Regional Anesthesia Practice Questions

Q: For which of the following surgeries is a supraclavicular block most commonly used?

Elbow surgery. ***Elbow surgery*** - A **supraclavicular block** effectively anesthetizes the entire upper extremity distal to the shoulder, making it ideal for procedures involving the **elbow**, forearm, and hand. - This block targets the **trunks of the brachial plexus** as they pass over the first rib, providing comprehensive coverage for elbow surgeries. *Shoulder surgery* - While it anesthetizes the upper extremity distal to the shoulder, it typically does not adequately cover the **shoulder joint itself**, as the suprascapular nerve and axillary nerve branches to the shoulder often arise more proximally. - **Interscalene blocks** are generally preferred for shoulder joint surgeries due to their more proximal spread and better pain control for shoulder-specific procedures. *Wrist surgery* - Although providing excellent anesthesia for wrist surgery, a **supraclavicular block** is often considered more extensive than necessary, given the potential for more distal, less invasive blocks (e.g., **axillary blocks** or specific nerve blocks at the wrist) that carry fewer risks. - Simpler, more targeted blocks might be chosen to minimize the risk of complications associated with a supraclavicular approach, such as **pneumothorax**. *Brachial plexus surgery* - A supraclavicular block is used to anesthetize the brachial plexus; it is generally not performed *for* brachial plexus surgery itself, but rather to provide surgical anesthesia for procedures *distal* to the shoulder. - Surgery on the brachial plexus often requires general anesthesia and careful nerve identification, rather than regional block for the plexus itself.

Q: What is the typical duration of a post spinal headache?

1 week. ***1 week*** - A post-dural puncture headache (PDPH) typically resolves spontaneously within **1 week**, although it can persist longer in some cases. - While supportive care is often sufficient, interventions like an **epidural blood patch** may be considered for severe or persistent symptoms. *10 minutes* - This duration is far too short for a typical **post-dural puncture headache**, which is a recognized complication and tends to last much longer. - Headaches lasting only minutes are more likely related to simple **hypotension** or other transient issues rather than cerebrospinal fluid leakage. *1 hour* - An hour is generally too short for a true **post-dural puncture headache**, which is characterized by a persistent CSF leak and positional pain. - Headaches resolving within an hour are often benign and not indicative of a significant dural puncture. *10 days* - While a **post-dural puncture headache** can occasionally last this long, 10 days is generally considered on the longer end of the typical duration. - If a headache persists this long, especially with severe symptoms, further evaluation or intervention might be considered.

Q: What is a contraindication to performing a neuraxial block?

Clotting disorders. ***Clotting disorders*** - **Coagulopathy** or **anticoagulation** significantly increases the risk of **epidural hematoma**, which can lead to spinal cord compression and permanent neurological damage. - The procedure involves puncturing blood vessels, and impaired clotting could result in uncontrolled bleeding into the epidural or intrathecal space. *Hypertension* - While careful management of blood pressure is needed before and during a neuraxial block, **controlled hypertension** is not an absolute contraindication. - Severe or uncontrolled hypertension may be a concern due to increased risk of hemodynamic instability but doesn't preclude the procedure itself. *Renal disease* - **Chronic renal disease** itself is not a direct contraindication, though it might impact drug clearance if local anesthetics are used in large doses. - However, severe renal disease can be associated with coagulopathies, which would then become the primary contraindication. *Diabetes* - **Diabetes mellitus** is generally not a contraindication to neuraxial blocks. - Careful monitoring of blood glucose is necessary, but the condition itself does not increase the specific risks associated with the procedure.

Q: Post dural puncture headache usually presents within ?

