Post-Anesthesia Care Unit Operations — MCQs

10 questions

The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

In an accident case, after the arrival of medical team, all should be done in early management except;

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

Shivering observed in the early part of the postoperative period is due to

Assessment of pre-ductal O₂ saturation in PDA of a 3-minute-old infant is done at?

Depth of anaesthesia can be best assessed by

Early and reliable indication of air embolism during anaesthesia can be obtained by continuous monitoring of:

All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?

Postoperative nausea and vomiting are uncommon with

Q10

In a post operative intensive care unit, five patients developed post-operative wound infection on the same day. Which of the following is the best method to prevent cross infection among patients in the same ward?

Post-Anesthesia Care Unit Operations Indian Medical PG Practice Questions and MCQs

Question 1: The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

A. Oxygen saturation
B. Torso
C. Verbal response (Correct Answer)
D. Cry

Explanation: ***Verbal response*** - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is designed for children **under one year of age**, who are typically pre-verbal. - While verbal complaints are not assessed, a child's **verbal response** (e.g., moaning, crying, or not making sounds at all) in relation to pain is a component of the scale, contributing to the interpretation of their comfort level. *Oxygen saturation* - **Physiological parameters** like oxygen saturation are typically not part of behavioral pain scales like CHEOPS, which focus on observable behaviors. - While low oxygen saturation can indicate distress, it is not a direct measure of pain for this scale. *Torso* - The CHEOPS scale assesses **pain-related behaviors** of extremities (e.g., legs, arms) and facial expressions, but does not specifically include observations of the "torso" as a separate category. - Behaviors like stiffening or arching of the torso might be implicitly considered under overall body tension, but it’s not a distinct domain. *Cry* - The **quality and intensity of crying** is a primary behavioral indicator of pain in pre-verbal infants and is a significant component of many pediatric pain scales, including CHEOPS. - A child's cry, along with other behaviors, helps differentiate between various levels of discomfort or pain.

Question 2: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 3: 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 4: 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 5: Assessment of pre-ductal O₂ saturation in PDA of a 3-minute-old infant is done at?

A. Left upper limb
B. Left lower limb
C. Right upper limb (Correct Answer)
D. Right lower limb

Explanation: ***Right upper limb*** - Pre-ductal oxygen saturation is measured in the **right upper extremity** (right hand or wrist) because the blood supply to this limb comes from the **right subclavian artery**, which branches from the brachiocephalic trunk **before the ductus arteriosus**. - This ensures the reading reflects oxygenation of blood that has **not yet mixed with desaturated blood** from the pulmonary artery shunted through a patent ductus arteriosus (PDA). - In newborn screening for critical congenital heart disease, the right hand is the **gold standard site** for pre-ductal saturation measurement. *Left upper limb* - The left upper limb receives blood from the **left subclavian artery**, which branches from the aortic arch closer to the ductus arteriosus insertion point. - This makes it **less reliable** for obtaining a true pre-ductal reading, as it may be influenced by ductal flow patterns depending on PDA size and hemodynamics. - Therefore, the left arm is **not the preferred site** for pre-ductal saturation assessment. *Left lower limb* - Measuring oxygen saturation in the left lower limb provides a **post-ductal reading**. - This value represents blood that has **passed beyond the ductus arteriosus** and potentially mixed with desaturated pulmonary arterial blood if the PDA is patent. - This site is actually useful for **comparison with pre-ductal values** to assess for differential cyanosis. *Right lower limb* - Like the left lower limb, the right lower limb receives **post-ductal blood**. - This measures blood from the descending aorta that has passed the ductus arteriosus and potentially mixed with **deoxygenated blood** from the pulmonary circulation. - Post-ductal measurements are typically done at either foot.

Question 6: Depth of anaesthesia can be best assessed by

A. ABG analysis
B. Pulse oximeter
C. End tidal Pco2
D. Bispectral index (Correct Answer)

Explanation: ***Bispectral index*** - The **Bispectral Index (BIS)** monitor processes **electroencephalogram (EEG)** signals to provide a numerical value (0-100) indicating the **level of consciousness** and hypnotic depth during anesthesia. - A lower BIS value (typically 40-60) indicates a deeper anesthetic state, helping clinicians avoid **awareness during surgery** and guide anesthetic agent delivery. *ABG analysis* - **Arterial Blood Gas (ABG)** analysis measures parameters like pH, PCO2, PO2, and bicarbonate, reflecting the patient's **acid-base balance** and **oxygenation**. - While important for overall physiological status, ABG analysis does not directly assess the **depth of anesthesia** or the patient's level of consciousness. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation (SpO2)** and heart rate, reflecting the adequacy of oxygen delivery. - It does not provide information about the **depth of consciousness** or the hypnotic effect of anesthetic agents. *End tidal Pco2* - **End-tidal PCO2 (EtCO2)** monitors the partial pressure of carbon dioxide at the end of exhalation, providing an indication of **ventilation** and CO2 elimination. - While EtCO2 is crucial for managing ventilation during anesthesia, it does not directly reflect the **depth of anesthesia** or the patient's neurological state.

