Tonsillectomy - On the day of surgery he had running nose

Question

029. A 5 year old patient is scheduled for tonsillectomy. On the day of surgery he had running nose, temperature 37.5ºC and dry cough. Which of the following should be the most appropriate decision for surgery?

1. Surgery should be cancelled.

2. Can proceed for surgery if chest is clear and there is no history of asthma

3. Should get x-ray chest before proceeding for surgery

4. Cancel surgery for 3 week and patient to be on antibiotic

Answer

4. Cancel surgery for 3 week and patient to be on antibiotic

Reference

Dhingra 3^rd Edition Page 490

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Discussion

Contraindications of Tonsillectomy are

1. Hemoglobin level <>
2. Presence of an acute infection in upper respiratory tract, even acute tonsillitis. Bleeding is more in the presence of infection
3. Children under 3 years of age. They are at poor surgical risks
4. Overt of submucous cleft palate
5. Bleeding disorders
6. At the time of epidemic of polio
7. Uncontrolled systemic disease like diabetes, cardiac disease
8. Tonsillectomy is avoided during the period of menses

Explanation

1. Surgery should be cancelled and there is no doubt about that, but this is an incomplete choice
2. Because of infection, the surgery cannot proceed even if the chest is clear
3. There is no need to get a X-Ray as we already know that there is an infection
4. Cancellation of surgery and starting the patient on antibiotic is the best option

Comments

Adenoidectomy was probably first performed in the late 1800s when Willhelm Meyer of Copenhagen, Denmark, proposed that adenoid vegetations were responsible for nasal symptoms and impaired hearing. However, tonsillectomy has been performed for at least 2000 years; Celsus first described the procedure as early as 50 CE. The hidden location of the adenoid certainly had an impact on the historical timing of discovery.

Tips

The 2 operations were routinely performed together beginning in the early part of the 1900s, when the tonsils and adenoids were considered reservoirs of infection that caused many different types of diseases. Tonsillectomy and adenoidectomy (T&A) was considered a treatment for anorexia, mental retardation, and enuresis or was performed simply to promote good health.

Post operative pain relief for Infant - Analgesic after surgery

028. A two month old infant has undergone a major surgical procedure. Regarding post operative pain relief which one of the following is recommended:

1. No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system

2. Only paracetamol suppository is adequate

3. Spinal narcotics via intrathecal route

4. Intravenous narcotic infusion in lower dosage

Answer

4. Intravenous narcotic infusion in lower dosage

Reference

http://www.nda.ox.ac.uk/wfsa/html/u07/u07_008.htm

Updates in Anaesthesia : Practical Procedures : Issue 7 (1997) Article 2: Page 6 of 7

The Management of Postoperative Pain (Continued)

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Management of pain in children is often inadequate and there is no evidence to support the idea that pain is less intense in neonates and young children due to their developing nervous system. Children tend to receive less analgesia than adults and the drugs are often discontinued sooner. Furthermore, it is simply not true that potent analgesics are dangerous when used in children because of the risks of side effects and addiction. As with all pain, successful management depends upon the identification and treatment of all the factors which contribute, in particular fear and anxiety. In this context, careful explanations to child and parents can be helpful. A major problem in treating pain in children is associated with the difficulty in assessment

Explanation

1. Though the neonates have an immature brain, they nevertheless feel pain and anesthesia is needed.
2. Paracetamol is effective for mild to moderate pain. It can be given as an oral suspension in a dose of 15mg/kg to a maximum of 60mg/kg in 24 hours. Slightly higher doses (20mg/kg) are needed if this drug is used rectally as absorption is less reliable. Obviously this is not suited for our child as the infant has undergone a major surgical procedure
3. Intrathecal route is not the first choice
4. Morphine is the drug of choice for children who are inpatients. The preferred route of injection is intravenous but other routes can be used. Intramuscular injection is painful and unpopular with patients and nurses, however, this route may be used during the operation to provide analgesia at the time the child awakens from anaesthesia. The subcutaneous route can be useful when venous access is difficult. Intravenous morphine is painless once access has been established and if an infusion is to be used the same precautions must be taken to prevent accumulation as were outlined earlier. Normally a loading dose is infused over 30 minutes followed by a background infusion, titrated against the child's pain and the presence of side effects. If staff are experienced in looking after children postoperatively, there is no need for high dependency or intensive care facilities whilst these techniques are employed.

