Regional Anesthesia Practice Questions

Q: Local anaesthetic usually used for retrobulbar block -

Bupivacaine. ***Bupivacaine*** - **Bupivacaine** is a long-acting local anaesthetic commonly chosen for retrobulbar blocks due to its prolonged duration of action, providing extended pain relief and akinesia. - Its slower onset compared to some other agents is often acceptable for ophthalmic procedures where prolonged block is more critical than rapid onset. *Prilocaine* - **Prilocaine** is an intermediate-acting local anaesthetic, generally having a shorter duration of action than bupivacaine, making it less ideal for procedures requiring sustained blockade. - High doses of prilocaine are associated with the risk of **methemoglobinemia**, which is a significant consideration in its use. *Tetracaine* - **Tetracaine** is primarily used as a topical anaesthetic, particularly for surface anaesthesia of the eye (e.g., prior to drops or contact lens insertion). - It is not typically used for injection in retrobulbar blocks due to its high systemic toxicity when administered via injection and its short duration of action. *Procaine* - **Procaine** is a short-acting ester-type local anaesthetic with a rapid onset but very brief duration of action. - Its short duration makes it unsuitable for retrobulbar blocks where prolonged akinesia and anaesthesia are desired for the surgical procedure.

Q: In Bier's block anesthetic agent given by which route?

Intravenous. ***Intravenous*** - In a **Bier's block** (intravenous regional anesthesia), the anesthetic agent is injected directly into a **peripheral vein** of the limb to be anesthetized. - A **tourniquet** is applied proximally to the injection site to prevent the anesthetic from reaching systemic circulation and to confine it to the limb. *Dermal* - **Dermal administration** involves applying the anesthetic agent to the skin surface, typically for topical numbing or local infiltration. - This route is used for procedures like laceration repair or skin biopsies and would not achieve regional anesthesia for a limb. *Peribulbar region* - The **peribulbar region** refers to the area around the eyeball, and anesthetic agents injected here are used for **ocular anesthesia** during eye surgeries. - This route is specific to ophthalmology and completely unrelated to limb anesthesia. *Retrobulbar area* - The **retrobulbar area** is located behind the eyeball, and injections here provide a deeper form of **ocular anesthesia** compared to peribulbar blocks. - Like peribulbar injections, this method is exclusively used for eye procedures and not for limb blocks.

Q: Post Spinal Headache can last for

7 - 10 days. ***7 - 10 days*** - **Post-dural puncture headache (PDPH)** typically has a self-limiting course, with symptoms usually resolving within **one to two weeks**. - The duration is often attributed to the continued leakage of **cerebrospinal fluid (CSF)** through the dural puncture site. *Upto 10 months* - While chronic daily headache can occur following dural puncture, a duration of **10 months** is extremely long and atypical for uncomplicated PDPH. - Such prolonged headaches would warrant investigation for alternative or **secondary causes** of headache. *Upto 10 hours* - Although some mild headaches after dural puncture may resolve quickly, a typical **post-dural puncture headache** usually persists for at least **24-48 hours** to several days. - Headaches resolving within **10 hours** are often considered to be non-PDPH or a mild, transient headache. *Upto 10 min* - A headache lasting only **10 minutes** is highly unlikely to be a true post-dural puncture headache (PDPH). - PDPH is characterized by a **positional headache** that worsens in the upright position and improves with recumbency, typically lasting for days.

Q: An anesthesia resident was giving spinal anesthesia when the patient had sudden aphonia and loss of consciousness. What could have happened?

Total spinal. ***Total spinal*** - A **total spinal** involves widespread blockade of spinal nerves, including those supplying the brainstem, leading to **aphonia** and **loss of consciousness** due to severe hypotension and respiratory depression. - This occurs when the local anesthetic spreads extensively cephalad, affecting the cervical and cranial nerves. *Vasovagal attack* - While a vasovagal attack can cause **loss of consciousness** due to transient hypotension and bradycardia, it does not typically cause **aphonia**. - Symptoms usually include nausea, pallor, and sweating, and recovery is often rapid once the patient is recumbent. *Intravascular injection* - **Intravascular injection** of local anesthetic during spinal anesthesia can cause systemic toxicity, leading to seizures, cardiac arrhythmias, or cardiac arrest, but not typically sudden **aphonia** as the primary presenting symptom. - It's a risk, but the presenting symptoms usually differ. *Partial spinal* - A **partial spinal** refers to inadequate or uneven spread of the local anesthetic, resulting in unblocked dermatomes or weak motor blockade. - It would not cause sudden **aphonia** or **loss of consciousness** as a presenting symptom.

