MODULE 3: INVESTIGATIONS & MONITORING

Q41: What are the common investigations ordered during PAC?

Answer:Common PAC Investigations:

Routine for All Patients:

1. Complete Blood Count (CBC)

   • Hemoglobin, hematocrit
   • WBC count, differential
   • Platelet count

2. Coagulation Studies

   • PT/INR, aPTT
   • Bleeding time (selective)

Additional Based on Age/Comorbidities:

Cardiac Patients:

• ECG, echocardiogram
• Cardiac enzymes (if recent MI)
• Stress test (if indicated)

Diabetic Patients:

• Blood glucose
• HbA1c
• Kidney function tests

Liver Disease:

• LFTs, bilirubin
• Albumin, protein levels

Kidney Disease:

• Serum creatinine, BUN
• Electrolytes, eGFR

Respiratory Disease:

• Chest X-ray
• Pulmonary function tests
• ABG analysis

Q42: Abbreviate WNL, NAD

Answer:Medical Abbreviations:

WNL = Within Normal Limits

• Used to indicate that test results fall within expected reference ranges
• Common in lab reports and clinical notes

NAD = No Abnormality Detected

• Used to indicate that physical examination findings are normal
• Alternative: NAD = Nothing Abnormal Detected

Q43: Name all types of consent used in Pre operative area

Answer:Types of Consent:

1. Informed Consent:

• Complete information about procedure
• Risks, benefits, alternatives
• Patient understanding demonstrated

2. Implied Consent:

• Patient behavior indicates consent
• Physical examination, vital signs

3. Expressed Consent:

• Written or verbal explicit consent
• Formal documentation required

4. Emergency Consent:

• When patient cannot consent
• Life-threatening situations
• Based on "best interest" principle

5. Surrogate Consent:

• Authorized person decides for patient
• Legal guardian, family member
• When patient incompetent

Q44: Write the NPO formula for neonates

Answer:NPO Guidelines for Neonates:

Formula for NPO Duration:

• Clear liquids: 2 hours before surgery
• Breast milk: 4 hours before surgery
• Formula/non-breast milk: 6 hours before surgery
• Solids/heavy meals: 6-8 hours before surgery

Special Considerations:

• Neonates have faster gastric emptying
• Higher metabolic rate
• Risk of hypoglycemia
• May need glucose monitoring
• Consider IV fluids if prolonged NPO

Modified Approach:

• Allow clear liquids up to 2 hours
• Encourage breastfeeding when possible
• Avoid formula 6 hours before surgery

Q45: Write down the most commonly used premedication drugs and dose/kg

Answer:Common Premedication Drugs:

1. Benzodiazepines:

• Midazolam: 0.05-0.1 mg/kg IV (max 2-5 mg)
• Diazepam: 0.1-0.2 mg/kg PO
• Lorazepam: 0.05 mg/kg PO

2. Opioids:

• Morphine: 0.1 mg/kg IM/IV
• Fentanyl: 1-2 mcg/kg IV
• Meperidine: 1-2 mg/kg IM

3. Anti-emetics:

• Ondansetron: 0.1 mg/kg IV (max 4 mg)
• Metoclopramide: 0.1-0.2 mg/kg IV

4. Anticholinergics:

• Atropine: 0.01 mg/kg IV/IM (min 0.1 mg)
• Glycopyrrolate: 0.005 mg/kg IV/IM

Q46: What is the name of the equipment required for calculating the depth of anesthesia?

Answer:Depth of Anesthesia Monitoring Equipment:

1. EEG-based Monitors:

• BIS (Bispectral Index) Monitor
• Entropy Monitor
• Narcotrend Monitor

2. Evoked Potentials:

• Auditory Evoked Potential (AEP) Monitor
• Somatosensory Evoked Potential (SSEP)

3. Clinical Monitoring:

• Pupilometer (pupil size measurement)
• Electromyography (EMG) monitors

BIS Monitor:

• Most commonly used
• Range: 0-100 (0 = no brain activity, 100 = awake)
• Target range: 40-60 for general anesthesia
• Limitations: influenced by temperature, drugs, electrical interference

Q47: Write down any few medication used by cardiac patient

Answer:Common Cardiac Medications:

1. Anti-hypertensives:

• ACE Inhibitors: Enalapril, Lisinopril
• Beta-blockers: Metoprolol, Atenolol
• Calcium channel blockers: Amlodipine, Diltiazem
• Diuretics: Furosemide, Hydrochlorothiazide

