

 TOPIC 4: SPINAL ANAESTHESIA ANAESTHESIA 12

71. Post Spinal Headache can last for • Severe Hypovolemia

A. upto 10 min • Raised ICT
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
..........(AIPGMEE - 1994) 75. Spinal anaesthesea should be injected into the space
between:
Post spinal Headache starts in 1st 3 days and lasts for 1- A. T12 – L1
2 weeks B. L1-L2
C. L3 – L4
72. Best way to prevent hypotension during spinal D. L5 – S1
anesthesia C
A. preloading with crystalloids ..........(AIPGMEE - 1997)
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
..........(AIPGMEE - 1995) equina rather than the spinal cord.
• The level of anaesthesia depends on volume and speed
Hypotension following spinal anaesthesia is due to of injection, specific gravity of drug solution & posture of
blockage of sympathetic vasoconstrictor outflow the patient.
to blood vessels, venous pooling and decreased return • Duration of spinal anaesthesia depends on drug used
to heart. Prevention is by preloading with crystalloids. and its concentration. e

73. Post sipnal headache is due to

A. Meningitis • Autonomic pre-ganglionic fibres are more sensitive
B. Encephaletics and somatic motor fibres less sensitve than somatic sensory
C. CSF leak fibres.
D. Increased ICT (Sympathetic block occurs before para-sympathetic and
C somatic block).
..........(AIPGMEE - 1995)
76. Which is the true statement regarding post-dural
‘Headache is due to seepage of CSF and can be minimized anesthetic headache:
by use of smaller bore needle’ A. Blood patch is the first line of treatment
B. Occurs due to low CSF pressrue
74. In all of the following conditions neuraxial blockade C. Increased incidence with early mobilization of patient.
is absolutely contraindicated, except: D. Use of small guage needle prevents hea
A. Patient refusal A
B. Coagulopathy ..........(PGI - 2001 - Dec)
C. Severe hypovolemia
D. Pre-existing neurological deficits 77. True about epidural anaesthesia in pregnancy:
D A. Given through subarachnoid space.
..........(AIPGMEE - 2003) B. Increases cardiac output.
C. Decreases venous return.
• Neuraxial block is combined name given to spinal, Epidural D. Venous pooling.
and Caudal Blocks. E. Decreased placental circulation
Principal site of action for neuroaxial block is Nerve root C
..........(PGI - DEC 2003)
Absolute contra indications are -
• Patient Refusal • In epidural anesthesia, the anesthetic drug is injected in
• Bleeding Diathesis a potential space within the bony cavity of the spinal canal
and outside the dural sac.

HELP LINE NO. 9391567707

 TOPIC 4: SPINAL ANAESTHESIA ANAESTHESIA 13

In spinal anesthesia, only the drug is injected in the DEFINITIVE

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 of
• Reduced cardiac output the following except-
A. Vital capacity
Hypotension B. Functional residual capacity
• In the absence of hypotension, neither epidurals nor
C. Compliance
spinal have any effect on the progress of labor nor
D. Respiratory rate
do they affect uterine blood flow.
Brief episode of hypotension do not appear to affect D
the clinical condition of the neonates, the duration ..........(AIIMS PGMEE - NOV 2004)
seems more important than the degree.
Hypotension during epidural is usually said to occur if blood Trendelenburg position or head down position 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
..........(PGI - DEC 2004)

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 first line of treatment This effects the lung volume in the following way
B Functional residual capacity -----> Decreases
..........(PGI - JUNE 2004) Total lung volume -----> Decreases
Vital capacity -----> Decreases
• Postdural puncture headache (PDPH) may occur after Lung compliance -----> Decreases
deliberate or accidental dural puncture, or even after
Although these changes are usually well tolerated by healthy
uncomplicated block.
patients, it may cause hypoxemia in obese patients
• Typically it comes on within an hour or two of the
anaesthesia & may be delayed for some days & may last and patients with preexisting lung disease.
for weeks or even months.
• Pain usually occurs in the occipital region & a/w pain &
stiffness in neck.
It is worsened by sitting up & relived by lying down or by
abdominal compression.

Factors affecting PDPH :

• Increasing
- Younger age
- Females> male
The above mentioned changes also lead to increased
• Larger needle
- Dural fibres cut transversely ventilation/perfusion mismatching and atelactasis.
- Pregnant females There is also increased likelihood of regurgitation.
- Multiple punctures
81. Site of action in epidural analgesia
• Treatment: A. Cortex
PROPHYLACTIC B. SubstantiaGelatinosa
- Avoided in pts with h/o frequent severe headache C. Ventral horn
- Use of smaller sized needle D. Sensory nerve ending
- Whitacre needle or sprotte needle should be used B
- Prevention of dehydration, ..........(AIIMS PGMEE - DEC 1998)

HELP LINE NO. 9391567707

 TOPIC 5: ANAESTHESIA COMPLICATIONS ANAESTHESIA 14

• The epidural space is situated between the dura mater

and the vertebral canal . It 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
space and b ind to receptors loc ated in the
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 84. Mendelson syndrome is due to:
blood vessels and may be distributed through the A. Aspiration pneumonitis
subarachnoid space in the cerebrospinal fluid (CSF). B. Chemical pneumonitis
C. Oesophagitis
D. Oesophageal spasm
Substantia Gelatinosa
A
..........(PGI - 1998 - Dec)

• Mendelson’s syndrome is acid aspiration 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
..........(PGI - 1998 - Dec)
TOPIC 5: ANAESTHESIA COMPLICATIONS
Diffusion hypoxia is seen during recovering anaesthesia. It is
82. Which d oes not cause broncho spasm after seen with N2O.
anaesthesia Mechanism
A. Regurgitation After prolonged N2 O anaesthesia when discontinued N2O
B. Aspiration having low Solubility rapidly diffuses to alveoli and dilutes
C. Postintubation alveolar air PP of oxygen in alveoli is reduced: Resulting
D. Halothane hypoxia is called DIFFUSION HYPOXIA
D
..........(AIIMS PGMEE - DEC 1994) 86. Incubator 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 – ..........(PGI - 1998 - Dec)
1) Surgical stimulation
a) Intubation under light aneasthesia • Incubator heat is delivered by radiation and convection.
b) Carinal stimulation by a tube that is too long Some incubators have humidifiers which will produce an
2) Respiratory infection ambient relative humidity within the canopy of 90% or
3) Pulmonary edema more (compared with 30—40% hunidity without
4) Severe r eduction in lung volume as in tension humidifier).
pneumothorax, Drugs.

83. Mismatc hed blood transfusio n manifests

intraoperatively as:
A. Rise in B. P.
B. Excessive bleeding
C. Dyspnoea
D. Hematuria
B
..........(PGI - 1999 - Dec)

Mismatched blood transfusion manifests intraoperatively as

EXCESSIVE BLEEDING.

HELP LINE NO. 9391567707

 TOPIC 5: ANAESTHESIA COMPLICATIONS ANAESTHESIA 15

At such humidity infants evaporative heat loss is very low. • Sodium Nitroprusside can sometimes cause toxicity due
Also sometimes wall of the incubator is doubled which to its conversion to cyanide and thiocyanate, when its
also helps to prevent evaporative loss of heat from infant. infused for longer duration.
In infant heat loss through conduction is very small as infants • “Toxic accumulation of cyanide leading to severe lactic
are not usually in direct contact with structure of acidosis, can occur usually if sodium nitroprusside is infused
high thermal capacity. at a rate greater than 5 microgm/kg.”
• Short-term side-effects of nitroprusside are d/t excessive
87. During intra operative anesthesia mismatched blood vasodilation with hypotension and its consequences
by transfusion is manifested by:
A. Hypotension 92. The most common cause of morbidity and mortality
B. Increase Bleeding in patients undergoing major vascular surgery is:
C. Bonchospasm A. Renal complications
D. Movement of limbs B. Thrombo embolic phenomenon
E. Rash C. Coagulopathies
A & B, C D. Cardiac complications
..........(PGI - JUNE 2006) Ans d
..........(AIIMS PGMEE - MAY 2005)
* Mismatched blood transfusion in anaesthetic patient
present as : 93. The most common rhythm disturbance during early
Immediate rapid severe and progressive hypotension. postoperative period is:
Tachycardia A. Bradycarida
General oozing from wound. B. Ventricular fibrillation
Urticarial rash. C. Tachycardia
Bronchospasm, raising airway pressures on intermittent positive D. Complete heart block
pressure ventilation. Later jaundice and oliguria in 5-10% Ans c
of these patient. ..........(AIIMS PGMEE - MAY 2005)

88. Cause of post-operative hypertension The most common acute post-operative arrhythmias
A. Pre-operative hypertension were junctional ectopic tachycardia
B. inadequate analgesia
C. Phaeochromocytoma 94. Most common cause of postoperative renal failure:
D. Hypoxaemia A. Decreased renal perfusion
E. Hypercarbia B. Toxicity of anesthetic drugs
All C. Toxicity of antibiotics
..........(PGI - JUNE 2004) D. ——
A
89. True about aspiration pneumonia ..........(AIIMS PGMEE - MAY 2008)
A. Affected by volume of aspiration
B. Affected by PH of aspiration fluid • Most common cause of postoperative renal failure
C. Increased incidence during induction is decreased renal perfusion due to hypovolemia.
D. Inflammation Hypovolemia usually results from inadequate intraoperative
E. Infection fluid replacement, continuing fluid sequestration by
All tissues {third spacing) or wound drainage or postoperative
..........(PGI - JUNE 2004) bleeding.

• Factors affecting Acid aspiration pneumonia:
- Aspirate volume > 25ml
- PH of aspirate <2.5
- Aspiration of partially digested food
• Conscious level of patients (e.g. alcoholics, drug
abusers, seizures, strokes or general anaesthesia)
- Mechanical impediments (e.g. nasogastric or
endotracheal tubes)
• Pure acid a spiration producing aspiration
pneumonitis or chemical pneumonitis (inflam­mation)
& aspiration of oropharyngeal secretion produces
severe bacterial pneumonitis.
95. Which of the following does not represent a
significant anaesthetic problem in the morbidly obese
patient?
A. Difficulties in endotracheal intubation
B. Suboptimal arterial oxygen tension
C. Increased metabolism of volatile agents
D. Decreased cardiac output relative to total body mass
D
..........(AIIMS PGMEE - NOV 2004)

91. Sodium nitroprusside infusion may result in:

A. Hypertension
B. Pulmonary oedema
C. Cyanide toxicity
D. Heart block
C
..........(AIIMS PGMEE - MAY 2005)

• Sodium Nitroprusside is an effective antihypertensive agent

(dilates both arteries and veins)

HELP LINE NO. 9391567707

 TOPIC 6: HALOTHANE ANAESTHESIA 16

Problems faced by obese patient during anaesthesia • Hemodynamic monitoring - It is done by

Perioperative
These patients are often difficult to intubate as a result
of limited mobility of temperomandibular and atlantoccipital
joints, a narrowed airway and a shortened distance
between mandible and sternal fat pads.
Increased risk of developing aspiration pneumonia,
therefo re routine t/t with H 2 antago nists an d
metoclopromide is given.
Intraoperative
Volatile anaesthetics are metabolized more rapidly while
the action of nonvolatile agents are prolonged.
Risk of aspiration
Difficulties in regional anaesthesia
Postoperative
Respiratory failure is the major problem
postoperatively
There is risk of postoperative hypoxia, so extubation should
be delayed until the effects of neuromuscular blocker is
completely reversed.
Central venous or pulmonary artery pressure monitoring.
The most sensitive hemodynamic correlates are derived
from pulmonary artery pressure monitoring -
Ischemia is frequently but not always associated with an
abrupt increase in pulmonary capillary wedge pressure.
The most common hemodynamic abnormalities observed
during ischemic episodes are hypertension and
tachycardia.
97. Sallick’s manouvere is used
A. To reduce dead space
B. To prevent alveolar collapse
C. To prevent gastric aspiration
D. To facilitate assisted respiration
C
..........(AIIMS PGMEE - DEC 1997)
• Sallick’s manoeuvre is application of backward pressure
on Cricoid cartilage to prevent gastric aspiration.

Cardiovascular changes in obesity TOPIC 6: HALOTHANE

• High Blood volume
• High Cardiac output 98. Hepatoxic anaesthetic agent is:
• Hypertension (Systemic and pulmonary) A. Ketamine
• High Workload on heart B. Ether
• High Stroke volume C. Nitrous Oxide
• Cardiomegaly D. Halothane
Respiratory changes in an obese patient D
• Decrease in vital capacity and functional residual capacity ..........(AIIMS PGMEE - JUNE - 1997)
• Hypoxemia
• Decrease compliance • Halothane is hepatoxic. It is “contraindicated” in liver
• Decrease respiratory drive diseases.
These patients require high FiO2 to achieve adequate • Other Important side effects of Halothane
oxygenation, the ratio of Nitrous Oxide by O2 is 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
96. The most sensitive and practical technique for C
detection of myocardial ischemia in the perioperative ..........(AIIMS PGMEE - MAY - 1994)
period is -
A. Magnetic Resonance Spectroscopy
• Halothane is a potent anaesthetic but poor analgesic
B. Radio labeled lactate determination
All the other agents mentioned in the question are good
C. Direct measurement of end diastolic pressure
analgesics
D. Regional wall motion abnormality detected with the help
Nitrous Oxide - It is good analgesic but poor anaesthetic.
of 2D transoesophagealechocardiography
Ether - It is potent anaesthetic as well as good analgesic
D
Cyclopropane - It is a good anaesthetic and a good analgesic
..........(AIIMS PGMEE - NOV 2005)
100. Which one of the following agents sensitizes the
Two dimensional transesophageal echocardiography is the
myocardium to catecholamines?
most sensitive method to detect myocardial ischemia in
A. Isoflurane
the perioperative period.
B. Ether
C. Halothane
D. Propofol
C
..........(AIPGMEE - 2006)

Halothane sensitize the heart to adrenaline (both

exogenous as well as endogenous, more prominently
exogenous) producing severe ventricular arrhythmias‘.

HELP LINE NO. 9391567707

 TOPIC 6: HALOTHANE ANAESTHESIA 17

101. Repeated use of halothane causes: 104. Anesthesia agent with least analgesic property
A. Hepatitis A. N2O
B. Encephalitis. . B. Halothane
C. Pancreatitis C. Ether
D. Bronchitis D. Propane
A B
..........(AIPGMEE - 1999), PGI - JUNE 1997 ..........(AIPGMEE - 1994)

Hepatitis Halothane is a potent anaesthetic but provides poor analgesia.

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 elevated 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:
following except: A. Isoflurane
A. Atropine B. NO
B. Halothane C. Melhoxyflurane
C. Massive pleural effusion D. Halothane
D. Inspiration D
C ..........(PGI - 1999 - Dec)
..........(AIPGMEE - 1999)
• Post operative jaundice can be cause by halothane. It
can cause massive hepatic necrosis, subclinical one is called
Anatomical dead space means those areas in the tracheo-
‘Halothane hepatitis.’
bronchial tree, where the gaseous exchange between
the lung and capillaries is not possible.
Note : Other causes of post. Operative jaundice
This area starts from the nasal cavity and includes,
- Phenothiaziges
larynx, trachea, bronchii and ends in the terminal - MAO inhibitors
bronchiole. - Blood. Transfusion
- Sepsis
Pleural effusion, normally tends to compress on the alveoli Coincidental viral infection.
and thus interferes with the physiological dead space
(space where gaseous exchange is occurring). 106. True about halothane:
However, with a massive effusion, atleast some of the structure A. 1% Thymol is used as preservative.
comprising the anatomical dead space may be compressed B. It sensitizes heart to catecholamines at 1 MAC.
thereby decreasing the anatomical dead space. C. 20% metabolized.
D. It is not usually given in same patient within 3 months.
103. All of the following are true except: E. It forms compound-A with sodalime,
A. Halothane is good as an analgesic agent B
B. Halothane sensitises the heart to action of catacholamines ..........(PGI - DEC 2003)
C. Halothane relaxes brochi & is preferred in anaes thetics
D. Halothane may cause Liver cell necrosis • Halothane is a volatile, liquid with sweet odour, nonirritant
A and noninflammable anaesthetic.
..........(AIPGMEE - 2001) • It contains 0.01% thymol for stability and decomposed
by light, but is stable when stored in amber-lime and the
Halothane is good as an analgesic agent vapour is absorbed by rubber.
• Halothane is a potent anaesthetic but not a good analgesic • An estimated 15-20% of absorbed halothane undergoes
or muscle relaxant. metabolism.
• Halothane sensitizes the heart to arrythmogenic action of • Sevoflurane reacts with soda-lime and thus produces
Adrenaline compound-i.e., pentafluoroisopropenyl fluromethyl ether.
• P ethidine is recommended in the management of
• R emember dr ugs which sensitizes the heat to
Halothane shakes.
arrythmogenic action of adrenaline include
• Halothane may persist in the liver for as long as 12 days
- Halothane
after administration.
- Methoxyflurance
- Trichloroethylene 107. True about halothane:
-
Cyclopropane A. Causes bronchodilation
B. Anti-arrhythmic
- Chloroform C. Ted cardiac index
- Halothane causes bronchodilation. Thus it is preferred in D. Uterine contraction occurs
asthmatics (also Ketamine) E. Causes hepatitis
• Massive hepatic necrosis is following halothane A&E
anaesthesia has been reported ..........(PGI - DEC 2002)

HELP LINE NO. 9391567707

 TOPIC 7: THIOPENTONE ANAESTHESIA 18

108. True about Halothane: While Intra arterial injection causes Vasospasm
A. Non-irritant intravenous injection causes Vasodilatation.
B. Antiarrhythmic
C. It antagonises bronchospasm 113. Thiopentone is contraindicated in:
D. Vasodilator A. Acute intermitent porphyria
A &C
B. Induction of GA
..........(PGI - DEC 2006)
C. CHF
• Halothane is a colourless, relatively non-irritant vapour. D. GI disease
It is non-flammable non-explosive when mixed with O2 in A
any concentrations used clinically. ..........(AIIMS PGMEE - FEB - 1997)

Effects on organs : • Acute intermitent porphyria

CVS : - Myocardial depression, fall of arterial pressure. • Barbitur ates (Thiopentone) ppt acute intermitent
- 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
Safe drugs in porphyria
E. Obesity
C&D
Local Anaesthesia Drugs used in anaesthesia
..........(PGI - June -2001)
Amethocaine Adrenaline
111. Which of the following fluorinated anaesthetics Bupivacaine Atropine
corrodes metal in vaporizers and breathing systems? Lignocaine 2 Cyclopropane
A. Sevoflurane Prilocaine Epinephrine
B. Enflurane Procaine Ether
C. Isoflurane T etracaine Isoflurane
D. Halothane Neostigmine
D Nitrous oxide
..........(AIIMS PGMEE - MAY 2006) Pancuronium
Phentolamine
• Halothane causes corrosion of metals in vaporizers and Propofol
breathing system Suxamethonium
TOPIC 7: THIOPENTONE Safe anticonvulsants in porphyria

112. Intra arterial injection of thiopentone causes: Anticonvulsants

A. Hypotension Clobazam
B. Necrosis of vessel wall Clonazepam
C. Vasodilation Gabapentin
D. Vasospasm Sodium
D valporate
..........(AIIMS PGMEE - Dec - 1995) 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

HELP LINE NO. 9391567707

 TOPIC 7: THIOPENTONE ANAESTHESIA 19

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

114. Intraarterial 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
..........(AIIMS PGMEE - NOV - 1993) C. Propofal
D. Ketamine
Signs and symptoms of intra arterial injection of B
thiopentone ..........(AIIMS PGMEE NOV - 2002)
a) Immediate -
i) Pain • During the surgery for aortic arch all the blood supply to
ii) White hand with cyanosed fingers the br ain has to be stopped so that proper arch
iii) Patches of skin discolouration anastomosis can be performed. This carries great risk for
iv) Onset of unconsciousness is delayed beyond the usual the brain. So the surgery for aortic arch aneurysm is
time performed now days using deep hypothermia and
b) Late circulatory arrest method.
i) Ulcers or blisters • It is based on the principle that brain can safely tolerate
ii) Edema of forearm and hand circulatory arrest for periods of upto 45minutes, if the
iii) Gangrene - rare temperature is carefully lowered to 15-17°C wide surgery.
So during surgery for aortic arch aneurysm temperature is
115. A pt. Selected for surgery who was induced with lowered till the temperature of the body is lowered up to
thiopentone i.v. through one of the antecubital veins 15-17°c and then surgery is performed.
complains of severe pain of whole hand. The next
line of management is: • During this process we need an anaesthetic agent which
A. Give I.V. Ketamine through same needle lowers the metabolic demands of the brain, so that the
B. Give I.V. propofol through same needle brain can sustain longer periods of circulatory arrest.
C. Leave it alone Thiopentone sodium is one such drug, which lowers
D. Give I.V. lignocaine through same needle the metabolic demands of brains and provides it
D added protection, when its blood supply it reduced
..........(AIIMS PGMEE MAY - 2001), AIPGMEE - 1997 during surgery.

Give I.V. lignocaine through same needle 117. Which of the following anesthetic agents does not
• Injection . has gone into the Artery which lies adjacent trigger malignant hyperthermia?
to the antecubital vein. A Halothane
• Immediate 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 spasm D
which may be accompanied or followed by arterial ..........(AIPGMEE - 2006)
thrombosis
3. Patches of skin discoloration in the limb ‘Muscle relaxant succinylcholine is the most commonly
4. Onset of unconsciousness may be delayed beyond the implicated agent. Halothane and isoflurane have also been
usual, time. implicated.
Barbiturates (thiopentone sodium) are safe drugs for
Treatment gener al anae sthesia in patients sus ceptible for
• Leave the canula in site malignanthyperthermia
• Heparin 1000 units is given via cannula in the Artery Malignant Hyperthermia
• Through Canula in the Artery inject Malignant hyperthermia is a familial syndrome characterized
(a) Papavarine 40 -80 mg in 10- 20 ml of Saline clinically by arise of temperature of at least 2DC/hour
Inheritance

HELP LINE NO. 9391567707

 TOPIC 7: THIOPENTONE ANAESTHESIA 20

Autosomal dominant inhe ritance with incomplete * Ketamine is having profound analgesic property.
penetration .Defect in gene on chromosome * Fentanyl is a synthetic opioid having intense analgesia.

