Complications in Anesthesia Practice Questions

Q: A patient undergoing surgery develops sudden deranged vitals following a failed attempt at subclavian vein catheterization. On examination, the trachea is shifted to one side and breath sounds are absent on the opposite side. What is the most likely diagnosis?

Tension pneumothorax. ***Correct: Tension pneumothorax*** - **Classic complication of subclavian vein catheterization** - inadvertent puncture of the pleura causes air accumulation in the pleural space - **Pathognomonic clinical features** present in this case: - **Tracheal deviation away from the affected side** (toward the opposite side where breath sounds are absent) - **Absent breath sounds on the affected side** due to complete lung collapse - **Hemodynamic instability** ("deranged vitals") from mediastinal shift compressing the great vessels and heart - **Medical emergency** requiring immediate needle decompression followed by chest tube insertion - The **tension** component occurs when air enters pleural space during inspiration but cannot escape during expiration (one-way valve effect), causing progressive pressure buildup *Incorrect: Aspiration pneumonitis* - Would present with bilateral crackles, hypoxia, and potential bronchospasm - Does **not cause tracheal deviation** or unilateral absent breath sounds - Typically occurs during induction or emergence from anesthesia, not during vascular access procedures *Incorrect: Pulmonary embolism* - Presents with sudden dyspnea, hypoxia, tachycardia, and possible hypotension - Does **not cause tracheal deviation** or unilateral absent breath sounds - Breath sounds remain present bilaterally (though may have localized crackles) - Not directly related to subclavian catheterization attempts *Incorrect: Bronchospasm* - Presents with **bilateral wheezing** and increased airway pressures - Does **not cause tracheal deviation** or unilateral findings - Breath sounds present bilaterally (though may be diminished with severe bronchospasm) - Would not explain the immediate temporal relationship with failed subclavian line attempt

Q: A known case of hyperthyroidism, who is not on medication, is scheduled for total thyroidectomy. The PAC check was not done properly. What is the leading complication that can occur during surgery?

Arrhythmia. ***Arrhythmia***- Uncontrolled **hyperthyroidism** significantly increases sympathetic cardiovascular stimulation, making the heart susceptible to **tachycardia** and cardiac instability during stress.- Intraoperative stress (from anesthesia and surgery) can trigger a **thyroid storm**, where the resulting severe ventricular tachycardia or **atrial fibrillation** poses the greatest immediate threat to life during the procedure.*Hyperthermia*- Although **hyperthermia** (high fever) is a critical classic sign of a **thyroid storm**, immediate cardiovascular collapse due to **arrhythmias** typically precedes or dominates the intraoperative crisis.- The underlying increase in the **basal metabolic rate (BMR)** in hyperthyroidism predisposes the patient to thermal dysregulation, which is exacerbated during surgery.*Hypothermia*- **Hypothermia** (low body temperature) is extremely unlikely as the leading complication in an actively hyperthyroid patient due to their persistently elevated **BMR**.- This complication would be more typical of severe non-thyroid disease or prolonged surgery with poor thermal management, not directly caused by unmedicated hyperthyroidism itself.*Hypothyroidism*- **Hypothyroidism** is a predictable *long-term complication* following a successful **total thyroidectomy** and subsequent removal of functional thyroid tissue.- This condition is not an acute, intraoperative complication resulting from the lack of proper preoperative control of the underlying **thyrotoxicosis**.

Q: A patient undergoing surgery is administered succinylcholine for muscle relaxation. Shortly after administration, he develops hyperthermia, muscle rigidity, tremors, and tachycardia. What is the most appropriate treatment for this condition?

Dantrolene sodium. ***Dantrolene sodium***- This is the specific and definitive antidote for **Malignant Hyperthermia (MH)**, characterized by signs like hyperthermia, muscle rigidity, and tachycardia after succinylcholine administration.- **Dantrolene** works directly on skeletal muscle by inhibiting the release of calcium from the **sarcoplasmic reticulum**, thereby interrupting the sustained muscle contraction and hypermetabolic state.*Neostigmine*- It is an **acetylcholinesterase inhibitor** used to reverse the effects of non-depolarizing neuromuscular blocking agents (e.g., rocuronium).- It is **contraindicated** in MH as it could potentially exacerbate muscle rigidity and the hypermetabolic crisis by increasing **acetylcholine** activity at the neuromuscular junction.*Atropine*- This is an **anticholinergic** drug primarily used to treat bradycardia or to dry secretions.- Although the patient exhibits severe tachycardia, atropine does not treat the underlying pathological hypermetabolism or the excessive calcium release that defines MH.*Midazolam*- This is a **benzodiazepine** used for anxiolysis, sedation, and if necessary, managing seizures.- While supportive care for MH might involve benzodiazepines if seizures occur due to hyperthermia, it is not the crucial drug needed to counteract the life-threatening hypermetabolic crisis.

