Emergence from Anesthesia — MCQs
Which of the following is the induction anesthesia of choice in the pediatric age group?
A patient admitted after a road traffic accident is put on mechanical ventilation. He opens his eyes on verbal command and moves all four limbs spontaneously. Calculate his GCS.
Child with aspiration risk needs emergency surgery. Best induction sequence is:
A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
Shivering observed in the early part of the postoperative period is due to
Emergence Delirium is characteristic of?
Patient was planned for surgery under GA, in the induction phase rocuronium was given 85mg but the anesthetist did not succeed in intubating. Which could be the best reversal agent used?
Which of the following drugs is most effective in preventing emergence delirium with ketamine?
All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
Which of the following is contraindicated in an epileptic patient posted for general anesthesia?
Emergence from Anesthesia Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is the induction anesthesia of choice in the pediatric age group?
- A. A. Sevoflurane (Correct Answer)
- B. B. Desflurane
- C. C. Halothane
- D. D. Isoflurane
Explanation: ***A. Sevoflurane*** - **Sevoflurane** is an inhalation anesthetic widely preferred for **pediatric induction** due to its rapid onset and non-pungent odor, which makes it well-tolerated by children. - Its low blood-gas partition coefficient allows for swift changes in anesthetic depth and rapid emergence. *B. Desflurane* - **Desflurane** has a **pungent odor** and is known to cause airway irritation, making it unsuitable for inhalational induction in children. - Its rapid onset and offset are beneficial, but its irritant properties limit its use for induction, especially in younger patients. *C. Halothane* - **Halothane** was previously used for pediatric induction but has largely been replaced due to its association with **hepatotoxicity** and cardiac arrhythmias. - It also has a slower onset and offset compared to newer agents like sevoflurane. *D. Isoflurane* - **Isoflurane** has a **pungent odor** and can cause airway irritation, making it less suitable for inhalational induction in children compared to sevoflurane. - While effective for maintenance, its irritant properties make for a less smooth and potentially distressing induction experience for pediatric patients.
Question 2: A patient admitted after a road traffic accident is put on mechanical ventilation. He opens his eyes on verbal command and moves all four limbs spontaneously. Calculate his GCS.
- A. Eyes-3, Verbal -NT, Motor-6 (Correct Answer)
- B. Eyes -3, Verbal-1, Motor -6
- C. Eyes-2, Verbal -1, Motor -5
- D. Eyes-2, Verbal -NT, Motor -5
Explanation: ***Eyes-3, Verbal -NT, Motor-6*** - **Eyes opening to verbal command** scores 3 points on the GCS [1]. - The patient is on **mechanical ventilation**, meaning their verbal response cannot be assessed, leading to a "Non-Testable" (NT) score for verbal [1]. **Spontaneous movement of all four limbs** indicates full motor function, scoring 6 points [2]. *Eyes -3, Verbal-1, Motor -6* - While **eyes opening to verbal command** (3 points) and **spontaneous motor movement** (6 points) are correct, a verbal score of 1 implies **no verbal response** if the patient were able to speak, which is not applicable here due to mechanical ventilation. *Eyes-2, Verbal -1, Motor -5* - **Eyes opening to pain** scores 2, but the patient responded to verbal command. A verbal score of 1 is for no response, and a motor score of 5 indicates localizing to pain, not spontaneous movement. *Eyes-2, Verbal -NT, Motor -5* - **Eyes opening to pain** scores 2, but the patient responded to verbal command (3 points). While **Verbal-NT** is correct due to mechanical ventilation, a motor score of 5 (localizes to pain) is incorrect, as the patient moved limbs spontaneously (6 points).
Question 3: Child with aspiration risk needs emergency surgery. Best induction sequence is:
- A. Preoxygenation-ketamine-succinylcholine
- B. Sevoflurane-propofol-succinylcholine
- C. Midazolam-propofol-rocuronium
- D. Preoxygenation-propofol-succinylcholine (Correct Answer)
Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.
