Monitored Anesthesia Care — MCQs
Which of the following is NOT a CONTRAINDICATION for laparoscopic surgery:
In an accident case, after the arrival of medical team, all should be done in early management except;
Which of the following intravenous anesthetic agents is contraindicated in epileptic patients posted for general anaesthesia
Arrange the following anesthetic agents based on their potency Nitrous oxide Halothane Isoflurane Methoxyflurane
A 40–year female has to undergo incisional hernia surgery under general anaesthesia. She complains of awareness during her past cesarean section. Which of the following monitoring techniques can be used to prevent such awareness ?
Problems which may result from hypotensive anesthesia include:
Which anaesthetic agent has maximum MAC ?
Early and reliable indication of air embolism during anaesthesia can be obtained by continuous monitoring of:
What term is used for a patient who is kept under observation in a hospital for a short period (typically less than 48 hours) to determine if formal admission is necessary?
The image given below shows neuromuscular monitoring of the patient after anesthesia. What is the most commonly used nerve for monitoring?
Monitored Anesthesia Care Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is NOT a CONTRAINDICATION for laparoscopic surgery:
- A. Severe COPD
- B. Bowel herniation
- C. Endometriosis (Correct Answer)
- D. Severe cardiac compromise
Explanation: ***Endometriosis*** - **Endometriosis** is a *common indication* for laparoscopic surgery, as laparoscopy allows for both diagnosis and treatment (e.g., excision or ablation of endometrial implants). - It is *not* a contraindication; in fact, laparoscopy is the **gold standard** for diagnosing and managing endometriosis due to its minimally invasive nature and excellent visualization. *Severe COPD* - **Severe COPD** is a significant *contraindication* because pneumoperitoneum increases intra-thoracic pressure and elevates the diaphragm, reducing functional residual capacity. - This can cause *hypercarbia*, *hypoxemia*, and respiratory compromise in patients with already limited pulmonary reserve, making general anesthesia and laparoscopy high-risk. *Bowel herniation* - **Incarcerated or strangulated bowel herniation** is generally a *relative contraindication* due to the risk of intestinal injury during trocar insertion or manipulation. - The presence of *adhesions* and compromised bowel can make laparoscopic access challenging, though experienced surgeons may still attempt laparoscopic repair in selected cases. *Severe cardiac compromise* - **Severe cardiac compromise** is a significant *contraindication* because pneumoperitoneum causes increased intra-thoracic pressure, reduced venous return, and increased systemic vascular resistance. - This can lead to decreased *cardiac output*, arrhythmias, and hemodynamic instability, posing substantial risk to patients with severe cardiovascular disease.
Question 2: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.
Question 3: Which of the following intravenous anesthetic agents is contraindicated in epileptic patients posted for general anaesthesia
- A. Thiopentone
- B. Midazolam
- C. Ketamine (Correct Answer)
- D. Propofol
Explanation: ***Ketamine*** - Ketamine is known to have **proconvulsant effects**, particularly at higher doses, and can exacerbate seizures in epileptic patients. - It causes **dissociative anesthesia** and can increase intracranial pressure, which is generally undesirable in patients with seizure disorders. *Thiopentone* - Thiopentone is a **barbiturate** that acts as an anticonvulsant and is often used to treat seizures or status epilepticus, making it safe in epileptic patients. - It **decreases cerebral metabolic rate** and intracranial pressure, which are beneficial for patients with neurologic conditions. *Midazolam* - Midazolam is a **benzodiazepine** with strong anticonvulsant properties, frequently used to terminate seizures. - It enhances GABAergic inhibition, making it a **safe and effective sedative** for epileptic patients. *Propofol* - Propofol has **anticonvulsant properties** and is often used in the management of refractory status epilepticus. - It **decreases cerebral blood flow** and metabolic rate, making it a favorable choice in patients with epilepsy.
