Common PACU Complications — MCQs
A postoperative patient with pH 7.25, MAP (mean arterial pressure) 60 mm Hg is treated with?
One of the most important complication of tracheostomy is:
Which of the following intravenous anaesthetic agent causes decrease in postoperative nausea and vomiting :
Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?
Problems which may result from hypotensive anesthesia include:
Which of the following agents is used for the treatment of post operative shivering?
Most common post-operative complication of spinal anesthesia?
A patient with multiple gallstones shows 8 mm dilation and has 4 stones in the common bile duct (CBD). What is the best treatment modality?
What causes sudden decreased end tidal CO2 in GA?
Which intravenous anaesthetic agent has analgesic effect also
Common PACU Complications Indian Medical PG Practice Questions and MCQs
Question 1: A postoperative patient with pH 7.25, MAP (mean arterial pressure) 60 mm Hg is treated with?
- A. Only normal saline
- B. fluid restriction
- C. Fluid therapy with CVP monitoring (Correct Answer)
- D. I.V. sodium bicarbonate
Explanation: ***Fluid therapy with CVP monitoring*** - The patient's **MAP of 60 mmHg** indicates **hypotension** and potential **hypovolemic shock**, while pH 7.25 suggests **acidosis**, which could be metabolic due to poor perfusion. Initial treatment should focus on **restoring circulating volume** to improve blood pressure and organ perfusion. - **Central venous pressure (CVP) monitoring** is crucial to guide fluid resuscitation. It helps assess the patient's fluid status and ensures that enough fluid is given to improve cardiac output without causing fluid overload, especially in a severely ill patient. *Only normal saline* - While normal saline is used for fluid resuscitation, simply stating "only normal saline" is insufficient because it doesn't address the **critical need for monitoring** to guide treatment. - The amount and rate of fluid administration need to be carefully controlled based on the patient's response and hemodynamic parameters. *Fluid restriction* - **Fluid restriction** would be contraindicated in this patient because the **low MAP** suggests **hypovolemia or cardiogenic shock**, requiring fluid repletion, not restriction. - Restricting fluids could further worsen hypotension and organ hypoperfusion, leading to increased acidosis and organ damage. *I.V. sodium bicarbonate* - Administering **I.V. sodium bicarbonate** to correct acidosis without addressing the underlying cause of hypotension and poor perfusion is generally not recommended. - The acidosis (pH 7.25) is likely due to **poor tissue oxygenation and lactic acid production** from inadequate blood flow; correcting this with fluids will resolve the acidosis.
Question 2: One of the most important complication of tracheostomy is:
- A. Hemorrhage
- B. Surgical emphysema
- C. Displacement of tube (Correct Answer)
- D. Recurrent laryngeal nerve palsy
Explanation: ***Displacement of tube*** - **Accidental decannulation** or displacement of the tracheostomy tube is considered one of the most serious and common complications, particularly in the immediate post-operative period. - This can lead to **loss of airway**, requiring immediate intervention to prevent severe hypoxia and potential brain injury or death. *Hemorrhage* - While hemorrhage can occur during or after tracheostomy, it is often a concern during the procedure or in the immediate postoperative period and is usually managed effectively. - Significant, life-threatening hemorrhage such as **tracheo-innominate fistula** is a rare but severe complication. *Surgical emphysema* - Surgical emphysema (subcutaneous emphysema) is a relatively common but usually benign complication that occurs when air leaks from the trachea into the subcutaneous tissues. - It typically resolves spontaneously and rarely poses a direct threat to the airway unless severe and rapidly progressive. *Recurrent laryngeal nerve palsy* - **Recurrent laryngeal nerve injury** is a rare complication of tracheostomy, as the nerve is usually well clear of the incision site in the neck. - While it can cause hoarseness or vocal cord paralysis, it typically does not present an immediate life-threatening situation or emergency comparable to airway compromise.
Question 3: Which of the following intravenous anaesthetic agent causes decrease in postoperative nausea and vomiting :
- A. Propofol (Correct Answer)
- B. Etomidate
- C. Ketamine
- D. Thiopentone
Explanation: ***Propofol*** - **Propofol** has antiemetic properties, which contributes to a reduced incidence of **postoperative nausea and vomiting (PONV)**. - Its mechanism of action in reducing PONV is thought to involve effects on **dopaminergic receptors** and **serotonin pathways** in the brain. *Etomidate* - **Etomidate** is not known to significantly reduce PONV and may even have a neutral effect or slightly increase it compared to propofol. - Its primary advantages include **cardiovascular stability**, which is unrelated to antiemetic effects. *Ketamine* - **Ketamine** is associated with a higher incidence of PONV, especially at higher doses, due to its **psychedelic side effects** and stimulation of the chemoreceptor trigger zone. - It is known for causing **emergence delirium** and does not possess antiemetic properties. *Thiopentone* - **Thiopentone** (Thiopental) does not have any significant antiemetic properties and is not typically used for its effect on PONV. - It was historically used as an induction agent but has largely been replaced by newer drugs like propofol.