Pathology 123. Intravenous thiopentone, produces

Abnormality of Ryanodine Receptor: calcium releasing A. Rash
channel of sarcoplasmic reticulum. Sudden rise 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 ..........(PGI - JUNE 2003)
C. Etomidate
D. Cyclopropane • Thiopentone is an ultra short acting barbiturate used for
D induction of anaesthesia.
..........(AIPGMEE - 1995) • The different effects produced by thiopentone are :

Classification of Anaesthe tic agents: CNS & Respiratory system : Sedation, hypnosis, anaesthesia
& respiratory depression.
Inhalation Intravenous - Increased cerebral blood flow, decrease I C pressure,
Cerebral metabolism & O2 consumption leading to cerebral
Gas Liquid Inducing agent Slower Acting
protection..
• N 2O • Ether • Propofol • Ketamine - CVS : hypotension due to vasodilatation in skin & muscle.
• Halothane • (dissociative Larynx : Increased sensitivity to stimuli producing laryngeal
Methohexitone anesthesia) spasm.
• Cyclopropane • Thiopentone • Fentanyl Eye : - pupils first dilate then constrict.
• Fluranes • Etomidate Droperidol - Loss of eyelash reflex is an excellent sign of adequate
(Neurolept induction.
analgesia) Allergic reaction : Rarely manifests as scarlantiniform rash,
- Enflurane angioneurotic edema & photosensitivity.
- Iso flurane Injection effects : - The incidence of pain on injection is
1-2% when injected into small veins & essentially none
- Desmoflurane when injected into larger veins.
- Sevoflurane - Perivenous injection produces pain, redness & swelling,
haematoma formation, bruising, rarely ulceration.
119. Sodium Thiopentone is ultra short acting d/t - Accidental intraarterial injection produces intense arterial
A. Rapid absorption spasm & excruciating pain that can be felt from the
B. Rapid metabolism injection site to the hand & fingers.
C. Rapid redistribution Musculo skeletal : Besides producing unconsciousness, it
D. Rapic excretion can cause mild muscular excitatory movements such as
C hypertonus, tremor or twitching & respiratory excitatory
..........(AIPGMEE - 1996) effects including cough & hiccup. These are dose
dependent effects.
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
..........(PGI - DEC 2004) ..........(AIIMS PGMEE - NOV 2007)

122. Which of the following 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
C. Methohexitone with an oxygen or sulfur at 2 position.
D. Ketamine • The three barbiturates commonly used for clinical
E. Fentanyl anaesthesia are :
B • Sodium thiopental
..........(PGI - DEC 2005) • Thiamylal
• Methohexital
* N2O (nitrous oxide) is a weak anaesthetic agent having Barbiturates are formulated as the sodium salts with
potent analgesic property. 6% sodium carbonate and reconstituted in water or
* Thiopentone & Methohexitone, both are barbiturate group isotonic saline to produce alkaline solutions with pH of 10-
of induction agent without analgesic properties. 11.
Thiopentone having ant-analgesic property only i.e. • Once reconstituted these are stable in solutions for
it decreases the pain threshold. upto 1 week.

HELP LINE NO. 9391567707

 TOPIC 8: PAEDIATRIC ANESTHESIA ANAESTHESIA 21

• Thiopentone is used for the induction of anaesthesia Other drugs used are -
because it has a very rapid onset of action. 1) Methohexitone
• The typical induction dose (3-5 mg/kg) of thiopentone 2) Propofol
produces unconsciousness in 10-30 seconds with a peak 3) Etomidate
effect in 1 minute and duration of anaesthesia of 5-8 4) Ketamine
minutes.
• Action of this drug terminates quickly because of rapid 126. The ideal muscle relaxant used for a neonate
redistribution. undergoing porto-enterostomy for biliary atresia is:
• Thiopentone is highly lipid soluble, therefore its A. Atracurium.
redistribution is very rapid and this accounts for its short B. Vecuronium
duration of action. C. Pancuronium.
• Sulphur is added to increase the lipid solubility of D. Rocuronium
thiopentone. A
• Thiopentone is given intravenously. ..........(.AIIMS PGMEE MAY - 2003)
• It produces little to no pain on injection.
• Venoirritation can be reduced by injection into larger non In this case a muscle relaxant is required whose metabolism
hand veins and by prior intravenous injectionof lidocaine. has nothing to do with liver (because liver is damaged in
• If sometimes thiopentone inadverten tly enter biliary atresia)
intraarterial circulation it causes severe inflammatory
and potentially necrotic reaction. • So Atracurium is the muscle relaxant of choice as it is
inactivated in plasma by spontaneous non enzymatic
Effects on system C.N.S.
degradation. (Hoffman elimination) so its duration of
• Besides producing a general anaesthesia, barbiturates
action will not be affected in patients with hepatic
reduce the cerebral metabolic rate, as measured by
insufficiency.
cerebr al oxygen consumpti on (CMR0 2 ) in a dose
dependent manner.
127. In a 2 months old infant undergoing surgery for
• As a consequence of the decrease in (CMRO2) cerebral
biliary atresia, you would avoid one of the following
blood flow and intracranial pressure are similarly reduced.
anaesthetic
• Because it markedly lowers cerebr al metabolism,
A. Thiopentone
thiopentone has been used as a protectant against
cerebral ischemia. B. Halothane.
• Thiopentone also reduces intraocular pressure. C. Propofol.
• Presumbaly in part due to their CNS depressant activity D. Sevoflurane
barbiturates are effective anticonvulsants. B
• Thiopentone in particular is a proven medication in the t/ ..........(.AIIMS PGMEE MAY - 2003)
t of status epilepticus.
halothane is known to cause liver toxicity. So Halothane
C.V.S should be avoided in a patient undergoing surgery for
• Thiopentone produces dose dependent decrease in Biliary atresia (as the liver is already damaged)
blood pressure.
• The effect is primarily due to vasodilation particularly
venodilation.
Respiratory
• Theiopentone is respiratory depressants.
• It 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
porphyria in patients with acute intermittent porphyria
and are contraindicated in such patients.
TOPIC 8: PAEDIATRIC ANESTHESIA
125. Method of anaesthetic induction in children is by
A. Intramuscular
B. Inhalation
C. Intravenous
D. Oxygen tent
C ..........(.AIIMS PGMEE MAY - 2003)
..........(AIIMS PGMEE - NOV - 1993)
• In children intravenous induction of anaesthesia is the
most common method used for induction of anaesthesia.
• The drug most commonly used is thiopentone
128. Regarding neonatal circumcision, which one of the
following is true:
A. It should be done without anaesthesia, as it is hazardous
to give anaesthesia.
B. It should be done without anesthesia, as neonates do not
perceive pain as adults.
C. It should be done under local anaesthesia only.
D. General anaesthesia should be given to neonate for
circumcision as they also feel pain as adults
D
Circumcision anaesthesia.
“A general anaesthetic is preferable in children, but in
adults local infiltrative anaesthesia, or regional anaesthesia
with a caudal or subpubic block is also satisfactory

HELP LINE NO. 9391567707

 TOPIC 8: PAEDIATRIC ANESTHESIA
129. Which of the following inhalational agents is the
induction agent of choice in children:
A. Methoxyflurane
B. Sevoflurane
C. Desflurane
D. Isoflurane
B
..........(AIPGMEE - 2006)
Faster, pleasant, and smooth in duction with no significant
systemic toxity makes sevoflurane the agent of choice
for induction, especially in children
130. A two-month-old infant has undergone a major
surgical procedure. Regarding postoperative pain
relief which one of the following is recommended:
A. No medication is needed as infant does not feel pain after
surgery due to immaturity of nervous system
B. Only paracetamol suppository is adequate
C. Spinal narcotics via intrathecal route
D. Intravenous narcotic infusion is lower dosage
Ans c
..........(AIPGMEE - 2006)
• Bupivacaine has, until recently, been the drug of choice
for postoperative epidural infusions in children. Despite a
reasonable safety profile, bupivacaine is currently being
replaced by many anesthesiologists with new local
anesthetics: levobupivacaine and ropivacaine. These
local anesthetics are associated with less risk for cardiac
and central nervous system toxicity and are also less likely
to result in unwanted postoperative motor blockade
131. A non ventilated preterm baby in incubator is under
observation. Which is the best way to monitor the
baby’s breathing and detect apnea?
A. Capnography
B. Impedence pulmonometry
C. Chest movement monitoring
D. Infrared End Tidal CO 2mesurement
A Morphine is also not commonly recommended in older children
..........(AIPGMEE - 2007)
• Capnography is the monitoring of the concentration or
partial pressure of carbon dioxide (CO2) in the
respiratory gases .
HELP LINE NO. 9391567707
ANAESTHESIA 22
• Its main development has been as a monitoring tool
for use during anaesthesia and intensive care .
• It is usually presented as a graph of expiratory CO2
plotted against time, or, less commonly, but more
usefully, expired volume. The plot may also show the
inspired CO2, which is of interest when rebreathing
systems are being used.
• 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 arterial blood. In healthy individuals, the difference
between arterial blood and expired gas CO2 partial
pressures is very small, and is probably zero in children. In
the presence of most forms of lung disease, and some
forms of congenital heart disease (the cyanotic lesions)
the difference between arterial blood and expired gas
increases and can exceed 1 kPa.
• During anaesthesia, there is interplay between two
components: the patient and the anaesthesia
administration device (which is usually a breathing circuit
and a ventilator or respirator). The critical connection
between the two components is either an endotracheal
tube or a mask, and CO2 is typically monitored at this
junction. Capnography directly reflects the elimination of
CO2 by the lungs to the anaesthesia device. Indirectly, it
reflects the production of CO2 by tissues and the
circulatory transport of CO2 to the lungs.
132. All of the following agents can be given for
induction of anaesthesia in children except:
A. Halothane
B. Servoflurane
C. Morphine
D. Nitrous oxide
C
..........(AIPGMEE - 2001)
Morphine
Morphine should not be used in infants specially those
less than 6 months of age.
(3-10 years) of age
Most commonly used method for inducing gaseous anaesthesia
is with O2, with or without N2O and either halothane
or sevoflurane.
 TOPIC 9: VENTILATOR
• Halothane is well tolerated in children , in which the
risk of halo thane induced hepatitis on repeated
administration is small.
• Enflurane and isoflurane are more pungent and not
recommended
• Sevoflurane, if available is the agent of choice
• Nitrous oxide is particularly useful because of the
speed of induction, absence of cardiovascular and
respiratory depression, its rapid onset and offset, and its
powerful analgesic action.
135. Upper respiratory tract infection is a common
problem in children. All the following anesthetic
complications can occur in children with respiratory
infections, except:
A. Bacteremia
B. Halothane granuloma
C. Increased mucosal bleeding
D. Laryngospasm
B
..........(AIPGMEE - 2002)
• Due to local infection there is hyperemia of the local area
& trauma can result in mucosal bleeding
• Due to local edema & inflammation laryngospasm can be a
complication
• Systemic infection can lead to Bacteremia
TOPIC 9: VENTILATOR
136. After Hyperventilating for some time holding the
breath is dangerous because:
A. Decrease CO2 shift the O2 dissociation curve to the left
B. Alkalosis can lead to tetany
C. It can lead to CO2 Narcosis
D. Due to lack of stimulation by CO2, anoxia can go into
dangerous levels
D
..........(AIIMS PGMEE NOV - 2000)
Due to lack of stimulation by CO2, anoxia can go into dangerous
levels
• In our body its not O2, but CO 2 that maintains the
respiratory drive (though main function of respiration is
to maintain adequate oxygen level in the body)
• Thus its not hypoxia but hypercarbia that is required
to inform the brain that respiration is inadequate.
• If normally a person holds his breath he will soon
have decrease O 2 level (hypoxia) and increase CO 2
level (hypercarbia)
• Hypercarbia will stimulate the brain and increase the
respiratory drive, forcing the person to take breath.
• What happens when a person hyperventilates ?
• decreased PaCO2 of blood
• normal O2 saturation (despite hyperventilation arterial
O2 saturation remains same as blood is almost fully
saturated at normal ventilation rate )
HELP LINE NO. 9391567707
ANAESTHESIA 23
• What happens when such a person holds his
breath.
• Soon his blood O2 level will fall (hypoxia) but his blood CO2
level will be normal or below normal (as he was hypocapnic
due to hyperventilation)
• His blood O2 level will continue to fall, but his CO 2 level
will still be not high enough to stimulate the brain for
respiratory drive.
• The person will continue to hold his breath and his
O2 level may fall to lethal levels without any respiratory
drive (his brain is still unaware that he is in danger
of dying from hypoxia.)
137. In volume cycled ventilation the inspiratory flow
rate is set at
A. 140-160L/min
B. 110-130 L/min
C. 60-100 L/min
D. 30-50 L/min
Ans : C
..........(AIIMS PGMEE NOV - 2002)
• Ventilators are devices which are used to provide warm
and humidified gas to the airway opening according to
specific volume pressure and time patterns. The ventilator
serves as energy source only during inspiration
replacing the muscles of chest wall and diaphragm.
• Expiration is passive driven by the recoil of the lung and
chest wall.
There are various modes of mechanical ventilation such as
(1) Assist control mode ventilation
(2) Continuous positive airway pressure
(3) Pressure control ventilation
(4) Pressure support ventilation
(5) Open lung ventilation
• These various modes of ventilation specifies the manner
in which ventilator breaths are triggered, cycled and
limited.
Lets see the meaning of these terms.
Trigger- It defines what the ventilator senses to initiate
an assisted cycle.
In volume-assist control, the patient can receive
controlled or assisted breaths – all identical
• One has to be careful with triggering devices: if the trigger
is too sensi tive the patient “overt riggers” and
hyperventilates, if it is not sensitive enough, the patient
becomes dysynchronous.
Cycle- Refers to the factors that determine the end of
inspiration
For e.g., in volume cycle ventilation inspiration ends
when a specified volume is delivered to the patient
Limiting factors-are operator specified values such as
airway pressure that are monitored by transducer’s
internal to the ventilatory circuit.
 TOPIC 9: VENTILATOR
• Volume cycle ventilation and Assist control mode of
ventilation.
Every breath whether triggered by patient or timer is a
volume cycled breath and the inspiratory flow rate is
maintained at 60 L/ min
Methods of Ventilatory Support
Continuous mandatory ventilation
• Breaths are delivered at preset intervals, regardless of
patient effort.
• This mode is used most often in the paralyzed or apneic
patient because it can increase the work of breathing
if respiratory effort is present.
• Continuous mandatory ventilation (CMV) has given
way to assist-control (A/C) mode because A/C with the
apneic patient is tantamount to CMV. Many ventilators do
not have a true CMV mode and offer A/C instead.
Assist-control ventilation
• The ventilator delivers preset breaths in coordination
with the respiratory effort of the patient .
• With each inspiratory effort, the ventilator delivers a full
assisted tidal volume.
• Spontaneous breathin g independent of the
ventilator between A/C breaths is not allowed.
• As might be expected, this mode is better tolerated
than CMV in patients with intact respiratory effort.
Intermittent mandatory ventilation
• With intermittent mandatory ventilation (IMV),
breaths are delivered at a preset interval, and
spontaneous breathing is allowed between ventilator-
administered breaths.
• Spontaneous breathing occur s agains t the
resistance of the airway tubing and ventilator
valves, which may be formidable. This mode has given
way to synchronous intermittent mandatory
ventilation (SIMV).
Synchronous intermittent mandatory ventilation
• The ventilator delivers preset breaths in
coordination with the respiratory effort of the
patient. Spontaneous breathing is allowed between
breaths. Synchronization attempts to limit barotrauma that
may occur with IMV when a preset breath is delivered to
a patient who is already maximally inhaled (breath stacking)
or is forcefully exhaling.
• The initial choice of ventilation mode (eg, SIMV, A/C) is
institution and practitioner dependent. A/C ventilation,
as in CMV, is a full support mode in that the ventilator
performs most, if not all, of the work of breathing. These
modes are beneficial for patients who require a high
minute venti lation. Full support re duces oxygen
consumption and CO2 production of the respiratory
muscles. A potential drawback of A/C ventilation in the
patient with obstructive airway disease is worsening of air
trapping and breath stacking.
• When full respiratory support is necessary for the
paralyzed p atient following neu romuscular
blockade, no difference exists in minute ventilation
or airway pressures with any of the above modes
of ventilation.
• In the apneic patient, A/C with a respiratory rate
(RR) of 10 and a TV of 500 mL delivers the same
minute ventilation as SIMV with the same parameters.
HELP LINE NO. 9391567707
ANAESTHESIA 24
Pressure support ventilation (PSV)
• For the spontaneously breathing patient, pressure
support ventilation (PSV) has been advocated to
limit barotrauma and to decrease the work of
breathing.
• Pressure support differs from A/C and IMV in that a
level of support pressure is set (not TV) to assist
every spontaneous effort.
• Airway pressure support is maintained until the patient’s
inspiratory flow falls below a certain cutoff (eg, 25% of
peak flow). With some ventilators, there is the ability to
set a back-up IMV rate should spontaneous
respirations cease.
• PSV is frequently the mode of choice in patients
whose respiratory failure is not severe and who have an
adequate respiratory drive. It can result in improved
patient comfort, reduced cardiovascular effects,
reduced risk of baro trauma, and improved
distribution of gas.
Noninvasive ventilation
• The application of mechanical ventilatory support through
a mask in place of endotracheal intubation is
becoming increasingly accepted and used in the
emergency department. Considering this modality for
patients with mild-to-moderate respiratory failure is
appropriate. The patient must be mentally alert enough
to follow commands. Clinical situations in which it has
proven useful include acute exacerbation of chronic
obstructive pulmonary disease (COPD) or asthma,
decompensated congestive heart failure (CHF) with
mild-to-moderate pulmonary edema, and pulmonary
edema from hypervolemia.
• It is most commonly applied as continuous positive
airway pressure (CPAP) and biphasic positive airway
pressure (BiPAP).
• BiPAP is commonly misunderstood to be a form of pressure
support ventilation triggered by patient breaths; in
actuality, BiPAP is a form of CPAP that alternates
between high and low positive airway pressures,
permitting inspiration (and expiration) throughout.
• Indications For Mechanical Ventilation
Clinical criteria
• Apnea or hypopnea
• Respiratory distress with altered mentation
• Clinically apparent increasing work of breathing
unrelieved by other interventions
• Obtundation and need for airway protection
Other criteria
• Controlled hyperventilation (eg, in head injury).
• Severe circulatory shock
Laboratory Criteria for Mechanical Ventilation
Blood gases PaO2 <55 mm Hg
PaCO2 >50 mm Hg and pH <7.32
Pulmonary function tests Vital capacity <10 mL/kg
Negative inspiratory force <25
cm H2O
FEV1 < 10mL/KG
Guidelines for Ventilator Settings
Mode of ventilation
• The mode of ventilation should be tailored to the needs
of the patient. In the emergent situation, the practitioner
 TOPIC 9: VENTILATOR
may need to order initial settings quickly. SIMV and A/C
are versatile modes that can be used for initial
settings.
• In patients with a good respiratory drive and mild-
to-moderate respiratory failure , PSV is a good initial
choice.
Tidal volume
• Observations of the adverse effects of barotrauma and
volutrauma have led to recommendations of lower tidal
volumes than in years past, when tidal volumes of 10-15
mL/kg were routinely used.
• An initial TV of 5-8 mL/kg of ideal body weight is generally
indicated, with the lowest values recommended in the
presence of obstructive airway disease and ARDS. The
goal is to adjust the TV so that plateau pressures are less
than 35 cm H2 O.
Respiratory rate
• A respiratory rate (RR) of 8-12 breaths per minute is
recommended for patients not requiring hyperventilation
for the treatment of toxic or metabolic acidosis, or
intracranial injury. High rates allow less time for exhalation,
increase mean airway pressure, and cause air trapping in
patients with obstructive airway disease. The initial rate
may be as low as 5-6 breaths per minute in
asthmatic patients when using a permissive hypercapnic
technique.
Supplemental oxygen therapy
• The lowest FiO2 that produces an arterial oxygen
saturation (SaO2) greater than 90% and a PaO2
greater than 60 mm Hg is recommended. No data
indicate that prolonged use of an FiO2 less than 0.4
damages parenchymal cells.
Inspiration/expiration ratio
• The normal inspiration/expiration (I/E) ratio to start
is 1:2. This is reduced to 1:4 or 1:5 in the presence
of obstructive airway disease in order to avoid air-
trapping (breath stacking) and auto-PEEP or intrinsic PEEP
(iPEEP). Use of inverse I/E may be appropriate in certain
patients with complex compliance problems in the setting
of ARDS.
Inspiratory flow rates
• Inspiratory flow rates are a function of the TV, I/E
ratio, and RR and may be controlled internally by the
ventilator via these other settings. If flow rates are set
explicitly, 60 L/min is typically used. This may be
increased to 100 L/min to deliver TVs quickly and
allow for prolonged expiration in the presence of
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 states
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
the lungs and there is no single “ideal” PEEP
appropriate for all alveoli; rather, a compromise PEEP
must be selected.
HELP LINE NO. 9391567707
ANAESTHESIA 25
• One obvious beneficial effect of PEEP is to shift lung water
from the alveoli to the perivascular interstitial space. It
does not decrease the total amount of extravascular lung
water. This is of clear benefit in cases of cardiogenic as
well as noncardiogenic pulmonary edema. An additional
benefit of PEEP in cases of CHF is to decrease venous
return to the right side of the heart by increasing
intrathoracic pressure.
• Applying physiologic PEEP of 3-5 cm H2 O is common
to prevent decreases in functional residual capacity
in those with normal lungs. The reasoning for increasing
levels of PEEP in critically ill patients is to provide acceptable
oxygenation and to reduce the FiO2 to nontoxic levels
(FiO2 <0.5). The level of PEEP must be balanced such
that excessive intrathoracic pressure (with a resultant
decrease in venous return and risk of barotrauma) does
not occur.
Sensitivity
• With assisted ventilation, the sensitivity typically is set
at -1 to -2 cm H2 O. The development of iPEEP
increases the difficulty in generating a negative
inspiratory force sufficient to overcome iPEEP and
the set sensitivity. Newer ventilators offer the ability to
sense by inspiratory flow instead of negative force. Flow
sensing, if available, may lower the work of breathing
associated with ventilator triggering.
Initial ventilator settings in various disease states.
Tidal volume RR I/E ratio PEEP FIO2
Normal lungs 8 mL/kg 10-12 1:2 4 1.0
Asthma/copd 6 mL/kg 5-8 1:4 4 1.0
ARDS 6 mL/kg 10-12 1:2 4-15 1.0
Hypovolemia 8 mL/kg 10-12 1:2 0-4 1.0
138. Laryngeal mask Airway (LMA) is used for;
A. Maintenance of the airway
B. Facilitating laryngeal surgery
C. Prevention of aspiration
D. Removing oral secretions
A
..........(AIIMS PGMEE NOV - 2003)
Laryngeal mask is used for maintenance of airway in patients
in whom tracheal intubation is difficult or impossible.
It is a cuffed mask designed to fit closely over the
laryngeal aperture. It forms a seal around the larynx.
- Laryngeal mask airway is also called as Bain Mask (after
the name of its inventor)
- It provides relatively safe anaesthesia for adults and
children in place of tracheal intubation.
 TOPIC 9: VENTILATOR
It should be remembered that it is only an adjunct to airway
management but not a substitute for tracheal intubation.
Moreover it does not protect the airway from pulmonary
aspiration.
139. The laryngeal mask airway used for securing the
airway of a patient in all of the following conditions
except:
A. In a difficult intubation.
B. In cardiopulmonary resuscitation.
C. In a child undergoing an elective/routine eye surgery.
D. In a patient with a large tumour in the oral cavity
D ..........(AIPGMEE - 2005)
..........(.AIPGMEE - 2005)
Oropharyngeal abscess or mass is a contraindication to the
use of laryngeal mask airway. (LMA)
Laryngeal Mask Airway
It is a special type of airway useful in difficult intubation.
It is placed blindly in the oropharynx and the cuff is
inflated with large volume of air inflated cuff seals
the lateral and posterior pharyngeal walls and patient can
be ventilated through ventilation parts.
Indications
1) As an alternative to intubation where difficult intubation
is anticipated.
2) Securing airway in emergency where intubation and mask
ventilation is not possible.
3) As a elective method for minor surgeries where
anaesthetist wants to avoid intubation.
4) As a conduit for bronchoscopes, small size tubes, gum
elastic bougies.
Advantages
Easy to insert (even paramedical staff can insert).
Does not require any laryngoscope and muscle relaxants
Does not require any specific position of cervical spine so
can be used in cervical injuries
Disadvantages
• It does not prevent aspiration so should not be used
for full stomach patients.
• High incidence of laryngospasm and bronchospasm
HELP LINE NO. 9391567707
ANAESTHESIA 26
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.
140. The following modes of ventilation may be used
for weaning off patients from mechanical ventilation
except:
A. Controlled Mechanical ventilation (CMV).
B. Synchronized intermittent mandatory ventilation (SIMV).
C. Pressure support ventilation (PSV).
D. Assist-control ventilation (ACV)
A
In controlled mode ventilation (CMV) patients own effort
is nil.
Only ventilator is delivering the present tidal volume. This
mode therefore will play no role in weaning a patient from
mechanical ventilation.
141. In apatient with fixed respiratory obstruction
Helium is used along with Oxygen instead of plain
oxygen because
A. It decreases oxygenation
B. It decreases turbulence
C. It decreases the dead space
D. It provides analgesia
D
..........(AIPGMEE - 2002)
It increases oxygenation
• Helium is given as Heliox [HeO2], a mixture of 20% to
80% He and 80% to 20% O 2 [usually 80% He with
20% O2]. It has about 1/3rd the density of O2 or air.
• Because helium is highly diffusible , the use of the
mixture greatly reduces the work of breathing in a patient
with narrowed airways and thus lead to improved aerosol
delivery and increased oxygenation in severe
asthma.
• It may also reduce the risk of barotrauma.
• Airway resistance is dictated by the diameter of the
airways and by the density of the inspired gas. Therefore
when nitrogen (of air) is replaced by helium, airway
resistance is reduced due to the lower density of
 TOPIC 9: VENTILATOR
the inspired gas. This means that when one breathes
Heliox, airway resistance is less, and therefore the
mechanical energy required to ventilate the lungs,
or the Work of Breathing (WOB) is decreased .
• Heliox is used mainly in the alleviation of many medical
conditions that involve a decrease in airway diameter
(and consequently increased airway resistance),
such as upper airway obstruction, asthma, chronic
obstructive pulmonary disease (COPD), bronchiolitis
and croup. Patients with these conditions may suffer a
range of symptoms including dyspnea (breathlessness),
hypoxemia (below-normal oxygen content in the arterial
blood) and eventually a weakening of the respiratory
muscles due to exhaustion, which can lead to respiratory
failure and require intubation and mechanical ventilation -
Heliox may reduce all these effects, making it easier for
the patient to breathe, and as it will reduce work of
breathing, Heliox can help to prevent this respiratory
failure. Heliox has also found utility in the weaning of
patients off mechanical ventilation, and in the nebulization
of inhalable drugs.
• It decreases turbulence. In COPD, Helium is used along
with O2 to decrease the viscosity of gaseous mixture
which increases its linearity & decreases resistance in
pathway.
142. All are true about PEEP except:
A. Useful in situations where PO2 is low
B. Decreased Cardiac output
C. Impaired renal function
D. Decreased ICT
D about ventilatory efficiency or dead space ventilation than
..........(PGI - June -1999)
• When PEEP (Positive End Expiratory Pressure) is applied,
there is rise in cerebral venous and intracranial pressures
in parallel with the increase in mean intrathroacic pressure.
• Cardiac output and venous return is reduced Rt. Atrial
pressure - rises.
• Useful in conditions where PO2 is low and also easier if
PCO2 is lowered.
143. End-tidal CO2 is increased to maximum level in:
A. Pulmonary. Embolism
B. Malignant hyperthermia
C. Extubation
D. Blockage of secretion
B
..........(PGI - June -2000)
• The PCO2 value at the end of exhalation is referred to as
End-tidal PCO2 (PETCO2).
The normal end-expiratory CO 2 partial pressure ranges
between 35 and 45 mm of Hg.
HELP LINE NO. 9391567707
ANAESTHESIA 27
It’s value’ is increased when there are :
- Increased CO2 production e.g. in malignant hyperpyrexia.
- Depression of respiratory center with concomitant
reduction of total ventilation and ExCO2.
- Reduction of effective ventilation induced by paralysis,
neurologic disease, high spinal anaesthesia,
weakened respiratory musculature or respiratory
disease.
Abnormally low end-tidal values (< 35 mm of Hg)
most often reflect hyperventilation but may be also be
caused by increased dead space with normal PaCO2 i.e.
alveolar gas emanating from a lung region with no
blood flow (and no local CO 2 relative to PaCO 2. So,
in pul. embolism it is decreased).
144. The physiological dead space is decreased by:
A. Upright position
B. Positive pressure ventilation
C. Neck flexion
D. Emphysema
A
..........(AIIMS PGMEE - MAY 2005)
The PaCO2 will be greater than or equal to end-ridal PaCO2
(PET CO 2 ) unles s the patient inspires or r eceives
exogenous ca rbon dioxide (e.g., fro m peritoneal
insufflation). The difference between PETCO2) 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
detected by comparing PET CO 2 with temper ature
corrected PaCO 2. Yamanaka and Sue52 found that the
PETCO2 in ventilated patients varied linearly with the dead
space to tidal volume ratio (VD/VT) and that PETCO2
correlated poorly with PaCO 2. Thus, in the critically ill,
mechanically ventilated patient, and in anesthetized
patients, monitoring PETCO2 gives far more information
it does about the absolute value of PaCO2.
145. Placement of a double lumen tube for lung surgery
is best confirmed by -
A. EtCO2
B. Airway pressure measurement
C. Clinically by auscultation
D. Bronchoscopy
D
..........(AIIMS PGMEE - NOV 2005)
TOPIC 10: ATRACURIUM
• During thoracic surgery there is a need for one lung to be
deflated and or isolated. This offers the surgeon easier
and better acess within the designated hemothorax.
In order to achieve this double lumen endobronchial
tubes are used that allow the anaesthetist to
selectively deflate one lung while maintaining
standard ventilation of the other.
146. The most common cause of hypoxia during one
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 trachea and the other lumen
ends in either the left or right main bronchus
• Each lumen has its own cuff (tracheal an bronchial cuffs)
and colour coded pilot balloons.
• The proximal end of these tubes is connected 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 correctly positioned the anaesthetist can
selectively 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.
• The position of the tubes should b e checked by
auscultation immediately after intubutation and after
positioning the patient for operation.
• The auscultatorv method 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.
147. Which of the following is the muscle relaxant of
HELP LINE NO. 9391567707
ANAESTHESIA 28
What is the use of end tidal CO2 determination (EtCO2) in
intubuation ?.
• The EtCO2 can be used to confirm the position of
the endotracheal tube, (whether the tube is in
oesophagus or trachea)
• The persistent detection of CO2 by a capnograph is the
best confirmation of tracheal placement of an
endotracheal tube (EtCO 2).
Capnography can detect whether the tube is in trachea
or oesophagus but can not differentiate between
tracheal intubation and endobronchial intubation
because in both these cases there will be persistent
detection of COr
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
..........(AIIMS PGMEE - NOV 2005)
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 fiber-
optic bronch oscopes or bronchial bl ockers, this
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
• Intentional collapse of the lung on the operative side
facilitates most thoracic 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 PA-a (alveolar to arterial) O2
gradient and can result in hypoxemia.
TOPIC 10: ATRACURIUM
choice in renal failure?
A. Rapacurium
B. Pancuronium
C. Atracurium
D. Rocuronium
C
..........(AIPGMEE - 2006), PGI - 1997 – Dec, AIIMS PGMEE -
NOV 2004
 TOPIC 10: ATRACURIUM ANAESTHESIA 29

