EDAIC Part I — European Diploma in Anaesthesiology and Intensive Care — Questions and Answers

Question 1: During epidural anesthesia, the 'loss of resistance' technique identifies needle entry into which space?

Subdural space
Epidural space (Correct answer)
Subarachnoid space
Paravertebral space

Correct answer: Epidural space

The epidural space is a negative-pressure potential space containing fat and venous plexuses; resistance to injection through ligamentum flavum gives way to easy injection upon entering this space.

Question 2: A 5-week-old infant is scheduled for pyloromyotomy due to persistent, non-bilious projectile vomiting. Preoperative correction of fluid and electrolyte status is crucial. What is the classic acid-base and electrolyte abnormality found in this condition?

Normal acid-base status with hyponatremia
Metabolic acidosis with hyperkalemia
Respiratory acidosis with hyperchloremia
Hypochloremic, hypokalemic metabolic alkalosis (Correct answer)

Correct answer: Hypochloremic, hypokalemic metabolic alkalosis

Persistent vomiting of gastric contents in pyloric stenosis leads to a significant loss of hydrogen (H+) and chloride (Cl-) ions. This loss of acid results in a hypochloremic metabolic alkalosis. To compensate for dehydration, the renin-angiotensin-aldosterone system is activated, leading to sodium and water retention at the expense of potassium excretion in the kidneys, causing or worsening hypokalemia.

Question 3: Which local anesthetic has the longest duration of action for peripheral nerve blocks?

Bupivacaine (Correct answer)
Ropivacaine
Mepivacaine
Lidocaine

Correct answer: Bupivacaine

Bupivacaine provides the longest duration (up to 12-18 hours for nerve blocks), though ropivacaine has a similar but slightly shorter duration with a better safety profile.

Question 4: A 72-year-old patient on rivaroxaban 20 mg once daily for non-valvular atrial fibrillation presents 4 hours after their last dose with a Glasgow Coma Scale of 8 and CT-confirmed large intracranial haematoma. Anti-Xa level is 195 ng/mL. Which andexanet alfa dosing regimen is correct?

Andexanet alfa is not licensed for rivaroxaban reversal; use 4-factor PCC instead
Low-dose bolus of 400 mg IV only, without a maintenance infusion
Low-dose: 400 mg IV bolus followed by 4 mg/min infusion for 120 minutes
High-dose: 800 mg IV bolus followed by 8 mg/min infusion for 120 minutes (Correct answer)

Correct answer: High-dose: 800 mg IV bolus followed by 8 mg/min infusion for 120 minutes

Andexanet alfa dosing is stratified by agent, dose, and time since last administration. For rivaroxaban: low-dose protocol applies when the dose was ≤10 mg OR the last dose was ≥8 hours prior; high-dose protocol applies when the dose was >10 mg AND the last dose was <8 hours prior. This patient received 20 mg (>10 mg threshold) just 4 hours ago (<8 h threshold), mandating the high-dose regimen (800 mg bolus + 8 mg/min × 120 min). The anti-Xa level of 195 ng/mL confirms significant residual drug activity. Andexanet alfa is licensed for both apixaban and rivaroxaban reversal.

Question 5: During mediastinoscopy, the surgeon reports loss of the right radial pulse. The most likely cause is:

Right arm venous tourniquet effect from patient positioning
Compression of the innominate (brachiocephalic) artery by the mediastinoscope (Correct answer)
Systemic hypotension from vagal stimulation
Inadvertent right subclavian artery ligation

Correct answer: Compression of the innominate (brachiocephalic) artery by the mediastinoscope

The mediastinoscope can compress the innominate artery against the trachea, reducing right-sided perfusion; pulse oximetry on the right hand detects this before serious sequelae occur.

Question 6: During resuscitation of a 44-year-old with massive pulmonary embolism confirmed on CTPA (submassive → massive transition with cardiac arrest), alteplase 50 mg IV is administered. CPR is continued for 90 minutes post-thrombolysis without ROSC. The next most appropriate step is:

Initiate surgical pulmonary embolectomy or catheter-directed therapy with ongoing mechanical CPR (Correct answer)
Administer unfractionated heparin infusion at full anticoagulation dose and continue CPR
Cease resuscitation as failure to achieve ROSC after thrombolysis indicates futility
Administer a second dose of alteplase 100 mg and continue CPR for another 60 minutes

Correct answer: Initiate surgical pulmonary embolectomy or catheter-directed therapy with ongoing mechanical CPR

When thrombolysis fails to achieve ROSC in massive PE, surgical pulmonary embolectomy or catheter-directed mechanical thrombectomy/aspiration with continued mechanical CPR (using a device such as LUCAS) represents the next rescue strategy. European guidelines support escalation to surgical or catheter-based intervention when systemic thrombolysis fails. A second dose of alteplase carries extreme haemorrhagic risk without established benefit. Cessation is premature as PE-related arrest can have good outcomes with definitive clot removal. Heparin alone will not rapidly relieve the mechanical obstruction causing cardiac arrest.

Question 7: Which of the following best describes the effect of milrinone on cardiac physiology?