Comments

Doses of morphine orally are 200-400mcg/kg 4 hourly.

Subcutaneous or intramuscular routes 100-150mcg/kg 4 hourly. Intravenous doses 50-100mcg/kg over 30 minutes as a loading dose and then 5-40mcg/kg hourly.

Tips

Many procedures associated with the relief of pain can themselves be painful. The performance of regional blockade, wound infiltration and the placement of intravenous or subcutaneous lines and catheters may be carried out without discomfort or resistance whilst the patient is anaesthetized.

Blalock and Taussig shunt is done between subclavian artery to the homolateral branch of the pulmonary artery

027. Blalock and Taussig shunt is done between:

1. Aorta to Pulmonary artery

2. Aorta to Pulmonary vein

3. Subclavian artery to Pulmonary vein

4. Subclavian vein to artery

Answer

1. Aorta to Pulmonary artery

Reference:

Nelson 15^th Edition Chapter 387.2

Nelson 16th Edition Page 1527

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Discussion

The modified Blalock-Taussig shunt is currently the most common aorto-pulmonary shunt procedure and consists of a Gore-Tex conduit anastomosed side to side from the subclavian artery to the homolateral branch of the pulmonary artery. Sometimes the conduit is brought directly from the ascending aorta to the main pulmonary artery and is called a central shunt. The Blalock-Taussig operation can be successfully performed in the newborn period using 4-5 mm diameter shunts and has been utilized successfully in premature infants. The original Blalock-Taussig shunt consisted of a direct anastomosis of the subclavian artery to a branch pulmonary artery.

Explanation

Self Explanatory. The operation was first successfully performed on November 29, 1944: anastomosis between arteria subclavia and arteria pulmonalis in a case of Fallot's tetralogy. In short it is an anastomosis between a branch of aorta and pulmonary artery. Hence we can opt for the first choice as the “best option” even though it is not the correct option

Comments

Other shunt procedures include a side-to-side anastomosis of the ascending aorta and right pulmonary artery (Waterson) and anastomosis of the descending aorta and left pulmonary artery (Potts).

Tips

These procedures are rarely done because of a higher frequency of complicating congestive heart failure and a higher risk for the development of pulmonary hypertension as well as greater technical difficulties in closing these shunts during subsequent corrective surgery.

Propofol suitable for day care surgery

026. Which of the following intravenous induction agents is the most suitable for day care surgery?

1. Morphine

2. Ketamine

3. Propofol

4. Diazepam

Answer

3. Propofol

Reference

Clinical Anaesthesia 3^rd Edition – Morgan Page 173

Also seen in

KDTripathi,5^th Edition Page 343

Lee, 12^th Edition, Pages 176, 417

SARP - SARP 6^th Edition Page 108

PARAS - PARAS 4^th Edition Page 46

Sure Sucess in PG Entrance 1^st Edition Page 93

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Discussion

Propofol is Di-Isopropylphenol

Ä It is prepared as an emulsion in 10% Soyabean oil and 1.2% egg phosphatide and 2.25%Glycerol

Ä Induction dose is 2-3 mg/kg

Ä Highly lipophilic

Ä 30%-40% of patients complain of pain/burning during injection.

Ä Induction is rapid and recovery of consciousness after 4-7 minutes

Ä Post anaesthetic Performance of Mental, Manual and Mechanical task is back to normal within 1-2 hours

Ä Suited for Day care Surgery

Ä Safe for patients with Acute Intermittent Porphyria

Ä It does not trigger Malignant hyperthermia

Ä Hypotension is a common side effect

Ä Apnoea is common after induction and may last for 40-50 seconds

Ä Antioxidant

Ä Antiemetic

Ä Antipruritic

Explanation

Self Explanatory.

