Ambulatory Anesthesia

Ambulatory Anesthesia Indian Medical PG Question 1: A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification

• A. ASA II
• B. ASA I
• C. ASA IV
• D. ASA III (Correct Answer)

Ambulatory Anesthesia Explanation: ***ASA III*** - This patient has **severe systemic disease** (angina at rest, COPD, obesity) that limits activity but is not incapacitating, aligning with the criteria for **ASA III**. - **Angina at rest** and **chronic obstructive pulmonary disease (COPD)** are significant comorbidities that place the patient in this category. *ASA II* - **ASA II** is defined by **mild systemic disease** that does not limit activity. - The patient's conditions such as **angina at rest** and **COPD** are more severe than what would be considered mild. *ASA I* - **ASA I** is reserved for a **normal, healthy patient** with no systemic disease. - This patient has multiple significant systemic diseases, unequivocally ruling out ASA I. *ASA IV* - **ASA IV** describes a patient with **severe systemic disease** that is a constant threat to life. - While critical, the patient's conditions (angina at rest, COPD) are stabilised enough for an **elective procedure** and are not an immediate, constant threat to life.

Ambulatory Anesthesia Indian Medical PG Question 2: Which of the following is used for day care surgery?

• A. Thiopentone
• B. Ketamine
• C. Etomidate
• D. Propofol (Correct Answer)

Ambulatory Anesthesia Explanation: ***Propofol*** - **Propofol** is favored for **day care surgery** due to its **rapid onset** and **rapid recovery** profile, allowing patients to be discharged quickly. - It produces a **clear-headed recovery** with less postoperative nausea and vomiting compared to other agents. *Thiopentone* - **Thiopentone** has a **longer recovery time** and greater potential for **postoperative sedation** and **nausea**, making it less suitable for day care surgery. - Its use often leads to a **delayed discharge** from the recovery unit. *Ketamine* - **Ketamine** can cause **psychomimetic effects** (e.g., hallucinations, vivid dreams) and **delirium** during emergence, which are undesirable for day care procedures. - It also leads to **increased heart rate** and **blood pressure**, which may prolong recovery and observation time. *Etomidate* - **Etomidate** is known to cause **adrenocortical suppression** and can be associated with **pain on injection** and **myoclonus**, which are not ideal for routine day care use. - While it has a relatively **stable cardiovascular profile**, these side effects limit its widespread use in short procedures where rapid, smooth recovery is paramount.

Ambulatory Anesthesia Indian Medical PG Question 3: Arrange the following anesthetic agents based on their potency Nitrous oxide Halothane Isoflurane Methoxyflurane

• A. Methoxyflurane > Halothane > Isoflurane > Nitrous oxide (Correct Answer)
• B. Methoxyflurane > Nitrous oxide > Halothane > Isoflurane
• C. Methoxyflurane > Isoflurane > Halothane > Nitrous oxide
• D. Halothane > Isoflurane > Nitrous oxide > Methoxyflurane

Ambulatory Anesthesia Explanation: ***Methoxyflurane > Halothane > Isoflurane > Nitrous oxide*** - Anesthetic potency is inversely related to its **MAC (Minimum Alveolar Concentration)** value. A lower MAC value indicates higher potency. - The MAC values for these agents are: Methoxyflurane (0.16%), Halothane (0.75%), Isoflurane (1.15%), and Nitrous oxide (104%), which directly corresponds to this order of potency. *Methoxyflurane > Nitrous oxide > Halothane > Isoflurane* - This order incorrectly places nitrous oxide as more potent than halothane and isoflurane. **Nitrous oxide** has a very high MAC (104%), indicating low potency. - **Halothane** and **isoflurane** have significantly lower MAC values (0.75% and 1.15%, respectively), making them much more potent than nitrous oxide. *Methoxyflurane > Isoflurane > Halothane > Nitrous oxide* - This order incorrectly places **isoflurane** as more potent than halothane. **Halothane** has a MAC of 0.75%, while **isoflurane** has a MAC of 1.15%. - Therefore, halothane is more potent than isoflurane, making this sequence incorrect. *Halothane > Isoflurane > Nitrous oxide > Methoxyflurane* - This order incorrectly places **halothane** as the most potent and **methoxyflurane** as the least potent among the listed agents. - **Methoxyflurane** has the lowest MAC (0.16%), making it the most potent, while **nitrous oxide** has the highest MAC (104%), making it the least potent.

Ambulatory Anesthesia Indian Medical PG Question 4: 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?

• A. Local infiltration
• B. Regional anesthesia (Correct Answer)
• C. General anesthesia
• D. Paracervical block

Ambulatory Anesthesia Explanation: ***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.

Ambulatory Anesthesia Indian Medical PG Question 5: Which of the following is a long-acting local anesthetic with a duration of action greater than 2 hours?

• A. Bupivacaine (Correct Answer)
• B. Tetracaine
• C. Etidocaine
• D. Prilocaine

Ambulatory Anesthesia Explanation: ***Bupivacaine*** - **Bupivacaine** is an amide-type local anesthetic known for its **long duration of action**, typically lasting 2-8 hours, making it suitable for prolonged pain control. - Its **high lipid solubility** and **protein binding** contribute to its extended effect by increasing tissue penetration and reducing systemic absorption. *Prilocaine* - **Prilocaine** is an intermediate-acting local anesthetic with a duration of action of approximately 1-2 hours. - It is associated with a risk of **methemoglobinemia** in higher doses, less common with other local anesthetics. *Etidocaine* - While considered a long-acting local anesthetic, **Etidocaine** generally has a slightly shorter duration of action compared to bupivacaine, typically 2-6 hours. - It is known for its **rapid onset** and high potency. *Tetracaine* - **Tetracaine** is an ester-type local anesthetic with a duration of action of about 2-3 hours and is primarily used for **spinal anesthesia** and topical applications due to its toxicity for peripheral nerve blocks. - Ester-type local anesthetics like tetracaine are more prone to causing **allergic reactions** due to their metabolism into PABA (para-aminobenzoic acid).

Ambulatory Anesthesia Flashcard 1 of 4

Question: _____ is the most common adverse effect that persists after discharge following day care anesthesia

Answer: Drowsiness

Ambulatory Anesthesia Flashcard 2 of 4

Question: Minimal post operative nausea and vomitting is _____ a criteria for consideration for day care surgery.

Answer: not

Ambulatory Anesthesia Flashcard 3 of 4

Question: The intravenous induction agent of choice for ambulatory anesthesia is _____

Answer: propofol

Ambulatory Anesthesia Flashcard 4 of 4

Question: _____ is the muscle relaxant of choice for day care surgery

Answer: Rocuronium