‘The unique feature of Atracurium is inactivation in plasma
by spontaneous nonenzymatic degradation (Hoffman
elemination) consequently its duration of action is not
altered in patients with renal / hepatic insufficiency, or
hypodynamic circulation. Hemodynamically it is almost
neupal
Atracurium gets inactivated in plasma by spontaneous
non-enzymatic Hoffman’s elemination.
It is short acting and reversal is mostly not required
The concept of Balanced anaesthesia was introduced by
Lundy and consist of

Preferred relaxants Thiopental For Induction

In renal failure : Vecuronium or Atracurium. N2O For Amnesia
In hepatic failure : Atracurium. Mepiridine (or other opioid) For Analgesia
In Myasthenia gravis : if relaxants are essential, one-tenth
Curare For Muscle relaxation
of the normal dose of atracurium
In short cases: atracurium, rapacurium, or mivacurium. Atracurium:
In obstetrics any relaxant except gallamine. Gets inactivated in plasma by spontaneous non-
In arterial surgery: to maintain art erial pressure enzymatic Hoffman’s elimination.
pancuronium. Short acting
To deliberately reduce BP: tubocurarine. Reversal is mostly not required
For rapid sequen ce induction: without using Vecuronium:
suxamethonium, Rocuronium or rapacurium. R ecovery is gener ally spon taneous not ne eding
neostigmine reversal unless repeated doses are
148. An elderly male on ventilator has received atracurium given.
infusion for 3 days. He now develops epileptic • Longterm administration of vecuronium to patients in ICU
fits.Probable cause for his epilepsy is: has resulted in prolonged neuro muscular blockade (upto
A. Allergy to drug sever al days) d/t accumulation of 3-Hydroxy
B. Accumulation of Atracurium metabolite, or development of polyneuropathy.
C. Accumulation of Laudanosine
D. Ventilator failure • Gallamine:
C Long acting
..........(AIPGMEE - 2007) Needs reversal
• Pancuronium:
Laudanosine is a metabolite of Atracurium and has CNS
Long acting
stimulating properties.
Needs reversal
Laudonosine may produce convulsions from its CNS
stimulating 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, A. Gallamine
such high concentrations are usually not reached, but B. Atracurium
the patient in question has been on atracurium for 3 C. Succinyl choline
consequestive days before he develops epilepsy and hence D. Tubocurare
high plasma concentration of Laudanosine could well be a B
probable cause for epilepsy. ..........(PGI - June -1998), PGI - June -1999

149. Shortest acting non-depolarising skeletal muscle 153. Muscle relaxant used In renal failure:
relaxant is: A. Ketamine
A. Mivacurium B. Atracurium
B. Vecuronium C. Pancuronium
C. Atracurium D. Fentanyl
D. Succinyl choline B
A ..........(PGI - June -1999)
..........(AIPGMEE - 2000)
Muscle relaxant of choice in renal failure is Atracurium. It 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
with 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 without 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. Gallamine B. Atracurium
C. Atracurium C. Rocuronium
D. Vecuronium D. Vecuronium
C B
..........(AIPGMEE - 2003) ..........(AIIMS PGMEE - MAY 2004)

HELP LINE NO. 9391567707

 TOPIC 11: INTUBATION
Neostigmine is given for reversal of action of non-
depolarizing muscle relaxants
Neostigmine is an anticholinesterase. Its action prevents
the metabolism of acetylcboline by the enzyme
acetylcholinesterase. This increases the concentration
of Acetylcholine in the synaptic cleft and leads to
development of action potential.
This causes the muscles paralysed by the muscle rerlaxants
to return back to their normal contractile state.
Neostigmine is usually required after long acting muscle
relaxants have been used, to hasten recovery at the end
of operation.
Among the muscle relaxants given in the option Atracurium
has the shortest duration of action and so it usually
does not require neostigmine for the reversal of its
action.
Mivacurium is the shortest acting competitive blocker
therefore it does not need reversal.
TOPIC 11: INTUBATION
157. Endotracheal intubation is contraindicated in:
A. Fracture mandible
B. Short neck
C. CSF rhinorrhoea
D. Fracture cervical spine
C
..........(AIIMS PGMEE - Dec - 1995)
CSF rhinorrohoea
“Endotracheal intubation can be done in patients with
fracture of cervical spine. It may be difficult and may
require fibreoptic intubation”.
158. During laryngoscopy and endo-tracheal intubation
which of the maneuver is not performed:
A. Flexion of the neck.
B. Extension of Head at the atlanto-occipital joint.
C. The laryngoscope is lifted upwards levering over the upper
incisors.
D. In a straight blade laryngoscope, the epiglottis is lifted by
the tip
C intubation and mechanical ventilation and is certainly not
..........(.AIIMS PGMEE MAY - 2003)
HELP LINE NO. 9391567707
ANAESTHESIA 30
Using upper incisors as lever to lift the laryngoscope will cause
damage to the upper incisors (in fact it will break the
upper incisors)
During endotracheal intubation a small pillow should be placed
under the occiput to flex the neck and extend the atlanto-
occipital joint. This straightens the path from upper
incisors to the larynx.
In both straight blade laryngoscope and curved blade
laryngoscope the tip of the laryngoscope is inserted firmly
into the vallecula and is used to lift the base of epiglottis.
159. The narrowest part of larynx in infants is at the
cricoid level. In administering anesthesia this may
lead to all except.
A. Choosing a smaller size endotracheal tube.
B. Trauma to the subglottic region.
C. Post operative stridor
D. Laryngeal oedema
D
..........(AIIMS PGMEE MAY - 2003)
The narrowest part of larynx in infants is at the cricoid level
(below the vocal cords), hence endotracheal tube
which passes through the vocal cords may not pass
through the cricoid-hence a smaller size of tube is
chosen.
Because cricoid (subglottic area) area is the narrowest - it
may get traumatized during 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 following is not an indication for
endotracheal intubation?
A. Maintenance of a patent airway
B. To provide positive pressure ventilation
C. Pulmonary toilet
D. Pneumo thorax
D
..........(AIPGMEE - 2006)
Pneumothorax requires urgent needle thoracocentesis
and/or Intercostal drainage .
Pneumothorax is a known complication of endotracheal
an indication for the same.
 TOPIC 11: INTUBATION ANAESTHESIA 31

INDICATIONS FOR ENDOTRACHERAL INTUBATION 162. True about endotracheal intubation is:
Indications for Endotrachea! Intubation in the A. It reduces the normal anatomical dead space
operating room include : B. It produces resistance to respiration
• The need to deliver positive pressure ventilation C. Sub-glottic oedema is the most common complication
• Protection of the respiratory tract from aspiration of gastric D. All of the above
contents A
• Surgical procedure involving the head and neck or in non- ..........(AIPGMEE - 1999)
supine positions that preclude manual airway support
• Endotracheal intubation decreases the normal anatomical
• Almost all situations involving neuromuscular paralysis dead space (150ml) to as less as 25ml, and thus provides
• Surgical procedures involving the cranium, thorax, or a distinct advantage.
abdomen • Endotracheal intubation increases the resistance to
• Procedures that may involve intracranial hypertension respiration.
To keep resistance at a minimum, use of widest internal
Some non-operative indications are: diameter endotrachal tube that will fill in the larynx is
• Profound disturbance in consciousness with the inability recommended.
to protect the airways • Subglotic edema, though a complication, is not the most
• Tracheobronchial toilet (pulmonary toilet) common one.
• Severe pulmonary or multisystem injury associated with
respiratory failure, such as sepsis, airway obstruction 163. True about endotracheal cuff:
hypoxemia, and hypercarbia A. Low-volume, high pressure
B. Low-volume, low pressure
161. Malampatti Grading is for: C. High-volume, low pressure
A. To assess mobility of cervical spine D. High volume, high pressure
B. To assess mobility if atlantotaxial joint E. Equal volume and pressure
C. For assessment of free rotation of neck before intubation. A&C
D. Inspection of oral cavity before intubation ..........(PGI - DEC 2002)
D
..........(AIPGMEE - 2000) Large volume, low pressure endotracheal tube cuffs
are claimed to have less deleterious effect on tracheal
Inspection of oral cavity before intubation mucosa than high pressure, low volume cuffs
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 Faucial pillars / soft palate / uvula masked by base of tounge
III Only soft palate
IV Hard palate

164. Indications of tracheostomy are:

A. Flail chest
B. Head injury
C. Tetanus
D. Cardiac tamponade
E. Foreign body
A, B, C & E
..........(PGI - JUNE 2003)

Indications for tracheostomy

To relieve upper airway obstruction

HELP LINE NO. 9391567707

 TOPIC 12: MUSCLE RELAXANT ANAESTHESIA 32

• Foreign body 165. True about Laryngoscopy & intubation except

• Trauma A. Hypertension
• Acute infection - acute epiglottitis, diphtheria B. Tachycardia
• Glottic oedema C. Decreased ICT
• 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 ..........(.PGI - JUNE 2004), PGI - June -2001
• Fulminating bronchopneumonia
• Chronic bronchitis and emphysema
Application of cricoid pressure reduces LES tone and may
• Chest injury and flail chest
Respiratory paralysis cause the esophagus to be displaced to the side rather
• Unconscious head injury than to be compressed. Compression in the backward
• Bulbar poliomyelitis and upward direction improves laryngoscopy.
• Tetanus
Advantages of tracheostomy over endotracheal intubation rise in intraocular pressure during laryngoscopy and
• Reduces patient discomfort intubation is a matter of concern in patients of acute
• Reduces need for sedation glaucoma
• Improves ability to maintain oral and bronchial hygiene
• Reduces risk of glottic trauma Topical anesthesia of oropharynx with lidocaine aerosol
• Reduces dead space and reduces work of breathing (6 ml of 4% for 5 min) prevented hypertension and
• Augments process of weaning from ventilatory tachycardia during laryngoscopy
support
TOPIC 12: MUSCLE RELAXANT
Tracheostomy technique
• Patient positioned supine with sandbag between scapulae
167. Train of four fade is a characteristic feature of:
• Transverse cervical skin incision 1 cm above sternal notch
A. Depolarizing block
• Incision should extend to the sternomastoid muscles
• Dissect through fascial planes and retract anterior jugular B. Non depolarizing block
veins C. Both depolarizing and non-depolarizing block
• Retract the strap muscles D. Malignant hyperthermia
• Divide thyroid isthmus and oversew to prevent bleeding B
• Place cricoid hook on 2 nd tracheal ring ..........(AIPGMEE - 2008)
• Stoma fashioned between 3 rd and 4 th tracheal rings
• Anterior portion of tracheal ring removed Train of four fade is a characteristic of a non-depolarizing
• No advantage in creating a tracheal flap block
• Endo-tracheal tube withdrawn to sub-glottis
• Tracheostomy tube inserted using obturator What is a Train of Four Stimulation and Fade
• When confirmed that in correct position the ET tube • Train-of-four stimulation denotes administration of four
removed successive 200|is stimuli in 2 seconds (2 Hz)
• Tube secured with tapes • The pattern seen with a depolarizing block differs from
that of a non-depolarizing block
With a non depolarizing block there is progressive
depression of height with each twitch (fade)
With a depolarizing block there is equal depression of all
four twitches

Complications of tracheostomy
Immediate
• Haemorrhage
• Surgical trauma - oesophagus, recurrent laryngeal nerve
• Pneumothorax
Intermediate
• Tracheal erosion
• Tube displacement Train-of-Four
• Tube obstruction
• Subcutaneous emphysema With 2-Hz stimulation, the mechanical or electrical response
• Aspiration & lung abscess decreases little after the fourth stimulus, and the degree
Late of fade is similar to that found at 50 Hz. 43 Thus, applying
• Persistent tracheo-cutaneous fistula train-of-Four stimulation at 2 Hz provides more sensitivity
• Laryngeal and tracheal stenosis than single twitch and approximately the same sensitivity
• Tracheomalacia as tetanic stimulation at 50 Hz. In addition, this relatively
• Tracheo-oesophageal fistula low frequency allows the response to be evaluated manually

HELP LINE NO. 9391567707

 TOPIC 12: MUSCLE RELAXANT ANAESTHESIA 33

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

impulses (four) eliminates the problem of posttetanic
facilitation. Train-of-four stimulation can be repeated every
12 to 15 seconds. There is a fairly close relationship
between single-twitch depression and train-of-four
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-twitch height has

recovered to 100%, the train-of-four ratio is approximately
70%.