Comments

Ketamine is the anaesthesia of choice for patients in shock and produces delirium and is not the drug for Day Care Anaesthesia. Morphine is used for pain relief and Diazepam for sedation

Tips

This is an Often Repeated Question. Similarly there is a long list of what to use and what not to use in each specific conditions and the fact is that those are asked often and you have no other way than to prepare them. Know the key details about all the anaesthetic agents.

Exopthalmus is not a sign of stellate ganglion block

025. Which of the following is not a sign of stellate ganglion block?

1. Meiosis

2. exopthalmus

3. Nasal congestion

4. Conjuctival redness

Answer

2. Exopthalmus

Reference

Oxford Text book of Surgery, Chapter. 7.9.2

Bailey and Love 24^th Edition, Page 953

Concise text book of Surgery, 3^rd Edition, Page 154

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Discussion

Damage to the stellate ganglion results in a Horner's syndrome with ptosis, pupillary constriction, and facial flushing and dryness on the affected side. Though cycloplegia does not occur, there may be difficulties in accomodation

Explanation

Horner's syndrome is characterized by an interruption of the oculosympathetic nerve pathway somewhere between its origin in the hypothalamus and the eye. The classic clinical findings associated with Horner's syndrome are ptosis, pupillary miosis and facial anhidrosis. Other findings may include apparent enophthalmos, increased amplitude of accommodation, heterochromia of the irides (if it occurs before age two), paradoxical contralateral eyelid retraction, transient decrease in intraocular pressure and changes in tear viscosity.

Comments

Sympathetic innervation to the eye consists of a three neuron arc. The first neuron originates in the hypothalamus. It descends and travels between the levels of the eighth cervical and forth thoracic vertebrae (C8-T4) of the spinal cord. There, it synapses with second order neurons whose preganglionic cell bodies give rise to axons. These axons pass over the apex of the lung and enter the sympathetic chain in the neck, synapsing in the superior cervical ganglion. Here, cell bodies of third order neurons give rise to postganglionic axons that course to the eye via the cavernous sinus. These sympathetic nerve fibers course anteriorly through the uveal tract and join the fibers of long posterior ciliary nerves to innervate the dilator of the iris. Postganglionic sympathetic fibers also innervate the muscle of Mueller within the eyelid, which is responsible for the initiation of eyelid retraction during eyelid opening. Postganglionic sympathetic fibers, responsible for facial sweating, follow the external carotid artery to the sweat glands of the face. Interruption at any location along this pathway (preganglionic or postganglionic) will induce an ipsilateral Horner's syndrome.

The common etiologies of acquired preganglionic Horner's syndrome include, but are not limited to, trauma, aortic dissection, carotid dissection, tuberculosis and Pancoast tumor. Common causes of post-ganglionic Horner's syndrome include trauma, cluster migraine headache and neck or thyroid surgery.

Tips

The diagnosis and the localization of a Horner's syndrome is accomplished with pharmacological testing. Ten percent liquid cocaine (topically applied), works as an indirect acting sympathomimetic agent by inhibiting the re-uptake of norepinephrine at the nerve ending. A Horner's pupil will dilate poorly because of the absence of endogenous norepinephrine at the nerve ending. The test should be evaluated thirty minutes after the instillation of the drops to ensure accuracy. The cocaine test is used to confirm or deny the presence of a Horner's syndrome. However, a positive cocaine test does not localize the lesion.

To localize the lesion as either preganglionic or postganglionic, Paradrine 1% (hydroxyamphetamine) or Pholedrine 5% (n-methyl derivative of hydroxyamphetamine) can be instilled 48 hours later. Pholedrine and Paradrine act similarly by producing the forced release of endogenous norepinephrine from the presynaptic vesicles. If the third neuron is damaged, there will be no endogenous norepinephrine and the pupil will not dilate, thus indicating a postganglionic lesion. Dilation indicates first or second order neuron lesion. There is currently no method of topical testing to differentiate a first order preganglionic lesion from a second order preganglionic lesion.