2. Cardiac Medications:

• Nitrates: Nitroglycerin, Isosorbide
• Antiarrhythmics: Amiodarone, Flecainide
• Digoxin: For heart failure, atrial fibrillation

3. Antiplatelet/Anticoagulants:

• Aspirin: 75-325 mg daily
• Clopidogrel: 75 mg daily
• Warfarin: Variable dosing
• DOACs: Apixaban, Rivaroxaban

4. Lipid-lowering:

• Statins: Atorvastatin, Simvastatin

Preoperative Management:

• Continue beta-blockers, calcium channel blockers
• Hold ACE inhibitors on surgery day
• Manage anticoagulants per guidelines

Q48: What are the leads used in ECG and mention their location of placement?

Answer:ECG Leads and Placement:

Limb Leads:

• Lead I: Right arm (-) to Left arm (+)
• Lead II: Right arm (-) to Left leg (+)
• Lead III: Left arm (-) to Left leg (+)

Augmented Leads:

• aVR: Right arm (+), Left arm & leg (-)
• aVL: Left arm (+), Right arm & leg (-)
• aVF: Left leg (+), Right arm & Left arm (-)

Chest Leads (V1-V6):

• V1: 4th intercostal space, right sternal border
• V2: 4th intercostal space, left sternal border
• V3: Midway between V2 and V4
• V4: 5th intercostal space, midclavicular line
• V5: Horizontal level of V4, anterior axillary line
• V6: Horizontal level of V4, midaxillary line

Additional Leads:

• V7: Posterior to V6
• V8: Lower border of scapula
• V9: Spinous process level

Q49: List any four items checked during anesthesia machine checking

Answer:Anesthesia Machine Check:

1. Oxygen Supply:

• Check oxygen cylinder pressure
• Verify oxygen flowmeter function
• Test oxygen failure alarm
• Check oxygen pipeline connections

2. Ventilator Function:

• Test ventilator bellows movement
• Verify pressure limits
• Check alarm systems
• Test manual ventilation

3. Circuit Integrity:

• Test for leaks
• Check valve function
• Verify CO2 absorber
• Test emergency oxygen flush

4. Monitoring Equipment:

• Verify capnography function
• Check pulse oximeter accuracy
• Test blood pressure monitor
• Check gas analyzer calibration

Q50: List any four essential items required for securing IV access before anesthesia

Answer:Essential IV Access Items:

1. IV Cannula:

• Size appropriate for patient (14G-24G)
• Check for proper flow
• Sterile packaging

2. IV Fluids:

• Normal Saline or Ringer's Lactate
• Check expiration date
• Proper fluid bag connections

3. Administration Set:

• Microdrip or macrodrip
• Roller clamp function
• Drip chamber integrity

4. Securing Materials:

• Transparent dressing
• Adhesive tape
• IV board/securement device

Additional Items:

• Tourniquet
• Antiseptic solution
• Sterile gauze
• Extension set
• Pressure bag (if needed)

Q51: List any four emergency drugs kept ready in the operation theatre

Answer:Emergency Drugs in OR:

1. Cardiovascular Drugs:

• Epinephrine: 1 mg (cardiac arrest)
• Atropine: 0.5-1 mg (bradycardia)
• Adenosine: 6-12 mg (supraventricular tachycardia)
• Amiodarone: 150 mg (ventricular arrhythmias)

2. Airway Management:

• Succinylcholine: 1-2 mg/kg (muscle relaxant)
• Rocuronium: 1.2 mg/kg (rapid sequence intubation)
• Lidocaine: 1-2 mg/kg (intubation, ventricular arrhythmias)

3. Resuscitation:

• Naloxone: 0.4-2 mg (opioid overdose)
• Flumazenil: 0.2-0.5 mg (benzodiazepine overdose)

4. Critical Care:

• Calcium Chloride: 500 mg-1 g (hyperkalemia, hypocalcemia)
• Glucose: 25-50 g (hypoglycemia)
• Methylprednisolone: 125 mg (anaphylaxis, status asthmaticus)

Q52: Mention any two special instructions given to diabetic patients before anesthesia

Answer:Special Instructions for Diabetic Patients:

