Neurological Complications — MCQs

10 questions

Which of the following intravenous anesthetic agents is contraindicated in epileptic patients posted for general anaesthesia

Complications of sling procedures (TVT) for USI are all except:

Which of the following should be considered as the cause of generalized convulsions 20 minutes postoperatively?

What are the characteristics of reversible pulpitis?

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 the hand. The commonest cause of this neurological dysfunction could be all of the following except :

Awareness during anaesthesia can be assessed by:

Problems which may result from hypotensive anesthesia include:

Which of the following is NOT a recognized complication of massive blood transfusion?

Malignant hyperthermia is a rare complication of the use of the following anaesthetic:

Q10

All are the Complication of CVP line except

Neurological Complications Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: Complications of sling procedures (TVT) for USI are all except:

A. Obturator nerve injury is about 10% (Correct Answer)
B. Overactive bladder in about 7% cases
C. Injury to bladder and wound haematoma
D. Sling erosion particularly with polytetrafluoroethylene (Goretex)

Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.

Question 3: Which of the following should be considered as the cause of generalized convulsions 20 minutes postoperatively?

A. Enflurane (Correct Answer)
B. Halothane
C. Isoflurane
D. Sevoflurane

Explanation: ***Enflurane*** - **Enflurane** is well-known to cause **generalized convulsions** or seizure-like activity during emergence from anesthesia, particularly when inspired concentrations exceed 3.0% or with hypocapnia. - The risk of seizures is a significant reason why enflurane is rarely used in modern anesthetic practice compared to newer volatile agents. *Halothane* - **Halothane** is associated with cardiac arrhythmias and hepatotoxicity but generally does not cause generalized convulsions as a primary side effect. - While it can lower the seizure threshold, overt seizures are not a common complication of halothane administration. *Isoflurane* - **Isoflurane** is associated with CNS depression and can, in rare cases, cause myoclonus, but it is not typically linked to generalized tonic-clonic convulsions. - It is often used in neurosurgery due to its beneficial effects on cerebral blood flow and minimal seizure-inducing potential. *Sevoflurane* - **Sevoflurane**, while capable of causing excitatory movements or myoclonus during induction and emergence, is not a common cause of clear-cut generalized convulsions in healthy patients. - High concentrations in pediatric patients or those with pre-existing seizure disorders might slightly increase the risk of seizure-like EEG changes, but it is less epileptogenic than enflurane.

Question 4: What are the characteristics of reversible pulpitis?

A. Aggravated by heat and may be relieved by cold
B. Aggravated by cold and may be relieved by heat
C. No reaction to hot and cold, indicating necrosis
D. Reacts to electric pulp tester (Correct Answer)

Explanation: ***Reacts to electric pulp tester*** - In **reversible pulpitis**, the pulp is still vital and responsive, thus it will react to an **electric pulp tester** (EPT) with a sharp, transient pain at a lower current. - The sensation elicited by EPT indicates the presence of nerve fibers and a viable pulp, consistent with a reversible condition. *Aggravated by heat and may be relieved by cold* - This symptom profile, where pain is **aggravated by heat** and **relieved by cold**, is characteristic of **irreversible pulpitis**, not reversible pulpitis. - The relief with cold often indicates a build-up of pressure within the pulp that is temporarily alleviated by the vasoconstrictive effect of cold. *Aggravated by cold and may be relieved by heat* - While some mild, transient cold sensitivity can occur in **reversible pulpitis**, severe or prolonged cold sensitivity is more indicative of irreversible pulpitis. Relief with heat is not a typical characteristic of reversible pulpitis and would be very unusual for any pulpitis. - This pattern of discomfort is not a direct characteristic of reversible pulpitis; reversible pulpitis typically presents with **sharp, transient pain to cold** that resolves quickly. *No reaction to hot and cold, indicating necrosis* - A lack of reaction to thermal stimuli (hot and cold) is indicative of a **necrotic pulp**, meaning the pulp tissue has died. - In **reversible pulpitis**, the pulp is inflamed but still vital, and therefore will react to thermal stimuli, usually with a sharp, transient pain to cold.

Question 5: 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 the hand. The commonest cause of this neurological dysfunction could be all of the following except :

A. Tourniquet pressure
B. Crush injury to the hand and lacerated nerves
C. A tight cast or dressing
D. Systemic toxicity of local anaesthetics (Correct Answer)

Explanation: ***Systemic toxicity of local anaesthetics*** - This typically presents with **acute neurological symptoms** (e.g., seizures, metallic taste, tinnitus) or **cardiovascular collapse** during or immediately after local anesthetic administration. - Persistent numbness and paresthesia on the second postoperative day are **not characteristic** of systemic local anesthetic toxicity, which is a transient effect. *Tourniquet pressure* - **Prolonged or excessively high tourniquet pressure** can lead to nerve ischemia and damage, causing paresthesia and numbness in the limb distal to the tourniquet. - These symptoms often persist for some time post-operatively, consistent with the patient's presentation. *Crush injury to the hand and lacerated nerves* - The initial **roadside accident** involving a severely injured limb could directly cause **nerve lacerations or crush injuries**, leading to immediate and persistent neurological deficits like numbness and paresthesia. - Such direct nerve trauma would manifest immediately and continue post-operatively, aligning with the patient's complaints. *A tight cast or dressing* - A **tight cast or dressing** applied to the forearm can compress nerves, leading to **ischemia and neuropathy**. - This mechanical compression can cause persistent numbness and paresthesia, which might become more noticeable as swelling increases post-surgery.

