Patient-Controlled Analgesia — MCQs
Disadvantage of ketamine is?
Which cannot be administered via epidural anesthesia?
What is the narcotic of choice for outpatient anesthesia?
Which of the following anesthetic drugs is contraindicated in chronic renal failure?
In extraction, the best time to administer analgesics is:
True about epidural opioid are all except:
Which opioid drug is effectively administered via the transbuccal route?
What are the advantages associated with the use of ketamine?
In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?
All are management of PDPH except-
Patient-Controlled Analgesia Indian Medical PG Practice Questions and MCQs
Question 1: Disadvantage of ketamine is?
- A. Increased heart rate
- B. Delirium
- C. Increased ICP
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - **Ketamine** is known to cause several adverse effects, including **cardiovascular stimulation** (increased heart rate and blood pressure), **emergence phenomena** (delirium, vivid dreams, hallucinations), and an **increase in intracranial pressure (ICP)**. - Therefore, all the listed options are recognized disadvantages of ketamine use. *Increased heart rate* - **Ketamine** has significant **sympathomimetic effects**, leading to increased release of **catecholamines** and direct cardiac stimulation, which results in an elevated heart rate. - This effect can be particularly concerning in patients with pre-existing **cardiovascular disease**. *Delirium* - **Emergence phenomena** are a well-known side effect of ketamine, particularly in adults, manifesting as **delirium**, vivid or unpleasant dreams, and hallucinations as the patient recovers consciousness. - These psychological effects are attributed to ketamine's action on the **N-methyl-D-aspartate (NMDA) receptors** in the brain. *Increased ICP* - **Ketamine** can cause an increase in **cerebral blood flow (CBF)** and **intracranial pressure (ICP)**, which is a significant concern in patients with **head injuries** or pre-existing intracranial pathology. - This effect is due to cerebral vasodilation and increased metabolic demand, making it generally avoided in neurosurgical settings unless brain protective strategies are in place.
Question 2: Which cannot be administered via epidural anesthesia?
- A. Morphine
- B. Alfentanil
- C. Fentanyl
- D. Remifentanil (Correct Answer)
Explanation: ***Remifentanil*** - **Remifentanil** is specifically designed for **continuous intravenous infusion** due to its **ultra-short duration of action** and rapid metabolism by plasma esterases. - Its rapid metabolism **precludes its use for epidural administration** as it would not provide sustained analgesia and its pharmacokinetic profile is not suitable for the epidural space. *Morphine* - **Morphine** is a commonly used opioid for **epidural analgesia** due to its relatively **long duration of action** and hydrophilic properties, allowing it to spread effectively within the CSF. - It provides **prolonged relief** from pain, particularly for postoperative or obstetric analgesia. *Alfentanil* - **Alfentanil** is a **synthetic opioid** that can be administered epidurally, although it is more commonly used intravenously. - It has a **faster onset and shorter duration** than morphine, making it suitable for certain epidural applications requiring rapid but not prolonged effect. *Fentanyl* - **Fentanyl** is a potent, **lipophilic opioid** frequently used for **epidural anesthesia** and analgesia. - Its lipid solubility allows for **rapid onset** of action due to quick absorption into neural tissue, but its duration is shorter than morphine.
Question 3: What is the narcotic of choice for outpatient anesthesia?
- A. Morphine
- B. Alfentanil (Correct Answer)
- C. Fentanyl
- D. Pethidine
Explanation: ***Alfentanil*** - **Alfentanil** has a **rapid onset** and **short duration of action** due to its low pKa (6.5) and high unionized fraction at physiologic pH, making it ideal for maintaining a stable anesthetic plane and rapid recovery in an outpatient setting. - Its **predictable pharmacokinetic profile** allows for precise titration and minimizes the risk of prolonged sedation post-procedure. *Morphine* - **Morphine** has a relatively **long duration of action** and active metabolites that can prolong sedation and respiratory depression, which is undesirable for outpatient procedures. - Its slower onset often requires higher initial doses, increasing the risk of **postoperative nausea and vomiting (PONV)**. *Fentanyl* - While **fentanyl** has a rapid onset and is potent, its **longer context-sensitive half-time** compared to alfentanil can lead to a slightly longer recovery profile, especially with prolonged infusions. - Its high lipophilicity can lead to drug accumulation in tissues, potentially prolonging its effects in outpatient settings. *Pethidine* - **Pethidine** (meperidine) has an **active metabolite, normeperidine**, which can accumulate and cause neurotoxicity (e.g., seizures), particularly with repeated doses or in patients with renal impairment. - It also has a **longer duration of action** and is associated with a higher incidence of tachycardia and other side effects compared to newer synthetic opioids.
Question 4: Which of the following anesthetic drugs is contraindicated in chronic renal failure?
