Kussmaul sign

Q) Kussmaul sign is not seen in

a) Restrictive Cardiomyopathy

b) Pulmonary embolism

c) Constrictive pericarditis

d) Severe right ventricular infarction

Answer b

Kussmaul sign is seen in massive pulmonary embolism only.

It is the abnormal variation in jugular venous pressure during inspiration. Normally during inspiration the mean venous pressure decreases and the amplitude of a wave increases. 

In Kussmaul sign, the jugular venous pressure increases or remains the same. This is seen in number of  conditions.

Constrictive or effusive pericarditis

Restrictive cardiomyopathy.

Predominant right ventricular infarction

Severe right ventricular dysfunction

Massive pulmonary embolism.

Partial obstruction of the vena cavae.

Right atrial and right ventricular tumors.

Severe tricuspid regurgitation

Occasionally tricuspid stenosis and congestive heart failure.

Rarely cardiac tamponade

Cirrhosis- Renal Dysfunction

Q) What is the most common cause of renal dysfunction in Cirrhosis

a) Spontaneous Bacterial Peritonitis

b) Hypovolemia due to Haematemesis

c) Intrinsic Renal Disease

d) Hepatorenal Syndrome




Infections are the most common cause of renal failure (creatinine more than 1.5mg%)  in cirrhosis (40%). The leading cause of infections is Spontaneous Bacterial Peritonitis followed by Spontaneous Bacteremia




Medicine and Critical Care- Pulmonary Embolism

Q) Pulmonary Embolism is a life threatening condition commonly seen in the ICU setting. Which of the following is not a feature of Echocardiography in patients with pulmonary embolism

a) Right ventricular dilatation with increased RV/LV diameter

b) Mitral Regurgitation

c) Bowing of interventricular septum

d) Pulmonary artery dilatation

Pulmonary embolism Physiology

Pathophysiology of pulmonary embolism



Its tricuspid regurgitation because the increased pressure is reflected on to the right side of the heart

Echocardiography is a useful tool in unstable patients because it is non invasive and readily available. Transesophageal Echocardiography is more sensitive.

Signs of Inadequate facemask ventilation

Q Which of the following are signs of inadequate facemask ventilation in general anesthesia?

a) Insufficient chest wall movements

b) Audible signs of airway obstruction or gastric distension

c) Decreasing saturation

d) Bradycardia, Hypotension



Answer d

Difficult airway ventilation is defined when positive pressure ventilation by unassisted anesthesiologist fails to maintain oxygen saturation above 90% or the ventilation effort fails to prevent or reverse the signs of inadequate gas exchange

The various signs are

1. Insufficient or Absent chest movement

2. Absent or Inadequate breath sounds

3. Audible signs of airway obstruction, gastric insufflation or  gastric dilatation

4. Cyanosis

5. Decreasing Saturation

6. Elevated end tidal carbon dioxide

7. Consequences of hypercarbia or Hypoxia like tachycardia, Hypertension, Arrythmias



Anesthesia MCQs – Post Operative Nausea and Vomiting

Post opertive nausea

Post opertive nausea

Q) Which of the following is not a risk factor for post operative nausea and vomiting?

a) History of smoking

b) Previous history of motion sickness

c) Female Gender

d) Use of Opioid



Non Smokers are at a higher risk of suffering from PONV. Other risk factors are young age, use of volatile anesthetic drugs, long duration of anesthesia and use of nitric oxide.

Management of PONV includes the following classes of drugs

1. 5 HT3 Antagonist-

2. Glucocorticoids

3. Anti histamines

4.Neurokinin Receptor 1 Antagonists like Aperipitant

5.Cholinergic antagonist

6 Butyrophenone

7. Metoclopramide

Anaesthesia MCQ

Q Patients with trauma and hemodynamic instability manifest all except

a) Tachycardia

b) Hypotension

c) Increased cardiac output

d) High and some times low cardiac output

Answer c

Cardiac output decreases and not increases after blood loss

When we are using invasive Arterial Blood pressure monitoring it is important to differentiate the physiological graph from artifacts. Patients with trauma can manifest various artifacts because of decreased cardiac output, hypotension and tachycardia.

Other factors responsible for altered graph formation are  pulse wave reflection in the arterial system and dynamic response of the Catheter Tube Transducer system (CTT)