Question 4: A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
- A. Sedate and reintubate
- B. Make him sit and do physiotherapy
- C. Assess the patient and give bag and mask ventilation and look for spontaneous breathing (Correct Answer)
- D. Give bag and mask ventilation and intubate
Explanation: ***Assess the patient and give bag and mask ventilation and look for spontaneous breathing*** - Upon accidental extubation, the immediate priority is to **assess the patient's airway, breathing, and circulation (ABCs)** and ensure oxygenation via **bag-mask ventilation** if needed, while observing for spontaneous breathing efforts. - This step allows for a controlled re-evaluation of the patient's respiratory status and provides time to plan for reintubation if indicated, without rushing into sedating or reintubating a potentially stable patient. *Sedate and reintubate* - While reintubation may ultimately be necessary, sedating and immediately attempting reintubation without prior assessment can be dangerous if the patient has **stable spontaneous breathing** or if there are other contributing factors like **airway swelling** that need to be addressed first. - Rushing to sedate and intubate could lead to complications if the patient's physiology is not fully understood post-extubation. *Make him sit and do physiotherapy* - This option is inappropriate for an intubated patient who has just accidentally self-extubated, as their airway and breathing status are of immediate concern. - Positioning for physiotherapy or performing chest physiotherapy is a secondary concern after ensuring **adequate oxygenation and ventilation** and confirming a stable airway. *Give bag and mask ventilation and intubate* - While bag-mask ventilation is an appropriate immediate step to maintain oxygenation, automatically proceeding to intubation without fully **assessing the patient's spontaneous breathing status** and overall stability is premature. - Some patients might tolerate extubation and breathe adequately on their own, negating the need for immediate reintubation.
Question 5: Shivering observed in the early part of the postoperative period is due to
- A. Hypothermia (Correct Answer)
- B. Pain
- C. Emergence delirium
- D. Drug withdrawal
Explanation: **Hypothermia** - Shivering is a primary physiological response to **hypothermia**, an attempt by the body to generate **heat** by increasing muscle activity. - Patients often experience a drop in core body temperature during surgery due to factors like cold operating rooms, exposed body cavities, and anesthetic effects. *Pain* - While pain can cause discomfort and muscle tension, it typically does not manifest as generalized **shivering** in the early postoperative period. - Pain is usually managed with analgesics, and shivering is more indicative of a **thermoregulatory disturbance**. *Emergence delirium* - Emergence delirium is characterized by disorientation, agitation, and non-purposeful movements, but not primarily by **shivering**. - This condition is often related to the residual effects of anesthetic agents or anxiety upon waking. *Drug withdrawal* - Drug withdrawal can cause tremors and agitation, but it is less likely to present as **shivering** in the immediate postoperative period in a patient without a known history of substance dependence. - Withdrawal symptoms typically manifest hours to days after the cessation of the drug, depending on its half-life.
Question 6: Emergence Delirium is characteristic of?
- A. Midazolam
- B. Thiopentone
- C. Opioids
- D. Ketamine (Correct Answer)
Explanation: ***Ketamine*** - **Emergence delirium**, characterized by vivid dreams, hallucinations, and confusion upon recovery from anesthesia, is a known side effect of **ketamine**, particularly in adults. - This effect is attributed to ketamine's action on **NMDA receptors** and can be attenuated by co-administration of benzodiazepines. *Midazolam* - **Midazolam** is a benzodiazepine often used for sedation and anxiolysis, and it typically causes amnesia and relaxation rather than a delirious state upon emergence. - While it can cause paradoxical agitation in some patients, it does not characteristically lead to emergence delirium similar to ketamine. *Thiopentone* - **Thiopentone** is a short-acting barbiturate used for induction of anesthesia, known for rapid onset and offset, leading to smooth emergence without significant delirium. - Its primary effect is general central nervous system depression, not dissociative anesthesia associated with emergence phenomena. *Opioids* - **Opioids** are potent analgesics that, at higher doses, can cause respiratory depression, nausea, and somnolence; however, they do not characteristically cause emergence delirium. - While they can contribute to postoperative cognitive dysfunction, it is distinct from the dissociative emergence state seen with ketamine.
Question 7: Patient was planned for surgery under GA, in the induction phase rocuronium was given 85mg but the anesthetist did not succeed in intubating. Which could be the best reversal agent used?
- A. Neostigmine (non-specific acetylcholinesterase inhibitor)
- B. Glycopyrrolate (anticholinergic agent)
- C. Edrophonium (non-specific acetylcholinesterase inhibitor)
- D. Sugammadex (specific reversal agent for rocuronium) (Correct Answer)
Explanation: ***Sugammadex (specific reversal agent for rocuronium)*** - **Sugammadex** is a modified gamma-cyclodextrin that forms a tight, water-soluble complex with **rocuronium**, effectively encapsulating and inactivating it. - It is highly effective for rapid reversal of **rocuronium**-induced neuromuscular blockade, especially in situations where immediate reversal is critical, such as a "cannot intubate, cannot ventilate" scenario. *Neostigmine (non-specific acetylcholinesterase inhibitor)* - **Neostigmine** acts by inhibiting **acetylcholinesterase**, increasing the amount of acetylcholine at the neuromuscular junction to overcome the competitive block. - Its reversal effect is slower and less reliable than sugammadex, especially after a large dose of rocuronium or deep blockade. *Glycopyrrolate (anticholinergic agent)* - **Glycopyrrolate** is an **anticholinergic** agent used to counteract the muscarinic side effects (e.g., bradycardia, salivation) of **acetylcholinesterase inhibitors** like neostigmine, but it has no direct reversal effect on neuromuscular blockade. - It is typically co-administered with neostigmine, not used as a standalone reversal agent for **rocuronium**. *Edrophonium (non-specific acetylcholinesterase inhibitor)* - **Edrophonium** is a short-acting **acetylcholinesterase inhibitor**, similar to neostigmine but with a more rapid onset and shorter duration of action. - It is less potent and effective than neostigmine for reversing moderate to deep neuromuscular blockade and would not be the best choice after a significant dose of **rocuronium**.
