Perioperative Pain Management — MCQs

10 questions

Postoperative nausea and vomiting are uncommon with

A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

Which of the following anaesthetic agent lacks analgesic effect? A) N2O B) Thiopentone C) Methohexitone D) Ketamine E) Fentanyl

Primary afferent fibers secrete which nociceptive substance at the dorsal horn?

A patient selected for surgery was induced with Thiopentone iv through one of the antecubital veins and complained of severe pain of the whole hand. The next line of management is:

Which Benzodiazepine decreases post-operative nausea & vomiting:-

What is the immediate treatment for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

Which of the following statements are correct regarding Cauda equine syndrome? I. Its presenting symptoms are perineal numbness, painless urinary retention and fecal incontinence. II. Urgent investigation with MRI is required. III. It is present most commonly in the 45-60 year age group. IV. Confirmed cases require early surgical decompression. Select the answer using the code given below :

Q10

Which of the following findings on colonoscopy is most consistent with angiodysplasia?

Perioperative Pain Management Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

A. Oral morphine
B. Diazepam rectal suppository
C. Intercostal cryoanalgesia (Correct Answer)
D. IV fentanyl

Explanation: ***Intercostal cryoanalgesia*** - **Intercostal cryoanalgesia** involves applying extreme cold to the intercostal nerves, leading to temporary nerve denervation and prolonged pain relief. This technique is particularly effective for **post-thoracotomy pain** due to its targeted action and reduced systemic side effects compared to opioids. - The goal is to provide **long-lasting pain control** specifically at the surgical site, allowing for better respiratory mechanics and early mobilization. *Oral morphine* - Oral morphine can provide systemic pain relief, but its onset of action is slower, and it carries the risk of significant **sedation** and **respiratory depression**, which are major concerns in a patient who has just undergone thoracotomy. - While effective, it may not provide optimal local pain control for incisional pain and often requires higher doses to achieve adequate relief, increasing the risk of adverse effects. *Diazepam rectal suppository* - Diazepam is a **benzodiazepine** primarily used for anxiety, muscle spasms, and seizures, not for severe acute surgical pain. It has **no significant analgesic properties**. - Its sedative effects would be contraindicated after thoracotomy due to the risk of respiratory depression and masking potential neurological changes. *IV fentanyl* - IV fentanyl is a potent opioid with a rapid onset and short duration of action, making it useful for breakthrough pain or during immediate post-operative periods. However, it requires **continuous monitoring** and frequent re-dosing. - Like other opioids, it carries risks of **respiratory depression**, nausea, and sedation, making it less ideal for sustained primary pain control immediately after thoracotomy where lung function is critical.

Question 3: Which of the following anaesthetic agent lacks analgesic effect? A) N2O B) Thiopentone C) Methohexitone D) Ketamine E) Fentanyl

A. N2O
B. Methohexitone
C. Ketamine
D. Fentanyl
E. Thiopentone (Correct Answer)

Explanation: ***Thiopentone*** - Thiopentone is a **barbiturate** anesthetic primarily used for inducing anesthesia. - It provides significant **hypnosis** and sedation but lacks intrinsic **analgesic properties**, meaning it does not relieve pain. *N2O* - **Nitrous oxide** (N2O) is an inhalation anesthetic that provides good **analgesia** at sub-anesthetic concentrations. - It is often used as an adjunct to other anesthetic agents to enhance pain relief during procedures. *Methohexitone* - Methohexitone is another **barbiturate** similar to thiopentone, used for induction of anesthesia. - While it provides rapid **hypnosis**, it also lacks significant **analgesic effects**. *Ketamine* - Ketamine is a **dissociative anesthetic** known for its potent **analgesic properties**. - It works by blocking **NMDA receptors**, providing pain relief even at sub-anesthetic doses. *Fentanyl* - Fentanyl is a powerful **opioid analgesic** that is commonly used in anesthesia for its strong pain-relieving effects. - It acts on **opioid receptors** in the central nervous system to reduce pain perception.

Question 4: Primary afferent fibers secrete which nociceptive substance at the dorsal horn?