169. Drug causing anaphylactoid reaction:

A. Propotol
B. Alcuronium
C. Thiopentone
D. Glycopyrrolate
B
..........(PGI - 1998 - Dec)

• Development of true allergy or antibody formation may of

course occur in days or weeks following exposure to any
Posttetanic count (PTC). During profound blockade, no of non depolarising muscle relaxants (i.e. ALCURONIUM)
response is seen to train-of-four (TOF) or tetanus. • They also cause TACHYPHYLAXIS.
However, because there is posttetanic facilitation, some
twitches can be seen after tetanic stimulation. In this 170. Neostigmine is used for reversing the adverse effect
example, the PTC is 9. of:
A. d - TC + pancuronium
168. Phase -II blocker is: B. d TC only
A. D - TC C. Alcuronium only
B. Cocaine D. Ketamine complication
C. Scoline A
D. Vencuronium ..........(PGI - JUNE 1997)
C
..........(PGI - 1998 - Dec) • By interfering with the breakdown of acetylcholine ,
neostigmine indirectly stimulates both nicotinic and
• Phase - II blocker is scoline muscarinic receptors.
Depolarising muscle relaxants have dual mechanism of • Unlike physostigmine, neostigmine has a quarternary
action (NM Blockade) : nitrogen; hence, it is more polar and does not enter
— Phase - I : Persistent depolarisation of muscle end the CNS. its effect on skeletal muscle is greater than
plate and is rapid onset. that of physostigmine, and it can stimulate contractility
— Phase -II : Slow onset, desensitization of the receptor before it paralyzes.
to acetvlcholine • Neostigmine has short duration of action , usually
• Decamethonium and suxamethonium have these actions. thirty minutes to two hours.
D - TC, Vecuronium are non-depolarising, competitively
block at NM junction on nicotinic (NM)cholinergic receptors, • Neostigmine binds to the anionic site of cholinesterase.
The drug blocks the active site of acetylcholinesterase so
Succinylcholine Tubocuraine the enzyme can no longer break down the acetylcholine
Phase I Phase II molecules before they reach the postsynaptic membrane
Administration of Antagonistic Augmented Additive
receptors. This allows for the threshold to be reached so
tubocuraine a new impulse can be triggered in the next neuron.
Administration of Additive Augmented Antagonistic
Succinylcholine • In myasthenia gravis there are too few acetylcholine
receptors so with the acetylcholinesterase blocked,
Effect of neostigmine Augmented1 Antagonistic Antagonistic
acetylcholine can bind to the few receptors and trigger a
Initial excitatory effect Fasciculations None None muscular contraction.
on skeletal muscle
Response to a tetanic Sustained2 Unsustained Unsustained • It is used to improve muscle tone in people with myasthenia
stimulus
gravis and routinely, in anesthesia at the end of an
Posttetanic facilitation No Yes Yes operation, to reverse the effects of non-depolarizing
Rate of recovery 4-8 min > 20 min 3 30-60 min 3 muscle rel axants such as rocu ronium and
vecuronium.

HELP LINE NO. 9391567707

 TOPIC 12: MUSCLE RELAXANT ANAESTHESIA 34

• It 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.
In a non-pregnant female whose menstrual period is • Shortest and fastest acting Succinylcholine
delayed, administration of neostigmine can provoke neuromuscular blocker (overall)
menstrual bleeding. Modern tests which rely on detecting • Longest acting neuromuscular Pancuronium
hCG in urine have rendered this application obsolete. blocker
• Neostigmine will cause slowing of the heart rate
(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
C. Mg2+ predisposes the block by
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
..........(PGI - JUNE 2005)

* Char acteristics features of Nondepol arizing
neuromuscular blocking drugs :
- They are competitive blockers & compete with Ach for
the end plate r eceptors but without causing
depolarization.
- Acts by preventing the access of Ach to the cholinergic
receptor, which are responsible for muscular tone &
contraction.
- Do not cause muscular fasciculation.
- Relatively slow onset (1-5 min).
- Among all the non-depo larizing relaxants, 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
& electrical ) stimuli.
- Block is potentiated by volatile agents, Mg 2+ &
hypokalemia.
- Ca 2+ enhances the release of Ach from the motor nerve
terminal & enhances excitation-contraction coupling in
muscles thus partially antagonizing the block
- 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 •
..........(AIIMS PGMEE - MAY 2008)
• Rapacuronium is the shortest ating drug.
• Rapacuronium has been withdrawn from the market
because it produces intense bronchospasm in a
significant number of patients.
• Alcuronium is a relatively short acting muscle relaxant.
• 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
173. Muscle relaxant excreted exclusively by kidney is:
A. Scoline
B. Atracurium
C. Vecuronium
D. Gallamine
D
..........(AIIMS PGMEE - JUNE 1998)
Gallamine
• “Urinary Excretion of Gallamine is > 95%.
• Its billiary excretion is < 1%”.
• Gallamine
• It is nephrotoxic so C/I in Renal Failure*.
• It crosses placenta so C/I in Pregnancy*.
• M.R. undergone Hoffman’s elimination —-Atracurium
• M.R. of choice in Renal failure & Hepatic failure
• Atracurium
• Atracurium is a neuromuscular-blocking drug or
skeletal muscle relaxant in the category of non-
depolarising neuromuscular blocking agents, used
adjunctively 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. causing minimum Histamine release —
Vecuronium*

HELP LINE NO. 9391567707

 TOPIC 12: MUSCLE RELAXANT ANAESTHESIA 35

• M.R. C/I in Hepatic failure They binds to ach receptors like acetycholine but are
• d-TC, Pancuronium, Scoline* incapable of inducing ion channel opening.
Since acetycholine is prevented from binding to its receptors
no end plate potential develops.
In this way they act as competitive antagonist 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

A summary of the pharmacology of nondepolarizing Depolarizing muscle relaxant

muscle relaxants. These drugs physically resemble Ach and therefore bind
to Ach receptors generating a muscle action potential
Relaxant Chemical Metabolism Primary Onset2 Duration3 Histamine Vagal but unlike Ach these drugs are not metabolized by
Structure1 Excretion Release4 Blockade5
Atracurium B +++ Insignificant ++ ++ + 0
acetylcholinesterase and their concentration in the
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
V ecuronium S + Billary ++ ++ 0 0
Rocuronium S Insignificant Billary +++ ++ 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 (mg/kg) intubating Intubating Boluses Infusion
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
A. Pancuronium
Vecuronium 0.05 0.12 2.0-3.0 40-90 0.01 1-2
Pancuronium 0.07 0.12 2.0-3.0 60-120 0.01 -
Pipecuronium 0.05 0.1 2.0-3.0 80-120 0.01 - B. Rocuronium
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 ..........(PGI - DEC 2002)
B. Preventing the release of Acetylcholine
C. Causing persistent depolarization 176. Which one of the following muscle relaxant has
D. Competitive inhibition the maximum duration of action?
D A. Atracurium
..........(AIIMS PGMEE - MAY 2004) B. Vecuronium
C. Rocuronium
Curare are also called non depolarizing muscle relaxants. D. Doxacurium
Non depolarizing muscle relaxants competitively inhibit D
acetylcholine ..........(AIPGMEE - 2006)

HELP LINE NO. 9391567707

 TOPIC 13: PROPOFOL ANAESTHESIA 36

TOPIC 13: PROPOFOL 179. Which of the following statements about propofol
is not true?
A. It is contraindicated in porphyria
B. It does not trigger malignant hyperthermia
C. Commercial preparations contains egg
D. It is a suitable agent for day care surgery
A
..........(AIPGMEE – 2008)

Propofol can be used safely in porphyria & malignant

177. The following combination of agents are the most
preferred for short day care surgeries
A. Propofol, fentanyl, isoflurane
B. Thiopentone sodium, morphine, halothane
C. Ketamine, pethidine, halothane
D. Propofol, morphine, halothane
A
..........(AIIMS PGMEE MAY - 2003), AIPGMEE – 2006
AIPGMEE – 2004, AIPGMEE - 2003
For day care surgery patients are sent back home the same
day. Therefore you need agents which are rapidly
eliminated so that no after effects are left. The agents
used are-
- Propofol
- Alfentanil
- Remifentanil
- N 20
- Isoflurane
- Sevoflurane
- Desflurane
‘Propofol is the intravenous induction agent of choice ’
because of its early induction and smooth recovery.
Patients remain clear headed and have low incidence of
post operative nausea and vomiting.
hyperthermia
• Propofol is an oil based preparation containing egg
lecithin
It is an alkylphenol, 2, 6-Disopropylphenol.
It is highly soluble in lipid but insoluble in water so it is presented
as a 1 or 2 percent emulsion in 10 percent soyabean oil
with 1.2 percent egg phosphatide as the emulsifying
agent
The addition of disodium edetate (0.005%) supresses
bacterial growth.
• Propofol is considered the agent of choice for day
care anaesthesia.
Smooth induction, rapid onset of action , easy
titration to effect, short clinical duration of action and
demonstr able antiemetic effect make propofol an
induction agent of choice for day care anaesthesia.
• Propofol is non contraindicated in porphyria
Propofol is considered safe in porphyria -
• Propofol does not trigger Malignant Hyperthermia
Propofol has been recommended as the agent of choice
for induction is susceptible individuals for malignant
hyperthermia
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.
Which one of the following induction agents is
preferred:
A. Thiopentone sodium
B. Ketamine
C. Diazepam
D. Propofol
D
..........(AIPGMEE - 2003)

The patient in question wishes to resume his work after

Day case surgery Agent of choice 6 hours and hence needs a day care anaesthetic agent
Intravenous induction Propofol that has the advantage of rapid recovry and little incidence
agent of post recovery compilations. Propofol as described above
Desflurane >Isoflurane is such an agent of choice.
Inhalation induction
agent Alfentanyl Remifentanyl
Intravenous opioid 183. True about Propofol
analgesia
Mivacurium A. It suppress adrenocortical hormone
B. I.M. injection is not painful
Muscle relaxants C. Hepatic metabolism
D. Di-isopropyl phenol
Agents used in day care anaesthesia include : E. Cerebral protector
1. Propofol B, C, D & E
2. Alfentanyl, Remifentanyl ..........(PGI - DEC 2005)
3. Isoflurane, Sevoflurane, Desflurane
4. Methohexitone
* Propofol (2, 6 - diisopropyl phenol) is an intravenous
5. Thiopentone
anaesthetic agent.
6. Etomidale

HELP LINE NO. 9391567707

 TOPIC 14: ISOFLURANE
* The main disadvantage in the use of propofol is the
production of pain on its injection into small veins.
This can be decreased by selecting larger veins or by prior
administration of 1% Lidocaine or a potent short-acting
opioid.
* Propofol metabolism in the liver is rapid & extensive.
* Propofol reduces cerebral metabolic rate of oxygen
(CMRO2) without reduction of cerebral perfusion
pressure (CPP), producing cerebral protection.
• Etomidate is also an anaesthetic agent which
suppresses the secretion of cortisol.
184. A 20-year-old patient presented with early
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
..........(AIIMS PGMEE - MAY 2006)
Rapid induction of propofol is due to its high Iipid solubility
and rapid recovery is due to very short distribution.
185. The following anaesthetic drug causes pain on
intravenous adminstration:
A. Midazolam
B. Propofol
C. Ketamine
D. Thiopentone sodium
B
..........(AIIMS PGMEE - MAY 2006)
• it is intraarterial (not intravenous) injection of
thiopentone, that causes intense pain.
• Intraarterial injection of thiopentone induces severe
inflammatory and potentially necrotic reaction and
should be avoided. Its intravenous injection does not
produce pain.
• Intravenous injection of propofol frequently
produces pain.
186. Induction agent for Day care Surgery is:
A. Ketamine
B. Diazepam
C. Thiopentone
D. Propofol
D propofol infusion syndrome . This potentially lethal
..........(AIIMS PGMEE - DEC 1998)
Propofol
• “Propofol is used as in inducing agent for day care
surgery because residual impairment is less marked and
incidence of post operative nausea and vomiting is low.”
• Day care anaesthesia −−− Isoflurane
• Day care analgesic −−− Alfentanyl
• Propofol is a short-acting intravenous anesthetic
agent used for the induction of general anesthesia in
adult patients and pediatric patients older than 3 years of
HELP LINE NO. 9391567707
ANAESTHESIA 37
age; maintenance of general anesthesia in adult patients
and pediatric patients older than 2 months of age; and
sedation in medical contexts, such as intensive care
unit (ICU) sedation for intubated, mechanically
ventilate d adults , and in proce dures such as
colonoscopy.
• It provides no analgesia
• 20 ml ampoule of 1% propofol emulsion
• A common hospital-worker slang term for Propofol is “Milk
of Amnesia/Milk of Anesthesiologists
• The elimination half-life of propofol has been estimated
to be between 2–24 hours. However, its duration of clinical
effect is much shorter because propofol is rapidly
distributed into peripheral tissues , and its effects
therefore wear off considerably within even a half
hour of injection.
• This, together with its rapid effect (within minutes of
injection) and the moderate amnesia it induces makes
it an ideal drug for IV sedation .
• Aside from the hypotension (m ainly through
vasodilatation) and transient apnea following
induction doses
• one of propofol’s most frequent side effects is pain on
injection, especially in smaller veins. This pain can be
mitigated by pretreatment with lidocaine.
• Patients tend to show great variability in their
response to propofol , at times showing profound
sedation with small doses.
• Propofol has been known to cause an adverse reaction in
some patients, known cases include myoclonia and
dystonia. Note this is extremely rare.
• Propofol appears to be safe for use in porphyria , and
has not been known to trigger malignant hyperpyrexia.
• A recently described rare but serious side effect is
metabolic derangement has been reported in critically-
ill patients after a prolonged infusion of high-dose
propofol in combination with catecholamines and/
or corticosteroids
TOPIC 14: ISOFLURANE
187. In raised intracranial tension, anaesthetic agent
used is
A. Nitrous oxide (N2O)
B. Trichloroethylene
C. Enflurane
D. Isoflurane
D
..........(AIIMS PGMEE - MAY - 1994)
 TOPIC 14: ISOFLURANE ANAESTHESIA 38

“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 Isoflurane causes the least
increase in cerebral blood flow. Therefore it is most
suitable inhalational agents in increased intracranial
pressure.

Isoflurane -
- It has got least effect on heart
- Agent of choice in renal and hepatic failure
- It has got rapid induction and recovery
- Pupils do not dilate and light reflex in not lost even at
deeper levels.
- It does not provoke seizures
• Isoflurane is the preferred agent for neuro surgical
It produces profound respiratory depression
anaesthesia as in Low concentration it does not cause
any increase in cerebral blood flow.
188. Which of the following statements about inhalation
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
..........(AIPGMEE - 2008)

Compared with isoflurane, sevoflurane is less potent

and lacks coronary vasodilating properties’

189. Which anaesthetic agent ha s the least

cardiovascular effect: • Isoflurane is used is day care surgery.
A. Isoflurane
B. Enflurane
C. Tnlene
D. Ketamine
A
..........(AIPGMEE - 2000)

Isoflurane
• Of the various inhalation agents available, isoflurane has
the advantage of providing stability to cardiac rhythm and
the lack of sensitization of heart to exogenous or
endogenous adrenaline
• It causes less myocardial depression than halothane on
enflurane.
It thus causes the least alternation of cardiovascualar
status.
• Isoflurane is always administered in conjunction with
air and/or pure oxygen . Often nitrous oxide is also used.
Isoflurane for maintainence not induction
• Although its physical properties means that anaesthesia
can be induced more rapidly than with halothane ,
its pungency can irritate the respiratory system, negating
this theoretical advantage conferred by its physical
properties.

• It is usually used to maintain a state of general anesthesia

that has been induced with another drug, such as
thiopentone or propofol.
• It vaporizes readily, but is a liquid at room temperature.
• It is completely non-flammable.
• Isoflurane 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
..........(AIPGMEE - 2001)

HELP LINE NO. 9391567707

 TOPIC 15: OPIOIDS ANAESTHESIA 39

Isoflurane ‘Of the various inhalation agents available, isoflurane

• Methoxyflurane has a high nephrotoxic potential has the advantage of providing stability of cardiac
• Enflurane is best avoided as nephrotoxic levels of rhythm and lack of sensitization of the heart to
fluoride ions have been seen just after 3.5 MAC-hours. exogenous and endogenous adrinaline.’ -
• Isoflurane, sevoflurane, desflurane and halothane result Isoflurane is stable and unlikely to be toxic.
in little 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 C. Isoflurane
is: D. Sevoflurane
A. Ether C
B. Halothane ..........(PGI - 1997 - Dec)
C. Methoxyflurane
D. Isoflurane Among all the fluorinated anesthetic agents mentioned here,
D isoflur ane is having the least fluori de content &
..........(AIPGMEE - 2001) methoxyflurane is having the highest amount of fluoride
content.
Isoflurane The higher the fluoride content, the more the side effect
of the drug.
Anaesthesia in chronic alcoholism :
Chronic alcoholism damages the liver but also induces drug TOPIC 15: OPIOIDS
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
• Isoflurane or sevoflurane are suitable anaesthesitc NONE
agents. ..........(PGI - 1998 - Dec)

• The perioperative use of certain narcotic opioids such as
morphine and oxycodone should be avoided in
patients with cirrhosis, because their bioavailability is
markedly increased and their half-life prolonged.[6] By
contrast, metabolism of fentanyl does not seem to
be affected by hepatic dysfunction .
• The metabolism of certain benzodiazepines (such as
midazolam and diazepam) can also be slowed in patients
with cirrhosis, whereas oxazepam and temazepam
undergo conjugation without hepatic metabolism
and their clearance rate is, therefore, not affected .
196. Best antagonist of Morphine
•
In patients with hepatic dysfunction, the increased
duration of action of benzodiazepines and narcotics
can lead to prolonged depression of the central
nervous system and hepatic encephalopathy ; these
agents should, therefore, be used with caution in the
perioperative setting.
• Of the volatile anesthetics, isoflurane is generally
recommended as it undergoes the least amount of
hepatic metabolism and does not impair hepatic blood
flow.
• By contrast, halothane undergoes significant hepatic
metabolism and reduces hepatic blood flow. Halothane
anesthesia carries with it a significant risk of drug-induced
hepatitis
• ‘Neurolept analgesia’ is Fentanyl and droperidol combination
and when 65% N2 O + 35% O 2 is adminstered it is
converted to ‘Neurolept anaesthesia’.
• Muscle dystonia, abnormal movements can occur as an
extrapyramidal side effect of droperidol .
• Fall in BP (due to a—adrenergic blocking action of
droperidol) is generally slight unless hypovolemia is
present or patient’s posture is changed .
Heart rate often decreases (fentanyl stimulates vagus)
but heart is not sensitized to adrenaline.
• Droperidol sometimes cause hypotension.
A. Pentazocine
B. Buprenorphi ne
C. Naloxone
D. Nalorphine
C
..........(AIIMS PGMEE - JUNE - 1997)
Naloxone
• T/t of choice for morphine poisoning is Naloxone (6
mg.IV) repeated every 3 min till respiration picks up)
• It is preferred due to no agonistic action and no
respiratory depression.
• Nalorphine is given only when Naloxone not available

192. Least Cardiotoxic anaesthetic agent 197. Which of the following opioids is not given
A. Enfluranc intrathecally
B. Isoflurane A. Remifentanil
C. Sevoflurane B. Morphine
D. Halothane C. Sufentanil
B D. Fentanyl
..........(AIPGMEE - 1996), AIPGMEE - 1998 A
..........(AIPGMEE - 2007)

HELP LINE NO. 9391567707

 TOPIC 15: OPIOIDS ANAESTHESIA 40

Remifentanil is not used intrathecatly because glycine in the 201. Which one of the following is the description used
drug vehicle can cause temporary motor paralysis. It is for the term allodynia during pain management?
generally given by continuous, intravenous infusion, A. Absence of pain perception
Opioids such as Morphine, Diamorphine, P ethiden B. Complete lack of pain sensation
(Meperidene), Fentanyl and Sufentanil may all be used C. Unpleasant sensation with or without a stimulus
intra thecally D. Perception of an ordinarily nonnoxious sitmulus as severe
pain
198. Drug with Ceiling effect D
A. Morphine ..........(.AIIMS PGMEE - MAY 2006)
B. Buprenorphine
C. Fentanyl Terms used in pain management
D. Mfentanyl Allodynia Perception of an ordinarily nonnoxious
B stimulus as pain
..........(AIPGMEE - 1994) 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 treatment 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 safety 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
..........(PGI - JUNE 2006) roots

• The potency of opioids in mg, relative to lOmg of 202. A 52 year old male diagnosed as triple vessel
morphine are: coronary artery disease with poor left ventricular
Pentazocine = 30 mg function. Coronary artery bypass grafting surgery
Nalbuphine = 10 mg was decided. During maintenance of anaesthesia
Butorphanol = 2 mg which one of the following agents should be
Buprenorphine = 0.2 mg preferred?
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 ..........(AIIMS PGMEE - NOV 2004)
Methadone = 10 mg
Tramadol = 100 mg Maintenance anaesthesia in patients with coronary
So, 0.5 mg of Buprenorphine = 25 mg of Morphine = 250mg heart disease.
of Tramadol = 75mg of Pentazocine. - Isoflurane is the most common maintenance anaesthesia
used in these cases, but doubts have been raised regarding
200. Which one of the common side effects is seen with its safety in patients with coronary artery disease.
fentanyl?
A. Chest wall rigidly - Isoflurane causes vasodilatation of coronary
B. Tachycardia arteries, so it is feared that it can cause coronary
C. Pain in abdomen steal phenomenon.
D. Hypertension - Isoflurane also causes minimal cardiac depression.
A Many anaestheists believe that opioids are better in these
..........(AIIMS PGMEE - MAY 2006) cases, opioids do not have any direct depressant on heart
and are also helpful in cases of heart failure.
Opioids (particularly Fentanyl, Sufentanil and
Alfentanil) can induce chest wall 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 The prospective clinical trials on isoflurane have not been
after large drug boluses and is effectively treated with able to prove that it causes coronary steal.
neuromuscular blocking drugs.

