Regional Anesthesia Practice Questions

Q: 80-year-old patient is admitted for open reduction and internal fixation of a fracture of the femur. Which one of the following techniques is the ideal anesthetic technique for this patient?

Regional anesthesia. ***Regional anesthesia*** - **Regional anesthesia** offers advantages in elderly patients undergoing hip fracture repair, including reduced risks of **postoperative cognitive dysfunction** and **cardiovascular complications**. - It provides **effective pain control** during and after surgery, potentially leading to faster recovery and fewer opioid-related side effects. *Local infiltration* - **Local infiltration** alone is typically inadequate for surgical pain control during an **open reduction and internal fixation of a fractured femur**. - It would not provide sufficient **muscle relaxation** or **sensory block** for such an invasive procedure. *General anesthesia* - While an option, **general anesthesia** in an 80-year-old patient carries a higher risk of **postoperative delirium** and **cardiopulmonary complications** compared to regional techniques. - It may also prolong recovery time and increase the need for **postoperative ventilation**. *Paracervical block* - A **paracervical block** is primarily used for **gynecological procedures**, such as cervical dilation and uterine procedures, due to its localized anesthetic effect around the cervix. - It is completely unsuitable for **femur fracture surgery**, as it would not provide any pain relief or surgical anesthesia to the lower limb.

Q: First fibres to be blocked in spinal anaesthesia is:

Sympathetic preganglionic. ***Sympathetic preganglionic*** - **Sympathetic preganglionic fibers** are generally the **smallest** and **unmyelinated** or **lightly myelinated**, making them most susceptible to local anesthetic blockade. - Their blockade leads to **vasodilation** and a potential drop in blood pressure, which is often the first physiological sign of spinal anesthesia taking effect. *Sensory fibres* - While sensory fibers are blocked in spinal anesthesia, they are typically **larger diameter** than sympathetic preganglionic fibers and require a higher concentration or longer exposure to be fully blocked. - The onset of sensory blockade, though rapid, usually follows the initial sympathetic blockade. *Motor nerves* - **Motor nerves** are among the **largest diameter** and **heavily myelinated** nerve fibers, making them the most resistant to local anesthetic blockade. - Motor paralysis is usually the last effect to manifest as the spinal block deepens. *Efferent motor nerves* - This option refers to the same set of fibers as "Motor nerves," which are **large and myelinated**, requiring a greater degree of blockade than sympathetic preganglionic fibers. - Their blockade is responsible for the skeletal muscle relaxation observed in spinal anesthesia, but this effect occurs later than sympathetic blockade.

Q: High spinal anaesthesia is characterized by:

Hypotension, bradycardia. ***Hypotension, bradycardia*** - High spinal anesthesia blocks the **sympathetic nervous system**, leading to **vasodilation** below the level of blockade and redistribution of blood, causing **hypotension**. - The blockade of **cardioaccelerator fibers** (T1-T4) can result in a loss of sympathetic tone to the heart, leading to **bradycardia**. *Hypertension, tachycardia* - This combination is more typical of a **pain response** or a systemic release of catecholamines, not the direct effect of high spinal anesthesia. - High spinal anesthesia primarily causes a decrease in sympathetic tone, which would counteract hypertension and tachycardia. *Hypertension, bradycardia* - This combination is sometimes seen in conditions like **Cushing's reflex** due to increased intracranial pressure, which is unrelated to spinal anesthesia. - The primary effect of high spinal anesthesia on blood pressure is hypotension, not hypertension. *Hypotension, tachycardia* - While hypotension is a feature of high spinal anesthesia, **tachycardia** is less common as the sympathetic blockade often extends to the cardioaccelerator fibers, leading to bradycardia. - Tachycardia in this context might indicate an **inadequate block** or a compensatory response to hypovolemia not directly caused by the anesthetic.

Q: True about epidural opioid are all except:

Function of the intestine is not affected. **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.

Q: Which block is described as regional anesthesia of the arm:-

Supraclavicular brachial plexus block. ***Supraclavicular brachial plexus block*** - The **supraclavicular block** targets the **trunks of the brachial plexus** as they exit the scalene muscles, providing comprehensive anesthesia to the entire upper limb, including the shoulder, arm, forearm, and hand. - This block is particularly effective for procedures involving the arm due to its proximal location within the brachial plexus, covering multiple nerve distributions. *Interscalene block* - An **interscalene block** primarily targets the **roots or trunks of the brachial plexus** and is typically used for shoulder and upper arm surgery, but may spare the ulnar nerve. - While it anesthetizes the arm, it is primarily chosen for more proximal procedures and may not provide complete distal arm anesthesia compared to the supraclavicular approach. *Infraclavicular block* - An **infraclavicular block** targets the **cords of the brachial plexus** and is suitable for procedures involving the elbow, forearm, and hand, providing good coverage for these areas. - While it does anesthetize the distal arm, it is more distal than the supraclavicular block and may not provide full coverage for the entire upper arm and shoulder. *Axillary block* - An **axillary block** targets the **terminal branches of the brachial plexus** in the axilla, mainly anesthetizing the forearm and hand. - This block is often used for procedures distal to the elbow and provides less comprehensive coverage for the entire upper arm and shoulder compared to more proximal blocks.

Q: Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?