A. Substance P (Correct Answer)
B. Acetylcholine
C. Norepinephrine
D. Epinephrine

Explanation: ***Substance P*** - **Substance P** is a neuropeptide released by **C fibers** and **A-delta fibers** (primary afferent nociceptors) in the dorsal horn of the spinal cord. - It acts as a **neurotransmitter** and **neuromodulator**, contributing to the transmission and amplification of pain signals. *Acetylcholine* - **Acetylcholine** is a primary neurotransmitter in the **neuromuscular junction** and the autonomic nervous system. - While it has some roles in the CNS, it is not the primary nociceptive substance secreted by afferent fibers in the dorsal horn. *Norepinephrine* - **Norepinephrine** (noradrenaline) is a neurotransmitter involved in the **fight-or-flight response** and mood regulation. - It can modulate pain, but it is not directly released by primary afferent fibers as a nociceptive substance in the dorsal horn. *Epinephrine* - **Epinephrine** (adrenaline) is a hormone and neurotransmitter primarily associated with the **sympathetic nervous system** and stress response. - It does not serve as a direct nociceptive transmitter released by primary afferent fibers in the spinal cord.

Question 5: A patient selected for surgery was induced with Thiopentone iv through one of the antecubital veins and complained of severe pain of the whole hand. The next line of management is:

A. Leave it alone
B. IV ketamine through same needle
C. Give IV propofol through same needle
D. IV lignocaine through same needle (Correct Answer)

Explanation: **_IV lignocaine through same needle_** - **Lignocaine** (lidocaine) is a **local anesthetic** that can alleviate the severe pain caused by the extravasation or intra-arterial injection of thiopentone by **vasodilatation** and nerve block. - This immediate intervention helps to mitigate the consequences of thiopentone injection outside the vein or into an artery, which can include **vasoconstriction**, tissue necrosis, and **compartment syndrome**. *Leave it alone* - Ignoring the patient's complaint of severe pain, especially after thiopentone administration, could lead to **severe tissue damage**, including **vasoconstriction**, necrosis, and potential limb loss. - Doing nothing is a **negligent approach** that fails to address a potentially serious complication of intravenous drug administration. *IV ketamine through same needle* - **Ketamine** is a dissociative anesthetic and analgesic, but it is not the primary drug for managing local pain and potential vascular complications from thiopentone extravasation or intra-arterial injection. - Administering ketamine in this scenario would **not address the underlying vascular injury** or tissue irritation caused by thiopentone and might only mask the pain without resolving the issue. *Give IV propofol through same needle* - **Propofol** is an intravenous anesthetic that generally causes less pain on injection than thiopentone and has some vasodilatory properties, but it is not the immediate or primary treatment for managing the severe pain and potential vascular injury caused by thiopentone outside the vein or in an artery. - While it may offer some comfort, propofol does not have the **specific local anesthetic action** or immediate **vasodilatory effect** needed to reverse the harmful effects of thiopentone in this situation.

Question 6: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |

A. A-1, B-3, C-2, D-4
B. A-4, B-1, C-3, D-2 (Correct Answer)
C. A-3, B-2, C-4, D-1
D. A-2, B-4, C-1, D-3

Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.

Question 7: Which Benzodiazepine decreases post-operative nausea & vomiting:-

A. Midazolam (Correct Answer)
B. Diazepam
C. Lorazepam
D. All of the options

Explanation: ***Midazolam*** - **Midazolam** is a commonly used benzodiazepine in anesthesia that has been shown to have **antiemetic properties** and can decrease the incidence of **postoperative nausea and vomiting (PONV)**. - Its mechanism may involve its sedative and anxiolytic effects, indirectly reducing the triggers for nausea. *Diazepam* - While **diazepam** is a benzodiazepine with sedative and anxiolytic effects, it is not primarily known for reducing PONV. - Its longer duration of action compared to midazolam can also contribute to unwanted **postoperative sedation**. *Lorazepam* - **Lorazepam** is another benzodiazepine used for anxiolysis and sedation but is not a primary agent for the prevention of PONV. - Like diazepam, its prolonged effects can lead to **delayed recovery** and drowsiness, which may not be desirable in the postoperative period. *All of the options* - While all listed drugs are benzodiazepines, only **midazolam** is consistently recognized and utilized for its ability to reduce PONV in the perioperative setting. - The other benzodiazepines do not demonstrate the same consistent benefit in PONV reduction and may have other side effects that limit their utility for this specific purpose.