HELP LINE NO. 9391567707

 TOPIC 16: BUPIVACAINE ANAESTHESIA 41

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 — Isoflurane
D. Bupivacaine
Advantages of Isoflurane in patients with CHD D
• They reduce myocardial O2 requirement ..........(PGI - 1997 - Dec)
• Protective role in reperfusion injuries Disadvantages of
Isoflurane in patients with CHD Bupivacaine is not metabolized by cholinesterase. Rest of the
• Negative inotropic effect drugs are metabolized by cholinester 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
Due to these advantage, i.v. opioids have become the C. Etidocaine
mainstay of anaesthesia in pts with poor left ventricular D. Lignocaine
function. A&C
..........(PGI - DEC 2005), PGI - 2000 - Dec
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
..........(.AIIMS PGMEE MAY - 2003) Metabolism Hepatic
All of these are included in short acting narcotic analgesics.
Half life 3.5 hours (adults)
This shortest acting among them is Remifentanil. 8.1 hours (neonates)
Onset Duration Excretion Renal, 4-10%
Remifentanil 30s - 60s 5-5 minutes
* Prilocaine is having intermediate duration of action like
Alfentanil 0.5 m 5-10 minutes
lignocaine.
Fentanyl 1-4 min 30 min
Sufentanil 1-4 min 30 min
208. Bupivacaine
TOPIC 16: BUPIVACAINE A. Less cardiotoxic than prilocine
B. It is an amide
204. The topical use of following 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 ..........(PGI - DEC 2005)
D. Dibucaine
B • Bupivacaine is an amide type local anaesthetic drug.
..........(AIIMS PGMEE NOV - 2002) – It is reputed to be four times as potent as both Mepivacaine
& Lignocaine.
Local anaesthetics * It is more cardiotoxic than other local anaesthetics & is
Used as surface Can not be used as surface made worse by hypoxia, hypercapnia & by pregnancy.
anaesthetics anaesthetics So, it is not used for I.V. regional anaesthesia (Bier’s block)
(a) Cocaine (a) Bupivacaine .
(b) Lidocaine (b) Procaine * It 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

HELP LINE NO. 9391567707

 TOPIC 17: PIN INDEX ANAESTHESIA 42

209. Levo-bupivacaine is administered by which of ; TOPIC 17: PIN INDEX

following routes
A. Nasogastric
B. Epidural
C. Intra-venous
D. Intra-theccal
E. Oral
B
..........(PGI - JUNE 2004)

• 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.

It can be used by the following routes.: 212. Pin index system is a safety feature adopted in
- Intrathecal anaesthesia. Machines to prevent:
A. Incorrect attachment of anaesthesia machines.
- Epidural
B. Incorrect attachment of anaesthesia face masks.
- Peripheral nerve blocks C. Incorrect inhalation agent delivery.
• Bupivacaine is more prone to induce cardiac arrythymia & D. Incorrect gas cylinder attachment
should not be used for IV regional anaesthesia. D
..........(.AIIMS PGMEE MAY - 2003)
210. Which one of the following local anaesthetics is
highly cardio-toxic: To understand this and the next question you are required
A. Lignocaine to have a preliminary knowledge of Boyle anaesthesia
B. Procaine machine.
C. Mepivacaine Boyle anaesthesia machine is a continuous flow type of
machine used for administration of inhalational anaesthesia.
D. Bupivacaine
It is equipped with two oxygen cylinders, two nitrous
D oxide cylinders, one carbondioxide cylinder and one
..........(AIIMS PGMEE - MAY 2005) cyclopropane cylinder.

211. A 30-year-old lady is to undergo surgery under These cylinders are locked to Boyle apparatus in metal
intravenous regional anesthesia for her left ‘trigger yoke with two pins and fiting holes on the cylinder
finger’. Which of the following should not be used head.
for this patient Each cylinder has a particular pin code and unless the
A. Lignocaine correct cylinder valve is attached the pins and holes will
not coincide. Thus it is practically impossible to fit any
B. Bupivacaine
cylinder to wrong yokes.
C. Prilocaine
D. Lignocaine + Ketorolac
B
..........(AIIMS PGMEE - MAY 2004)

Intravenous 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.
213. The Pin index code of Nitrous oxide is:
The anaesthetic is inserted on the dorsum of the hand through A. 2,5.
an intravenous catheter. B. 1,5.
This techqnique is most commonly used for carpal tunnel C. 3,5.
release. D. 2,6
C
..........(.AIIMS PGMEE MAY - 2003)
Local aneasthetics used are –Lidocaine ,Prilocaine
Local anaesthetic contraindicated - 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 ventricular • Cyclopropane -> 3 and 6
tachycardia or cardiac depression. • Carbondioxide -> 1 and 6
The site of action of drug in this technique is peripheral International colour code for cylinders
nerve ending. • Oxygen* -> black with white shoulders
• Nitrous oxide* -> Blue

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 43

• Carbon dioxide* -> Gray • N2O is a colourles, odourless, heavier than air, non-
• 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 Ib/sq. inch (Psi)
Cynlinders are made up of: • Pin-index is 3, 5
A. Molybdenum steel MAC-value between 100% and 105%
B. Iron + molybedenum
C. Cooper + steel
D. Iron
A
..........(AIPGMEE - 2000)

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

218. All of the following are used to maintain proper

215. An anaesthetist orders a new attenant to bring oxygen flow to the patient except:
the oxygen cylinder. He will ask the attendant to A. Placement of nitrogen flowmeter downstream of the
identify the correct cylinder by following color code: oxygen flowmeter
A. Black cylinders with white shoulders B. A proportionater between N2 and O2 control valve
B. Black cylinders with grey shoulders- C. Different pin index for nitrogen and oxygen
C. White cylinders with black shoulders D. Calibrated oxygen concentration analyses
D. Grey cylinder with white shoulders C
A ..........(AIIMS PGMEE - MAY 2008)
..........(AIPGMEE - 2003)
• Pin index safety system for cylinders prevents incorrect
cylinder attachments.
Gas Colour of Cylinder
Oxygen Black body, white It is a safeguard introduced to eliminate cylinder
shoulder interchanging and the possibility of accidently
placing the incorrect gas on a yoke designed to
Air Grey body, black and
accomodate another gas.
white shoulder It has nothing to do with hypoxia.
N2O Blue
The systems used to prevent
Entonox (O2 and N2O Blue body, white and hypoxia:-
mixture in equal blue quartered shoulder Low oxygen pressure alarm It detects oxygen supply failure at
volume) the common gas inlet that activates
a gas whistle or electric alarm
Cyclopropane Orange Minimum oxygen/nitrous oxide Prevent delivery of less than 21 %
Carbondioxide Grey ratio controller device (hypoxic oxygen
guard)
Thiopentone Y ellow Oxygen must enter the common Prevent hypoxia in event of
manifold down-stream to other proximal gas leak
Halothane Amber (Purple - Red) gases
Oxygen concentration monitor Prevents administration of hypoxic
217. True about N2O cylinder and alarm gas mixtures in event of a low
A. Pressure is 2200 PSI pressure system leak; precisely
B. Blue in colour regulate oxygen concentration
C. Gas in liquid form
D. Pin index 3.5 TOPIC 18: MAC
E. It is flammable
B,D 219. Partition coefficient of gas:
..........(PGI - JUNE 2004), (PGI - 2000 - Dec) A. Measure of potency

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 44

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

C. Measures solubility individuals. It is accepted as a valid measure of potency
D. All of the above of inhalational GAs because it remain fairly constant for
C a given species even under varying conditions.
..........(PGI - June -1998)
222. Characteristic of an ideal gas is:
• Blood/Gas partition co-efficient is the ratio (at equillibrium) A. Volume is directly proportional to change in pressure
of concentration in blood to that in Gas. B. Volume is inversely proportional to change in temperature
• It measures the solubility of the gas. C. At absolute temp, volume of gas is 1
The MAC (minium alveolar concentration) measures the D. Obeys charles, boyles and avagadro’s laws
potency of inhalational anaesthetics. D
The MAC of a no. of GAS shows excellent correlation ..........(PGI - June -1998)
with their oil/gas partition co-efficient.
• An ideal gas obeys charle’s, boyle’s and avogadro’s law.
For a highly soluble gas-alveolar concentration can rise Boyle’s Law :- Volume (V) is inversely proportional to the
SLOWLY where as a low soluble gas-the alveolar pressure.
concentration rises RAPIDLY so, there is an inverse Charles’s Law :- Volume of a given mass of gas is proportional
relationship. to its^absolute Temperature if pressure remains constant.

220. All of the following factors decrease the Minimum 223. The potency of an Inhalational anesthetic depends
Alveolar Concentration (MAC) of an inhalation on:
anaesthetic agent except. A. Blood gas partition co-efficient
A. Hypothermia B. Oil-gas partition co-efficient
B. Hyponatremia C. Gas pressure
C. Hypocalcemia D. Blood pressure
D. Anemia B
C ..........(PGI - June -1999)
..........(AIIMS PGMEE MAY - 2003)
• The physical property of anaesthetic that correlates best
Minimum alveolar concentration with anaesthetic potency is the lipid solubility (i.e., oil-gas
- Is the concentration of anaesthetic gas needed to partition co-efficient), whereas the best estimate of
eliminate movements among 50% of patients challenged anaesthetic potency is the minimum alveolar concentration
by standardized skin incision. The MAC is usually expressed (MAC) (at 1 atm) of an agent that produces immobility in
as percentage of gas in a mixture required to achieve the 50% of those subjects exposed to a noxious stimulus.
effect. The MAC of a number of GAs partion coefficient shows
excellent correlation with their oil-gas. partition coefficient
Factors causing decrease in MAC. The blood-gas partition coefficient is the ratio of the
1. Hypothermia concentration of anaesthetic in blood to that in the gas
2. Anaemia phase. It is an index of solubility of the GA in blood. The
3. Hyponatremia uptake of anaesthetics depends on blood-gas coefficient.
4. Pregnancy
5. Hypoxemia 224. Lowest concentration of Anaesthetic agent in
6. Cholinesterase inhibitors pulmonary alveoli needed to produce immobility in
7. Reserpine, a methyldopa response to painful stimulus in 50% individual is
8. Severe hypotension termed 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 ..........(AIIMS PGMEE - JUNE 1998)
Remember, numerically MAC is small fo r potent
anaesthetics, such as halothane and large for less potent Minimal alveolar concentration
anaesthetics such as nitrous oxide. • Minimal alveolar concentration (MAC)
Therefore the inverse of MAC is an index of potency “is the lowest concentration of the anaesthetic in
of the anaesthetic. pulmonary alveoli needed to produce immobility in
response to a painful stimulus in 50% individuals.
221. Index of potency of general anaesthesia It is accepted as a valid measure of potency of
A. Minimum alveolar concentration inhalational general anesthetics.”
B. Diffusion coefficient
C. Dead space concentration Meyer-Overton hypothesis
D. Alveolar blood concentration • The MAC of a volatile substance is inversely proportional
A to its lipid solubility (oil:gas coefficient) , in most
..........(PGI - 1997 - Dec) cases.
• This is the Meyer-Overton hypothesis. MAC is inversely
• MAC is the lowest concentration of the anaesthetic in related to potency i.e. high mac equals low potency.
pulmonary alveoli needed to produce immobility in

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 45

TOPIC 19: MC GILL CIRCUIT

228. In 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
..........(AIPGMEE - 2000)

• In gener al anaesthesia, recovery and emergency

resuscitation procedures involve the use of a breathing
Mapleson D
system. The principle of anaesthetic systems is to
(Coaxial Bain)
efficiently eliminate exhaled carbon dioxide, without greatly
• This system is mainly used with spontaneous respiration.
increasing dead space or resistance.
• The Fresh Gas Flow is close to the patient and the
• In 1954 Mapleson classified breathing systems based on
APL valve is placed away from the patient . The risk
their efficiency in eliminating carbon dioxide during
of rebreathing in this circuit will be high especially in
spontaneous respiration.
patients who have a short expiratory pause or do not
• The breathing systems are classified in order of
have an expiratory pause (infants). To overcome this
increased requirement of fresh gas flow (FGF) to
problem a high FGF of 2 - 4 times of the patient’s Minute
prevent re breathing during s pontaneous
Volume is required. If Mapleson D is used with controlled
respiration.
or assisted ventilation a high FGF is required to prevent
• System A requires 0.8 - 1 times, B and C require 1.5-2
all rebreathing. In practice some rebreathing is tolerated
times and D, E and F require 2-4 times of the patient’s
and in an adult an FGF of 6 - 7 litres/minute will maintain
minute volume.
a normal arterial C02 tension.
Equal to Minute alveolar Ventilation
‘Mapleson system A is also known as Magill system’ :
This is the most efficient system with spontaneous
respiration

Mapleson E
(Infant T-piece, and Ayres T-Piece without Bag)
A flow of about 5 L/min (equal to minute ventilation) • This system is primarily for use in neonates and paediatrics,
is required in young healthy patients to flush Co2 from where low resistance is of great importance . There
the system) is no APL valve (to reduce resistance) and a high FGF, 2 -
4 times of the patient’s Minute Volume (with a minimum
Mapleson B flow of 3 litres/minutes) is required to eliminate rebreathing
• In this system the Reservoir bag, fresh gas supply risk during spontaneous ventilation.
and APL valve are closer to the patient . This will cause
mixing of inspiratory and expiratory gases and therefore a
higher flow rate (1.5 - 2 times of the patient’s minute
volume, i.e. 12 - 16 litres/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

• Mapleson C
(Waters Bag, Bagging System (Adult, Direct and Paediatric)
and Resuscitation Bag)
This system is similar to Mapleson B , however, the bag is
positioned very close to the patient. This system is used
for manual ventilation during resuscitation. A flow rate of
1.5 - 2 times of the Minute Volume is required to avoid
rebreathing
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 1/3 rd of
the tidal volume)
The main advantage of a ‘T’ piece is the absence of Resistance
to Expiration a factor of crucial importance to children.
Jackson Rees made a great improvement to T-Pieces
(Mapleson E) by adding an open tail 0.5 litre reservoir
bag to the end of expiratory (reservoir) limb .

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 46

This allows manual ventilation and the application of Positive • Mapleson C

End Expiratory Pressure (PEEP) to help maintain open
airways.
Mapleson F
• Jackson Rees Modification (Infant T-piece, and Ayres T-
Piece with open end Bag)
Jackson Rees made a great improvement to T-Pieces
(Mapleson E) by adding an open tail 0.5 litre reservoir
bag to the end of expiratory (reservoir) limb .
This allows manual ventilation and the application of Positive
End Expiratory Pressure (PEEP) to help maintain open
airways.
• For controlled ventilation, normocapnia can be maintained
with a FGF of 1000ml + 100ml/kg body weight.
Used in postoperative recovery room
• Mepleson D
Most efficient in assisted and controlled ventilation
• Mepleson E
Used in infants and children (flow rate = 2x minute volume)
It is as efficient as Mepleson D in assisted and controlled
ventilation
Also known as Ayre ‘s tube.
227. The most appropriate circuit for ventilating a
spontaneously breathing infant during anaesthesia
is:
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
..........(.AIPGMEE - 2005)

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 Being incomplete it was classically modified by Jackson
A Rees who added a bag for monitoring and IPPV.
..........(AIIMS PGMEE - DEC 1994) Jackson’s Rees modification of Ayre’s T piece has thus
become the most appropriate circuit for ventilating
226. All of the following are suitable anaesthetic circuits a spontaneously breathing infant.
for both controlled and assisted ventilation except
A. MaplesonA
B. MaplesonB&C
C. MaplesonD
D. MaplesonE
A
..........(AIIMS PGMEE NOV - 2003)

Mapleson A system is most useful in spontaneous

respiration and least useful in assisted and controlled
ventilation.
• Efficiency of the systems with spontaneous
respiration
A>D&E>C>B
• Efficiency of systems with IPPV (assisted and
controlled ventilation) Efficacy of Mapleson’s systems for spontaneous
D&E>B>C>A respiration
A>D&E>C>B
Mapleson A system - Although the most efficacious system for spontaneous
Also known as Magill system respiration is Mapleson A, in the context of infants and
Most satisfactory with spontaneous respiration small children ,Ayre’s T tube with Jackson Rees modification
Flow of about 5 L/min is maintained becomes the answer of choice.
‘The main advantage of the T piece technique is the
• Mapleson B absence of resistance to expiration, a factor of crucial
Not in common clinical use importance in small children.’

HELP LINE NO. 9391567707

 MINOR TOPICS 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 will be fast with agent with less B/G
spontaneous respiration. The mos t efficient partition coefficient and induction and recovery with
anaesthetic circuiit is: be slower with agents with high B/G partition
A. Maplelson A coefficients.
B. Mapleson B
C. Mapleson C Agent Blood gas partition
D. Mapleson coefficient
A Desflurane 0.42
.........(AIPGMEE - 2003)
Cyclopropane 0.44
CO2 will be exhaled into B. tube or directly vented through Nitrous oxide 0.47
an open pop off valve Sevoflurane 0.69
Before inhalation occurs if the fresh gas flow exceeds alveolar
minute volume the inflow of fresh gas will force the Isoflurane 1.38
remaining alveolar gas in B. tube to exit from valve and Enflurane 1'.8
inspiration will only contain fresh gas.
Halothane 2.4
Because a fresh gas flow equal to minute volume is sufficient
to prevent rebreathing of exhaled air ,Mapleson A is Chloroform 8
the most efficient circuit for spontaneous ventilation Trielene 9
Ether 12
Methoxyflurane 15

It can be concluded from the table that induction will be

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

232. Which one of the following anaesthetic agents

230. Magill circuit air flow is: causes a rise in the Intracranial pressure:
A. Equal to minute volume A. Sevoflurane.
B. Twice to minute volume B. Thiopentone sodium.
C. Half to minute volume C. Lignocaine.
D. Equal to alveolar volume D. Propofol
A A
..........(AIPGMEE - 1998) ..........(AIPGMEE - 2005)
Equal to minute volume ‘Intracranial pressure increases at high inspired
- Magil system is synonymous with Mapelson system A concentrations of sevoflurane‘
- This is the most satisfactory system for spontaneous
respiration In the given options only sevoflurane causes rise in
- Gas flow here needs to be maintained at flow rates of 5- intracranial pressure while 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
TOPIC 20: SEVOFLURANE IOP ors tnodics
• Ketamine ■ Halothane • Ketamine (Preferred in (Contraindica
asthmatics) ted in
231. Which one of the following is the fastest acting Asthmatics)
inhalational agent? • N2O • Morphine • Pentazocin • Ketamine • Ether
A. Halothane. (most dilators)
B. Isoflurane. • Etomidate ■ Decreased BP • • Halothane • N2O
C. Ether. Pancuronium
D. Sevoflurane • Thiopental • Halothane • • Thiopentone
D Promethazine
• • Morphine
..........(.AIPGMEE - 2005) Hexamathonium
• Trimethaphan • d-Tc
The fastest induction is seen with sevoflurane

Blood Gas Partition Coefficient (B/G Coff.) 233. Which of the following volatile anaesthetic agents
This is the most important factor determining the uptake should be preferred for induction of anaesthesia in
of agent and so the speed of induction and recovery. children ?
A. Enflurane
Agents will low blood gas partition coefficient will B. Isoflurane
have high alveolar concentration e.g., nitrous oxide C. Sevoflurane
with blood gas partition coefficient of 0.47 means D. Desflurane
concentration (or partial pressure) in blood is 47% of C
alveolar concentration. Since alveolar concentration ..........(AIPGMEE - 2004)

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 48

Induction in Pediatric Patient A. Sevoflurane

B. Methoxyflurane
Inhalation Intravenous Intramuscular C. Desflurane
(Preferred (reserved method) D. Isoflurane
method) A
Sevoflurane Rapid acting Ketamine ..........(AIIMS PGMEE - MAY 2004)
Barbiturate
Children become very anxious at the mere sight of a needle
(Thiopental)
so intravenous induction is difficult in children.
propofol
So inhalational anaesthetics are used to induce anaesthesia
followed, by non
in children.
depolarizing MR
Sevoflurane is commonly used to induce anaesthesia in
234. True about sevoflurane: children.
A. Isopropyl ether (Halothane can also be used)
B. MAC is 2%
C. Good to use in old age Desflurane and isoflurance can also induce aneasthesia but
D. Blood gas partition coefficient is more they are not used because of the following side effects.
E. Formation of compound ‘A with Baralyme - They are pungent
A,B,C & E - Cause coughing
..........(PGI - DEC 2004) - Breath holding
- Produce laryngospasm
235. A 6 month old child is suffering from patent ductus
arteriosus (PDA) with congestive cardiac failure. Agents used if i.v. induction is done in children
Ligation of ductus arteriosus was decided for surgical Thiopentone
management. The most appropriate inhalational
anaesthetic agent of choice with minimal Used in children are -» non depolarizing muscle relaxants (e.g.)
haemodynamic alterat ion fro induction of Rapacuronium
anaesthesia is - Rocuronium
A. Sevoflurane Atracurium
B. Isoflurane Miva curium
C. Enfiurane Sometimes succinyl choline can also be used
D. Halothane
A TOPIC 21: AIRWAY
..........(AIIMS PGMEE - NOV 2005)
237. Oxygen delivery is regulated by all, EXCEPT
• Sevoflurane is the agent of choice for inhalational A. Oxygen tent
induction of anaesthesia in pediatric procedures. B. Nasal catheter
• It is an excellent choice for smooth and rapid inhalational C. Venti mask
induction in pediatric procedures because D. Polymask
- It has sweet odour, so induction is smooth B
- Rapid increase in alveolar anaesthetic concentration ..........(AIIMS PGMEE - NOV - 1993)
(therefore rapid onset of action)
Its low blood solubility results in rapid fall in alveolar O2 is delivered through the following devices
anaesthetic concentration upon discontinuation and 1) Nasal catheter
results in quicker emergence when compared to other 2) BIB mask
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 238. In a patient with multiple injuries, first thing to be
is not smooth. done is:
A. Patency of airway
236. A 6-year-old child is posted for elective urology B. Maintenance of B. P
surgery under general anesthesia. He refuses to allow C. Immobilize cervical spine
the anesthe siologist an IV acces s. The best D. Lateral position with mouth gag
inhalational agent of choice for induction of A
anesthesia is ..........(PGI - 1999 - Dec), PGI - 2000 - Dec

