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Anesthesia

Clinical anesthesiology, local and general anesthesia delivery systems, monitoring, and perioperative care.

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QUESTION 331

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MD DNB Questions 1 Describe the cell based model of coagulation and how it differs from classical cascade.Explain the principals of TEG and ROTEM and their clinical parameters.Outline a goal directed massive transfusion protocol using viscoelastic testing. 2 Revised Cardiac Risk index 3 CPET principals and parameters for surgical risk stratification 4 Perioperative Beta blockade latest recommendations 5 Physiological effects of CO2 pneumoperitoneum on CVS and RS system 6 Epidural haematoma incidence risk factors and time critical management

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QUESTION 332

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Aspiration pneumonia in Anesthesia and critical .

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QUESTION 333

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CHRONIC PAIN 1Classify opioids according to their action on opioid receptors. Compare and contrast fentanyl and remifentanyl. 2What is eutectic mixture? Describe the principle of transdermal drug delivery. Describe the advantages and disadvantages of transdermal fentanyl patch. 3 CRPS 4 Definition and classification all details of Osteoarthritis knee.Give all treatment and modalities of non surgical treatment of OA knee as a pain physician latest guidelines and modalities 5 Radio frequency Ablation in Chronic Pain Management

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QUESTION 334

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Cardiopulmonary Bypass and Myocardial Protection Principles of CPB — Components, Physiological Consequences & Management, Myocardial Protection Strategies Including Cardioplegia, Haemodynamic Management of Protamine Administration & Its Adverse Effects ✦ A Note on the Most Current Evidence

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QUESTION 335 person Asked by Dr. Ananya S.

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Describe the principle and technique of thromboelastography (TEG). Define each parameter (R, K, Alpha angle, MA, LY30) and its clinical significance. Compare TEG with standard coagulation tests. Outline TEG-guided management of coagulopathy in major haemorrhage.

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Standard laboratory coagulation tests (PT, APTT, fibrinogen, platelet count) are performed on plasma at 37°C in test tubes — they measure individual components in isolation, take 30–60 minutes, and fail to assess platelet function, clot strength, or fibrinolysis. TEG, by contrast, measures the entire coagulation process in whole blood in real time — providing a dynamic, holistic picture of haemostasis. This allows targeted component therapy (FFP, cryoprecipitate, platelets, TXA) based on the failing phase of the cascade.

A. Principle and Technique 2 marks

Physical principle: A small sample of whole blood (~0.36 mL) is placed in an oscillating cylindrical cup. A pin suspended by a torsion wire is lowered into the blood. As the blood clots, fibrin strands bind the cup and pin, transmitting the cup's rotation to the pin. This displacement is measured and plotted as the TEG waveform.
Modern systems: TEG (Haemonetics) uses an oscillating cup; ROTEM uses a rotating pin in a stationary cup. The two systems are not directly interchangeable (different parameters and reference ranges).
Activators used: Kaolin (intrinsic pathway); tissue factor/TF (extrinsic pathway — Rapid TEG); heparinase (neutralises heparin to measure true coagulation status); functional fibrinogen (inhibits platelets to measure fibrinogen only).

B. TEG Parameters — Normal Values & Clinical Significance 4 marks

Parameter	What It Measures	Normal Range	Abnormal → Interpretation → Action
R (Reaction time)	Time from placement to first detectable fibrin formation (2mm amplitude). Reflects clotting factors.	5–10 minutes (kaolin activated)	↑R (prolonged): clotting factor deficiency or anticoagulant effect (heparin, warfarin) → Give FFP (or protamine if heparin).
K (Kinetics time)	Time from R to when clot amplitude reaches 20mm. Reflects speed of clot formation (fibrinogen & platelets).	1–3 minutes	↑K: low fibrinogen or thrombocytopenia → Give cryoprecipitate (or platelets).
Alpha angle (α)	The angle of the tangent to the TEG curve at 2mm. Represents rate of fibrin build-up.	53–72 degrees	↓Alpha (flat): low fibrinogen or low platelets → Give cryoprecipitate + platelets.
MA (Maximum Amplitude)	Maximum width of the waveform. Reflects total clot strength (primarily 80% platelets, 20% fibrinogen).	55–73 mm	↓MA: thrombocytopenia or platelet dysfunction → Give platelets (or desmopressin).
LY30 (Lysis at 30 min)	Percentage decrease in clot amplitude 30 mins after MA. Reflects fibrinolysis status.	<8% lysis	↑LY30 (>8%): hyperfibrinolysis → Give Tranexamic Acid (TXA).