1. Medication Management:

• Insulin Adjustment:
  • Hold long-acting insulin on morning of surgery
  • Check blood glucose 2-4 hours preoperatively
  • IV insulin infusion if needed
  • Monitor glucose hourly during surgery

2. Monitoring Requirements:

• Frequent Glucose Checks:
  • Preoperative glucose level
  • Intraoperative monitoring every 1-2 hours
  • Postoperative monitoring until stable
  • Target glucose: 140-180 mg/dL

Additional Instructions:

• Hold oral hypoglycemics on day of surgery
• Avoid prolonged fasting
• Consider dextrose-containing IV fluids
• Monitor for ketoacidosis
• Watch for hypoglycemia signs

Q53: Explain the indications, contraindications of IBP, complications of IBP

Answer:Intra-arterial Blood Pressure (IBP) Monitoring:

Indications:

• Major cardiovascular surgery
• Critical care patients
• Hemodynamically unstable patients
• Need for frequent ABG sampling
• Severe hypertension/hypotension
• Cardiac surgery with bypass

Contraindications:

• Absolute: Severe coagulopathy, infected site
• Relative:
  • Peripheral vascular disease
  • AV fistula
  • Cellulitis at insertion site
  • Raynaud's disease

Complications:

1. Immediate:

   • Bleeding, hematoma
   • Arterial spasm
   • Air embolism
   • Nerve injury

2. Delayed:

   • Infection, sepsis
   • Thrombosis
   • Embolism
   • Ischemia, gangrene
   • Pseudoaneurysm formation

Q54: Name all the monitoring systems we use intraoperatively

Answer:Intraoperative Monitoring Systems:

Standard Monitoring (ASA Standards):

1. Oxygenation: Pulse oximetry, oxygen analyzer
2. Ventilation: Capnography, respiratory rate, airway pressure
3. Circulation: ECG, blood pressure (NIBP/IBP)
4. Temperature: Core temperature monitoring

Advanced Monitoring: 5. Neuromuscular: Nerve stimulator, TOF monitoring 6. Depth of Anesthesia: BIS monitor, entropy 7. Cardiac Output: (in specialized cases) 8. Cerebral Monitoring: EEG, cerebral oximetry

Specialized Monitoring: 9. Urine Output: Foley catheter 10. Blood Loss: Estimated and measured 11. Fluid Balance: Intake and output monitoring 12. ABG Analysis: Blood gas monitoring

Q55: Explain briefly about types of laryngoscopes

Answer:Types of Laryngoscopes:

1. Direct Laryngoscopes:

• Macintosh Blade (Curved):

  • Most commonly used
  • Blades: Size 3, 4 (adults)
  • Less trauma, better for experienced users

• Miller Blade (Straight):

  • Straight design
  • Blades: Size 2, 3 (adults)
  • Better for anterior larynx

2. Indirect Laryngoscopes:

• Video Laryngoscope:

  • Camera on blade tip
  • Better visualization
  • Useful for difficult airway

• Fiberoptic Laryngoscope:

  • Flexible scope
  • Good for nasal intubation
  • Awake intubation option

3. Specialized Laryngoscopes:

• Glidescope:

  • Angulated blade design
  • Built-in camera
  • Steep learning curve

• Airtraq:

  • Optical laryngoscope
  • Disposable blades
  • Portable design

Q56: Name 5 emergency drugs along with their functions and complications

Answer:Emergency Drugs:

1. Epinephrine (Adrenaline):

• Function: Cardiac arrest, anaphylaxis, severe bradycardia
• Dose: 1 mg IV (cardiac arrest), 0.1-0.5 mg (anaphylaxis)
• Complications: Hypertension, tachycardia, arrhythmias

2. Atropine:

• Function: Bradycardia, AV block, organophosphate poisoning
• Dose: 0.5-1 mg IV (max 3 mg)
• Complications: Tachycardia, dry mouth, blurred vision

3. Naloxone (Narcan):

• Function: Opioid overdose reversal
• Dose: 0.4-2 mg IV, repeat every 2-3 minutes
• Complications: Withdrawal, pulmonary edema, arrhythmias

4. Amiodarone:

• Function: Ventricular arrhythmias, atrial fibrillation
• Dose: 150 mg IV bolus, then infusion
• Complications: Hypotension, bradycardia, pulmonary toxicity