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 49

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

the care of the airway. B. Venturi mask
- The first step in cardio-pulmonary resuscitation is AIRWAY C. O2 by T-piece
MAINTAINANCE D. Edinburgh mask
- The intention for CPR is maintain O2 perfusion until definite B
interventions instituted. ..........(AIIMS PGMEE - MAY 2005)
- The elements of CPR
TOPIC 22: CPR
• Maintainance of airway (A)
• Breathing (B) 242. In a patient with cardiorespiratory arrest, basic life
• Circulation (C) support is given to support which of the following
systems:
240. Laryngeal mask airway is indicated In: A. Respiratory system
A. To prevent aspiration of stomach contents B. Cardiovascular system
B. Short surgical procedure C. Renal system
C. Where endotracheal intubation is contra-indicated D. Gastrointestinal system
D. Difficult airway E. CNS
E. Facilitate endotracheal intubation A
B&D ..........(PGI - 2001 - Dec)
..........(PGI - 2001 - Dec)

243. During cardiac resuscitation, the following can occur

except:
A. Rupture of Lungs
B. Rupture of liver
C. Rupture of Stomach
The Laryngeal mask airway is an alternative airway device
D. Rupture of Spleen
used for anesthesia and airway support. it consists of an
E. Disseminated intravascular coagulation occurs
inflatable silicone mask and rubber connecting tube. it is
None
inserted blindly into the pharynx, forming a low-pressure
..........(PGI - 2001 - Dec)
seal around the laryngeal inlet and permitting gentle
positive pressure ventilation. all parts are latex-free.
244. In a 10 year old child presented anaphylactic shock,
drug of choice is:
The laryngeal mask airway is an appropriate airway choice
A. I/V adrenaline
when mask ventilation can be used but endotracheal
B. S.C. adrenaline
intubation is not necessary.
C. Anti histamine
contraindications:
D. Corticosteroids
Non-fasted patients
A
Morbidly obese patients
..........(PGI - JUNE 1997)
Obstructive or abnormal lesions of the oropharynx
Status epilepticus is said to occur when a seizure lasts beyond
Advantages:
30 minutes or seizures are repetitive, prolonged & the
- Allows rapid access
patient remains unconscious in between the seizures.
- Does not require laryngoscope
Best drug to use in status epilepticus is lorazepam
- Relaxants not needed
in a dose of 0.l mg/kg b.w by I.V. route. This may be
- Provides airway for spontaneous or controlled ventilation
repeated after 5 minutes. Lorazepam effect lasts longer
- Tolerated at lighter anesthetic planes
than diazepam. If lorazepam is not available, immediately
Disadvantges:
diazepam is given in a dose of 0.3 mg/kg by IV route.
Does not fully protect against aspiration in the non – fasted
Seizures may recur after 15-30 minutes since half life of
patient standard LMA does not allow high positive pressure
diazepam is short. Hence, diazepam should be followed
ventilation Requires re - sterilization
by phenytoin in a dose of 10-15 mg/kg IV. If the fits are
not controlled even with this, 20 mg/kg of phenobarbitone
241. Which one of the following device provides fixed
may be given I.V, at a rate of 1 mg/kg/ minute.
performance oxygen therapy:

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 50

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

A. Can be given intratracheally
B. I.V. route better than intracardiac
C. Intracardiac route better than IV
D. Converts coarse fibrillation into fine ones
E. The dose used is 2ml. containing 1 in 1000 concentration
NO ANSWER
..........(PGI - June -2001)
• During CPR, adrenaline is given every 3 –5 min – this
reflects its half-life. When switching from the non-shockable
to the shockable side of the algorithm, the next dose of
adrenaline will be given before the first or the second
shock depending on when adrenaline was last given
D. Rate of intravenous fluid replacement
E. Assess need for plasma transfusion
A
..........(PGI - 2001 - Dec)
CVP is a useful means of assessing the circulating blood volume
and therefore appropriate for rate of intravenous fluid
replacement.
• So, CVP has importance in — assessing need for blood
and plasma transfusion.
• CVP is not a good guide for daily fluid requirements e.g. A
pt. can easily be waterloaded or dehydrated in presence
of a normal CVP.

248. In 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
..........(.PGI - DEC 2003)

• In a hypovolemic patient, the adequacy of IVF replacement

can be assessed by :
- Clinical pulse, BP
- Urine output
246. The outcome following resuscitation of a cardiac - Invasive CVP and PCWP
arrest is worsened if during resuscitation patient is
given - • Normal PCWP = 8-12 mm Hg
A. Ringer’s lactate Pulmonary artery pressure = 25 mm Hg-Systolic ; 10 mm
B. Colloids Hg- Diastolic.
C. 5% Dextrose
D. Whole blood transfusion Interpretation of CVP and PCWP in various
C conditions :
..........(AIIMS PGMEE - NOV 2005)
CONDITION CVP PCWP
• While performing cardiopulmonary resuscitation for cardias Hypovolemic shock Low Low
arrest, therapy with hyperglycemic intravenous fluid Right heart failure High N
should be avoided.
• Therapy with intravenous glucose solutions results in Left heart failure N High
worse neurological outcome. Cardiogenic shock (Rt and Lt heart N/High High
• Increase in blood and thus brain glucose during global failure)
cerebral ischemia will profoundly affect outcome of the Cardiac tamponade High High
patient
• In high risk patients, intravenous glucose solutions should Pulmonary embolism N/High High
be avoided or used judiciously and blood glucose 249. ‘C wave in JVP tracing seen in:
concentr atio ns should be maintaine d within the A. Ventricular systole
normoglycemic range until the patients have passed the B. Ventricular diastole
period of high risk for hemodynamic compromise. C. Atrial systole
• Most critically ill patients do not need acute glucose D. Protodiastole
supplementations. A
• In patients who require glucose, however we recommend ..........(PGI - DEC 2006)
administering it in a manner (e.g. mini drip devices, infusion
pumps) that will avoid large infusions at the time of an • The different waves of JVP :
ischemic event. ‘a’ wave : Positive, produced by venous distention due to
• Specifically, glucose containing solutions should not be used right atrial contraction and is dominant wave in JVP.
in intravenous lines that will facilitate volume expansion
and drug administrations during t/t of shock or ‘c’ wave : Positive, produced by the bulging of the tricuspid
cardiac arrest. valve into the right atrium during Rt. ventricular
isovolumetric systole.
TOPIC 23: CVP
‘x’ descent : due to both atrial relaxation and to the
247. Importance of CVP measurements is: downward displacement of the tricuspid valve during
A. Need for blood transfusion ventricular systole.
B. Assess amnount of fluid to be given

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 51

fibreoptics for determination of mixed venous O2

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

251. While introducing the Swan-ganz catheter, 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 tracing has diacrotic notch from closure of
pulmonary valve
D. RV pressure tracing for plateau and sharp drop in early
diastole
B
..........(AIIMS PGMEE - NOV 2005)

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 ventricle through tricuspid valve (RV are displayed (15-25 systolic and
tricuspid valve is closed. pressure) 0-l0 diastolic)
‘y ; decent : Produced mainly by the opening of the tricuspid
Catheter advances Systolic pressure
valve and the subsequent rapid inflow of blood into the
into pulmonary artery remains same as in
right 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
..........(PGI - DEC 2006) artery (where it wedges) mean pressure of
Pulmonary capillary 4 -12mmHg
• Swan-Ganz pulmonary artery catheter is the mainstay for wedge pressure
assessment of cardiac function in the critical care and This reflects the left atrial
perioperative settings. It is used to measure : Pressure.
- direct pressure of Rt. atrium, Rt. ventricle and pulmonary
artery (PAWP). TOPIC 24: INTRAOPERATIVE MANAGEMENT
- indirect pressure in Ieft. atrium.
- cardiac output by indicator dilution 252. Which of the following agents is not used to
- Rt. ventricular ejection fraction, provide induced hypotension during surgery?
A Sodium nitroprusside
B. Hydralazine
C. Mephenterrnine
D. Esmolol
C
..........(AIPGMEE - 2006)

Mephentermine acts directly on both a and beta

receptors to cause cardiac stimulation and vasoconstriction.
It increases the cardiac output and both systolic and
diastolic BP.
It 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.

The clinical criteria is to reduce the blood pressure by one

• Recent refinements have included the addition of fast-
third of preoperative value.
response thermistors, high fidelity pressure transducers,

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 52

Techniques include the following : • 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 2 < alveolar CO 2 < arterial CO\
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
D. Procainamide Why is End tidal CO2 less than alveolar COr ?
A • Because the end tidal carbon di oxide is always diluted
..........(AIPGMEE - 2007) with alveolar dead space gas from unperfused alveoli.
These alveoli do not take part in gas exchange and so
Non selective long acting b blockers are avoided for contain no carbon di oxide.
controlling arrythmias (or heart rate) during surgery .
Why is alveolar CO2 less than arterial CO2?
254. Use of Intraarterial cannula in major surgery • Because the blood from the unvetilated alveoli and lung
A. Measurement of direct intra arterial BP parenchyma (both have higher CO2 contents) mixes with
B. Sample for ABG the blood from ventilated alveoli.
C. Drug injection
D. BT • In healthy adults with normal lungs end tidal CO2 is 3 to
A,B,C & D .6 kPa less than arterial CO 2.
..........(PGI - June -2001) • This difference is reduced if the lungs are ventilated with
large tidal volumes.
255. All the following drugs are recommended for
treatment of beta blocker induced excessive Uses of End tidal CO2 (Et CO,). Capnographv
bradycardia and/or decrease in cardiac output, • To detect correct placement in tracheal intubation.
except: Persistent detection of CO 2 by a caphograph is best
A. Dopamine confirmation of tracheal placement of endotracheal
B. Dobutamine tube. If the tracheal tube goes into the oesophagus no,
C. Glucagon or very little CO2 is detected.
D. Calcium chloride
B • To diagnose lung embolism as a sudden decrease in
..........(AIIMS PGMEE - MAY 2005) end tidal carbon di oxide, assuming that the arterial blood
pressure remain stable.
256. Which of the following is not a cardiovascular • To diagnose malignant hyperpyrexia as a gradual
monitoring technique - increase in end tidal carbon di oxide.
A. Transesophageal echocardiography • As a disconnection alarm for a ventilator or breathing
B. Central venous pressure monitoring system. There is sudden absence of end tidal CO2.
C. Pulmonary artery catheterization
D. Capnography Cardiovascular monitoring techniques.
D Non invasive mathods
..........(AIIMS PGMEE - NOV 2005) (1) ECG
(2) Blood pressure
Capnography is a respiratory monitor system (not a (3) Transesophageal echocardiography
cardiovascular)
Capnography - Invasive
• It is the determination of End tidal CO 2 (Et COj) (1) Invasive blood pressure
concentration to confirm adequate ventilation.
• It is useful during all anaesthetic procedures TOPIC 25: DESFLURANE

Principal of End tidal CO 2 determination (capnography) 257. Rapid induction of anaesthesia occurs with which
• Gases with molecules that contain at least two dissimilar of the following inhalational anesthetics?
atoms absorb radiation in the infrared region of the A. isoflurane
spectrum. B. halothane

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 53

C. desflurane Metabolism of Desflurane - Desflurane undergoes minimal

D. sevoflurane metabolism in humans therefore serum and urine
C inorganic fluoride levels following anaesthesia are essentially
..........(AIIMS PGMEE NOV - 2002) unchanged from preanaesthetic levels.

• Rapid induction of anaesthesia is seen with both Desflurane Cardiovascular effects of Desflurane
& Sevoflurane but Desflurane is the anwer as it causes The cardiovascular effects of desflurance appear to be
more rapid induction of anaesthesia then similar to that of isoflurane i.e., it also causes minimal cardiac
Sevoflurane. depression like isoflurane.
• The speed of induction by inhalational anaethestics The specific effects are: -
in descending order is: Blood pressure ----> decrease
(a) Nitrous oxide Heart rate ----> No change or increase
(b) Desflurane Systemic vascular resistance -----> Decrease
(c) Sevoflurane Cardiac output -----> No change or decrease
(d) Isoflurane
(e) Halothane 260. A 70-year-old male is posted for a surgery, which is
• Rate of indu ction of anaesthesia by inhalational likely to last for 4-6 hours. The best inhalational agent
anaesthetics is inversly proportional to its blood gas of choice for maintenance of anesthesia in such a
partition coefficient i.e. the agents with low blood gas case is
partition coefficient eg. Nitrous oxide will have faster rate A. Methoxyflurane
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 ..........(AIIMS PGMEE - MAY 2004)
B. Sevoflurane
C. Desflurane In a geriatric patient the normal physiological functions
D. Nitrous oxide are already compromised so pros and cons of an
C anaesthetic must be carefully weighed against before
..........(AIIMS PGMEE - MAY 2006) giving an anaesthetic.

Blood gas partition coe fficient in ascending order Methoxyflurane-

- It is highly nephrotoxic and this limits its use.
Agent Blood gas partition - In old patients the G.F.R. is already low so any nephrotoxic
coefficient agent shold be avoided.
• Desflurane .42
Ether-
• Nitrous oxide .47 - Ether was very popular in the past but it is not used now
• Sevoflurane .68 because of its inflammable and unpleasant properties.
• Isoflurane 1.4
Trichlorethylene
• Enflurane 1.9 - It forms explosive mixtures and should not be used in
• Halothane 2.3 closed circuit
Desflurane-
259. Which one of the following statements regarding - Desflurane is a recently developed, fluorinated congener
desflurane is correct? of isoflurane which is quiet safe like isoflurane.
A. It causes severe myocardial depression - It can serve as a good alternative to isoflurane for
B. It is a structural analogue of isoflurane routine surgery as well as prolonged operations
C. It has very high blood and tissue-gas partition coefficients (Here operation is long and lasts for 4-6 hrs).
D. It is metabolically unstable
B Properties of Desflurane-
..........(AIIMS PGMEE - NOV 2004) - No renal and hepatic toxicity has no arrythmogenic action
- Coronory circulation is mantained
Desflurane’s structure is very similar to that of - Very low solubility in blood and tissues because of which
isoflurane induction and recovery are very fast.
It is a recently developed all fluorinated congener of - Agent of choice for induction of anaesthesia in Geriatric
isoflurane (The only difference is substitution of a fluorine patients —> Etomidate, thiopentone
atom for isoflurane’s chlorine atom). - Inhalational agent of choice for ma intenance of
Its special properties are It is highly volatile anaesthesia in Geriatric patient - Isoflurane.

Extremely low oil gas partition coefficient Very low solubility
in blood and tissues i.e., very low blood and tissue-gas
partition coefficients Because of these unique properties
it’s induction and recovery are very fast.
Due to this short action it is commonly used as
anaesthesia for out patient departments.
TOPIC 26: MUSCULAR DYSTROPHY/MYASTHENIA
261. A 5 year old boy suffering from Duchenne Muscular
Dystrophy and Polymyositis has been fasting for 8
hour and has to undergo tendon lengthening
procedure, which Anaesthetics should be used

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 54

A. Induction by I.V. scol ine and N2O halothane for 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
..........(.AIIMS PGMEE JUNE - 2000). AIPGMEE - 2003
..........(AIIMS PGMEE MAY - 2003)
• In this boy with duchene muscular dystrophy, there is
high risk of malignant hyperthermia It has been repeated several times before that succinylcholine
• The earliest signs are masseter muscle rigidity causes hyperkalemia in par aplegic patients. This
(MMR), Tachycardia, and hypercarbia due to increased hyperkalemia is responsible for cardiac complications such
CO2 production as dysarrythmias, conduction abnormalities and cardiac
arrest.
Malignant Hyperthermia (MHS) is a pharmacogenetic
predisposition leading to adverse reactions to commonly
“Suxamethonium may be dangerous in the period b/w
used anaest hetic drugs (e.g. halo thane,
succinycholine). Patients respond to these drugs by about 3 days and 6 months or perhaps longer after onset
excessive release of intracellular calcium which triggers a of paraplegia. It releases more potassium than usual from
potentially lethal muscle hypermetabolism Central Core muscles and the extreme hyperkalemia can cause
Disease (CCD) is a chronic muscle weakness and arrythmias or cardiac arrest.”
degeneration due to leakage of intracellular calcium
stores. Both conditions share a common genetic cause: 264. In myasthcnia gravis, which druges should not be
Mutations in the muscle calcium release channel RYR1. used:
A. Gallamine
B. Noestigmine
C. Aminoglycosides
D. Metronidazole
E. Ampicillin
A&C
..........(PGI - June -2002)

• The muscles affected by MG are hypersensitive to non-

depolarizing muscle relaxants.
Even myasthenics successfully treated with 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, N2O and O2 for maintenance
• This boy has chances of developing malignant hyperthermia • Myasthenics are resistant to the effects of depolarizing
because muscular diseases (duchene muscular dystrophy muscle relaxants like Suxamethonium and Decamethonium.
and polymyositis) predispose to malignant hyperthermia.
• Drugs like Aminoglycoside antibiotics (neomycin,
Predisposing conditions streptomycin, gentamicin), tetr acycline, quinidine,
• Arthrogryposis multiplex congenita* procainamide, penicillamine and beta-blockers can worsen
• Osteogenesis imperfecta*
MG and so avoided.
• Congenital ptosis
Ampicillin & Metronidazole are not contraindicated in
• Strabismus
• Hernia, kyphoscoliosis MG.
• Cleft palate
• Duchenne muscular dystrophy* TOPIC 27: PREANESTHETIC MEDICATION

Drugs which precipitate malignant hyperthermia 265. Most potent antiemetic agent used in preoperative
• Anaesthetic ——> Succinylcholine*, (MC) Halothane* period:
• Monoamine oxidase inhibitor A. Glycopyrrolate
• Phenothiazines
B. Hyoscine
• Amide local anaesthetics
C. Atropine
• TCA’s
D. Metochlorpromide
262. The administration of succinylocholine to a B
paraplegic patient led to the ap pearance of ..........(AIIMS PGMEE - SEP 1996)

HELP LINE NO. 9391567707

MINOR TOPICS ANAESTHESIA 55

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

(prevents dizziness), and antispasmodic (reduces smooth
muscle contr actions; although a der iv ate called
butylscopolamine, that does not cross the blood-brain
barrier, is used preferably).
• It can be used as a pre-anesthetic sedation, as an
antiarrhythmic during anesthesia, and for the prevention
of motion sickness.
• Transdermal patches, , are avail able for the
prevention of symptoms of travel sickness.

• Scopolamine, also known as hyoscine

• It acts as a competitive antagonist at muscarinic
acetylcholine receptor (M1); it is thus classified as an
anticholinergic or as an anti-muscarinic drug. 266. Atropine as preanesthesia has all effects except
Scopolamine hydrobromide. A. decrease secretion
– It can be used as a depressant of the central nervous B. Bronchoconstriction.
system, though it can cause excitement, restlessness, C. prevent bradycardia
hallucinations, or delirium in the presence of pain, mydriasis D. prevebt hypotension
(pupillary dilation), and cycloplegia (paralysis of the eye B
muscles). ..........(AIPGMEE - 1996)
– When combined with morphine, it produces amnesia
and a tranquilized state known as twilight sleep. Atropine is a bronchodialator and reduces air way resistance
Although originally used in obstetrics, it is now considered specially COPD and Asthma patients.
dangerous for that purpose. Sometimes side effects of
scopolamine can be mistaken for symptoms of cancer 267. Drugs commonly used in pre- anaesthetic
because of the nausea and anisocoria associated with brain medication:
tumors. However, scopolamine induced anisocoria clears A. Diazepam
up usually within 3 days. B. Scopolamine
C. Morphine
• It is used in ophthalmology to deliberately cause cycloplegia D. Succinylcholine
and mydriasis so that certain diagnostic procedures may E. Atracuronium
be performed. It is also used in the treatment of A, B, & C
iridocyclitis. ..........(PGI - DEC 2004)

• Scopolamine is the other name of Hyoscine hydrobromide

which is anticholinergic drug 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 C. Prevent aspiration
airway D. Produce amnesia for peri-operative events
E. Relieve anxiety
A, D & E
..........(PGI - June -2002)

• 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.
- Supplement analgesic action of anaesthetics and
potentiate them so that less anaesthetic is needed.
- DECREASE -Secretions and vagal stimulation caused by
anaesthetics.