Question 8: What is the immediate treatment for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

A. Intravenous Diltiazem
B. Cardioversion (Correct Answer)
C. Intravenous Ibutilide
D. Intravenous beta-blockers

Explanation: ***Cardioversion*** * **Synchronized cardioversion** is the immediate treatment for hemodynamically **unstable** patients with **supraventricular tachycardia (SVT)** to quickly restore sinus rhythm and prevent cardiovascular collapse. * Hemodynamic instability includes symptoms such as **hypotension**, altered mental status, signs of shock, acute heart failure, or ischemic chest pain, directly caused by the arrhythmia. *Intravenous Diltiazem* * **Diltiazem** is a calcium channel blocker used for **rate control** in stable SVT, but it is not appropriate for unstable patients due to its slower onset of action and potential for further hypotension. * In hemodynamically unstable patients, delaying cardioversion to administer medications like diltiazem can worsen the patient's condition. *Intravenous Ibutilide* * **Ibutilide** is an antiarrhythmic drug used for recent-onset atrial fibrillation or flutter, but it is typically reserved for **hemodynamically stable** patients. * It is not the drug of choice for immediate management of unstable SVT as it has a slower onset and can potentially cause proarrhythmia. *Intravenous beta-blockers* * **Beta-blockers** are used for **rate control** in hemodynamically **stable** patients with SVT by blocking AV nodal conduction. * They are contraindicated in unstable patients as they can exacerbate hypotension, especially in those with reduced cardiac function.

Question 9: Which of the following statements are correct regarding Cauda equine syndrome? I. Its presenting symptoms are perineal numbness, painless urinary retention and fecal incontinence. II. Urgent investigation with MRI is required. III. It is present most commonly in the 45-60 year age group. IV. Confirmed cases require early surgical decompression. Select the answer using the code given below :

A. I, II and III
B. I, III and IV
C. I, II and IV (Correct Answer)
D. II, III and IV

Explanation: ***I, II and IV*** - Perineal numbness leading to **saddle anesthesia**, painless urinary retention, and fecal incontinence are classic red-flag symptoms of **cauda equina syndrome (CES)** indicating compression of the nerve roots [1]. - Early diagnosis via **urgent MRI** and prompt surgical decompression are critical to prevent permanent neurological deficits due to irreversible nerve damage [2]. *I, II and III* - While statements I and II are correct, statement III is inaccurate as CES can affect adults of any age due to various causes like **herniated discs** [1] or trauma [2]. - **Urgent intervention** is prioritized over age group considerations in managing this condition [2]. *I, III and IV* - Although statements I and IV are correct, statement III incorrectly restricts CES to a specific age group, as it can occur across a **broad age spectrum**. - The primary focus in CES is on symptom recognition and **rapid surgical intervention** [2]. *II, III and IV* - While statements II and IV are correct, statement III is factually incorrect regarding the typical age of presentation for Cauda Equina Syndrome. - **Accurate identification of symptoms** (statement I) is crucial for triggering the necessary urgent investigations and treatment [1].

Question 10: Which of the following findings on colonoscopy is most consistent with angiodysplasia?

A. Inflamed diverticula
B. Dilated submucosal veins (Correct Answer)
C. Mucosal ulcers
D. Mass lesion

Explanation: Dilated submucosal veins - **Angiodysplasia** is characterized by the presence of **dilated, tortuous submucosal venules and capillaries** that are prone to bleeding. - On colonoscopy, these lesions typically appear as small, flat, cherry-red spots or fern-like vascular patterns. *Inflamed diverticula* - **Diverticulitis** involves inflammation and infection of outpouchings in the colon wall, presenting with pain, fever, and leukocytosis. - Colonoscopy during acute diverticulitis is generally avoided due to the risk of perforation, and the findings would be localized inflammation, not dilated vessels indicative of angiodysplasia. *Mucosal ulcers* - **Mucosal ulcers** are breaks in the mucosal lining, often associated with inflammatory bowel disease, infections, or ischemia. - While ulcers can cause bleeding, they represent a different pathological process than the vascular malformations characteristic of angiodysplasia. *Mass lesion* - A **mass lesion** suggests a tumor, polyp, or other growth within the colon. - This finding is more indicative of a neoplastic process or a large inflammatory lesion, distinct from the small, flat vascular lesions of angiodysplasia.

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