Question 6: Awareness during anaesthesia can be assessed by:

A. ARTERIAL B.P
B. ETCO2
C. BIS (Correct Answer)
D. NEUROMUSCULAR MONITOR

Explanation: ***

Question 7: 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 8: Which of the following is NOT a recognized complication of massive blood transfusion?

A. Hypokalemia
B. Hypothermia
C. Hypocalcemia
D. Hypernatremia (Correct Answer)

Explanation: ***Hypernatremia*** - Massive transfusions, especially of packed red blood cells (PRBCs) preserved in solutions like **CPDA-1**, actually tend to cause **hyponatremia** due to the low sodium content of the transfusion products relative to plasma. - While PRBCs have some sodium, the net effect of large volumes is a dilutional effect on plasma sodium and the infusion of sodium-poor fluids, making hypernatremia an unlikely complication. *Hypokalemia* - Although stored blood products accumulate extracellular potassium (leading to hyperkalemia), **hypokalemia** can occur post-transfusion due to the rapid uptake of potassium by metabolically active cells. - This is particularly true if the patient has pre-existing conditions or is on certain medications that can shift potassium intracellularly. *Hypothermia* - Stored blood is refrigerated, and rapid infusion of large volumes of cold blood can significantly lower the patient's **core body temperature**. - **Hypothermia** can exacerbate coagulopathy and lead to cardiac arrhythmias. *Hypocalcemia* - The citrate anticoagulant used in blood products chelates calcium, reducing the amount of **ionized calcium** available in the patient's bloodstream. - Massive transfusions overwhelm the liver's ability to metabolize citrate, leading to significant **hypocalcemia**.

Question 9: Malignant hyperthermia is a rare complication of the use of the following anaesthetic:

A. Thiopentone sodium
B. Halothane (Correct Answer)
C. Ether
D. Ketamine

Explanation: **Halothane** - **Halothane** is a potent volatile anesthetic and a classic trigger for **malignant hyperthermia** due to its effect on ryanodine receptors, leading to excessive calcium release from the sarcoplasmic reticulum. - While its use has declined, it remains a critical example of an anesthetic agent known to induce this life-threatening genetic disorder. *Thiopentone Sodium* - **Thiopentone sodium** is an intravenous barbiturate anesthetic and is **not associated** with triggering malignant hyperthermia. - It is often used for induction of anesthesia and has a different mechanism of action involving GABA receptors. *Ether* - **Diethyl ether** was one of the earliest general anesthetics but is **not a trigger** for malignant hyperthermia. - Its use has largely been discontinued due to its flammability and adverse side effects, but it doesn't cause MH. *Ketamine* - **Ketamine** is a dissociative anesthetic that acts as an NMDA receptor antagonist and is **not a trigger** for malignant hyperthermia. - It is often used for its analgesic and sedative properties and is considered safe in patients susceptible to MH.

Question 10: All are the Complication of CVP line except

A. Haemothorax
B. Airway injury (Correct Answer)
C. Air embolism
D. Septicemia

Explanation: ***Airway injury*** - While central venous catheterization can cause various complications, direct **airway injury** (e.g., tracheal puncture) is extremely rare and not a typical complication of the procedure itself as the insertion sites are generally not near the major airways. - Complications usually involve vascular, pleural, or infectious issues rather than direct damage to the respiratory tree. *Haemothorax* - **Haemothorax** can occur if the subclavian or internal jugular vein is punctured and the needle or catheter inadvertently punctures an adjacent artery (e.g., subclavian artery), leading to bleeding into the pleural space. - This complication presents with respiratory distress and signs of hypovolemia as blood accumulates in the thoracic cavity. *Air embolism* - **Air embolism** is a serious complication, especially during insertion or removal of a CVP line, if the catheter lumen is exposed to air and negative intrathoracic pressure sucks air into the venous system. - It can lead to sudden cardiorespiratory collapse and is a recognized risk of CVP placement. *Septicemia* - **Septicemia** (or central line-associated bloodstream infection, CLABSI) is a common and serious complication, particularly with prolonged catheter dwelling times, poor aseptic technique, or inadequate site care. - Bacteria can colonize the catheter surface and enter the bloodstream, leading to systemic infection.

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