Ulnar. ***Ulnar*** - The **ulnar nerve** (C8-T1) emerges from the lower trunk of the brachial plexus. During an **interscalene block**, the local anesthetic is typically deposited at the level of the roots and trunks (C5-C7), which is superior to the origin of the lower trunk that gives rise to the ulnar nerve. - Due to the **cephalad spread** of the local anesthetic from an interscalene block, the **C8 and T1** nerve roots (and thus the ulnar nerve) are often not adequately blocked, leading to suboptimal anesthesia in its distribution. *Median* - The **median nerve** (C5-T1) originates from the lateral and medial cords, which are typically well-covered by the spread of local anesthetic in an interscalene block due to its formation from the middle and upper trunks. - Optimal anesthesia in the distribution of the median nerve is generally achieved with an interscalene block, as its nerve roots are within the targeted antegrade spread. *Musculocutaneous* - The **musculocutaneous nerve** (C5-C7) arises from the lateral cord, which is formed by the upper and middle trunks. These structures are reliably blocked during an interscalene approach. - Sensory and motor functions of the musculocutaneous nerve, such as **biceps contraction** and lateral forearm sensation, are usually well anesthetized. *Radial* - The **radial nerve** (C5-T1) is a branch of the posterior cord, which receives fibers from all three trunks. Its upper and middle trunk components are generally well-blocked by an interscalene approach. - While complete anesthesia of the entire brachial plexus can be variable, the radial nerve is more consistently affected by an interscalene block than the ulnar nerve due to its more extensive proximal root contributions which are within the typical spread.

Q: All are absolute contraindication of neuraxial anaesthesia except:

Spinal deformity. ***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.

Q: All of the following are complications of epidural anaesthesia, EXCEPT:

Hypertension. ***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.

Q: In all of the following conditions, neuraxial blockade is absolutely contraindicated, except:

Pre-existing neurological deficits. ***Pre-existing neurological deficits*** - While careful consideration is needed, pre-existing neurological deficits are generally a **relative contraindication** rather than an absolute one for neuraxial blockade. - The decision depends on the nature and stability of the deficit, potential for worsening, and the benefits of neuraxial anesthesia versus the risks. *Patient refusal* - **Patient refusal** is always an absolute contraindication for any medical procedure, including neuraxial blockade. - Informed consent requires the patient's voluntary agreement, and a refusal must be respected. *Severe hypovolemia* - **Severe hypovolemia** is an absolute contraindication for neuraxial blockade due to the risk of profound hypotension. - Neuraxial blockade causes sympathetic blockade, leading to vasodilation and reduced venous return, which can be catastrophic in an already hypovolemic patient. *Coagulopathy* - **Coagulopathy**, whether intrinsic or iatrogenic, is an absolute contraindication due to the high risk of **epidural hematoma** or **spinal hematoma**. - These hematomas can cause nerve compression, leading to devastating neurological complications like paraplegia.

Question 1

80-year-old patient is admitted for open reduction and internal fixation of a fracture of the femur. Which one of the following techniques is the ideal anesthetic technique for this patient?

Accepted Answer

Regional anesthesia

Answer

Local infiltration

Answer

General anesthesia

Answer

Paracervical block

Question 2

First fibres to be blocked in spinal anaesthesia is:

Accepted Answer

Sympathetic preganglionic

Answer

Sensory fibres

Answer

Motor nerves

Answer

Efferent motor nerves

Question 3

In spinal anaesthesia, which of the following statements about the segmental levels of blockade is correct?

Accepted Answer

The sympathetic block occurs at a higher level than the sensory block.

Answer

The sympathetic block occurs at a lower level than the sensory block.

Answer

The sympathetic, motor, and sensory blocks occur at the same level.

Answer

The motor block occurs at a higher level than the sensory block.

Question 4

High spinal anaesthesia is characterized by:

Accepted Answer

Hypotension, bradycardia

Answer

Hypertension, tachycardia

Answer

Hypertension, bradycardia

Answer

Hypotension, tachycardia

Question 5

True about epidural opioid are all except:

Accepted Answer

Function of the intestine is not affected

Answer

Act on dorsal horn substantia gelatinosa

Answer

Can cause Itching

Answer

Can cause respiratory depression

Question 6

Which block is described as regional anesthesia of the arm:-

Accepted Answer

Supraclavicular brachial plexus block

Answer

Interscalene block

Answer

Infraclavicular block

Answer

Axillary block

Question 7

Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?

Accepted Answer

Ulnar

Answer

Median

Answer

Musculocutaneous

Answer

Radial

Question 8

All are absolute contraindication of neuraxial anaesthesia except:

Accepted Answer

Spinal deformity

Answer

Local infection of site

Answer

Raised Intracranial pressure

Answer

Coagulopathy

Question 9

All of the following are complications of epidural anaesthesia, EXCEPT:

Accepted Answer

Hypertension

Answer

Urinary retention

Answer

Total spinal analgesia

Answer

Hypopnoea

Question 10

In all of the following conditions, neuraxial blockade is absolutely contraindicated, except:

Accepted Answer

Pre-existing neurological deficits

Answer

Patient refusal

Answer

Severe hypovolemia

Answer

Coagulopathy

Regional Anesthesia — MCQs

Regional Anesthesia — MCQs

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