A 45 year old woman waiting for emergency laparotomy for peritonitis due to perforated bowel. What is/are true regarding the anesthetic mx of this patient, a) Extubation is safer in lateral position than in supine position b) Intubation with a non-depolarizing muscle relaxant c) Laryngeal mask airway is appropriate d) Rapid sequence induction can be carried out e) Six hours fasting ensures gastric emptying
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Anesthetic Management of Emergency Laparotomy for Peritonitis
This patient has peritonitis from a perforated bowel — she has a presumed full stomach and is at very high risk of pulmonary aspiration. This is the central principle governing all the answers below.
a) Extubation is safer in the lateral position than supine — TRUE
After emergency abdominal surgery with peritonitis, the patient remains at high risk of regurgitation and aspiration even at extubation. Extubating in the lateral (recovery/left lateral) position allows any vomitus/regurgitated material to drain from the mouth by gravity rather than being aspirated into the trachea. This is safer than supine extubation in full-stomach patients. Extubation should only occur once airway reflexes and consciousness have fully returned. — Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 539
b) Intubation with a non-depolarizing muscle relaxant — TRUE (with caveat)
A non-depolarizing relaxant can be used for RSI — specifically rocuronium at high dose (0.9–1.2 mg/kg) provides rapid, reliable intubating conditions comparable to succinylcholine and is an accepted RSI agent. If rocuronium is used, sugammadex must be available for reversal if intubation fails. The classical agent is succinylcholine (depolarizing), but rocuronium is a well-established non-depolarizing alternative for RSI. — Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 538; Current Surgical Therapy 14e, p. 1281
c) Laryngeal mask airway is appropriate — FALSE
An LMA does not protect the airway against regurgitation and aspiration. It does not seal the trachea and provides no protection from gastric contents entering the airway. In a full-stomach patient with peritonitis and bowel perforation, an LMA is contraindicated. Definitive airway management with a cuffed endotracheal tube is mandatory. — Current Surgical Therapy 14e
d) Rapid sequence induction can be carried out — TRUE
RSI (Rapid Sequence Induction and Intubation) is the technique of choice in this scenario. It involves:
- Preoxygenation (3–5 minutes)
- IV induction agent (propofol, ketamine, etomidate — dose-adjusted for haemodynamic status)
- Immediately followed by succinylcholine (1.5 mg/kg) or high-dose rocuronium (0.9–1.2 mg/kg)
- Cricoid pressure (Sellick manoeuvre) — controversial but commonly applied
- No bag-mask ventilation (to avoid gastric insufflation)
- Rapid laryngoscopy and intubation with cuffed ETT
RSI is specifically designed for full-stomach/aspiration-risk patients like this one. — Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 537–538; Current Surgical Therapy 14e, p. 1281
e) Six hours fasting ensures gastric emptying — FALSE
Standard 6-hour fasting guidelines apply to elective surgery with normal gastric emptying. This patient has:
- Peritonitis and acute pain (both dramatically slow gastric motility)
- Opioid analgesia (further delays emptying)
- Bowel perforation/obstruction (may prevent normal transit entirely)
- Ongoing acute illness
Even in healthy elective patients, up to 5% still have a full stomach despite fasting. In this patient, 6 hours of fasting provides no guarantee of an empty stomach — she must be treated as having a full stomach regardless of fasting duration. — Barash Clinical Anesthesia, 9e
Summary Table
| Option | Answer | Reason |
|---|---|---|
| a) Lateral position safer for extubation | TRUE | Gravity drains vomitus away from airway |
| b) Non-depolarizing muscle relaxant for intubation | TRUE | High-dose rocuronium (0.9–1.2 mg/kg) is valid for RSI |
| c) LMA is appropriate | FALSE | LMA does not protect against aspiration |
| d) RSI can be carried out | TRUE | RSI is the technique of choice for full-stomach patients |
| e) 6 hours fasting ensures gastric emptying | FALSE | Peritonitis, pain, and opioids all delay gastric emptying |
Answers: a, b, d are TRUE; c and e are FALSE.