12-72 Hrs. ***12-72 Hrs*** - The onset of a **post-dural puncture headache (PDPH)** typically occurs within **12 to 72 hours** after the dural puncture. - This delay is thought to be related to the time it takes for significant **cerebrospinal fluid (CSF) leakage** and corresponding intracranial hypotension to develop. *0-6 Hrs* - Headaches presenting within this timeframe are less likely to be true **PDPH** as the typical latency period for significant CSF leakage and its symptomatic effects hasn't usually manifested. - Such early headaches might be due to other causes like **anxiety**, **dehydration**, or mild irritation from the procedure. *6-12 Hrs* - While possible, onset within this timeframe is less common than the 12-72 hour window for **classic PDPH**. - Moderate **CSF leakage** might lead to symptoms in some individuals, but the vast majority present later. *72-96 Hrs* - Although PDPH can persist for days or even weeks, its **onset** is significantly less common in this range. - A headache beginning this late may prompt consideration of other differential diagnoses, though late-onset PDPH is not unheard of.

Q: Drug of choice for Bier's block ?

Lidocaine. ***Lidocaine*** - **Lidocaine** is the preferred local anesthetic for **Bier's block** (intravenous regional anesthesia) due to its rapid onset and good safety profile. - Its relatively short duration of action and **minimal cardiotoxicity** upon systemic release are favorable for this technique. *Bupivacaine* - **Bupivacaine** has a **longer duration of action** and is associated with a higher risk of **cardiotoxicity** when inadvertently delivered systemically, making it less suitable for Bier's block. - Its use in Bier's block is generally avoided due to the potential for significant adverse events if the tourniquet malfunctions or is released prematurely. *Etidocaine* - **Etidocaine** is a potent, **long-acting local anesthetic** with a similar toxicity profile to bupivacaine, making it less ideal for Bier's block. - Its prolonged action and higher potential for systemic toxicity make it less favorable for a procedure where rapid washout and lower systemic risk are desired. *Ropivacaine* - **Ropivacaine** is an amide-type local anesthetic with a similar efficacy to bupivacaine but with a **lower potential for cardiotoxicity**. - While safer than bupivacaine, **lidocaine** is still generally preferred for Bier's block due to its established safety record, faster onset, and lower cost.

Q: Which of the following is NOT a contraindication for spinal anaesthesia?

Hypertension. ***Hypertension*** - While **severe uncontrolled hypertension** may necessitate blood pressure stabilization before surgery, **mild to moderate hypertension** is not an absolute contraindication for spinal anesthesia. - In fact, spinal anesthesia can sometimes be beneficial in hypertensive patients due to its **vasodilatory effects**, which may help lower blood pressure. *Bleeding disorder* - A **bleeding disorder** (e.g., thrombocytopenia, coagulopathy) is a **major contraindication** due to the high risk of **epidural or spinal hematoma** formation. - A hematoma can lead to **spinal cord compression** and irreversible neurological damage. *Raised intracranial tension* - **Raised intracranial tension (ICT)** is a **strict contraindication** because the drop in cerebrospinal fluid (CSF) pressure during spinal anesthesia can worsen the pressure gradient across the foramen magnum. - This can precipitate **herniation of the brainstem** and lead to catastrophic neurological injury or death. *Infection at injection site* - The presence of an **infection at the injection site** is an absolute contraindication as it poses a significant risk of introducing bacteria into the **subarachnoid space**. - This can lead to serious complications such as **meningitis** or a **spinal abscess**.

Q: Which of the following cannot be given by epidural anaesthesia?

Remifentanil. ***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**.

Q: What clinical sign is used to confirm the success of an epidural block?

Loss of sensation in the T10 dermatome. ***Loss of sensation in the T10 dermatome*** - The **T10 dermatome** is a common and reliable landmark for assessing the spread and effectiveness of an epidural block, especially for surgical procedures or labor analgesia impacting the abdominal and pelvic regions. - A successful epidural block should produce a **bilateral, symmetric sensory deficit** to pinprick or cold sensation within the target dermatomes, indicating proper anesthetic distribution. *Inability to dorsiflex the foot* - This symptom suggests a motor block primarily affecting the **deep peroneal nerve** (L4-L5 nerve roots), which would be a sign of a dense spinal block rather than a typical epidural, or an overly extensive epidural block, especially if it's bilateral. - While some motor weakness is expected with an epidural block, a complete inability to dorsiflex the foot is not the primary or most sensitive indicator of its success for general pain relief. *Loss of resistance (used during block placement)* - **Loss of resistance** is a technique used *during the placement* of an epidural needle to identify the epidural space (passing through the ligamentum flavum). - It is a procedural step for correct needle positioning, not a clinical sign used *after* injection to confirm the block's effect. *Westphal's sign (diminished patellar reflex)* - **Westphal's sign** refers to the absence or diminution of the patellar reflex (an L2-L4 reflex), which can indicate a neurological issue involving the quadriceps muscles or the femoral nerve pathway. - While a dense epidural block can affect motor function and reflexes, Westphal's sign is not typically used as the primary or most accurate indicator of a successful epidural block's sensory coverage.