C. TEG Waveform Patterns — Quick Recognition 2 marks

Pattern	Appearance	Interpretation	Treatment
Normal	Classic "footprint" shape, mild narrowing after MA.	All parameters normal.	None required.
Factor deficiency	Elongated R time; normal or slightly reduced MA.	Slow initial clot formation.	FFP (or factor concentrate).
Fibrinogen deficiency	Normal R; prolonged K; reduced Alpha; reduced MA.	Fibrin formation slow and weak; thin/fragile clot.	Cryoprecipitate 10 units or fibrinogen concentrate.
Platelet dysfunction	Normal R; normal K and Alpha; markedly reduced MA.	Poor platelet contribution to clot strength.	Platelet transfusion; desmopressin.
Hyperfibrinolysis	Normal R/K/Alpha/MA initially; then dramatic narrowing ("onion peel" shape).	Clot forms normally but is rapidly lysed (↑LY30 >8%).	Tranexamic acid 1g IV immediately.

D. TEG vs Standard Coagulation Tests 1 mark

Feature	TEG / ROTEM	Standard Tests (PT, APTT, Platelets)
Sample	Whole blood (includes platelets, RBCs, WBCs — holistic).	Plasma (platelets removed — function NOT assessed).
Result time	10–30 minutes for actionable results.	45–90 minutes (laboratory processing time).
Fibrinolysis	YES — directly measured via LY30.	NO — PT/APTT cannot detect fibrinolysis (D-dimer is indirect).

forum Viva Corner

Q. Why can a patient have a completely normal PT and APTT yet still have a clinically significant coagulopathy that TEG would detect?

The PT and APTT are performed on cell-free plasma and only measure the time to initial fibrin formation. They provide no information about platelet function, clot strength, or fibrinolysis. For example, a patient on dual antiplatelet therapy (aspirin + clopidogrel) or a patient with severe hyperfibrinolysis will have completely normal PT and APTT, yet their TEG will show a severely reduced MA or elevated LY30, respectively, indicating a high risk of surgical hemorrhage.

grade Examiner's Pearl

Reproduce the five parameters (R/K/Alpha/MA/LY30) with exact normal ranges in a table. The link between abnormal parameters and specific clinical actions (prolonged R → FFP; low Alpha/K → cryo; low MA → platelets; high LY30 → TXA) is the key grading milestone.

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QUESTION 336 person Asked by Dr. Rahul V.

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Describe the safety features incorporated in the modern anaesthesia workstation to prevent delivery of a hypoxic or toxic gas mixture. Include: fail-safe valve, oxygen proportioning system, Pin Index Safety System, Diameter Index Safety System, pre-use check, and ventilator alarms.

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QUESTION 337 person Asked by .

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Fluid Regimes in Diabetic Patient in Anesthesia

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Aspiration pneumonia in Anesthesia and critical .

Cardiopulmonary Bypass and Myocardial Protection Principles of CPB — Components, Physiological Consequences & Management, Myocardial Protection Strategies Including Cardioplegia, Haemodynamic Management of Protamine Administration & Its Adverse Effects ✦ A Note on the Most Current Evidence

Describe the principle and technique of thromboelastography (TEG). Define each parameter (R, K, Alpha angle, MA, LY30) and its clinical significance. Compare TEG with standard coagulation tests. Outline TEG-guided management of coagulopathy in major haemorrhage.

A. Principle and Technique 2 marks

B. TEG Parameters — Normal Values & Clinical Significance 4 marks

C. TEG Waveform Patterns — Quick Recognition 2 marks

D. TEG vs Standard Coagulation Tests 1 mark

Describe the safety features incorporated in the modern anaesthesia workstation to prevent delivery of a hypoxic or toxic gas mixture. Include: fail-safe valve, oxygen proportioning system, Pin Index Safety System, Diameter Index Safety System, pre-use check, and ventilator alarms.

Fluid Regimes in Diabetic Patient in Anesthesia

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