Question 7: Early and reliable indication of air embolism during anaesthesia can be obtained by continuous monitoring of:

A. Oxygen saturation
B. End Tidal CO2 (Correct Answer)
C. ECG
D. Blood pressure

Explanation: ***End Tidal CO2*** - A sudden and unexplained decrease in **End Tidal CO2 (EtCO2)** is often the first sign of an air embolism. - This occurs because air in the pulmonary circulation obstructs blood flow, leading to reduced CO2 delivery to the lungs. *Oxygen saturation* - **Oxygen saturation** changes are typically a later sign of air embolism, as significant pulmonary impairment or right-to-left shunting must occur before a drop is detectable. - A decrease in saturation indicates a more advanced and potentially severe embolism. *ECG* - **ECG changes**, such as arrhythmias or signs of right heart strain, are usually late and non-specific indicators of air embolism. - These changes reflect the cardiovascular consequences of the embolism rather than its initial event. *Blood pressure* - A drop in **blood pressure** is a late and often profound sign of an air embolism, reflecting significant cardiovascular compromise. - Early detection methods precede observable changes in systemic blood pressure.

Question 8: 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 9: Postoperative nausea and vomiting are uncommon with

A. Propofol (Correct Answer)
B. Etomidate
C. Thiopentone
D. All of the options

Explanation: ***Propofol*** - **Propofol** is known for its antiemetic properties, which contributes to a lower incidence of **postoperative nausea and vomiting (PONV)**. - Its mechanism involves modulating **dopaminergic activity** in the chemoreceptor trigger zone and possibly direct effects on serotonin receptors. *Etomidate* - While etomidate is a fast-acting induction agent, it does not inherently possess antiemetic properties. - Its use does not significantly reduce the risk of **PONV** compared to other induction agents, and some studies suggest it may even increase the risk slightly. *Thiopentone* - **Thiopentone**, a barbiturate, is typically associated with a higher incidence of **PONV** compared to propofol. - It does not offer any protective effect against nausea and vomiting and can contribute to these side effects in the postoperative period. *All of the options* - This option is incorrect because **etomidate** and **thiopentone** do not share the **antiemetic properties** of propofol. - Only **propofol** is specifically known to reduce the incidence of **PONV**.

Question 10: In a post operative intensive care unit, five patients developed post-operative wound infection on the same day. Which of the following is the best method to prevent cross infection among patients in the same ward?

A. Give antibiotics to all other patients in the ward
B. Practice proper hand washing (Correct Answer)
C. Disinfect the ward with sodium hypochlorite
D. Fumigate the ward

Explanation: ***Practice proper hand washing*** - **Proper hand washing** is the **single most effective measure** to prevent hospital-acquired infections, including cross-transmission of pathogens between patients in a ward. - It physically removes transient microorganisms acquired from patient contact or the environment, thus breaking the chain of infection. *Give antibiotics to all other patients in the ward* - This approach promotes **antibiotic resistance** and can disrupt the patients' normal flora, potentially leading to other infections like *Clostridioides difficile*. - Administering antibiotics prophylactically to uninfected patients is generally discouraged due to these risks and the lack of specific indication. *Disinfect the ward with sodium hypochlorite* - While **surface disinfection** is important, it is less effective than hand hygiene in preventing direct patient-to-patient transmission of pathogens carried by healthcare workers. - Frequent chemical disinfection of an entire ward with strong agents like **sodium hypochlorite** can also be harmful to equipment and may not address all modes of transmission effectively. *Fumigate the ward* - **Fumigation** is a drastic measure typically reserved for specific outbreaks or terminal disinfection, not for routine infection prevention in an occupied ICU. - It is often impractical, costly, requires patient evacuation, and may not target the primary vectors of cross-infection, such as direct contact via healthcare worker hands.

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