Q: Epidural narcotics are preferred over epidural local anesthetics because they cause –

No motor paralysis. **No motor paralysis** - Epidural narcotics (opioids) provide **analgesia** by binding to opioid receptors in the spinal cord, primarily affecting pain sensation pathways. - This selective action allows for pain relief without significantly impacting **motor nerve fibers**, thus avoiding motor paralysis. *Less respiratory depression* - While epidural opioids can cause less systemic respiratory depression compared to intravenous administration, they still carry a **risk of respiratory depression**, especially with higher doses or inadequate monitoring. - This is not a primary reason for preference over local anesthetics, as local anesthetics at appropriate doses have a different mechanism and profile regarding respiratory effects. *Less dose is required* - The dose comparison depends on the specific drug and desired effect; however, the primary advantage of epidural narcotics over local anesthetics is not necessarily that a "lesser" dose is required for a therapeutic effect. - Local anesthetics require higher doses to achieve complete **sensory and motor blockade**, whereas opioids provide targeted analgesia at lower doses. *No retention of urine* - Epidural opioids are known to cause **urinary retention** as a common side effect due to their action on sacral parasympathetic outflow. - This is a significant disadvantage, unlike epidural local anesthetics, which can also cause urinary retention but through a different mechanism (motor block of the bladder).

Q: Most common post-operative complication of spinal anesthesia?

Hypotension due to spinal anesthesia. ***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 1

For which of the following surgeries is a supraclavicular block most commonly used?

Accepted Answer

Elbow surgery

Answer

Brachial plexus surgery

Answer

Shoulder surgery

Answer

Wrist surgery

Question 2

What is the typical duration of a post spinal headache?

Accepted Answer

1 week

Answer

10 minutes

Answer

1 hour

Answer

10 days

Question 3

What is a contraindication to performing a neuraxial block?

Accepted Answer

Clotting disorders

Answer

Renal disease

Answer

Hypertension

Answer

Diabetes

Question 4

Post dural puncture headache usually presents within ?

Accepted Answer

12-72 Hrs

Answer

0-6 Hrs

Answer

6-12 Hrs

Answer

72-96 Hrs

Question 5

Drug of choice for Bier's block ?

Accepted Answer

Lidocaine

Answer

Bupivacaine

Answer

Etidocaine

Answer

Ropivacaine

Question 6

Which of the following is NOT a contraindication for spinal anaesthesia?

Accepted Answer

Hypertension

Answer

Raised intracranial tension

Answer

Bleeding disorder

Answer

Infection at injection site

Question 7

Which of the following cannot be given by epidural anaesthesia?

Accepted Answer

Remifentanil

Answer

Morphine

Answer

Alfentanil

Answer

Fentanyl

Question 8

What clinical sign is used to confirm the success of an epidural block?

Accepted Answer

Loss of sensation in the T10 dermatome

Answer

Inability to dorsiflex the foot

Answer

Loss of resistance (used during block placement)

Answer

Westphal's sign (diminished patellar reflex)

Question 9

Epidural narcotics are preferred over epidural local anesthetics because they cause –

Accepted Answer

No motor paralysis

Answer

Less respiratory depression

Answer

Less dose is required

Answer

No retention of urine

Question 10

Most common post-operative complication of spinal anesthesia?

Accepted Answer

Hypotension due to spinal anesthesia

Answer

Post-dural puncture headache

Answer

Urinary retention post-anesthesia

Answer

Infection leading to meningitis

Regional Anesthesia — MCQs

Regional Anesthesia — MCQs

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