Combined Spinal-Epidural Anesthesia — MCQs
All of the following are complications of epidural anaesthesia, EXCEPT:
The gold standard of labor analgesia is which of the following:
What is the maximum concentration allowed for epidural block?
True about Epidural anesthesia:
Which of the following cannot be given by epidural anaesthesia?
Which is false regarding post dural puncture headache?
In spinal anesthesia, the drug is deposited between
Which of the following is advised for severe preeclampsia complicating cesarean delivery?
Which is not true about spinal anesthesia?
All are absolute contraindication of neuraxial anaesthesia except:
Combined Spinal-Epidural Anesthesia Indian Medical PG Practice Questions and MCQs
Question 1: All of the following are complications of epidural anaesthesia, EXCEPT:
- A. Urinary retention
- B. Total spinal analgesia
- C. Hypopnoea
- D. Hypertension (Correct Answer)
Explanation: ***Hypertension*** - Epidural anesthesia commonly causes **vasodilation** and a subsequent drop in **blood pressure** (hypotension), not hypertension, due to sympathetic blockade. - While hypertension can occur due to pain or anxiety during the procedure, it is not a direct physiological complication of the epidural anesthetic itself. *Urinary retention* - Epidural anesthesia can affect the nerves controlling the **bladder**, leading to temporary **urinary retention**. - This is a common complication, often requiring catheterization until the epidural wears off. *Total spinal analgesia* - This occurs if the epidural needle inadvertently punctures the **dura** and a large dose of local anesthetic is injected into the **subarachnoid space**. - It results in widespread **sensory and motor blockade**, potentially leading to respiratory arrest and hemodynamic collapse. *Hypopnoea* - High epidural blocks or accidental **intrathecal administration** can cause paralysis of **intercostal muscles** and the diaphragm. - This can lead to **respiratory depression** (hypopnoea) or even apnea, necessitating ventilatory support.
Question 2: The gold standard of labor analgesia is which of the following:
- A. Continuous lumbar epidural (Correct Answer)
- B. IV opioid infusion
- C. Continuous inhalational agent
- D. Nerve block
Explanation: ***Continuous lumbar epidural*** - Provides the most **effective and comprehensive pain relief** for labor, blocking sensory nerves from the uterus, cervix, and perineum. - Allows the mother to remain **awake and alert**, participate in the birth process, and can be easily titrated to maintain comfort. *IV opioid infusion* - Offers systemic pain relief but often causes **sedation** in both mother and baby and provides less effective pain relief compared to epidurals. - Can lead to **respiratory depression** in the neonate if administered too close to delivery. *Continuous inhalational agent* - Agents like nitrous oxide offer **mild to moderate analgesia** but can cause **nausea, dizziness, and incomplete pain relief** during active labor. - Not considered the gold standard due to its limited efficacy for severe labor pain. *Nerve block* - While effective for specific areas (e.g., pudendal block for perineal pain), nerve blocks are usually **surgical procedures** (e.g. cervical nerve block, paracervical block) and provide **localized pain relief only**, often not sufficient for global labor pain. - Unlike **epidurals**, they don't provide continuous, widespread pain management for all stages of labor.
Question 3: What is the maximum concentration allowed for epidural block?
- A. Chlorprocaine (Correct Answer)
- B. Lidocaine
- C. Ropivacaine
- D. Bupivacaine
Explanation: ***Chlorprocaine*** - **Chlorprocaine** is an ester-type local anesthetic that can be safely used in higher concentrations for epidural blocks up to **3%**, due to its rapid hydrolysis by plasma pseudocholinesterase, leading to a very short half-life and reduced systemic toxicity. - Its rapid metabolism minimizes the risk of accumulation and systemic toxicity, making it a suitable choice when a dense block is needed and a short duration of action is acceptable. *Lidocaine* - **Lidocaine** is an amide-type local anesthetic commonly used in epidural blocks, but its maximum concentration for this application is typically limited to **2%** to avoid systemic toxicity. - Higher concentrations of lidocaine are associated with an increased risk of neurological and cardiovascular adverse effects. *Ropivacaine* - **Ropivacaine** is an amide-type local anesthetic that is less cardiotoxic than bupivacaine, with common concentrations for epidural use ranging from **0.2% to 1%**. - Its maximum concentration is significantly lower than chlorprocaine due to its longer duration of action and potential for systemic toxicity at higher doses. *Bupivacaine* - **Bupivacaine** is a potent amide-type local anesthetic with a high risk of cardiotoxicity, and its maximum concentration for epidural use is generally restricted to **0.5%** or even less for continuous infusions. - Using concentrations above this limit significantly increases the risk of severe cardiovascular complications, including arrhythmias and cardiac arrest.
