Risk Management and Prevention — MCQs
A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification
Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?
Arrange the following anesthetic agents based on their potency Nitrous oxide Halothane Isoflurane Methoxyflurane
Malignant hyperthermia is a rare complication of the use of the following anaesthetic:
Treatment of malignant hyperthermia is
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 ?
Steps in review of patient's history during secondary survey of trauma care can be summarised as
A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?
Which of the following is not seen in scoline apnea?
Modified Mallampati grading is used in assessment of -
Risk Management and Prevention Indian Medical PG Practice Questions and MCQs
Question 1: A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification
- A. ASA II
- B. ASA I
- C. ASA IV
- D. ASA III (Correct Answer)
Explanation: ***ASA III*** - This patient has **severe systemic disease** (angina at rest, COPD, obesity) that limits activity but is not incapacitating, aligning with the criteria for **ASA III**. - **Angina at rest** and **chronic obstructive pulmonary disease (COPD)** are significant comorbidities that place the patient in this category. *ASA II* - **ASA II** is defined by **mild systemic disease** that does not limit activity. - The patient's conditions such as **angina at rest** and **COPD** are more severe than what would be considered mild. *ASA I* - **ASA I** is reserved for a **normal, healthy patient** with no systemic disease. - This patient has multiple significant systemic diseases, unequivocally ruling out ASA I. *ASA IV* - **ASA IV** describes a patient with **severe systemic disease** that is a constant threat to life. - While critical, the patient's conditions (angina at rest, COPD) are stabilised enough for an **elective procedure** and are not an immediate, constant threat to life.
Question 2: Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?
- A. International Normalized Ratio (INR) (Correct Answer)
- B. Partial Thromboplastin Time (PTT)
- C. Clotting Time
- D. Differential Count
Explanation: ***International Normalized Ratio (INR)*** - The **INR** is specifically used to monitor the effectiveness of **warfarin** therapy, as it standardizes the prothrombin time (PT) for variations in thromboplastin reagents. - Before surgery, an INR measurement helps assess the patient's **coagulation status** and guides decisions on temporary cessation or bridging therapy to minimize bleeding risk. *Partial Thromboplastin Time (PTT)* - **PTT** primarily measures the **intrinsic and common pathways** of coagulation and is used to monitor **heparin** therapy, not warfarin. - While prolonged in some bleeding disorders, it is not the standard test for assessing warfarin's anticoagulant effect. *Clotting Time* - **Clotting time** is a very general and less precise measure of overall coagulation that is **rarely used** in modern clinical practice due to its low sensitivity and specificity. - It does not offer sufficient detail or standardization to guide pre-operative management for patients on warfarin. *Differential Count* - A **differential count** measures the different types of **white blood cells** within a blood sample and is used to diagnose infections, inflammatory conditions, or hematologic disorders. - It provides no information about a patient's coagulation status or the effects of anticoagulant medications like warfarin.
Question 3: 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 4: 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 5: Treatment of malignant hyperthermia is
- A. Propranolol
- B. Dantrolene (Correct Answer)
- C. Halothane
- D. Nitrous oxide
Explanation: ***Dantrolene*** - **Dantrolene** is a **ryanodine receptor antagonist** that blocks calcium release from the sarcoplasmic reticulum in muscle cells, directly addressing the underlying pathophysiology of malignant hyperthermia. - Administration of dantrolene is the **first-line and specific treatment** for malignant hyperthermia, rapidly reversing its life-threatening symptoms. *Propranolol* - **Propranolol** is a **beta-blocker** primarily used to treat hypertension, angina, and arrhythmias, by reducing heart rate and contractility. - It does not have any direct action on the **ryanodine receptors** or the excessive calcium release responsible for the muscle rigidity and hypermetabolism seen in malignant hyperthermia. *Halothane* - **Halothane** is an **inhalational anesthetic** that is a well-known trigger of malignant hyperthermia, particularly in genetically susceptible individuals. - Administering halothane would **exacerbate** malignant hyperthermia due to its potent ability to induce uncontrolled calcium release from the sarcoplasmic reticulum. *Nitrous oxide* - **Nitrous oxide** is an **inhalational anesthetic** that is generally considered a weak trigger for malignant hyperthermia and is often used in combination with other agents. - While typically considered safe regarding malignant hyperthermia, it does not possess any therapeutic properties to treat the condition and would not be used once malignant hyperthermia is suspected.
Question 6: 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 7: Steps in review of patient's history during secondary survey of trauma care can be summarised as
- A. TRIAGE
- B. ABCDE
- C. AMPLE (Correct Answer)
- D. None of the options
Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.