Pethidine - Treatment of postoperative shivering

024. Which of the following agents is used for the treatment of postoperative shivering?

1. Thiopentone

2. Suxamethonium

3. Atropine

4. Pethidine

Answer

4. Pethidine

Reference

Ajay yadav, Page 101

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In course of anaesthesia, Shivering occurs as a protective mechanism as inhalational agents, spinal/epidural block causes vasodilatation leading to heat loss. Shivering can be abolished by inhibition of hypothalamus,

Explanation

Treatment of Shivering

1. Pethidine or Pentazocine
2. Oxygen Inhalation

Comments

Oxygen consumption may increase upto 4 times (400 %) during shivering. So oxygen inhalation during shivering is mandatory.

Tips

Most commonly shivering is seen after Halothane

Mephenteramine is not used to provide induced hypotension during surgery

023. Which of the following agents is not used to provide induced hypotension during surgery?

1. Sodium nitroprusside

2. Hydralazine

3. Mephenteramine

4. Esmolol

Answer

3. Mephenteramine

Reference

KDTripathi,4^th Edition Page 112

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Discussion

Mephentermine (Wyamine)

Brand names

Mephentine

Category:

• Adrenergic Drug

Description:

• Antihypotensive

Indications:

• Hypotension during spinal anesthesia

Contraindications:

• Hypotension induced by chlorpromazine
• Concurrent use with any MAOI

Precautions:

• Pregnancy category C
• Cardiovascular disease, chronically ill patients
• Hemorrhagic shock, hyperthyroidism, hypertension

Explanation

Sodium nitroprusside, hydralazine and esmolol are used to produce hypotension while mephentermine is used to protect against hypotension

Comments

Dosage:

Administered intramuscularly, intravenously

• Adult:
• Prevention of hypotension during spinal anesthesia:
• IM 30-45mg 10-20 minutes prior to anesthesia
• Hypotension following spinal anesthesia:
• IV 30-45mg, repeat doses of 30mg as needed to maintain blood pressure
• IV INF use 0.1%

Tips

Adverse Reactions (Side Effects):

• CNS: anxiety, confusion, drowsiness, incoherence, tremors
• CV: hypertension, palpitations, tachydardia

Pneumothoraxis not an indication for endotracheal intubation

022 Which of the following is not an indication for endotracheal intubation?

1. Maintenance of a patent airway

2. To provide positive pressure ventilation

3. Pulmonary toilet

4. Pneumothorax

Answer

4. Pneumothorax

Reference

Sabiston 15^th Edition Chapter 17

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Discussion

INDICATIONS FOR ENDOTRACHEAL INTUBATION

Indications for ENDOTRACHEAL INTUBATION in the operating room include:

• the need to deliver positive pressure ventilation
• protection of the respiratory tract from aspiration of gastric contents
• surgical procedures involving the head and neck or in non-supine positions that preclude manual airway support
• almost all situations involving neuromuscular paralysis
• surgical procedures involving the cranium, thorax, or abdomen
• procedures that may involve intracranial hypertension

Some non-operative indications are:

• profound disturbance in consciousness with the inability to protect the airway
• tracheobronchial toilet
• severe pulmonary or multisystem injury associated with respiratory failure, such as sepsis, airway obstruction, hypoxemia, and hypercarbia

Explanation

Self Explanatory

Comments

Objective measures may also be used to help determine the need for intubation:

• respiratory rate > 35 breaths per minute
• vital capacity <>
• inability to generate a negative inspiratory force of 20 mm Hg
• PaO2 (arterial partial pressure of oxygen) <>
• A-a gradient (Alveolar-arterial) > 350 mm Hg on 100% oxygen
• PaCO2 (arterial partial pressure of carbon dioxide) > 55 m Hg (except in chronic retainers)
• dead space > 0.6 L

Tips

Alternative techniques to establish an airway

* Oral Airway

* Nasal Airway

* Mask Ventilation

* Transtracheal Jet Ventilation

* Retrograde Intubation

* Laryngeal Mask Airway

* Light Wand

* Blind Nasal Intubation

* Combitube

* Emergency Cricothyrotomy Devices

Thiopentone doesn’t trigger malignant hyperthermia

Question

021. Which of the following anesthetic agents doesn’t trigger malignant hyperthermia?

1. Halothane

2. Isoflurane

3. Suxamethonium

4. Thiopentone

Answer

4. Thiopentone

Reference

KDTripathi 5^th Edition Page 315

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Discussion

• Malignant Hyperthermia is the clinical syndrome observed during general anaesthesia associated with rapidly increasing temperatures as great as 1^oC/5 minutes
• It is due to abnormality of Ryanodine receptor, which is calcium releaseing channel of sarcopalsmic reticulum.