Q: True about Epidural anesthesia:

C/I in coagulopathies. ***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.

Q: Which anesthetic modality is to be avoided in sickle cell disease?

Intravenous Regional Anaesthesia. ***Intravenous Regional Anaesthesia*** - Intravenous regional anesthesia (IVRA), also known as a **Bier block**, involves injecting local anesthetic into an extremity isolated by a tourniquet; removal of the tourniquet rapidly introduces the local anesthetic into the systemic circulation. - In patients with **sickle cell disease**, the **venous stasis** and **acidosis** induced by the tourniquet and ischemia can precipitate **sickling crises** and **thrombosis** within the isolated limb. *Spinal Anaesthesia* - Spinal anesthesia is generally considered safe in sickle cell patients, as it leads to **sympathectomy** and **vasodilation**, which can improve blood flow and oxygenation. - Careful attention to **fluid balance** and **blood pressure maintenance** is crucial to prevent hypovolemia and hypotension. *General Anesthesia* - General anesthesia can be used in sickle cell patients, provided there is meticulous management of **oxygenation**, **hydration**, and **temperature** to prevent a sickle cell crisis. - It requires careful monitoring of **end-tidal CO2** and arterial blood gases to avoid hypoxia and acidosis. *Brachial Plexus Block* - Peripheral nerve blocks like a **brachial plexus block** are generally safe and often preferred in sickle cell patients, as they provide effective analgesia without systemic hemodynamic changes. - The local anesthetic does not significantly alter the systemic circulation or oxygenation, reducing the risk of a **sickling crisis**.

Q: All are absolute contraindications for regional anesthesia EXCEPT:

INR > 2 in ophthalmic procedures. ***INR > 2 in ophthalmic procedures*** - While a high INR (international normalized ratio) indicates increased bleeding risk, an INR > 2 is generally considered a **relative contraindication** for most regional anesthesia procedures, especially in ophthalmic cases where the risk of significant hemorrhage might be lower compared to deeper blocks. - The decision to proceed often depends on the specific procedure, patient's overall condition, and a careful risk-benefit analysis, rather than being an absolute bar. *Lack of resuscitation facilities* - The absence of proper **resuscitation equipment and trained personnel** is an absolute contraindication for regional anesthesia, as serious complications (e.g., local anesthetic systemic toxicity, respiratory depression) can occur, requiring immediate intervention. - Performing regional anesthesia in such a setting puts the patient at extreme risk of irreversible harm or death in the event of an adverse reaction. *Infection at injection site* - Performing regional anesthesia through an infected area carries a high risk of introducing bacteria into deeper tissues, including the **neuraxial space** or surrounding nerves, leading to serious complications like **abscess formation, meningitis, or osteomyelitis**. - This is an **absolute contraindication** to prevent the spread of infection. *Patient refusal* - **Informed consent** is a fundamental ethical and legal principle in medicine; a competent patient's refusal to undergo a procedure, including regional anesthesia, must always be respected. - Proceeding against a patient's wishes constitutes **assault and battery** and is an absolute contraindication for any medical intervention.

Q: Which approach of brachial plexus block targets cords of the brachial plexus:-

Infraclavicular. ***Infraclavicular*** - The **infraclavicular approach** targets the brachial plexus at the level of the **cords**, which lie deep to the pectoralis muscles and medial to the coracoid process. - This block is particularly useful for surgeries involving the **distal upper limb**, as it blocks all divisions of the cords. *Supraclavicular* - The **supraclavicular approach** targets the brachial plexus at the level of the **trunks**, specifically where they emerge between the anterior and middle scalene muscles. - While it provides good anesthesia for the entire upper limb, it is proximal to the cord level. *Axillary* - The **axillary approach** targets the terminal nerves (e.g., median, ulnar, radial, musculocutaneous) after the brachial plexus has divided into individual nerves in the **axilla**. - This block is distal to the cords and is often used for surgeries of the forearm and hand. *All of the options* - This option is incorrect because only the **infraclavicular approach** specifically targets the cords of the brachial plexus. - The other approaches target either the trunks (supraclavicular) or the terminal nerves (axillary).

Q: In a patient with sickle cell trait, which mode of anesthesia should be avoided?