Question 4: Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?
- A. Lorazepam
- B. Metoclopramide
- C. Promethazine
- D. Ondansetron (Correct Answer)
Explanation: ***Ondansetron*** - **Ondansetron** is a **5-HT3 receptor antagonist** and is considered a first-line agent due to its high efficacy and favorable side effect profile in preventing PONV. - It works by blocking serotonin receptors in the **chemoreceptor trigger zone** and the **gastrointestinal tract**, reducing the sensation of nausea and vomiting. *Lorazepam* - **Lorazepam** is a **benzodiazepine** primarily used for its **anxiolytic** and **sedative effects**, and sometimes as an adjunct for refractory nausea, but not as a first-line antiemetic for PONV prophylaxis. - While it can help indirectly by reducing anxiety, it does not directly target the key pathways involved in PONV as effectively as 5-HT3 antagonists. *Phenytoin* - **Phenytoin** is an **anticonvulsant** medication used to prevent seizures and has no role in the direct treatment or prophylaxis of PONV. - It primarily acts on voltage-gated sodium channels in neurons and does not possess antiemetic properties. *Metoclopramide* - **Metoclopramide** is a **dopamine D2 receptor antagonist** and a **prokinetic agent** that can be used for PONV, particularly when gastric stasis is a concern. - However, it is generally considered a second-line agent due to the risk of **extrapyramidal side effects**, especially with higher doses or prolonged use. *Promethazine* - **Promethazine** is a **first-generation antihistamine** with **antidopaminergic** and **anticholinergic properties** that can be effective for nausea and vomiting. - It is often used as a rescue antiemetic or in combination therapy, but its sedative effects and potential for extrapyramidal symptoms make it less preferable as a first-line prophylactic agent compared to ondansetron.
Question 5: 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 6: Which of the following agents is used for the treatment of post operative shivering?
- A. Atropine
- B. Thiopentone
- C. Pethidine (Correct Answer)
- D. Suxamethonium
Explanation: ***Pethidine*** - **Pethidine (meperidine)** is a **synthetic opioid** known for its **mu-receptor agonism** and weak anticholinergic properties, making it effective in treating **post-operative shivering**. - Its mechanism in reducing shivering is thought to involve modulation of the **thermoregulatory center** in the hypothalamus. *Atropine* - **Atropine** is an **anticholinergic drug** that primarily blocks muscarinic acetylcholine receptors, leading to effects like increased heart rate and decreased secretions. - It does not directly act on the thermoregulatory centers or muscle activity responsible for shivering. *Thiopentone* - **Thiopentone** is a **barbiturate** used as an intravenous anesthetic, primarily for induction of anesthesia. - While it has CNS depressant effects, it is not indicated or effective for the specific treatment of post-operative shivering. *Suxamethonium* - **Suxamethonium (succinylcholine)** is a **depolarizing neuromuscular blocker** used to induce muscle paralysis, typically for intubation. - It would prevent shivering by paralyzing skeletal muscles, but this is a dangerous and inappropriate treatment for shivering due to its profound respiratory depressant effects.
Question 7: Most common post-operative complication of spinal anesthesia?
- A. Post-dural puncture headache
- B. Hypotension due to spinal anesthesia (Correct Answer)
- C. Urinary retention post-anesthesia
- D. Infection leading to meningitis
Explanation: ***Hypotension due to spinal anesthesia*** - **Hypotension** is the **most common** immediate complication of spinal anesthesia due to **sympathetic blockade**, leading to **vasodilation** and decreased venous return. - This effect is often dose-dependent and can be managed with fluids and vasopressors if clinically significant. *Post-dural puncture headache* - While a notable complication, a **post-dural puncture headache (PDPH)** is less common than hypotension, occurring in a smaller percentage of spinal anesthesia cases. - PDPH results from persistent leakage of **cerebrospinal fluid** through the dural puncture site, leading to intracranial hypotension. *Urinary retention post-anesthesia* - **Urinary retention** is a relatively common complication after spinal anesthesia, but it is typically not as immediate or frequent as hypotension. - It occurs due to the **blockade of sacral parasympathetic nerves** that control bladder function, requiring temporary catheterization in some cases. *Infection leading to meningitis* - **Meningitis** is a **rare but severe** complication of spinal anesthesia, usually resulting from inadequate aseptic technique during the procedure. - Its incidence is very low compared to hemodynamic changes or even PDPH.