Question 4: Arrange the following anesthetic agents based on their potency Nitrous oxide Halothane Isoflurane Methoxyflurane
- A. Methoxyflurane > Halothane > Isoflurane > Nitrous oxide (Correct Answer)
- B. Methoxyflurane > Nitrous oxide > Halothane > Isoflurane
- C. Methoxyflurane > Isoflurane > Halothane > Nitrous oxide
- D. Halothane > Isoflurane > Nitrous oxide > Methoxyflurane
Explanation: ***Methoxyflurane > Halothane > Isoflurane > Nitrous oxide*** - Anesthetic potency is inversely related to its **MAC (Minimum Alveolar Concentration)** value. A lower MAC value indicates higher potency. - The MAC values for these agents are: Methoxyflurane (0.16%), Halothane (0.75%), Isoflurane (1.15%), and Nitrous oxide (104%), which directly corresponds to this order of potency. *Methoxyflurane > Nitrous oxide > Halothane > Isoflurane* - This order incorrectly places nitrous oxide as more potent than halothane and isoflurane. **Nitrous oxide** has a very high MAC (104%), indicating low potency. - **Halothane** and **isoflurane** have significantly lower MAC values (0.75% and 1.15%, respectively), making them much more potent than nitrous oxide. *Methoxyflurane > Isoflurane > Halothane > Nitrous oxide* - This order incorrectly places **isoflurane** as more potent than halothane. **Halothane** has a MAC of 0.75%, while **isoflurane** has a MAC of 1.15%. - Therefore, halothane is more potent than isoflurane, making this sequence incorrect. *Halothane > Isoflurane > Nitrous oxide > Methoxyflurane* - This order incorrectly places **halothane** as the most potent and **methoxyflurane** as the least potent among the listed agents. - **Methoxyflurane** has the lowest MAC (0.16%), making it the most potent, while **nitrous oxide** has the highest MAC (104%), making it the least potent.
Question 5: A 40–year female has to undergo incisional hernia surgery under general anaesthesia. She complains of awareness during her past cesarean section. Which of the following monitoring techniques can be used to prevent such awareness ?
- A. Color doppler
- B. Transesophageal echocardiography
- C. Bispectral index monitoring (Correct Answer)
- D. Pulse plethysmography
Explanation: ***Bispectral index monitoring*** - **Bispectral Index (BIS) monitoring** is a technology that processes electroencephalogram (EEG) signals to provide a numerical value (0-100) indicating the patient's **level of consciousness or depth of anesthesia**. - A lower BIS value (typically 40-60) indicates a suitable depth of anesthesia for surgery, helping to prevent **intraoperative awareness**, especially in patients with a history of it. *Color doppler* - **Color Doppler** is an imaging technique used to visualize blood flow in vessels and assess the speed and direction of flow. - It is primarily used to diagnose conditions like **deep venous thrombosis**, *arterial stenosis*, or to evaluate blood flow to organs, and has no direct role in monitoring depth of anesthesia. *Transesophageal echocardiography* - **Transesophageal echocardiography (TEE)** is an invasive imaging technique that uses ultrasound from a probe inserted into the esophagus to provide detailed images of the heart. - TEE is critical for assessing **cardiac function**, *valvular heart disease*, or *aortic dissection* during surgery, but it does not monitor brain activity or the depth of anesthesia. *Pulse plethysmography* - **Pulse plethysmography** is a non-invasive method that measures changes in blood volume in a part of the body, often used to determine **heart rate** and assess peripheral perfusion. - While it is a component of pulse oximetry, it does not provide information about the **depth of anesthesia** or brain activity.
Question 6: Problems which may result from hypotensive anesthesia include:
- A. Deep vein thrombosis
- B. Reactionary hemorrhage
- C. Retraction anemia
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - Hypotensive anesthesia is a technique used to reduce **blood pressure** during surgery, aiming to decrease **blood loss** and improve the **surgical field visibility**. - While beneficial, it carries inherent risks including **deep vein thrombosis (DVT), reactionary hemorrhage**, and complications like **retraction anemia** if not managed properly. *Deep vein thrombosis (DVT)* - While hypotension might seem to reduce the risk by lowering **blood flow velocity**, prolonged immobility and potential for **venous stasis** during any surgery, especially under hypotension, can increase DVT risk. - The combination of **endothelial dysfunction** and **hypercoagulability** often seen in surgical patients, coupled with reduced peripheral blood flow due to hypotension, can contribute to DVT formation. *Reactionary hemorrhage* - This is a common post-operative complication where bleeding restarts hours after surgery. With hypotensive anesthesia, **blood vessels** are constricted and may not be actively bleeding during the surgery. - As the patient's **blood pressure** returns to normal post-operatively, these previously undetected bleeds can manifest as significant **hemorrhage** due to the increased pressure. *Retraction anemia* - This term is less commonly used in medical literature. However, it likely refers to the complications arising from prolonged tissue retraction during surgery, which, when combined with reduced **perfusion** from hypotensive anesthesia, can lead to **tissue ischemia** or damage akin to anemia in the affected area. - The reduced **oxygen delivery** to tissues during hypotensive states, especially when further compromised by retraction, may result in localized tissue injury or contribute to systemic complications if severe or prolonged.
Question 7: Which anaesthetic agent has maximum MAC ?