IVRA (intravenous regional anesthesia). ***IVRA (intravenous regional anesthesia)*** - **IVRA** involves injecting a local anesthetic into an isolated limb, which can lead to **stasis** and **hypoxia** if the tourniquet is left on too long or if the block is incomplete. - In patients with **sickle cell trait**, these conditions predispose to **sickling crises**, as the red blood cells deform under low oxygen tension, obstructing blood flow and causing tissue damage. *Brachial plexus block infraclavicular approach* - This regional anesthetic technique involves injecting local anesthetic around the brachial plexus nerves, which does not typically lead to **ischemia** or **stasis** in the extremity. - It maintains normal blood flow, thereby avoiding the triggers for **sickling** seen in sickle cell trait patients. *Supraclavicular brachial plexus block* - Similar to other brachial plexus blocks, the supraclavicular approach provides anesthesia without compromising **blood flow** to the limb. - As long as proper technique is used and no **vascular compromise** occurs, it is generally safe for patients with sickle cell trait. *Brachial plexus block axillary approach* - The axillary approach to the brachial plexus block is another regional technique that provides excellent anesthesia to the arm and hand. - It does not induce **hypoxia** or **vascular stasis** in the limb, making it a safer option for patients with sickle cell trait compared to IVRA.

Q: IVRA is contraindicated in -

Sickle cell disease. ***Sickle cell disease*** - **Intravenous regional anesthesia (IVRA)** involves injecting local anesthetic into an isolated limb, which can lead to **stasis** and **ischemia** when the tourniquet is inflated. - In sickle cell disease, **hypoxia** and **acidosis** from stasis can precipitate or worsen a **sickle cell crisis**, leading to severe pain and potential organ damage. *Cancer of the hematogenous system* - While certain cancers of the hematogenous system might indirectly affect anesthetic choice, there is **no direct contraindication** for IVRA in these conditions. - Local anesthetics used in IVRA do not typically interfere with the systemic treatment or progression of hematological malignancies. *Coagulopathy* - Coagulopathy is a relative contraindication to regional anesthesia due to the risk of **hematoma formation** if a nerve block is performed or if there is trauma during venipuncture. - However, IVRA primarily uses **intravenous access**, and the major risk is generally not hematoma due to bleeding at the injection site but rather systemic effects if the tourniquet fails. *Hypertension* - **Hypertension** itself is not a contraindication for IVRA. - While local anesthetics, if they escape the tourniquet, can cause systemic effects, properly performed IVRA has minimal systemic absorption until the tourniquet is released.

Question 1

Local anaesthetic usually used for retrobulbar block -

Accepted Answer

Bupivacaine

Answer

Prilocaine

Answer

Tetracaine

Answer

Procaine

Question 2

In Bier's block anesthetic agent given by which route?

Accepted Answer

Intravenous

Answer

Dermal

Answer

Peribulbar region

Answer

Retrobulbar area

Question 3

Post Spinal Headache can last for

Accepted Answer

7 - 10 days

Answer

Upto 10 months

Answer

Upto 10 hours

Answer

Upto 10 min

Question 4

An anesthesia resident was giving spinal anesthesia when the patient had sudden aphonia and loss of consciousness. What could have happened?

Accepted Answer

Total spinal

Answer

Vasovagal attack

Answer

Intravascular injection

Answer

Partial spinal

Question 5

True about Epidural anesthesia:

Accepted Answer

C/I in coagulopathies

Answer

Given in subarachnoid space

Answer

Effects start immediately

Answer

All of the options

Question 6

Which anesthetic modality is to be avoided in sickle cell disease?

Accepted Answer

Intravenous Regional Anaesthesia

Answer

Spinal Anaesthesia

Answer

Brachial Plexus Block

Answer

General Anesthesia

Question 7

All are absolute contraindications for regional anesthesia EXCEPT:

Accepted Answer

INR > 2 in ophthalmic procedures

Answer

Lack of resuscitation facilities

Answer

Infection at injection site

Answer

Patient refusal

Question 8

Which approach of brachial plexus block targets cords of the brachial plexus:-

Accepted Answer

Infraclavicular

Answer

Supraclavicular

Answer

Axillary

Answer

All of the options

Question 9

In a patient with sickle cell trait, which mode of anesthesia should be avoided?

Accepted Answer

IVRA (intravenous regional anesthesia)

Answer

Brachial plexus block infraclavicular approach

Answer

Supraclavicular brachial plexus block

Answer

Brachial plexus block axillary approach

Question 10

IVRA is contraindicated in -

Accepted Answer

Sickle cell disease

Answer

Cancer of hematogenous system

Answer

Coagulopathy

Answer

Hypertension

Regional Anesthesia — MCQs

Regional Anesthesia — MCQs

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