Question 8: A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?
- A. Pain gradually increases
- B. Caused most commonly by atherosclerosis
- C. Level of occlusion cannot be decided based on symptoms
- D. Rest pain at night in advanced stages (Correct Answer)
Explanation: ***Rest pain at night in advanced stages*** - Intermittent claudication is defined by pain with exercise that resolves with rest [1]. **Rest pain** indicates critical limb ischemia, a more advanced stage of peripheral artery disease, and is distinct from intermittent claudication itself, although it can develop from it [1]. - While rest pain can occur in patients with severe peripheral artery disease, it is **not typically seen in intermittent claudication**, but rather represents progression to a more severe form of the disease. *Pain gradually increases* - The pain of intermittent claudication typically **gradually increases** during physical activity as the oxygen demand of the muscles exceeds the compromised blood supply. - This progressive pain forces the patient to stop activity, at which point the pain subsides with rest. *Caused most commonly by atherosclerosis* - **Atherosclerosis** is the underlying pathology in the vast majority of cases of peripheral artery disease, leading to stenosis or occlusion of the arteries that supply the lower limbs [1]. - This narrowing of the arterial lumen restricts blood flow, causing inadequate oxygen delivery to muscles during exertion. *Level of occlusion cannot be decided based on symptoms* - The **anatomical level of arterial occlusion** can often be inferred to some extent by the location of the claudication pain (e.g., buttock claudication suggests aortoiliac disease, calf claudication suggests femoropopliteal disease) [1]. - However, the precise extent and severity of the occlusion cannot be solely determined by symptoms, and imaging studies like **duplex ultrasound** or angiography are required for definitive diagnosis.
Question 9: Which of the following is not seen in scoline apnea?
- A. It occurs due to deficiency of acetylcholinesterase (Correct Answer)
- B. It is due to succinylcholine
- C. Patients usually do not die of scoline apnea if they are properly managed
- D. It can be inherited
Explanation: ***It occurs due to deficiency of acetylcholinesterase*** - **Scoline apnea** is caused by a deficiency of **pseudocholinesterase (butyrylcholinesterase)**, not acetylcholinesterase. - **Pseudocholinesterase** is responsible for metabolizing **succinylcholine**, while acetylcholinesterase breaks down acetylcholine at the neuromuscular junction. *It is due to succinylcholine* - **Scoline apnea** is indeed triggered by the administration of **succinylcholine** in individuals with a genetic defect in **pseudocholinesterase**. - Without proper metabolism by pseudocholinesterase, succinylcholine prolongs its action, leading to prolonged neuromuscular blockade. *Patients usually do not die of scoline apnea if they are properly managed* - With appropriate management, which involves **mechanical ventilation** until the succinylcholine is metabolized, patients typically recover fully from scoline apnea. - The primary risk is respiratory failure due to prolonged paralysis, which can be managed by supportive care. *It can be inherited* - The deficiency of **pseudocholinesterase** that causes scoline apnea is an **autosomal recessive inherited disorder**. - Genetic testing can identify individuals who are at risk for this condition.
Question 10: Modified Mallampati grading is used in assessment of -
- A. Difficulty of intubation (Correct Answer)
- B. Obstruction of the airway
- C. Aspiration-related death
- D. Endotracheal intubation procedure
Explanation: ***Difficulty of intubation*** - The **Modified Mallampati score** assesses the visibility of pharyngeal structures, which directly correlates with the ease or difficulty of performing **direct laryngoscopy** and **endotracheal intubation**. - A higher Mallampati class (e.g., III or IV) indicates less visibility of the soft palate, uvula, and pillars, suggesting a more difficult airway and increased likelihood of a challenging intubation. *Obstruction of the airway* - While a high Mallampati score might indirectly indicate potential for **airway obstruction** during anesthesia due to anatomical features, its primary purpose is not to diagnose or quantify existing airway obstruction. - Airway obstruction is more directly assessed by monitoring breathing sounds, respiratory effort, and oxygen saturation. *Aspiration-related death* - The **Mallampati score** helps predict the difficulty of securing the airway but does not directly assess the risk of **aspiration**. - Aspiration risk is evaluated based on factors like gastric contents, gag reflex, and patient positioning. *Endotracheal intubation procedure* - The **Modified Mallampati score** helps in **planning the intubation procedure** by identifying potential difficulties but is not a measure of the intubation procedure itself. - It is a **pre-procedure assessment tool** to gauge airway anatomy, not a description or evaluation of the steps involved in endotracheal intubation.
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