- A. Atracurium
- B. Fentanyl
- C. Pethidine (Correct Answer)
- D. Morphine
Explanation: ***Pethidine*** - **Pethidine** is contraindicated in chronic renal failure due to its active metabolite, **normeperidine**, which is eliminated renally. - Accumulation of **normeperidine** can lead to **central nervous system (CNS) toxicity**, including seizures, tremors, and hyperreflexia. *Atracurium* - **Atracurium** undergoes **Hofmann elimination** and **ester hydrolysis**, which are independent of renal or hepatic function. - This makes it a relatively safe choice for patients with **renal impairment**. *Fentanyl* - **Fentanyl** is primarily metabolized by the liver, with its metabolites being inactive. - While some dose adjustment may be considered in severe renal failure, it is generally **safe** for use in patients with chronic renal impairment as its metabolites are inactive. *Morphine* - **Morphine** is metabolized in the liver to **morphine-3-glucuronide (M3G)** and **morphine-6-glucuronide (M6G)**, both of which are renally excreted. - **M6G** is an active metabolite with potent analgesic effects, and its accumulation in renal failure can cause **prolonged sedation** and **respiratory depression**. While significant caution and dose reduction are needed, it's not strictly contraindicated in the same way pethidine is due to the more neurotoxic nature of normeperidine.
Question 5: In extraction, the best time to administer analgesics is:
- A. Prior to the procedure (Correct Answer)
- B. After anaesthesia has worn off
- C. When pain is moderate to severe
- D. Just before anaesthesia wears off
Explanation: ***Prior to the procedure*** - Administering analgesics **preemptively** helps to reduce the overall perception of pain post-operatively by blocking pain pathways before they are fully activated. - This approach is known as **preemptive analgesia** and has been shown to reduce post-operative pain intensity and analgesic consumption. *After anaesthesia has worn off* - Waiting until the anesthesia has worn off means the patient will likely experience the onset of significant pain, making it harder to control effectively. - This approach is reactive rather than proactive, and does not leverage the benefits of **preemptive pain management**. *When pain is moderate to severe* - At this point, the pain is already established and may be more difficult to manage, requiring higher doses or stronger analgesics. - **Pain management** is more effective when initiated before pain becomes severe, preventing the sensitization of pain pathways. *Just before anaesthesia wears off* - While this is better than waiting until the anesthesia has completely worn off, it still misses the opportunity for **preemptive analgesia**. - The pain pathways may already be activated or becoming sensitized as the anesthetic effect diminishes, making it less effective than administering prior to the procedure.
Question 6: True about epidural opioid are all except:
- A. Act on dorsal horn substantia gelatinosa
- B. Can cause Itching
- C. Can cause respiratory depression
- D. Function of the intestine is not affected (Correct Answer)
Explanation: **Function of the intestine is not affected** - **Epidural opioids** can indeed cause **constipation** and other gastrointestinal side effects by affecting opioid receptors in the **gut wall**, thus disturbing normal intestinal motility. - The phrase "not affected" is incorrect because **opioids inherently reduce gastrointestinal motility**, leading to common side effects such as nausea, vomiting, and constipation. *Act on dorsal horn substantia gelatinosa* - This statement is true; **epidural opioids work primarily by binding to opioid receptors** in the **substantia gelatinosa** of the dorsal horn of the spinal cord. - This binding **inhibits the release of neurotransmitters** like substance P, thus preventing the transmission of pain signals. *Can cause Itching* - **Pruritus (itching)** is a very common side effect of **epidural opioids**, often concentrated around the face and trunk. - It results from the **activation of opioid receptors** in the central nervous system and the release of histamine. *Can cause respiratory depression* - **Respiratory depression** is a serious and potentially life-threatening side effect of **epidural opioids**, particularly with higher doses or systemic absorption. - It occurs due to the **suppression of the medullary respiratory centers** in the brainstem.
Question 7: Which opioid drug is effectively administered via the transbuccal route?
- A. Sulfentanil
- B. Remifentanil
- C. Fentanyl (Correct Answer)
- D. Alfentanil
Explanation: ***Fentanyl*** - **Fentanyl** is a potent, **lipophilic opioid** that is well-absorbed through mucous membranes, making it suitable for **transbuccal administration**. - Its high potency and rapid onset of action when administered transbuccally make it useful for breakthrough pain or rapid analgesia. *Sulfentanil* - While also a potent opioid, **sulfentanil** is primarily used intravenously for anesthesia and is not commonly formulated or administered via the transbuccal route. - Its chemical properties and pharmacokinetic profile do not lend themselves as readily to transbuccal absorption compared to fentanyl for practical clinical use. *Remifentanil* - **Remifentanil** is an **ultra-short-acting opioid** metabolized by plasma esterases, making it ideal for continuous intravenous infusions where rapid offset is desired. - Its rapid metabolism and specific pharmacokinetic properties make it unsuitable for transbuccal extended release or sustained absorption. *Alfentanil* - **Alfentanil** is a short-acting opioid predominantly used intravenously for induction and maintenance of anesthesia. - Although it has a rapid onset, it is not optimized or commonly utilized for transbuccal administration due to its lower lipophilicity and different absorption characteristics compared to fentanyl.