HELP LINE NO. 9391567707

 MINOR TOPICS 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
Sedative-Hypnotics-Barbiturates Anticholinergics-
Atropine or hyoscine Neuroleptics-chlorpromazine
H2 blockers-Ranitidine/Famotidine
Antiemetics-Metoclorpr amide, Domperidone, or
Ondansetron.
Left parasternal long axis view with air shadow in the aorta
TOPIC 28: AIR EMBOLISM

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
..........(AIIMS PGMEE - NOV – 1993)

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: ‘
Treatment
A. Venous air embolism
• irrigate operative site with fluid
B. Left lung collapse
• apply occlusive material to bone edges
C. Endotracheal tube in Oesophagus
• gently compress internal jugular veins
D. Endotracheal tube blocked with secretions
• head down position
A
• aspirate air through right atrial catheter (best if tip is at
..........(AIIMS PGMEE JUNE - 2000)
SVC-RA junction)
• discontinue N2O
Venous air embolism
• inotropes may be needed
• BEWARE: PEEP, by reversing RA-LA pressure
• The cranial sinuses have negative air pressure .
gradient, may lead to paradoxical air emboli via PFO
– So, it is possible that if the pt. is in wrong position while
operation, the sinuses may suck some air d/t their negative
271. About diagnosing air emb olism with
pressure which can cause venous embolism
transesophageal echocardiography, which of the
• The given value for the gases can occur only in Venous air
following is false:
embolism.
A. It can quantify the volume of air embolised
B. It is a very sensitive investigation
Venous Air Embolism (VAE)
C. Continuous monitoring is needed to detect venous
• consider whenever head > 5 cm above heart
embolism
• transected veins in cut edge of bone or dura may not
D. Interferes with doppler when used together
collapse
A
• air -> RV -> pulmonary circulation
..........(AIIMS PGMEE MAY - 2002)
• decreased pulmonary blood flow, pulmonary edema,
bronchoconstriction, cardiovascular collapse, hypoxemia
A “four-chamber” view. The right atrium is in the upper left
• paradoxical (air) embolism
corner of the picture.
• coronary or cerebral circulations
The central venous catheter can be seen as a small dot in
• via patent foramen ovale (PFO) (20-30% of adults have
the center of the atrium
probe-patent foramen ovale) detection

• precordial Doppler ultrasound near right upper

sternal border is most sensitive non-invasive
monitor (detects 0.25 ml)
• trans-esophageal echocardiography is more
sensitive, but more invasive and cumbersome
• sudden decrease in ETCO2, incease in ETN2

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

murmur
• Apical four chamber view with air shadows in both right
and left ventricle

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 57

four-chamber view recorded during dissection of a vascular Oxygen

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

If 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 cerebr a l excitabili ty and an in creased
electroshock seizure threshold.
• Higher levels of CO2 (30% above normal) result in
TOPIC 29: HYPOTHERMIA increased cerebral excitability and epileptiform
discharges.
272. Hypothermia is used in all except: • High levels (50% above normal) produce 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. consis ting of an initial activation (a t
..........(PGI - 1998 - Dec) subanaesthetic doses) follows by dose dependent
depression.
• There is substantial protection against ischemia and hypoxia
is provided by. just 1—3° C hypothermia Inhalational anaesthetics
Hypothermia reduces the tissue metabolic rate about • Halothane produces a typical biphasic pattern.
8%/°C. • Isoflurane is the only volatile anaesthetic that produces
• It decreases the cerebr al metabolic r ate and is isoelectric E.E.G.
cerebroprotective during episode of cerebral ischemia. • Desflurane and sevoflurane produces a burst suppression
pattern at high does but not electrical silence.
The protection afforded by mild hypothermia is so great that Nitrous oxide increases both frequency and amplitude.
reduced core temperature — 34° C is probably indicated
in : Intravenous agent
- Carotid artery surgery • Benzodizeapenes produce a typical biphasic pattern
- tieurosurgery on E.E.G.
- Procedures where tissue ischemia can be anticipated • Barbiturates, etomidate and propofol produces a
- Traumatic brain injury ARDS typical bipha sic pattern and are the only
intravenous agents capable of producing burst
273. Hypothermia is used in: suppression and electrical silence at high dose.
A. Hyperpyrexia • Opioids produce monophasic dose dependent
B. Prolonged surgeries depression of the E.E.G.
C. Massive blood transfusion Ketamine produces an unusual activation consisting of
D. Hypertension rhythmic high amplitude theta activity followed by very
A&B high amplitude gamma and low amplitude beta activities.
..........(PGI - June -2000)
Electroencephalographic changes during anaesthesia
274. Which of the following in anaesthesia will produce Activation Depression
decreased EEG activities • Inhalational agents (1-2 MAC)
• Inhalational agent
A. Hypothermia • Barbiturates
(subanaesthetic) •
B. Early hypoxia • Opioids
Barbiturates (small doses)•
C. Ketamine Benzodiazepenes (small • Propofol
D. N2O doses) • Etomidate
A • Hypocapnia
• Etomidate (small doses)•
..........(AIIMS PGMEE - NOV 2006) • Marked hypercapnia
Nitrous oxide
• Hypothermia
Effect of various conditions on E.E.G. Body temperature • Ketamine
• Hypothermia causes progressive slowing of the brain • Mild hypercapnia
activity. • Sensory stimulation
At core temperature below 35°C complete electrical • Hypoxia (early) • Hypoxia (late) ischemia
silence occurs with profound hypothermia.

HELP LINE NO. 9391567707

 MINOR TOPICS
TOPIC 30: NITRIC OXIDE
275. Which of the following inhaled gases is used to
decrease pulmonary artery pressure in adults &
infants
A. nitrous oxide
B. nitrogen dioxide
C. nitric oxide
D. nitrogen
C ..........(AIPGMEE - 2006)
..........(AIIMS PGMEE NOV - 2002)
Nitric oxide causes decrease in pulmonary artery
pressure in both adults and infants.
It is the most effective agent used to decrease in
pulmonary artery hypertension. It is an endothelium
derived vasodilator
276. At the end of anaesthesia after discontinuation of
nitrous oxide and removal of endotracheal tube,
100% oxygen is administered to the patient to
prevent:
A. Diffusion Hypoxia
B. Second gas effect
C. Hyperoxia
D. Bronchospasm
A Tramadol is the drug of choice
..........(AIIMS PGMEE NOV - 2003)
N2O has low blood solubility. So when N2O is discontinued
after prolonged anaesthesia, due to its low blood solubility
it rapidly diffuses into the alveoli and dilutes the alveolar
air.
This causes excess of N2O in alveoli so the partial pressure
of oxygen in the alveoli is reduced.
• This results in hypoxia and it is known as diffusion
hypoxia
If the cardiac reserve is normal diffusion hypoxia is not of
much significance but if cardiac reserve is low, diffusion
hypoxia can be very dangerous.
• Prevention: -
It can be prevented by continuing 100% O2 inhalation for a
few minutes after discontinuing N2O
Diffusion hypoxia is not significant with other anaesthetics
because the y are administered a t very low
concentrations (2 - 4%) and so they cannot dilute
alveolar air by more than 1-2%
277. Which of the following statements is true regarding
Nitric oxide:
A. Used in pulmonary hypertension
B. Decreases the dose of anaesthetics
C. Sympathomimetic action
D. Causes systemic hypotension
E. Used as a vasoconstrictor
Ans a,c
..........(PGI - 2001 - Dec)
• It is reasonable to expect that inhalation of(NO) could be
beneficial as a long-term therapy for pulmonary arterial
hypertension (PAH)
HELP LINE NO. 9391567707
ANAESTHESIA 58
TOPIC 31: POSTOPERATIVE COMPLICATIONS
278. Which of the following agents is used for the
treatment of postoperative shivering?
A Thiopentone
B. Suxamethonium
C. Atropine
D. Pethidine
D
Treatment of postoperative shivering involves the use
of Tramadol, pethidine or pentazocine and oxygen
inhalation.
• Shivering occurs as a protective mechanism as inhalational
agents, spinal/epidural blocks cause vasodilatation leading
to heat loss.
• Shivering can be abolished by inhibition of hypothalamus.
• Most commonly shivering is seen after halothane.
Treatment of shivering
Oxygen inhalation: O2 consumption may increase upto 4
times (400%) during shivering and hence oxygen inhalat
ion during shivering is mandatory. . . :
Drugs:
. Pethidine/pentazocine may be used.
279. A 25 year old male with roadside accident
underwent debridement and reduction of fractured
both bones right forearm under axillary block. On
the second postoperative day the patient complained
of persistent numbness and paresthesia in the right
forearm and hand) The commonest cause of this
neurological dysfunction could be all of the following
except:
A. Crush injury to the hand and lacerated nerves
B. A tight cast or dressing
C. Systemic toxicity of local anaesthetics
D. Tounriqet pressure
C
..........(AIPGMEE - 2004)
Systemic toxicitv of LA include
• CNS toxicity
• Cardiovascular system
• Methemoglobinemia
• Allergies
But the involvement of the peripheral nerve is characterized
by parathesies, numbness, hypaesthesia, pain are
indication of local peripheral nerve injury.
280. When a patient develops supra ventricular
tachycardia with hypotension un der general
anaesthesia, all of the following treatments may be
instituted except:
A. Carotid sinus massage
B. Adenosine 3-12 mg IV
C. Direct current cardioversion
D. Verapamil 5 mg IV
D
..........(AIPGMEE - 2004)
Verapamil should not be used in presence of SVT with
adverse factors such as hypotension. It can cause
 MINOR TOPICS ANAESTHESIA 59

prolonged hypotension and depression of ventricular • TC causes hypotension by :

function, especially in the presence of anaesthetic agents - Ganglion blockade.
that cause myocardial depression. - Histamine release.
- decreased venous return.
Supraventicular tachycardia (SVT) can occur at any time during • It cause vagal ganglionic blockade - so t ed HR.
the 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 TOPIC 33: VECURONIUM
cases and thus these should be tried initially.
If attempts to increase vagal tone and terminate the SVT 284. Which of the following statement is not correct
by carotid sinus message are unsuccessful, the treatment for Vecuronium ?
of choice is adenosine by fast IV injection. This is safe and A. It has high incidence of cardiovascular side effects.
effective during haemodynamic intability because B. It has short duration of neuro muscular block
adenosine has duration of action of less than 60 seconds. C. In usual doses the dose adjustment is not required in kidney
It blocks AV conduction without compromising ventricular disease
function. Adenosine should not be given to patients wi D. It has high lipophilic property
th asthma or AV conduction block. A
..........(AIIMS PGMEE NOV - 2002)
• If adenosine is unavailable and the patient is
normotensive, IV verapamil can be given. However, Properties of Vecuronium.
verapamil can cause prolonged hypotension and depression (1) It is non depolarising muscle relaxant
of ventricular function, especially in the presence of (2) It is highly lipophilic
anaesthetic agents that cause myocardial depression. (3) It has dual excretory pathway i. e.,Itis 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
TOPIC 32: TUBOCURARINE duration. Still Vecuronium is not contraindicted in
renal failure.
281. d-TC (d-Tubocurarine) is a The advantage of Vecuronium is that its side effects are
A. Ganglion blocker very few.
B. Depolarizing blocker It does not have any cardiovascular side effects.
C. Competitive neuromuscular block
D. a + c both 285. Skeletal muscle relaxant having no CVS side effects:
D A. Vecuronium
..........(AIIMS PGMEE - MAY - 1993) B. Doxacurium
C. Pancuronium
282. Which one of the following antibacterials should D. Rocuronium
not be used with d-tubocurarine? E. Mivacurium
A. Norfloxacin A, B & D
B. Streptomycin ..........(PGI - DEC 2006)
C. Doxycycline
D. Cefotaxime 286. Bradycardia during anaesthesia seen in
B A. Pancuronium
..........(AIPGMEE - 2006) B. Vecuronium
C. Atracurium
Use of Strep tomycin along with com petitive non D. Propofol
depolarizing blockers like d-tubocurarine can potentiate E. Succinylcholine
its action and produce prolonged apnea . B, C , D & E
..........(PGI - JUNE 2004)
Streptomycin should therefore not be used with d-
tubocurarine. • Pancuronium causes a moderate increase in heart rate.
• Vecuronium is about 20 times weaker as a vagolytic
Streptomycin and Neomyein have higher propensity substance than pancuronium.
than other aminoglyco sides. Tobramycin is least • Bradycardia seen after adminstration of vecuronium &
likely to produce these effects . atracurium.
• Propofol produces bradycardia due to central vagal
283. True about d TC is: activity.
A. Excreted unchanged by kidney Succinylcholine produces bradycardia & cardiac arrest on
B. Causes hypotension by ganglion blocking action the second on even after the first injection.
C. Vagolytic action
D. Effect lasts for 2-3 hours TOPIC 34: ABG
B
..........(PGI - June -1998) 287. Heparin interferes with which of the following
results of ABG:
Tubocurarine is partly metabolized in body. The unchanged A. PO2
drug is excreted in urine as well as in bile. B. PCo2.

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 60

C. PH. • Stage of Anaesthesia are as follows *

D. HCO3. • Stage I —> Analgesia
E. An ion gap • Stage II —> Delirium or excitement, partially dilated pupil
C • Stage III —> Stage of Surgical Anaesthesia
..........(.PGI - DEC 2003) It 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,
D. Skin pigmentation Pupils widely dilated*
B, C & D • Stage IV —> Stage of Medullary Paralysis
..........(PGI - JUNE 2005)
TOPIC 36: ATROPINE
* Pulse oxymeter is accurate in detecting oxygen saturation,
but there are many sources of error: 291. In belladona poisoning, antidote is:
- Different Hemoglobins: A. Physostigmine
B. Neostigmine
Methemoglobin : It absorbs light at equal wave lengths used C. Ami histamine
by pulse oxymeters, so there might be erroneously high D. Atropine
values of saturation. A
Carboxyhemoglobin:
..........(PGI - JUNE 1997)
Pulse oxymeters overread by the presence of HbCO.
Fetal hemoglobin: Only very high level can cause some
• Belladona poisoning may occur due to drug overdose or
inaccuracy.
Hemoglobin S: Controversial. consumption of seeds & berries of belladona/datura plant.
- Bilirubin : Children are highly susceptible. Manifestations are due to
Severe hyperbilirubinemia does not affect pulse oxymetry exaggerated pharmacological actions.
readings.
- Malposition of sensor Physostigmine 1-3 mg. S.C or i.v. antagonizes both central
- Poor peripheral pulsation & peripheral effects. It may be repeated 4-6 hourly.
- Skin pigmentation : Pulse oxymeter readings are Neostigmine is less satisfactory.
erroneously high in patients with dark skin color.
- Dyes: Like methylene blue, indocyanine green can cause 292. Atropine is used in following except:
large transient decrease in saturation without actual A. Glaucoma
decrease in the same. B. Mushroom poisoning
- Optical interferance : Sunlight, operating room light, C. Malathion poisoning
infrared heating lamps results in erratic readings. D. Organophosphorous poisoning
- Electrical interferance : A
Electrical interferance from an electrosurgical unit can ..........(PGI - JUNE 1997)
cause the oxymeter to give an incorrect pulse count.
- Nail polish & coverings :
• Topical instillation of atrepine cause mydriasis, abolition of
Black, blue & green (but not red or purple) nail polish may
light reflex & cycloplegia lasting 7-10 days. This results in
cause significantly lower saturation readings.
photophobia & blurring of near vision. The ciliary muscles
TOPIC 35: ANAESTHESIA STAGES recover somewhat earlier than sphincter pupillae. The
intraocular tension tends to rise, especially in narrow angle
289. Visual analogue scale (VAS) most widely used to glaucoma; conventional systemic doses produce minor
measure ocular effects.
A. Sleep
B. Sedation Atropine is also used to awtegonise muscarinic effects of drugs
C. Pain intensity & poisons. It is the specific antidote for anti ChE &
D. Depth of Anaesthesia early mushroom poisoning. It is also given to block
C muscarinic action of neostigmine used for rnyasthenia
..........(AIIMS PGMEE MAY - 2003) gravis, decurarization or cobra envenomation.

290. Stages of Anaesthesia were established by: TOPIC 37: CALCIUM CHANNEL BLOCKERS
A. Ether
B. Nitrous Oxide 293. Drugs which interfere with anesthesia are:
C. Cyclopropane
A. Calcium channel blocker nifedipine
D. Chloroform
B. Beta blockers
A
..........(AIIMS PGMEE - JUNE - 1997) C. Aminoglycosides
D. Steroid administration
Ether E. D-tubocurarine
• Guedel’s staging of Anaesthesia was given for Ether A, B, & C
..........(PGI - 2001 - Dec)

HELP LINE NO. 9391567707

 MINOR TOPICS
294. Ca2 + channel blockers In anesthesia. True is:
A. Needs to be decreased as they augment hypotension &
muscle relaxation
B. withheld because they lower LES pressure
C. Should be given in normal doses as they prevent MI &
angina
D. All of the above
C halothane but it is better skeletal muscle relaxant
..........(PGI - June -2000)
• Calcium channel blockers (CCB) at therapentic doses have
no significant role in the release of normal Ach or on the
strength of normal neuromuscular (NM) transmission/There
have been a few reports, however, that CCB may block
of NM transmission induced by non-depolarising relaxants.
• CCBs relaxes the smooth muscles of esophagus thus
causing lowering of LES, but there is no such indication
of stoppage of this drug during anaesthesia for the same
complications.
• The use of CCBs have several important implication for
anaesthetic management.
They are :
(i) Along with inhalational and narcotic anesthetics, nifedipine
causes decreased systemic vascular resistance, BP, and
contractility may be additive and alongwith verapamil, they
decrease the AV conduction times and additively decrease
BP, systemic vascular resistance and contractility.
(ii) Verapamil and presumably the other CCBs have been found
to decrease anesthetic requirement by 25%.
(iii) Because slow channel activation of Ca2+ is necessary to
cause spasm of of cerebral and coronary vessels, broncho-
constriction and normal platelet aggregation, these drugs
may have a role in treating ischemia of the CNS and
CVS, bronchoconstriction and untoward clotting
disorders perioperatively.
TOPIC 38: ENFLURANE
295. Which of the following is contraindicated in epilepsy
A. Isoflurane
B. Halothane
C. Enflurane
D. Ether
C synthesis.
..........(AIIMS PGMEE - MAY - 1994)
• Enflurane precipitates generalized tonic clottic
seizures therefore it is contraindicated in epileptics.
• Other questions on Enflurane
It slighty stimulates salivary and respiratoxy secretions
It causes fall in B.P. due to decrease in peripheral resistance.
It does not sensitize the heart to adrenaline (Arrythmias are
rare).
It causes bronchodilation
It is contraindicated in renal failure.
296. Which of the following inhalational agent is
contraindicated in a patient with history of epilepsy;
A. Isoflurance
B. Enflurane
C. Halothane
D. Sevoflurane
B •
..........(AIIMS PGMEE NOV - 2003)
HELP LINE NO. 9391567707
ANAESTHESIA 61
Brief clonic seizures occur with the use of enflurane. Therefore
enflurane is contraindicated.
Enflurane
- Though it can give rise to fluoride as a metabolite, the
quantity is insufficient to cause renal toxicity.
- Bronchodilation and uterine relaxation is similar to
- It stimulates salivary and respiratory secretions slightly, but
they generally do not pose any problem.
- It does not sensitize the heart to adrenaline (Arrythmias
are rare)
- Fall in B.P. is similar to that caused by halothane as it also
decreases peripheral resistance to some extent.
TOPIC 39: ETOMIDATE
297. Which of the following statements is not true about
etomidate?
A. It is an intravenous anesthetic
B. It precipitates coronary insufficiency
C. It inhibits cortisol synthesis
D. It causes pain at site of injection
B
..........(AIPGMEE - 2006)
Etomidate does not precipitate coronary insufficiency.
Cardiovascular & respiratory depression do not occur with
etomidate.
Etomidate:
P otent ultrashort acting non barbiturate®
intravenous anaesthetic.
298. Induction agent that may cause adrenal cortex
suppression is:
A. Ketamine
B. Etomidate
C. Propofol
D. Thiopentione
B
..........(AIPGMEE - 2003)
• Induction doses of etomidate transiently inhibit
enzymes involved in cortisol and aldosterone
Long term i nfusions lead to adr enocortical
suppression.
• It is suitable for day care anaesthesia but less preferred
than propofol
Its use is contraindicated in porphyria6, adrenal insufficiency.
TOPIC 40: GALLAMINE
299. Muscle relaxant contraindicated in Renal failure is:
A. Atracurium
B. D-tubocurare
C. Vecuronium
D. Gallamine
D
..........(AIIMS PGMEE - Dec - 1995), (AIPGMEE - 1999)
• Gallamine is a muscle relaxant C/I in Renal failure as it is
almost exclusively excreted by kidney.
Gallamine (as gallamine triethiodide) is a non-depolarising
muscle relaxant. It acts by combining with the cholinergic
 MINOR TOPICS ANAESTHESIA 62

receptor sites in muscle and competitively blocking the
transmitter action of acetylcholine. Gallamine has a
parasympatholytic effect on the cardiac vagus nerve which
causes tachycardia and occasionally hypertension. Very high
doses cause histamine release.
• Gallamine is commonly used to stabilize muscle
contractions during surgical procedures .
Gallamine
- Gallamine is excreted entirely unchanged in the Kidney,
so it is contraindicated in patients with Renal failure –
Preferred relaxants:
• In hepatic failure: Atracurium
• In Myaesthenia Gravis : one tenth of normal of Atracurium
(ifrelaxants are essential).
• In Obstretrics : any relaxant except Gallamine
• In Arterial surgery (to maintain BP): Pancuronium
To deliberately reduce blood pressure : Tubocurarine
TOPIC 41: LAPROSCOPY
301. Which gas is most commonly used in laparoscopy:
A. O2
B. CO,
C. N2O
D. N,
B without adrenaline (epinephrine)- 200 mg i.e. 3 mg/
..........(AIIMS PGMEE - MAY 1995)
B. Dose needs to be altered in renal failure
C. It is very little affected by pH and heat
D. Loading dose before continuous infusion
B
..........(AIIMS PGMEE - MAY - 1994)
Effect of lidocaine on refractory period
i) In normal cells - It decreases refractory period
ii) In depolarized cells - It increases the refractory period
iii) AV Nodal refractory period –
It has no effect on AV nodal refractory period
• The important point about lidocaine is that it has no
electrophysiologycal effects on normal cardiac tissue while
it has marked electrophysiologial effect on depolarized
tissue.
304. Lignocaine in high doses produces
A. Convulsion
B. Respiratory depression
C. Hypotension
D. Cardiac arrest
E. Hypothermia
A,B,C & D
..........(PGI - JUNE 2004)
• The maximum safe dose of Lignocaine for a 70 kg man
with adrenaline (epinephrine)- 500mg i.e. 7 mg/kg;
kg body weight.