5. Calcium Chloride:

• Function: Hyperkalemia, hypocalcemia, calcium channel blocker overdose
• Dose: 500 mg-1 g IV slowly
• Complications: Tissue necrosis, bradycardia, arrhythmias

Q57: Write about IV Induction agents along with their contra-indications

Answer:IV Induction Agents:

1. Propofol:

• Dose: 2-2.5 mg/kg IV
• Advantages: Rapid onset, quick recovery, antiemetic
• Contraindications:
  • Hypersensitivity to egg/soy allergy
  • Severe cardiovascular depression
  • Children ❤️ years (controversial)

2. Thiopentone:

• Dose: 3-5 mg/kg IV
• Advantages: Rapid induction, cerebral protection
• Contraindications:
  • Porphyria
  • Barbiturate allergy
  • Severe cardiovascular disease

3. Etomidate:

• Dose: 0.3 mg/kg IV
• Advantages: Hemodynamic stability
• Contraindications:
  • Hypersensitivity
  • Pediatric sedation (seizure risk)

4. Ketamine:

• Dose: 1-2 mg/kg IV
• Advantages: Bronchodilation, analgesia, sympathetic stimulation
• Contraindications:
  • Increased intracranial pressure
  • Severe hypertension
  • Open globe injury

Q58: Discuss briefly about supraglottic airway devices

Answer:Supraglottic Airway Devices (SADs):

Advantages:

• Easy insertion
• Less invasive than intubation
• Better hemodynamic stability
• Reduced airway trauma
• Faster emergence

Types:

1. Classic Laryngeal Mask Airway (LMA):

• Reusable silicone cuff
• Sizes: 3-6 (adults)
• Good for spontaneous ventilation

2. ProSeal LMA:

• Second lumen for gastric access
• Higher seal pressure
• Better protection against aspiration

3. i-Gel:

• Cuffless design
• Thermoplastic material
• Built-in bite block

4. Supreme LMA:

• Single-use device
• Gastric access
• Improved seal

Limitations:

• Risk of aspiration
• Not for positive pressure ventilation >20 cmH2O
• Limited for prone position

Q59: Write about first and second generation of supraglottic airway

Answer:Generation Classification of SADs:

First Generation:

• Characteristics:

  • Single lumen
  • No gastric access
  • Basic airway seal
  • Limited protection against aspiration

• Examples:

  • Classic LMA
  • Flexible LMA
  • Cuff LMA

• Limitations:

  • No protection against regurgitation
  • Cannot decompress stomach
  • Risk of aspiration

Second Generation:

• Characteristics:

  • Gastric access port
  • Better seal pressure
  • Improved aspiration protection
  • Drain tube for secretions

• Examples:

  • ProSeal LMA
  • Supreme LMA
  • i-Gel
  • LMA Supreme

• Advantages:

  • Gastric tube placement possible
  • Better seal (25-30 cmH2O)
  • Reduced aspiration risk
  • Higher success rates

Clinical Implications:

• Second generation preferred for higher-risk patients
• Better for prolonged procedures
• Enhanced safety profile

Q60: What are the advantages of regional anesthesia over general anesthesia?

Answer:Advantages of Regional Anesthesia:

Patient-Related Benefits:

1. Avoid General Anesthesia Risks

   • No airway manipulation
   • Reduced respiratory complications
   • Less nausea and vomiting

2. Better Pain Control

   • Prolonged postoperative analgesia
   • Reduced opioid requirements
   • Earlier mobilization

3. Consciousness Preservation

   • Patient can communicate
   • Reduced anxiety for some patients
   • Avoids awareness risk

Surgical Benefits:

1. Reduced Blood Loss

   • Sympathetic blockade effects
   • Lower surgical bleeding

2. Better Surgical Conditions

   • Relaxed abdominal wall
   • Reduced bowel movements
   • Improved visualization

3. Immediate Neurological Assessment

   • Can assess motor function
   • Early detection of complications

Systemic Benefits:

1. Improved Recovery

   • Faster return of function
   • Shorter hospital stay
   • Reduced costs

2. Better Immune Function

   • Reduced stress response
   • Better wound healing
   • Lower infection rates

3. Reduced Thromboembolism

   • Early mobilization
   • Better circulation

Specific Blocks:

• Spinal/Epidural: Excellent for lower abdominal/extremity surgery
• Peripheral Blocks: Targeted pain relief
• Continuous Techniques: Prolonged postoperative analgesia