Explanation

The drugs causing malignant hyperthermia are

1. Muscle relaxants
1. Succinyl Choline is the most commonly implicated drug
2. Inhalational agents
1. Halothane is the most common inhalational agent
2. Isoflurane
3. Desflurane
4. Sevoflurane
5. Methoxyflurane
3. Local Anaesthetics
1. Lignocaine
4. Others
1. Tricyclic antidepressants
2. Mono amine oxidase inhibitors
3. Phenothiazines

Comments

· Clinical features

a. Hyperthermia 0 may be even 109^oC

b. Increased end tidal CO₂ (ETCO₂). This may rise to more than 100 mm Hg (normal 32 to 42 mm Hg). Increase in ETCO2 is the most sensitive early sign of malignant hyperthermia

c. Hypoxia

d. Cyanosis

e. Tachycardia

f. Hypertension

g. Cardiac Arrhythmias

h. Severe metabolic acidosis (pH <>

i. Hyperkalemia, Muscle rigidity, Increased Creatine Phosphokinase, increased myoglobin.

j. Renal Failure, DIC, pulmonary and cerebral edema

k. Death

· Treatment

a. Stop anaesthetics

b. Hyperventilation with 100 % oxygen

c. Control temperature

d. Control Acidosis with Sodium bi carbonate 2 to 4 mEq/kg

e. Correct electrolyte imbalance(hyperkalemia)

f. Maintain Urine Output

g. Dantrolene 2mg/kg to be repeated every 5 minutes to a maximum of 10mg/kg

Tips

· Screening

a. High levels of Creatine Phosphokinase make an individual susceptible

b. Masseter spasm after Succinyl Choline

· Other causes of hyperthermia

a. Malignant Neurolept syndrome

Sevoflurane - Inhalational agents is the induction agent of choice in children

Question

020. Which of the following inhalational agents is the induction agent of choice in children?

1. Methyoxyflurane

2. Sevoflurane

3. Desflurane

4. Isoflurane

Answer

2. Sevoflurane.

Reference

KDTripathi 5^th edition Page 341

Lee 12^th Edition Page 509

Also seen in

PARAS - PARAS 4^th Edition Page 40

Sure Sucess in PG Entrance 1^st Edition Page 100

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Discussion

Sevoflurane is polyflurinated methyl isopropyl alcohol. Sevoflurane is indicated for the induction and maintenance of general anesthesia in adult and pediatric patients during inpatient or outpatient surgery. Often, sevoflurane is used with other medications to induce or supplement anesthesia. Sevoflurane has several effects that serve to lower blood pressure. It depresses cardiac function, decreases cardiac contractility, and decreases peripheral vascular resistance in a manner similar to that of isoflurane. Due to its lack of pungency, sevoflurane is widely used for induction of anesthesia in pediatric patients.

Explanation

1. Methoxyflurane is 2,2-Dichloro-1,1-difluoro-1-methoxyethane; Penthrane Pentran; Pentrane; 2,2-Dichloro-1,1-difluoroethyl methyl ether; Methflurane; Methoxflurane. Methoxyflurane (Metofane) is no longer being manufactured in the United States or Canada.

2. Sevoflurane is the agent of choice for Children, as it poses no problem in induction and absence of pungency makes it pleasant and administrable through mask

3. Desflurane is a fluorinated congener of Isoflurane

4. Isoflurane is fluorinated methyl ethyl ether and causes least alteration of cardiovascular status

Comments

· Sevoflurane is contraindicated in Closed circuit with Soda Lime or Baralyme since a toxic compound is produced. The toxic compound produced is Compund A - PIPE - Pentafluoroisopropenyl fluoro methyl ether

· Other agents contraindicated in closed circuit are

1. Trichloroethylene

2. Chloroform

3. Methoxyflurane

Tips

Enflurane is the anesthesia of choice in Pheochromocytoma