Q: A 35-year-old male undergoing abdominal surgery under general anesthesia develops sudden generalized muscle rigidity, rapid increase in body temperature, and tachycardia shortly after administration of sevoflurane and succinylcholine. His end-tidal CO2 is rising despite controlled ventilation. What is the most appropriate immediate treatment?

Dantrolene. ***Dantrolene*** - This clinical scenario is a classic presentation of **Malignant Hyperthermia (MH)**, a life-threatening pharmacogenetic disorder triggered by volatile anesthetics (like sevoflurane) and succinylcholine. - **Dantrolene sodium** is the only specific treatment for MH; it acts by directly interfering with excitation-contraction coupling in skeletal muscle, reducing the intracellular calcium release from the sarcoplasmic reticulum. *Diazepam* - Diazepam is an anxiolytic/sedative and an anticonvulsant; it might be used to control generalized seizures or anxiety, but it is **not effective** against the massive muscle contracture seen in Malignant Hyperthermia. - Administering diazepam would only treat minor symptoms or anxiety and delay the necessary specific treatment, leading to potentially fatal outcomes from **rhabdomyolysis and hyperkalemia**. *Pancuronium* - Pancuronium is a **non-depolarizing neuromuscular blocking agent** (muscle relaxant) and will not halt the underlying pathological process of Malignant Hyperthermia, which involves uncontrolled calcium release from the sarcoplasmic reticulum. - Although it causes paralysis, it would not address the **hypermetabolic state** (characterized by rising ETCO2 and temperature) that is the hallmark of MH. *Vecuronium* - Vecuronium is also a **non-depolarizing neuromuscular blocking agent** used for muscle relaxation during anesthesia, similar to pancuronium. - While it causes muscle paralysis, it does not correct the massive, uncontrolled increase in intracellular calcium that drives the **malignant hyperthermic crisis**.

Q: During induction of anesthesia, after thiopentone injection patient develops discoloration of hand. All are true about this condition and its management except:

Immediately remove the needle from the vessel. ***Immediately remove the needle from the vessel*** - This is an **incorrect** management step for accidental intra-arterial injection of thiopentone because removing the needle can lead to **vasospasm** and further compromise blood flow. - The needle should be left in place to facilitate administration of vasodilator and antispasmodic agents, helping to mitigate the damage. *Inject lignocaine* - **Intra-arterial lignocaine** (without adrenaline) is a crucial step to induce vasodilation and alleviate pain caused by the irritation and arterial spasm. - This helps to restore blood flow and prevent further tissue ischemia. *Dilute heparin* - Administering **dilute heparin** directly into the artery helps to prevent or treat **thrombosis**, a common complication of intra-arterial injection of irritant substances like thiopentone. - Thiopentone's high pH can cause endothelial damage, leading to clot formation and further reducing perfusion. *Intra-arterial thrombolysis* - If conservative measures fail and there is evidence of severe ischemia or thrombosis, **intra-arterial thrombolysis** with agents like urokinase or streptokinase may be considered. - This highly invasive procedure aims to dissolve existing clots and restore arterial patency to salvage tissue.

Q: A patient presented with rigidity, tremors, and trismus after being administered an anesthetic agent. Which anesthetic agent is most likely to have been administered?