Which of the following combinations are most appropriate for post operative pain management A. Epidural anasthesia- abdominal surgery B. Lignocaine infusion - Laparoscopic surgery C. Patient controlled analgesia - Day case surgery D. Subcutaneous morphine- Carpel tunnel syndrome E. Transverse abdominis plane block- Laparotomy
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Postoperative Pain Management — Most Appropriate Combinations
A. Epidural anaesthesia — Abdominal surgery: TRUE ✓
Thoracic epidural analgesia is the gold standard for postoperative pain management after open abdominal surgery. It provides:
- Superior static and dynamic (movement) pain relief compared with systemic opioids
- Blunting of the neuroendocrine stress response
- Reduced postoperative morbidity, attenuated catabolism, and accelerated functional recovery
- Better cough facilitation and reduced respiratory complications
Long-acting local anaesthetics (ropivacaine 0.2%, bupivacaine 0.0625–0.125%) are given by continuous epidural infusion or PCEA, often combined with lipophilic opioids. This is a well-established, highly appropriate pairing.
Important caveat: Its usefulness in minimally invasive (laparoscopic) abdominal surgery is questionable — it may actually prolong in-hospital recovery in those cases. — Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 2120
B. Lignocaine (lidocaine) infusion — Laparoscopic surgery: TRUE ✓
Intravenous lignocaine infusion is particularly well-suited to laparoscopic surgery. Evidence shows:
- IV lidocaine infusion reduces postoperative pain and opioid consumption after abdominal surgery
- It specifically facilitates acute rehabilitation after laparoscopic colectomy (and similar procedures)
- It is a preferred adjunct where neuraxial techniques (epidural) are disproportionately invasive relative to the procedure
- Anti-inflammatory and visceral analgesic properties make it useful where visceral pain (from CO₂ insufflation) is a component
This is an appropriate and evidence-based combination for minimally invasive surgery. — Barash Clinical Anesthesia, 9e; Morgan & Mikhail's Clinical Anesthesiology, 7e
C. Patient-controlled analgesia (PCA) — Day case surgery: FALSE ✗
PCA is not appropriate for day-case (ambulatory/outpatient) surgery for several reasons:
- PCA typically involves IV opioid infusion systems — patients cannot be safely discharged home with IV PCA pumps
- Day-case patients must be discharged the same day, requiring oral analgesia regimens (paracetamol, NSAIDs, ± oral opioids)
- PCA is designed for inpatient use in patients with significant postoperative pain (e.g., major abdominal, thoracic, orthopaedic surgery)
- The infrastructure, monitoring, and supervision required for PCA are only available in inpatient settings
Day-case analgesia should follow a multimodal oral/topical approach enabling safe discharge. — Miller's Anesthesia, 10e
D. Subcutaneous morphine — Carpal tunnel syndrome: FALSE ✗
This is an inappropriate combination:
- Carpal tunnel syndrome decompression is a minor, superficial peripheral procedure with low-to-moderate postoperative pain
- It is typically performed under local anaesthesia (wrist block or wide-awake local anaesthesia no tourniquet — WALANT) or regional nerve block
- Postoperative analgesia is well managed with oral paracetamol ± NSAIDs
- Subcutaneous morphine is reserved for patients who cannot take oral medications or have severe pain — it is disproportionate for carpal tunnel surgery and carries unnecessary opioid risks (nausea, sedation, respiratory depression)
- The procedure is almost always day-case, making subcutaneous morphine infusions impractical and unsafe at home
E. TAP (Transverse Abdominis Plane) block — Laparotomy: TRUE ✓
TAP block is appropriate as part of multimodal analgesia for laparotomy:
- Blocks somatic (parietal) pain of the anterior abdominal wall by targeting T7–L1 intercostal, iliohypogastric, and ilioinguinal nerves
- Provides significant opioid-sparing effect after midline laparotomy
- Ultrasound-guided bilateral TAP blocks are now standard in enhanced recovery protocols (ERAS) for colorectal surgery
- Particularly valuable when epidural is contraindicated or has failed
Important distinction: TAP block addresses somatic/parietal pain but does not cover visceral pain — so it complements but does not replace other analgesics (opioids, NSAIDs) for laparotomy. It is used as part of multimodal analgesia, not as a sole technique. — Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 2121
Summary
| Option | Combination | Appropriate? |
|---|---|---|
| A | Epidural — Abdominal (open) surgery | TRUE ✓ |
| B | IV Lignocaine infusion — Laparoscopic surgery | TRUE ✓ |
| C | PCA — Day case surgery | FALSE ✗ |
| D | SC Morphine — Carpal tunnel syndrome | FALSE ✗ |
| E | TAP block — Laparotomy | TRUE ✓ |
Answers: A, B, and E are the most appropriate combinations.