Question 8: A patient with multiple gallstones shows 8 mm dilation and has 4 stones in the common bile duct (CBD). What is the best treatment modality?
- A. ESWL
- B. ERCP followed by cholecystectomy (Correct Answer)
- C. None of the options
- D. Cholecystectomy with choledocholithotomy at the same setting
Explanation: ***ERCP followed by cholecystectomy*** - This is the **current standard of care** for managing choledocholithiasis with cholecystolithiasis - **ERCP with sphincterotomy** effectively clears CBD stones with success rates >90% - Followed by **laparoscopic cholecystectomy** (either during same admission or within 2 weeks) - This approach is **minimally invasive**, has lower morbidity, and shorter hospital stay compared to open surgery - Pre-operative ERCP is preferred when CBD stones are confirmed pre-operatively *Cholecystectomy with choledocholithotomy at the same setting* - This represents **open surgical approach** which is now largely **outdated** - Reserved only for cases where ERCP fails or is unavailable - Associated with higher morbidity, longer recovery, and larger incisions - **Laparoscopic CBD exploration** is preferred over open approach if surgical clearance is needed *ESWL (Extracorporeal Shock Wave Lithotripsy)* - ESWL is **not indicated for CBD stones** - Primarily used for **kidney stones** and occasionally for large gallbladder stones - CBD stones require endoscopic or surgical removal - Risk of stone fragments causing obstruction or pancreatitis *None of the options* - ERCP followed by cholecystectomy is the appropriate modern management - This option is not applicable as a correct option exists
Question 9: What causes sudden decreased end tidal CO2 in GA?
- A. Cardiac arrest (Correct Answer)
- B. Pulmonary embolism
- C. Pulmonary hypertension
- D. Malignant hyperthermia
Explanation: ***Cardiac arrest*** - In **cardiac arrest**, there is a sudden cessation of effective **cardiac output**, which leads to a dramatic reduction in pulmonary blood flow. - As a result, **CO2 is not transported to the lungs** for exhalation, causing an abrupt and severe drop in **end-tidal CO2**. *Pulmonary embolism* - A **pulmonary embolism** causes an acute obstruction of pulmonary arterial blood flow, leading to an **increase in alveolar dead space**. - While it can decrease **end-tidal CO2** due to reduced perfusion, the drop is often less sudden and complete than in cardiac arrest, and the primary mechanism is **ventilation-perfusion mismatch**. *Pulmonary hypertension* - **Pulmonary hypertension** involves chronically elevated pressures in the pulmonary arteries, which can lead to **right ventricular dysfunction** and reduced cardiac output over time. - It typically causes a more gradual and chronic reduction in **end-tidal CO2** due to impaired gas exchange, rather than a sudden, precipitous drop. *Malignant hyperthermia* - **Malignant hyperthermia** is characterized by a rapid and severe increase in **metabolic rate** and CO2 production. - This condition typically leads to a **sudden increase in end-tidal CO2** as the body produces more CO2 than can be eliminated, rather than a decrease.
Question 10: Which intravenous anaesthetic agent has analgesic effect also
- A. Thiopentone
- B. Ketamine (Correct Answer)
- C. Propofol
- D. Etomidate
Explanation: ***Ketamine*** - Ketamine acts as an **N-methyl-D-aspartate (NMDA) receptor antagonist**, providing significant **analgesia** in addition to its anaesthetic effects. - It induces a state of **dissociative anaesthesia**, where the patient appears awake but is unresponsive to pain, making it unique among intravenous anaesthetics. *Thiopentone* - Thiopentone is a **barbiturate** that acts as a potent hypnotic and anaesthetic but provides no significant analgesic properties. - It can even cause **anti-analgesia** (hyperalgesia) at sub-hypnotic doses, increasing sensitivity to pain. *Propofol* - Propofol is a potent intravenous anaesthetic that works primarily as a **GABA-A receptor agonist**, but it lacks intrinsic analgesic properties. - While it can cause some sedation and reduced pain perception due to CNS depression, it does not directly modulate pain pathways in the way an analgesic would. *Etomidate* - Etomidate is a hypnotic agent highly valued for its **cardiovascular stability**, making it suitable for patients with compromised cardiac function. - Like propofol and thiopentone, etomidate primarily acts on **GABA-A receptors** to induce unconsciousness and offers no significant analgesic effects.
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