Halothane. ***Halothane*** - The combination of **rigidity**, **tremors**, and **trismus** after an anesthetic agent suggests **malignant hyperthermia (MH)**, a rare but life-threatening inherited condition. - **Halothane (and other volatile anesthetics)**, along with succinylcholine, are known triggers for malignant hyperthermia. *Nitrous Oxide (N2O)* - While an anesthetic agent, **nitrous oxide** is not a known trigger for **malignant hyperthermia**. - It works by modulating **NMDA receptors** and does not typically cause rigidity, tremors, or trismus as a side effect. *Thiopentone sodium* - **Thiopentone sodium** is a **barbiturate** anesthetic and is not associated with triggering **malignant hyperthermia**. - Its effects primarily involve potentiation of **GABA-A receptors**, leading to sedation and hypnosis. *Etomidate* - **Etomidate** is a short-acting intravenous anesthetic that is not a known trigger for **malignant hyperthermia**. - It is typically associated with minimal cardiovascular depression but can cause **adrenocortical suppression** with prolonged use.

Q: A patient is undergoing surgery where anesthesia is maintained with halothane. The patient develops hyperthermia and muscle rigidity. Which of the following agents is most likely responsible?

Suxamethonium. ***Suxamethonium*** - **Suxamethonium** (succinylcholine) is a depolarizing neuromuscular blocker that can trigger **malignant hyperthermia** in susceptible individuals, characterized by **hyperthermia** and **muscle rigidity**. - This adverse reaction occurs due to an uncontrolled release of calcium from the **sarcoplasmic reticulum** in skeletal muscle, leading to sustained muscle contraction and increased metabolism. *Cisatracurium* - **Cisatracurium** is a non-depolarizing neuromuscular blocker, which works by competing with acetylcholine at the **neuromuscular junction**. - It does not typically cause **malignant hyperthermia** and is less likely to be associated with hyperthermia or muscle rigidity as a direct side effect. *D-tubocurarine* - **D-tubocurarine** is a non-depolarizing neuromuscular blocker that causes muscle relaxation by blocking nicotinic acetylcholine receptors. - While it can cause **histamine release**, leading to hypotension and bronchospasm, it is not implicated in triggering **malignant hyperthermia**. *Rocuronium* - **Rocuronium** is a rapid-onset, intermediate-acting non-depolarizing neuromuscular blocker, used for muscle relaxation during surgery. - Like other non-depolarizing agents, it does not directly trigger **malignant hyperthermia** and is not associated with hyperthermia and muscle rigidity in this context.

Q: A 60 year old male patient was undergoing laparoscopic cholecystectomy. During the surgery, a sudden drop in EtCO2 to 8 mmHg was noted. His SpO2 became 90%, his blood pressure dropped to 80/50 mmHg, and peak airway pressure was 18 cm of H2O. What is the diagnosis?

Gas embolism. ***Gas embolism*** - A sudden drop in **EtCO2** to 8 mmHg, **hypotension**, and **hypoxemia** during laparoscopic surgery are classic signs of a gas embolism, often from insufflated CO2 entering the bloodstream. - The drop in EtCO2 is due to a sudden decrease in pulmonary blood flow, preventing CO2 from reaching the lungs for exhalation. *Anaphylaxis* - While anaphylaxis can cause hypotension and hypoxemia, it typically presents with **bronchospasm** (increased peak airway pressure), **tachycardia**, and skin manifestations like **urticaria** or angioedema, which are not explicitly mentioned. - Anaphylaxis does not typically cause a drastic, sudden drop in EtCO2 to such low levels as seen with a gas embolism. *Malignant hyperthermia* - This condition is characterized by a rapid and sustained increase in **EtCO2**, **tachycardia**, muscle rigidity, and hyperthermia, which is the opposite of the EtCO2 findings here. - Malignant hyperthermia would lead to a significant elevation in metabolic CO2 production, not a sudden drop in EtCO2. *Pneumothorax* - A pneumothorax would typically present with **increased peak airway pressures**, **hypoxia**, and **hypotension**, but the EtCO2 would likely initially rise or remain stable before dropping due to decreased ventilation, not an acute drop to 8 mmHg. - The primary physiological issue in pneumothorax is lung collapse, leading to ventilation-perfusion mismatch, but not directly causing a sudden near-absence of exhaled CO2 in this manner.