70 years old male has been given spinal anaesthesia for right side inguinal hernia repair. 2 minutes after the anaesthesia he complains of shortness of breaths & coarse voice. His upper limbs are flaccid. What is the possible reason for that? A. Anaphylaxis B. Epidural analgesia C. High spinal block D. Hypoglycaemia E. Local anaesthetic toxicity
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Answer: C. High Spinal Block
Clinical Reasoning
This presentation is a classic high (total) spinal block. Let's map each symptom to the underlying mechanism:
| Symptom | Explanation |
|---|---|
| Shortness of breath (dyspnoea) | Block ascending to C3–C5 → phrenic nerve paralysis → diaphragm weakness; also medullary hypoperfusion from hypotension |
| Coarse/hoarse voice | Block reaching cervical levels → recurrent laryngeal nerve involvement (cranial nerve extension = "total spinal") |
| Flaccid upper limbs | Block ascending to C5–T1 → motor paralysis of upper limbs (brachial plexus roots blocked) |
| Onset at 2 minutes post-injection | Consistent with rapid cephalad spread of intrathecal local anaesthetic |
For inguinal herniorrhaphy, a spinal block to approximately T10 is sufficient. If the local anaesthetic spreads significantly beyond this — to the cervical cord or brainstem — it produces a high or total spinal.
"Spinal anesthesia ascending into the cervical levels causes severe hypotension, bradycardia, and respiratory insufficiency. Unconsciousness, apnea, and hypotension resulting from high levels of spinal anesthesia are referred to as a 'high spinal,' or when the block extends to cranial nerves, as a 'total spinal.'" — Morgan & Mikhail's Clinical Anesthesiology, 7e
"Signs and symptoms include numbness and weakness in the upper extremities, dyspnea, inability to speak, and finally apnea and loss of consciousness." — Swanson's Family Medicine Review
Why the other options are wrong
A. Anaphylaxis — Would present with urticaria, bronchospasm, angioedema, and cardiovascular collapse. Would not cause flaccid upper limb paralysis. Onset may be similar but the neurological picture is absent.
B. Epidural analgesia — Not relevant here; the patient received spinal anaesthesia. (A high/total spinal can complicate epidural if unintended intrathecal injection occurs, but that's not the scenario described.)
D. Hypoglycaemia — Would cause confusion, sweating, tremor, and altered consciousness. It does not produce localised flaccid paralysis of the upper limbs or hoarse voice.
E. Local anaesthetic toxicity (LAST) — Occurs after intravascular injection of epidural/regional doses (large volumes). With spinal anaesthesia, the dose used is tiny (1.5–3 mL) and intrathecal — LAST from systemic absorption does not occur at spinal doses. LAST also causes CNS excitation (seizures, tinnitus) and cardiovascular toxicity, not ascending motor block.
Management of High Spinal Block
- Immediate: Reassure, 100% oxygen, call for help
- Airway: If respiratory insufficiency progresses → rapid sequence intubation and mechanical ventilation
- Circulation: IV vasopressors (ephedrine/epinephrine), rapid IV fluid bolus
- Bradycardia: IV atropine (early), epinephrine if severe
- Position: Supine/slight Trendelenburg — do not tilt head up (worsens cephalad spread and reduces cerebral perfusion)
Answer: C — High Spinal Block
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