Question 8: Which of the following drugs is most effective in preventing emergence delirium with ketamine?
- A. Atropine
- B. Droperidol
- C. Thiopentone
- D. Midazolam (Correct Answer)
Explanation: ***Midazolam*** - **Midazolam**, a short-acting **benzodiazepine**, is highly effective in preventing and treating **emergence delirium** associated with ketamine. - Benzodiazepines like midazolam work by enhancing the effect of **GABA**, leading to anxiolytic, sedative, and amnesic effects that counteract the psychomimetic side effects of ketamine. *Atropine* - **Atropine** is an **anticholinergic drug** primarily used to prevent bradycardia and reduce secretions; it has no direct role in preventing or treating ketamine-induced emergence delirium. - Its mechanism of action involves blocking **muscarinic acetylcholine receptors**, which is unrelated to the psychomimetic effects of ketamine. *Droperidol* - **Droperidol** is a **butyrophenone** (dopamine antagonist) that can cause sedation and reduce the incidence of postoperative nausea and vomiting, but it is not the primary choice for ketamine-induced emergence delirium. - While it can provide sedation, its effectiveness in specifically targeting the psychomimetic effects of ketamine is less pronounced compared to benzodiazepines. *Thiopentone* - **Thiopentone** is a **barbiturate** commonly used for induction of anesthesia due to its rapid onset and short duration of action. - Although it provides sedation and hypnosis, it is not specifically indicated or highly effective in managing or preventing the **emergence delirium** associated with ketamine.
Question 9: All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
- A. Halothane
- B. Propofol (Correct Answer)
- C. Nitrous Oxide
- D. Opioids
Explanation: ***Propofol*** - Propofol is known to have **antiemetic properties** and is often used to reduce the incidence of postoperative nausea and vomiting (PONV). - Its mechanism involves modulating **GABA-A receptors** and potentially other pathways that suppress emetic responses. *Halothane* - **Inhalational anesthetics** like halothane are a significant risk factor for PONV, particularly in children and following surgeries like squint repair. - They tend to increase PONV by directly stimulating the **chemoreceptor trigger zone** and altering gut motility. *Opioids* - Opioids, commonly used for postoperative pain control, are a well-known cause of **nausea and vomiting**. - They activate **opioid receptors** in the chemoreceptor trigger zone and the gastrointestinal tract, leading to emesis and delayed gastric emptying. *Nitrous Oxide* - The use of **nitrous oxide** as part of a general anesthetic regimen has been consistently associated with an increased risk of PONV. - It is believed to contribute to PONV by increasing the risk of **bowel distension** and stimulating neurotransmitter release involved in emesis.
Question 10: Which of the following is contraindicated in an epileptic patient posted for general anesthesia?
- A. Propofol
- B. Midazolam
- C. Thiopentone
- D. Ketamine (Correct Answer)
Explanation: ***Ketamine*** - **Ketamine** is known to increase **intracranial pressure (ICP)** and can be associated with **psychotomimetic effects** and **seizure-like activity** in some patients. - While not an absolute contraindication for all epileptic patients, its use requires careful consideration due to the potential for **central nervous system stimulation** and **exacerbation of seizure disorders**. *Propofol* - **Propofol** generally has **antiepileptic properties** and can suppress seizure activity, making it a relatively safe choice for induction and maintenance of anesthesia in epileptic patients. - It reduces cerebral metabolic rate and **intracranial pressure**, which is beneficial in neurological contexts. *Midazolam* - **Midazolam** is a **benzodiazepine** with significant **antiepileptic activity**, commonly used to treat status epilepticus and as a premedication for surgery in epileptic patients. - It enhances **GABAergic inhibition**, thereby reducing neuronal excitability and seizure risk. *Thiopentone* - **Thiopentone**, a **barbiturate**, is a potent **antiepileptic agent** that effectively suppresses seizure activity by enhancing GABAergic transmission. - It is often used to induce anesthesia in patients with epilepsy due to its **cerebroprotective effects** and ability to decrease cerebral metabolic rate.
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