Q: False statement about post-dural puncture headache (PDPH):

Headache is relieved in sitting standing position. ***Headache is relieved in sitting standing position*** - This statement is **false** because a cardinal feature of PDPH is that the headache is **worse in the upright position** (sitting or standing) and **relieved by lying flat**. - The postural nature of the headache is due to the continued leakage of CSF, leading to reduced intracranial pressure, which is exacerbated by gravity when upright. *Commonly occipito-frontal in location* - PDPH typically presents as a headache that can be **holocranial**, **occipital**, or **frontal**, often radiating to the neck. - The location is due to changes in **intracranial pressure** affecting pain-sensitive structures like blood vessels and meninges. *Onset of headache is usually 12-72 hours following procedure* - The onset of PDPH is typically **delayed**, occurring in the vast majority of cases between **12 to 72 hours** after the dural puncture. - Although it can occur immediately or up to five days later, this delayed presentation is characteristic. *Breach of dura* - PDPH is a direct consequence of the intentional or accidental **breach of the dura mater** during procedures like spinal anesthesia or lumbar puncture. - This breach allows for continuous leakage of **cerebrospinal fluid (CSF)**, leading to a reduction in intracranial pressure, which causes the headache.

Q: 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:

IV lignocaine through same needle. **_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 1

A patient undergoing surgery develops sudden deranged vitals following a failed attempt at subclavian vein catheterization. On examination, the trachea is shifted to one side and breath sounds are absent on the opposite side. What is the most likely diagnosis?

Accepted Answer

Tension pneumothorax

Answer

Aspiration pneumonitis

Answer

Pulmonary embolism

Answer

Bronchospasm

Question 2

A known case of hyperthyroidism, who is not on medication, is scheduled for total thyroidectomy. The PAC check was not done properly. What is the leading complication that can occur during surgery?

Accepted Answer

Arrhythmia

Answer

Hypothyroidism

Answer

Hypothermia

Answer

Hyperthermia

Question 3

A patient undergoing surgery is administered succinylcholine for muscle relaxation. Shortly after administration, he develops hyperthermia, muscle rigidity, tremors, and tachycardia. What is the most appropriate treatment for this condition?

Accepted Answer

Dantrolene sodium

Answer

Neostigmine

Answer

Midazolam

Answer

Atropine

Question 4

A 35-year-old male undergoing abdominal surgery under general anesthesia develops sudden generalized muscle rigidity, rapid increase in body temperature, and tachycardia shortly after administration of sevoflurane and succinylcholine. His end-tidal CO2 is rising despite controlled ventilation. What is the most appropriate immediate treatment?

Accepted Answer

Dantrolene

Answer

Vecuronium

Answer

Diazepam

Answer

Pancuronium

Question 5

During induction of anesthesia, after thiopentone injection patient develops discoloration of hand. All are true about this condition and its management except:

Accepted Answer

Immediately remove the needle from the vessel

Answer

Inject lignocaine

Answer

Dilute heparin

Answer

Intra-arterial thrombolysis

Question 6

A patient presented with rigidity, tremors, and trismus after being administered an anesthetic agent. Which anesthetic agent is most likely to have been administered?

Accepted Answer

Halothane

Answer

Nitrous Oxide (N2O)

Answer

Thiopentone sodium

Answer

Etomidate

Question 7

A patient is undergoing surgery where anesthesia is maintained with halothane. The patient develops hyperthermia and muscle rigidity. Which of the following agents is most likely responsible?

Accepted Answer

Suxamethonium

Answer

Cisatracurium

Answer

D-tubocurarine

Answer

Rocuronium

Question 8

A 60 year old male patient was undergoing laparoscopic cholecystectomy. During the surgery, a sudden drop in EtCO2 to 8 mmHg was noted. His SpO2 became 90%, his blood pressure dropped to 80/50 mmHg, and peak airway pressure was 18 cm of H2O. What is the diagnosis?

Accepted Answer

Gas embolism

Answer

Anaphylaxis

Answer

Malignant hyperthermia

Answer

Pneumothorax

Question 9

False statement about post-dural puncture headache (PDPH):

Accepted Answer

Headache is relieved in sitting standing position

Answer

Commonly occipito-frontal in location

Answer

Onset of headache is usually 12-72 hours following procedure

Answer

Breach of dura

Question 10

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:

Accepted Answer

IV lignocaine through same needle

Answer

Leave it alone

Answer

IV ketamine through same needle

Answer

Give IV propofol through same needle

Complications in Anesthesia — MCQs

Complications in Anesthesia — MCQs

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