Question 4: True about Epidural anesthesia:
- A. Given in subarachnoid space
- B. Effects start immediately
- C. C/I in coagulopathies (Correct Answer)
- D. All of the options
Explanation: ***C/I in coagulopathies*** - **Coagulopathy** is a **contraindication** for epidural anesthesia due to the significant risk of **epidural hematoma** formation. - An epidural hematoma can compress the spinal cord, leading to **neurological damage** or **paralysis**. *Given in subarachnoid space* - Epidural anesthesia involves injecting anesthetic agents into the **epidural space**, which is superficial to the **dura mater**. - Injection into the **subarachnoid space** is characteristic of **spinal anesthesia**, not epidural anesthesia. *Effects start immediately* - The onset of action for epidural anesthesia is typically **slower** compared to spinal anesthesia, usually taking **10-20 minutes**. - This delay is due to the need for the anesthetic to diffuse across the dura and nerve roots to reach the spinal cord. *All of the options* - This option is incorrect because only one of the statements provided (C/I in coagulopathies) is true regarding epidural anesthesia. - The other statements about the injection site and onset of action are false.
Question 5: Which of the following cannot be given by epidural anaesthesia?
- A. Morphine
- B. Remifentanil (Correct Answer)
- C. Alfentanil
- D. Fentanyl
Explanation: ***Remifentanil*** - **Remifentanil** is specifically designed for **intravenous administration** and is rapidly metabolized by plasma esterases, making it unsuitable for epidural use. - Due to its short half-life and rapid metabolism, epidural administration would provide inconsistent and fleeting analgesia, and its breakdown products are not inert in the epidural space, potentially causing **neurotoxicity**. *Morphine* - **Morphine** is a commonly used opioid for **epidural analgesia** due to its hydrophilicity, allowing for prolonged action in the cerebrospinal fluid. - It provides effective **postoperative pain relief** and has a relatively slow onset but long duration of action when administered epidurally. *Alfentanil* - **Alfentanil** is a synthetic opioid that has been used for **epidural analgesia**, though less commonly than fentanyl or sufentanil, sometimes in conjunction with local anesthetics. - It has a faster onset and shorter duration of action compared to morphine, but still provides effective **analgesia** when administered epidurally. *Fentanyl* - **Fentanyl** is a widely used lipophilic opioid for **epidural analgesia**, often combined with local anesthetics, for both surgical and obstetric pain. - Its lipophilicity allows for rapid absorption and a relatively quick onset of action, providing effective **segmental analgesia**.
Question 6: Which is false regarding post dural puncture headache?
- A. Definitive cure is obtained with epidural blood patch
- B. Head ache is aggravated by sitting and relieved by lying down
- C. Incidence is reduced by pencil point spinal needles
- D. Longer the duration anesthesia , greater will be the chance of developing PDPH (Correct Answer)
Explanation: ***Longer the duration anesthesia , greater will be the chance of developing PDPH*** - This statement is **false** because the duration of epidural or spinal anesthesia does **not directly correlate** with the incidence of post-dural puncture headache (PDPH). - PDPH is primarily caused by **cerebrospinal fluid (CSF) leakage** through the dural puncture site, which is related to needle size, type, and technique, rather than the length of time anesthetic drugs are administered. *Definitive cure is obtained with epidural blood patch* - An **epidural blood patch** is considered the most effective and often definitive treatment, providing relief in over 90% of cases. - It works by injecting autologous blood into the epidural space, which then clots and seals the CSF leak. *Head ache is aggravated by sitting and relieved by lying down* - This is a **classic symptom** of PDPH, as CSF pressure decreases in the upright position, causing traction on pain-sensitive structures like blood vessels and nerves. - Lying flat reduces this traction, leading to symptomatic relief. *Incidence is reduced by pencil point spinal needles* - **Pencil-point needles** (e.g., Sprotte or Whitacre) push aside dural fibers rather than cutting them, leading to a smaller and more self-sealing dural defect. - This design significantly **reduces the risk** of CSF leakage and subsequent PDPH compared to cutting-tip needles (e.g., Quincke).
Question 7: In spinal anesthesia, the drug is deposited between
- A. Dura and arachnoid
- B. Pia and arachnoid (Correct Answer)
- C. Dura and vertebra
- D. Into the cord substance
Explanation: ***Pia and arachnoid*** - Spinal anesthesia involves injecting anesthetic into the **subarachnoid space**, which is the anatomical region located between the pia mater and the arachnoid mater. - This space contains **cerebrospinal fluid (CSF)**, allowing the anesthetic to mix and spread, blocking nerve impulses at the spinal cord roots. *Dura and arachnoid* - The space between the dura mater and arachnoid mater is the **subdural space**, and it is typically a potential space rather than an actual one for anesthetic injection. - Injecting here would lead to a **subdural block**, which is distinct from spinal anesthesia and has different characteristics and risks. *Dura and vertebra* - The space between the dura mater and the vertebral canal is the **epidural space**. - **Epidural anesthesia** involves injecting anesthetic into this space, but it is distinct from spinal anesthesia as the drug does not mix directly with CSF and requires a larger dose. *Into the cord substance* - Injecting anesthetic directly into the **spinal cord substance** (intrathecal injection into the cord) would be highly dangerous and cause severe neurological damage. - Anesthetic drugs exert their effect by blocking nerve roots as they exit the spinal cord, not by acting directly on the cord parenchyma.