Question 8: What are the advantages associated with the use of ketamine?
- A. Rapid onset of anesthesia and analgesia
- B. Bronchodilation and preserved airway reflexes
- C. Cardiovascular stability with minimal respiratory depression
- D. All of the above (Correct Answer)
Explanation: ***All of the above*** - Ketamine provides a unique combination of **rapid onset of anesthesia**, potent **analgesia**, and desirable physiological effects, making it versatile for various clinical scenarios. - Its ability to induce **dissociative anesthesia** while maintaining spontaneous respiration and cardiovascular stability distinguishes it from many other anesthetic agents. *Rapid onset of anesthesia and analgesia* - This is a key advantage, as ketamine quickly achieves an anesthetic state and provides robust pain relief. - Its rapid action allows for efficient induction and management in emergency settings or procedures requiring prompt intervention. *Bronchodilation and preserved airway reflexes* - Ketamine's **bronchodilatory effect** makes it a favorable choice in patients with reactive airway diseases like asthma. - The **preservation of airway reflexes** helps protect against aspiration, which is a significant benefit compared to other anesthetics that depress these reflexes. *Cardiovascular stability with minimal respiratory depression* - Ketamine typically causes an increase in **heart rate and blood pressure**, contributing to cardiovascular stability, especially in patients with compromised hemodynamics. - Compared to many other anesthetics, ketamine causes **minimal respiratory depression**, maintaining spontaneous breathing and reducing the need for mechanical ventilation.
Question 9: In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?
- A. 2000 ml Ringer's lactate bolus
- B. 1000 ml Ringer's lactate bolus, then regulated by clinical indicators (Correct Answer)
- C. 250 ml Ringer's lactate bolus
- D. 500 ml Ringer's lactate bolus, then regulated by clinical indicators
Explanation: ***1000 ml Ringer's lactate bolus, then regulated by clinical indicators*** - For **hemodynamically unstable** polytrauma patients, the initial recommended crystalloid bolus is typically **1 liter (1000 mL)** of Ringer's lactate. - This initial bolus allows for rapid assessment of the patient's response and guides subsequent fluid management based on **clinical indicators** such as blood pressure, heart rate, and urine output, avoiding over-resuscitation. *2000 ml Ringer's lactate bolus* - A **2000 ml bolus** is generally considered too large for an initial dose in trauma, as it can lead to **dilutional coagulopathy**, worsening hemorrhage, and **abnormal fluid shifts**, especially in cases where definitive hemorrhage control is not yet achieved. - Excessive fluid administration can lead to complications such as **abdominal compartment syndrome** and **acute respiratory distress syndrome (ARDS)**. *250 ml Ringer's lactate bolus* - A **250 ml bolus** is generally too small to effectively address **hemodynamic instability** in a polytrauma patient, offering insufficient volume to significantly improve circulation or organ perfusion. - While small boluses might be used in specific situations (e.g., small children or patients with cardiac comorbidities), this dose is not adequate for initial resuscitation in a severely unstable adult trauma patient. *500 ml Ringer's lactate bolus, then regulated by clinical indicators* - While **500 mL** is a common bolus size in other medical settings, it may be insufficient for the initial resuscitation of a **hemodynamically unstable adult polytrauma patient**. - Current trauma guidelines often recommend a larger initial bolus (e.g., 1000 mL) to gain a more immediate and measurable hemodynamic response for assessment.
Question 10: All are management of PDPH except-
- A. Stool softeners (Correct Answer)
- B. Analgesic + caffeine
- C. Intravenous / oral fluids
- D. Upright position
Explanation: ***Stool softeners*** - While **stool softeners** may be prescribed to prevent **straining** in patients experiencing PDPH, they do not directly treat the underlying cause or symptoms of PDPH. - The primary goal of PDPH management is to re-establish **CSF pressure** and relieve headache, which stool softeners do not achieve. *Analgesic + caffeine* - **Caffeine** is a common component of PDPH management as it causes **cerebral vasoconstriction**, which can help alleviate the headache. - **Analgesics** (e.g., NSAIDs, opioids) are used to manage the pain associated with PDPH. *Intravenous / oral fluids* - Increasing **fluid intake**, both oral and intravenous, helps to promote **CSF production** and potentially increase intracranial pressure, thereby alleviating PDPH symptoms. - This is a supportive measure for rehydration and to potentially restore **CSF volume**. *Upright position* - An **upright position** typically **worsens** PDPH symptoms because it increases the gravitational pull on the CSF, further lowering intracranial pressure. - Patients with PDPH are usually advised to maintain a **supine (flat)** position to minimize headache severity.
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