- A. Ether
- B. Methoxyfluorane
- C. Halothane
- D. Nitrous Oxide (N2O) (Correct Answer)
Explanation: ***Nitrous Oxide (N2O)*** - **Nitrous Oxide** has the highest **minimum alveolar concentration (MAC)** of all commonly used inhalational anesthetics, approximately 104%. - A high MAC indicates **low potency**, meaning that a large concentration is required to achieve anesthetic effects. *Ether* - **Ether** has a MAC of about 1.92%, which is significantly lower than that of Nitrous Oxide. - Its use has largely been replaced due to its flammability, slow induction, and recovery times. *Methoxyfluorane* - **Methoxyfluorane** is known for having a very low MAC, around 0.16%, making it the most potent inhalational anesthetic. - Due to its high potency and significant nephrotoxicity, its use is now very limited. *Halothane* - **Halothane** has a MAC of approximately 0.75%. - While it was a widely used inhalational anesthetic, it has largely been replaced due to concerns about **halothane hepatitis** and arrhythmogenicity.
Question 8: Early and reliable indication of air embolism during anaesthesia can be obtained by continuous monitoring of:
- A. Oxygen saturation
- B. End Tidal CO2 (Correct Answer)
- C. ECG
- D. Blood pressure
Explanation: ***End Tidal CO2*** - A sudden and unexplained decrease in **End Tidal CO2 (EtCO2)** is often the first sign of an air embolism. - This occurs because air in the pulmonary circulation obstructs blood flow, leading to reduced CO2 delivery to the lungs. *Oxygen saturation* - **Oxygen saturation** changes are typically a later sign of air embolism, as significant pulmonary impairment or right-to-left shunting must occur before a drop is detectable. - A decrease in saturation indicates a more advanced and potentially severe embolism. *ECG* - **ECG changes**, such as arrhythmias or signs of right heart strain, are usually late and non-specific indicators of air embolism. - These changes reflect the cardiovascular consequences of the embolism rather than its initial event. *Blood pressure* - A drop in **blood pressure** is a late and often profound sign of an air embolism, reflecting significant cardiovascular compromise. - Early detection methods precede observable changes in systemic blood pressure.
Question 9: What term is used for a patient who is kept under observation in a hospital for a short period (typically less than 48 hours) to determine if formal admission is necessary?
- A. Inpatient
- B. Outpatient
- C. Urgent care patient
- D. Observation status (Correct Answer)
Explanation: ***Observation status*** - Patients under **observation status** are monitored in a hospital setting for a short period (typically less than 24-48 hours) to determine if inpatient admission is necessary. - This status is used when the medical condition is uncertain, requiring further evaluation and diagnostic tests to guide treatment decisions. *Inpatient* - An **inpatient** is formally admitted to the hospital for an expected stay of more than 24 hours, often requiring a hospital bed overnight. - This classification is associated with specific billing and care delivery models distinct from observation status. *Outpatient* - An **outpatient** receives medical care at a hospital, clinic, or doctor's office without being admitted for an overnight stay. - Examples include routine check-ups, specialist consultations, and minor surgical procedures performed on the same day. *Urgent care patient* - An **urgent care patient** receives immediate medical attention for illnesses or injuries that are not life-threatening but require prompt treatment. - This care is typically provided in an urgent care clinic, not usually in a hospital setting for 24-hour observation.
Question 10: The image given below shows neuromuscular monitoring of the patient after anesthesia. What is the most commonly used nerve for monitoring?
- A. Ulnar nerve (Correct Answer)
- B. Median nerve
- C. Radial nerve
- D. Metacarpal nerve
Explanation: ***Ulnar nerve*** - The **ulnar nerve** is the most commonly chosen site for neuromuscular monitoring due to its ease of accessibility and predictable response of the **adductor pollicis muscle**. - Stimulation of the ulnar nerve at the wrist causes **adduction of the thumb**, which is easily quantifiable and provides reliable information about neuromuscular blockade. *Median nerve* - While the median nerve can be monitored, it is **less commonly used** than the ulnar nerve due to potential for confusing responses or less clear twitch measurements. - Stimulation of the median nerve primarily leads to **flexion of the thumb and fingers**, but the adductor pollicis response from ulnar nerve stimulation is often preferred for its clear isolation. *Radial nerve* - The radial nerve innervates muscles involved in **wrist and finger extension**, which are not typically targeted for standard neuromuscular monitoring. - Its stimulation can be more complex to interpret and may not provide the precise information needed for monitoring paralytic depth in the same way as the ulnar nerve. *Metacarpal nerve* - The term "metacarpal nerve" is broad and refers to nerves near the metacarpals, which are **not primary sites** for direct neuromuscular blocking agent monitoring. - Specific named peripheral nerves like the ulnar, median, or radial nerves are targeted for their predictable muscle responses, not generalized metacarpal innervation.
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