CO2 Higher doses produces toxicities like :

• The gas used is CO2 , as it is common to the human
body and can be removed by the respiratory system if it
absorbs through tissue.
• It is also non-flammable, which is important due to the
fact that electrosurgical devices are commonly used
in laparoscopic procedures.
CNS : Stimulation followed by depression, restlessness,
hysterical behaviour, vertigo, tremor, convulsions, and
respiratory failure.
CVS : Hypotension, primary cardiac failure, feeble pulse,
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

TOPIC 43: MALIGNANT HYPERTHERMIA

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
..........(PGI - 2001 - Dec) NONE
..........(PGI - DEC 2002)
TOPIC 42: LIDOCAINE
306. Malignant hyperthermia is caused by:
303. All are true about Lidocaine, except A. Halothane
A. Prolongs refractory period B. Cyclopropane

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 63

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

D. Ether use has been discontinued.
A&C • Eflur ane is also nephrotoxic, though lesser than
..........(AIIMS PGMEE - DEC 1997) Methoxyflurane and is also not recommended.
• Isoflurane, sevoflurane and halothane result in little or no
Halothane & Suxamethonium increase in fluoride levels and are preferred.
• C/f of Malignant Hyperthermia :
• Heat production exceeds the heat loss in the body to TOPIC 45: MIVACURIUM
cause a rise of temperature of at least 2 c/h.
• It is characterized by 309. Mivacurium false is
• Hypercapnia A. Hypertension
• Hyperventilation B. Increasing the dose produces rapid onset of action
• Hyperkalemia* C. Bronchospasm
• Metabolic Acidolis* D. Flushing RADIOLOGY
• Arrhythmia A
• Diffuse intravascular coagulation ..........(AIIMS PGMEE - NOV 2007)
• Pyrexia
• • Mivacurium belongs to non depolarizing blocker or
• There is – increased hemolysis* competitive skeletal muscle relaxants.
- increased Creatine phosphtinase* • This class of drugs acts by competitively inhibiting the
- increased Transaminase NM receptors and thus causing relaxation.
• Management : • The action of these dr ugs can be reversed by
• Early withdrawal of the volatile anaesthetic agent is of anticholinesterase like neostigmine.
utmost importance • Mivacurium is the only nondepolarising neuromuscular
• Cool the patient blocker that is metabolised by plasma cholinesterase.
• Acidosis corrected • Mivacurium is the shortest acting non depolarizing
• Administer Dantrolene muscle relaxant.
• Correction of Hyperkalemia • The usual intubuting dose is 1.5—2 mg/kg.
• Promote diuresis • Mivacurium causes histamine, release but it generally
• Give Dexamethasone does not cause serious side effects except for small degree
of hypotension. But when mivacurium is given in
TOPIC 44: METHOXYFLURANE large doses to increase the onset of action it causes
increased release of histamine which leads to
307. Nephrotoxic anaesthetic agent is: hypotension, flushing and bronchospasm.
A. Halothane • Mivacurium causes histamine release due to direct action
B. Isoflurane on mast cells.
C. Methoxyflurane • On increasing the dose, the onset of action is increased.
D. Nitrous Oxide
C 310. Shortest acting non depolarising muscle relaxant:
..........(AIIMS PGMEE - JUNE - 1997), AIPGMEE - 1998 A. Vecuronium
B. Atracurium
Methoxyflurane C. Succinylcholine
• Methoxyflurane has the highest fluoride content so it D. Mivacurium
is highly Nephrotoxic D
• There is high output renal failure and high chances ..........(AIIMS PGMEE - JUNE 1998)
of Oxalate stone.
• Its minimum alveolar concentration (MAC) is 0.2,
Shortest acting non depolarising muscle relaxant is ---->
hence it is extremely potent.
Mivacurium
• It has a high lipid solubility (oil:gas coefficient around Longest acting non depolarising muscle relaxant is ---->
950) giving it a very slow onset/offset, thus undesirable Pipecuronium*
for anesthetic purposes. Most potent N.D muscle relaxant ----> Doxacurium*
• Methoxyflurane has a high nephrotoxic potential and its Least potent N.D muscle relaxant ----> Gallamine*
use has been discontinued. Shortest acting depolarising M.R. ----> Succinylcholine*
• Eflur ane i s also nephrotoxic, thoug h lesser than Overall shortest acting M.R. ----> Succinylcholine*
Methoxyflurane and is also not recommended. • Most potent N.D muscle relaxant
Isoflurane, sevoflurane and halothane result in little or no – Doxacurium
increase in fluoride levels and are preferred.
• Least potent N.D muscle relaxant
– Gallamine
308. Nephrotoxicity is caused by:
A. Seroflurane
B. Methoxyflurane TOPIC 46: OXYGEN CONCNTRATOR
C. Isoflurane
D. Halothane 311. True about oxygen concentrator:
B A. Zeolite activation
..........(AIPGMEE - 1998) B. Delivers O2
C. Requires power supply

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 64

D. Gives O2 at 100 % Hematological advantages of Membrane oxygenators vs Bubble

A, B & C oxygenators.
..........(PGI - JUNE 2005) i) Less trauma to red blood cells
ii) Less trauma to platelets
• Oxygen concentrators are devices that extracts O2 from iii) Less trauma 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 Due to these advantages membrane oxygenators have
certain pressure which selectively retains the N2 & other largely replaced bubble oxygenators .
constituents of air & thus O2 of about 95% can be The oxygenators which were used in past Vertical screens
achieved. Disc oxygenators

312. Which of the following produces the least damage TOPIC 47: PERIBULBAR BLOCK
to blood elements -
A. Disc oxygenator 313. Complication of peribulbar block:
B. Membrane oxygenator A. Retrobulbular haemorrhage
C. Bubble oxygenator B. Globe rupture
D. Screen oxygenator C. Optic neuritis
B D. Local anaesthetic solution can migrate to brain
..........(AIIMS PGMEE - NOV 2004) E. Vasovagal syncope
ALL
Oxygenators are devices used in cardiopulmonary bypass ..........(PGI - DEC 2004)
surgeries.
Currently only two types of oxygenators i.e. membrane and 314. In general, the last muscle to be rendered akinetic
bubble oxygenators are in use. with a retrobulbar anesthetic block is:
Membrane oxygenators (Pump oxygenerators) are more A. Superior rectus
commonly used because they have improved the efficiency B. Superior oblique
of gas exchange while minimizing the trauma to the C. Inferior oblique
blood elements. D. Levator palpebral superioris
B
..........(AIIMS PGMEE - MAY 2006)

Retrobulbar anaesthesia -
• Retrobulbar block is regional anaesthesia for eye surgery.
• In this technique local anaesthetic is injected behind
the eye into the cone formed by extraocular
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.
• To enhance the retrobulbar spread of local anaesthetic
Membrane oxygenators imitate the natural lung by
Hyaluronidase, a hydrolyzer of connective tissue
interspersing a thin membrane between gas and blood
polysaccharide is frequently added.
phases.
This eliminates gaseous microemboli formation and
• A properly placed retrobulbar injection is effective within
minimizes blood trauma.
seconds and blocks all extraocular muscles except the
superior oblique muscle, affects the 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

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 65

TOPIC 48: PORPHYRIA

315. Drugs contraindicated in acute intermittent

porphyria:
A. Thiopentone
B. Etomidate
C. Ketamine
D. Propofol
E. Midazolam
A&B
..........(PGI - DEC 2004)

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 • onset of Horner’s syndrome indicates a successful stellate
Ketorolac, phenacetin & pentazocine Unsafe block.
Muscle relaxants
Succinylcholine, pancuronium, Safe
atracurium, vecuronium
Anticholinergics
• Stellate ganglion block (cervicothoracic sympathetic
Atropine & glycopyrrolate Safe block)
Anticholinestenase Indications
Neostigmine safe Pain syndromes
Complex regional pain syndrome type I and II
316. The drug which is not suitable for patients with Refractory angina
acute porphyria for intravenous induction is: Phantom limb pain
A. Thiopentone sodium Herpes zoster
B. Propofol Shoulder/hand syndrome
C. Midazolam Angina
D. Etomidate Vascular insufficiency
NONE Raynaud’s syndrome
..........(AIIMS PGMEE - MAY 2005) Scleroderma
Frostbite
TOPIC 49: STELLATE GANGLION BLOCK Obliterative vascular disease
Vasospasm
317. A pt. in the ICU was on invasive monitoring with Trauma
intra arterial cannulation through the right radial Emboli
artery. For the last 3 days later he developed swelling Contraindications
and discoloration of the right hand. The next line of – Coagulopathy
management is: Recent myocardial infarction
A. Brachial block Pathological bradycardia
B. Stellate ganglion block Glaucoma
C. Application of lignocaine jelly over the site
D. Radial nerve block on the same side • Chassaignac’s tubercle
B This is the anterior tubercle of the transverse process of
..........(AIIMS PGMEE MAY - 2001) the sixth cervical vertebra, which lies lateral to and at a
slightly higher level than the posterior tubercle, and against
Stellate ganglion block which the carotid artery may be compressed by the finger.
• Anatomy
The stellate ganglion refers to the ganglion formed by • Stellate ganglion blocks have been traditionally performed
the fusion of the inferior cervical and the first blindly by palpating the transverse process of C6 and
thoracic ganglion as they meet anterior to the vertebral infiltrating a large volume (as much as 20 mL) of local
body of C7. It is present in 80% of subjects. It usually lies anesthetic. This technique is dependent on enough
on or above the neck of the first rib. volume reaching the stellate ganglion to result in an
effective block.

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 66

• Pain due to arterial insufficiency can be treated with a 320. The following are used for treatment of
stellate ganglion block, but this would have no effect on postoperative nausea and vomiting following squint
someone with 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 which of the following nerve D. Dexamethasone
A. Musculocutaneous A
B. Ulnar ..........(.AIPGMEE - 2005)
C. Radial
D. Median Ketamine is not used for treatment of postoperative
B nausea and vomiting. In fact ketamine use is itself
..........(AIPGMEE - 2003) associated with nausea and vomiting and requires
prophylaxis.
“Blockage of inferior trunk of brachial plexus may be incomplete ‘Nausea and vomiting occur and require prophylaxis’
requiring specific blockage ofulnar nerve at the elbow”
TOPIC 51: ASPIRIN
Brachial Plexus Block
Interscalene Axillary Approach Supra clavicular & 321. A pt. Who has on Aspirin for a long period was
Approach Infraclavicular
selected for an elective surgery what should be done:
approaches
A. Infusion of platelet concentrate
Most intense at C5 - C7 Most intense block in More even distribution
dermatomes and least C7-T, of local anaesthesia &
B. Infusion of fresh frozen plasma
intense at C8- T , (ulnar (ulnar can be used for C. Stop Aspirin for 7 days
nerve area) nerve).distribution least procedures on arm, D. Go ahead with surgery maintaining adequate hemostasis
Most optimal for intense in C5-C6 forearm and hand C
Procedures on dermatome ..........(AIIMS PGMEE MAY - 2001)
shoulder, arm and Most optimal for
forearm procedures from elbow
to hand Stop Aspirin for 7 days

TOPIC 50: STRABISMUS SURGERY • Aspirin inhibits TxA2 Synthesis by platelet’s even
in small doses.
319. A 5 Yr old child is scheduled for strabismus(squint)
correction .Induction of anae sthesia is
uneventful.After conjunctival incision as the surgeon This inhibits platelet aggregation
grasps the medial rectus, the anesthesiologists looks
at the cardiac monitor .Why do you think he did that Bleeding time prolonged nearly twice
?.
A. he wanted to check the depth of anesthesia
B. he wanted to be sure that the BP did not fall Effect lasts for about a week
C. he wanted to see if there was an oculocardiac (Turn over time for platelet is 7 days)
reflex
D. He wanted to make sure there was no ventricular if Aspirin is stopped for a week before Surgery
dysrhythmias which normally accompany incision =
C all platelet’s will be renewed
..........(AIIMS PGMEE NOV - 2002) =
bleeding time will become normal.
The anaesthesiologist looked at the cardiac monitor to check
for oculocardiac reflex. The Oculocardiac reflex is induced • Other measures will not help as Aspirin is irreversible
by inhibitor of Tx.A2.
(a) Pressure on the eyeball
(b) Traction on the extra ocular muscle TOPIC 52: BOYLE’S APPARATUS
(c) Orbital haematoma
(d) Ocular trauma 322. True about Boyle’s apparatus:
(e) Eye pain A. Continuous flow machine
B. Liquid anesthetic vapours not used
It is a trigeminovagal reflex. C. Resistance very high
The afferent pathway is through Trigeminal nerve and D. Resistance low
the efferent pathway is through Vagus nerve. A&D
..........(PGI - DEC 2006)
Manifestations-,
• Bradycardia ( most common) • Boyles apparatus was first developed for use in 1917. It
• Cardiac arrythmias was one of the most common types of anaesthetic
• Nodal rhythum equipment used in operating theatre.
• Ectopic beats • It operates on the continuous flow principle whereby
• Ventricular fibrillation gas flows all the time during the inspiratory and expiratory
• Asystole phase of patient respiration, being temporarily stored
during expiration in a reservoir bag.

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 67

• The basic principles of gas anaesthesia have been known section. Which of the following is the anaesthesia
for over a hundred years and are still used. An anaesthetising technique of choice -
agent is delivered to the patient via flow controllers and A. Spinal anaesthesia
mix controllers. B. Epidural anaesthesia
C. General anaesthesia
Normally a mixture of N2O and O2 would act as a carrier for D. Local anaesthesia with nerve blocks
the main agent (i.e. Halothane). C
Most gas apparatus used today is based on the Boyles ..........(AIIMS PGMEE - NOV 2005)
apparatus, and although dated, it is still used in many
hospitals. In coarctation of Aorta, Aorta narrows any where along its
course.
• In Boyles apparatus, the resistance offered by the bottles The most common site for coarctation of Aorta is
is overcome by the pressure of gases from the cylinders. • Just distal to origin of left subclavian artery
After leaving the bottles, the gases accumulate in the • Near the insertion of ligamentum arteriosus
reservoir bag. So, the common clinical presentation in coarctation of Aorta
The rubber tubing connecting this bag with the mask is
is of wide bore, thus minimal resistance to inspiration is • Hypotension, ischemia, distal to the obstruction,
presented to the patient. (circulation is usually diminished in obdominal organs and
pulses are absent in lower extremities)
TOPIC 53: CARBON MONOXIDE • Hypertension proximal to the site of obstruction
(the B.P. in upper extrenities and head and neck is
323. The gas which produces systemic toxicity without increased)
causing local irritation is:
A. Ammonia Effect of coarctation of Aorta on Pregnancy.
B. Carbon monoxide Coarctation of Aorta may lead to compromise of
C. Hydrocyanic acid placental circulation, because the placental circulation
D. Sulfur dioxide is derived from uterine artery, which is a branch of internal
D iliac artery
..........(AIPGMEE - 2002) (all the vessels originating distal to coarctation will
have diminished perfusion)
Carbon monoxide • So, the fetal circulation is in a compromised state in
Carbon monoxide is a colorless, tasteless, non-irritative coarctation of Aorta.
gas, which is produced due to incomplete combustion of
carbon. Anaesthetic considerations that should be taken into
account in case of coarctation of Aorta.
TOPIC 54: CHLORAL HYDRATE • In coarctation of Aorta, any decrease in cardiac output or
cardiac return is deleterious to the fetus because the
324. Which is safest to be used in asthmatic patients: placental circulation is already compromised on account
A. Nitrazepam of coarctation.
B. Phenobarbitone • So any anaesthetic procedure or drug which causes
C. Chloral hydrate hypotension should be avoided in these patients.
D. All hypnotics are safe Regional anaesthetic procedures such as spinal
E. Morphine anaesthesia and epidural anaesthesia should be avoided
C in these patients because hypotension is the most
..........(PGI - 2001 - Dec) common side effect of these procedures.
The consequence of decreased venous return and
• Benzodiazepines at usual hypnotic doses don’t affect decreased systemic vascular resistance as a result of
these procedures would be hazadrous to the
respiration or cardiovascular functions. They are now
patient.
popularly used as preanaesthetic medications because
they produce tranquility and smoothen induction
TOPIC 57: ETHER
with little respiratory depression.
327. All of the following are the disadvantages of
• Benzodiazepines are safe in asthmatics but these
anesthetic ether, except:
tranquilisers (also Nitrazepam), sedatives, opiates, should
A. Induction is slow.
be absolutely avoided in severely ill with asthma, as risk of
B. Irritant nature of ether increases salivary and bronchial
developing depression of alveolar ventilation is great and
secretions.
respiratory arrest may occur.
C. Cautery cannot be used
• Barbiturates cause respiratory and circulatory
D. Affects blood pressure and is liable to produce arrhythmias
depression.
D
Chloral hydrate, promethazine, diphenhydramine can be
..........(.AIPGMEE - 2005)
used satisfactorily.
BP & respiration are generally well maintained because of
TOPIC 55: COARCTATION OF AORTA
reflex stimulation and high sympathetic tone- kdt Cardiac
arrythmias occur rarely with ether and there is no
325. A 30 year old woman with coarctation of aorta is
sensitizatio n of the myocardium to circulating
admitted to the labour room for elective caesarean
catecholamines –

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 68

Induction with ether is very slow (blood gas coefficient • Endotracheal tube one-half size smaller than usual to
12.0) and very unpleasant maximize 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
It should not be used when diathermy is needed in the • Thiopentone is used as induction agent
airways, because of risk of fire or explosion • The patient is not artificially ventilated to avoid filling
of stomach with gas and thereby increasing the risk of
TOPIC 58: FAT EMBOLISM emesis
• If intubation fails, spontaneous ventilation should be
328. Factors favouring fat embolism in a patient with allowed to return and awake intubation performed
major trauma: • After surgery , patient should remain intubated until
A. Mobility of # airway reflexes and consciousness has been regained.
B. Hypovolemic shock
C. Resp. failure TOPIC 61: TORNIQUET
D. Diabetes
A&D 331. Tourniquet pressure in lower limb surgery:
..........(PGI - June -2001) A. 50 mmHg above systolic
B. 100 mm Hg above systolic
TOPIC 59: OPIOIDS 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 ..........(PGI - JUNE 2006)
B. Morphine
C. Alfentanil * Tourniquet pressure is about 100 mm of Hg above the
D. Pethidine systolic blood pressure. The pressure for upper limb is =
C SBP+50mm of Hg & for lower limb is = 2 X SBP.
..........(AIIMS PGMEE - DEC 1994)
TOPIC 62: TRILENE
In outpatient anaesthesia the patients are sent back home
the same day. Therefore agents which are rapidly 332. Which is not compatible with Soda lime:
eleminated are used so that no after effects are left The A. Halothane
agents used are – B. Ether
• Propofol C. N2O
• Alfentanil D. Trilene
• Remifentanil D
• N 2O ..........(AIIMS PGMEE - FEB - 1997)
• Isoflurane • 90% Ca(OH)2*
• Sevofiurane Trilene • 5% Sodium
Hydroxide*
• Desflurane • Soda lime is a mixture of * —>
•1% Potassium
Hydoroxide*
TOPIC 60: RAPID SEQUENCE ANAESTHESIA • 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
B
..........(AIPGMEE - 2003)

Rapid sequence Induction

This induction technique is used in patient with 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 - • Soda lime is used to absorb CO2. When it absorbs CO2
• Patient is always preoxygenated prior to induction it produces heat. All volatile anaesthetic agents are
• Prior Curarization with nondepolarization MR to prevent decomposed by the heat produced as a result of absortion
increase in intra abdominal pressure that accompanies use of CO2 by Soda lime.
of succinyl choline.

HELP LINE NO. 9391567707

 MINOR TOPICS ANAESTHESIA 69

• Thermal decomposition of trilene (trichlor ethylene)

and Sevoflurane results in toxic compounds therefore
neither of them should be used with sodalime.
• Function of soda lime
Soda lime is used in breathing systems to absorb
expired CO 2 during anaesthesia.
• It can be incorporated in a Mapleson C system or a circle
system. Exhaled gases are circled back to the canister,
where CO2 absorption takes place and water and heat
are produced. The warmed and humidified gas joins the
fresh gas flow to be delivered to the patient.
The reaction:
CO2 + H2O leads to H2CO3
2H2CO3 + 2NaOH leads to Na2CO3 + 4H2O + Heat
2Ca(OH)2 + Na2CO3 leads to 2CaCO3 + 2NaOH + Heat
• In soda lime absorption, the carbon dioxide first reacts
with water to form carbonic acid , which then reacts
with sodium hydroxide to form a soluble carbonate. The
soluble sodium carbonate then reacts with calcium
hydroxide to form an insoluble carbonate and replenishes
the sodium hydroxide. Heat and water are produced
during the reaction. Exhaustion of its activity is indicated
by dyes; the most common one changes from pink to
white
• Xenon was discovered in 1898 and found to be the only
noble gas to be anaesthetic under normobaric conditions.
• For anaesthetic purposes, it was found very close to the
‘ideal agent”.
Advantages of Xenon anaesthesia
• Inert probably nontoxic with no metabolism
• Unlikely to be involved in any biochemical events in the
body, can be eliminated via lungs.
• Minimal cardiovascular effects.
• Low blood solubility.
• Rapid induction and recovery (lowest blood gas
partition coefficient)
• Does not trigger malignant hyperthermia
• Environmental friendly
• Non explosive
Disadvantages
• High cost
• Low potency
• No commercially available anaesthesia equipment

• 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 when

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

TOPIC 63: XENON

333. Which of the following 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
C
..........(AIIMS PGMEE - NOV 2006

HELP LINE NO. 9391567707