Question 8: Which of the following is advised for severe preeclampsia complicating cesarean delivery?
- A. Epidural anesthesia (Correct Answer)
- B. Local infiltration
- C. Spinal anesthesia
- D. Combined spinal-epidural anesthesia
Explanation: ***Epidural anesthesia*** - **Epidural anesthesia** allows for a **gradual decrease in sympathetic tone** and blood pressure, which is beneficial in severe preeclampsia to avoid rapid hemodynamic changes. - It also provides excellent postoperative analgesia and can be used for **blood pressure control** if needed. *Local infiltration* - **Local infiltration** provides inadequate surgical anesthesia for a cesarean delivery and would be insufficient for pain management. - It does not offer any systemic benefits or control over the hemodynamic instability often seen in severe preeclampsia. *Spinal anesthesia* - **Spinal anesthesia** is generally contraindicated in severe preeclampsia due to the risk of a **sudden and profound drop in blood pressure**, which can compromise placental perfusion and maternal vital signs. - The rapid onset and intense sympathetic blockade can lead to **uncontrolled hypotension**, which is dangerous given the already compromised cardiovascular status. *Combined spinal-epidural anesthesia* - While **combined spinal-epidural (CSE)** offers rapid onset (spinal component) and titratability (epidural component), the **spinal component still carries the risk of significant hypotension**, similar to spinal anesthesia alone. - The initial rapid drop in blood pressure from the spinal component can be detrimental in a patient with severe preeclampsia, despite the subsequent epidural control.
Question 9: Which is not true about spinal anesthesia?
- A. Useful for lower limb surgery
- B. It produces more hemodynamic alteration than epidural anesthesia
- C. Produces complete sensory and motor paralysis below the level (Correct Answer)
- D. Autonomic fibers are affected above the sensory level
Explanation: ***Produces complete sensory and motor paralysis below the level*** - While spinal anesthesia produces significant sensory and motor blockade, it is rarely a **complete paralysis** below the level of injection, especially in terms of all muscle groups and deep sensation. - The degree of blockade depends on the **dose of anesthetic**, the patient's individual anatomy, and the spread of the drug within the cerebrospinal fluid, leading to a variable rather than absolute "complete" paralysis. *Useful for lower limb surgery* - Spinal anesthesia is **highly effective** and commonly used for lower limb surgeries as it provides excellent surgical anesthesia and postoperative analgesia. - It targets the nerve roots innervating the lower extremities, successfully blocking sensation and motor function, which is ideal for procedures like **knee or hip replacements**. *It produces more hemodynamic alteration than epidural anesthesia* - Spinal anesthesia typically causes a more **rapid and profound sympathetic blockade** than epidural anesthesia, due to direct and rapid diffusion of local anesthetic into the cerebrospinal fluid (CSF). - This rapid blockade often leads to a more significant and faster decrease in **blood pressure and heart rate** due to widespread vasodilation and reduced venous return. *Autonomic fibers are affected above the sensory level* - Sympathetic (autonomic) fibers are typically smaller and unmyelinated, making them **more susceptible to local anesthetic blockade** than sensory or motor fibers. - Therefore, the **sympathetic blockade** often extends two to three dermatomes higher than the sensory block, resulting in vasodilation and potential hemodynamic changes in areas above the perceived sensory level.
Question 10: All are absolute contraindication of neuraxial anaesthesia except:
- A. Spinal deformity (Correct Answer)
- B. Local infection of site
- C. Raised Intracranial pressure
- D. Coagulopathy
Explanation: ***Spinal deformity*** - While a **spinal deformity** can make neuraxial anesthesia technically challenging, it is generally considered a **relative contraindication**, not an absolute one. - The procedure can still be performed by an experienced anesthetist, potentially with imaging guidance, if the benefits outweigh the risks. *Local infection of site* - A **local infection** at the needle insertion site is an **absolute contraindication** due to the high risk of spreading infection into the central nervous system, leading to potentially life-threatening conditions such as **meningitis** or **epidural abscess**. - Introducing bacteria into the cerebrospinal fluid or epidural space is a severe complication to avoid. *Raised Intracranial pressure* - **Raised intracranial pressure (ICP)** is an **absolute contraindication** because puncturing the dura mater can lead to a rapid decrease in cerebrospinal fluid (CSF) pressure, resulting in brain herniation. - This sudden pressure gradient can cause devastating neurological injury or death. *Coagulopathy* - **Coagulopathy**, whether intrinsic (e.g., hemophilia) or iatrogenic (e.g., anticoagulation), is an **absolute contraindication** to neuraxial anesthesia. - The primary concern is the formation of an **epidural or spinal hematoma**, which can compress the spinal cord and lead to permanent neurological damage, including paralysis.
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