Pure chronotropic effect with no inotropy
Positive inotropy and vasodilation via PDE3 inhibition (Correct answer)
Positive inotropy with vasoconstriction
Negative inotropy with vasodilation

Correct answer: Positive inotropy and vasodilation via PDE3 inhibition

Milrinone inhibits phosphodiesterase III, increasing cAMP, causing positive inotropy in the heart and vasodilation in peripheral vessels (inodilator).

Question 8: During thoracoscopic sympathectomy for hyperhidrosis under general anaesthesia with a laryngeal mask airway (LMA) and spontaneous ventilation, CO₂ is insufflated into the right pleural cavity. The patient's end-tidal CO₂ rises to 68 mmHg and SpO₂ falls to 89%. Which physiological mechanism BEST explains the combination of hypercapnia and hypoxaemia in this scenario?

Vagally-mediated apnoea triggered by pleural stretch receptors causing breath-holding
CO₂ absorption from the pleural insufflation combined with ipsilateral lung compression creating an intrapulmonary shunt (Correct answer)
Systemic venous CO₂ embolism causing pulmonary dead-space ventilation
Endobronchial migration of the LMA tip causing right main bronchus intubation with left lung atelectasis

Correct answer: CO₂ absorption from the pleural insufflation combined with ipsilateral lung compression creating an intrapulmonary shunt

Pleural CO₂ insufflation for thoracoscopy causes two simultaneous effects: first, CO₂ is absorbed across the pleural membrane directly into the systemic circulation, causing hypercapnia (especially problematic with spontaneous ventilation and an unprotected airway like an LMA that cannot deliver controlled higher minute volumes); second, the ipsilateral lung is compressed by the pneumothorax, converting a ventilated region to one that continues to receive pulmonary blood flow but no ventilation — a true intrapulmonary shunt causing hypoxaemia. Vagal apnoea is rare and does not produce sustained SpO₂ drop. LMA migration would cause a different pattern. CO₂ venous embolism is exceptional in pleural insufflation and would present with cardiovascular collapse.

Question 9: Which feature of the Cormack–Lehane grade IV laryngoscopic view differentiates it from grade III?

Only the epiglottis tip is visible
Only the posterior commissure is visible
The entire glottis is obscured by secretions
No laryngeal structures are visible at all (Correct answer)

Correct answer: No laryngeal structures are visible at all

Cormack–Lehane grade IV indicates that neither the epiglottis nor any glottic structures are visible, whereas grade III shows only the epiglottis.

Question 10: A 65-year-old male with severe biventricular heart failure is receiving an intravenous infusion of milrinone. What is the primary mechanism of action responsible for its inotropic and vasodilatory effects?

Stimulation of beta-1 adrenergic receptors, increasing intracellular cAMP.
Blockade of voltage-gated calcium channels, causing smooth muscle relaxation.
Inhibition of phosphodiesterase-3 (PDE3), leading to increased intracellular cAMP. (Correct answer)
Sensitization of the contractile apparatus to calcium, without increasing intracellular calcium levels.

Correct answer: Inhibition of phosphodiesterase-3 (PDE3), leading to increased intracellular cAMP.

Milrinone is a phosphodiesterase-3 (PDE3) inhibitor. By inhibiting PDE3, it prevents the breakdown of cyclic adenosine monophosphate (cAMP) in both cardiac myocytes and vascular smooth muscle. The resulting increase in intracellular cAMP in the heart leads to enhanced calcium influx and a positive inotropic effect (increased contractility). In the vascular smooth muscle, increased cAMP promotes relaxation, leading to both arterial and venous vasodilation, which reduces afterload and preload.

Question 11: Which feature of the pregnant airway increases the risk of difficult intubation compared to non-pregnant patients?

Decreased Mallampati score
Reduced tongue size
Increased mouth opening
Mucosal edema and friability (Correct answer)

Correct answer: Mucosal edema and friability

Pregnancy causes airway mucosal edema, engorgement, and friability that worsen Mallampati class and increase bleeding risk during instrumentation.

Question 12: Which condition is associated with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure forming the classic TTP triad?

DIC
Heparin-induced thrombocytopenia
Hemophilia A
Thrombotic thrombocytopenic purpura (TTP) (Correct answer)

Correct answer: Thrombotic thrombocytopenic purpura (TTP)

TTP classically presents with microangiopathic hemolytic anemia, thrombocytopenia, and organ dysfunction due to ADAMTS13 deficiency.

Question 13: The 'duty of candour' in anaesthetic practice requires a clinician to do which of the following when an intraoperative complication affects a patient?

Only disclose the complication if the patient asks specifically about it
Maintain confidentiality about the complication to protect other team members from blame
Proactively inform the patient (or their representative) that something went wrong, apologise, and explain what is known and what will be done (Correct answer)
Report the incident to the police within 24 hours

Correct answer: Proactively inform the patient (or their representative) that something went wrong, apologise, and explain what is known and what will be done

Duty of candour — now enshrined in professional codes across Europe (GMC, professional societies) and statute in some jurisdictions — requires healthcare professionals to be open and honest with patients when things go wrong. This includes: telling the patient something has gone wrong, offering an apology, explaining what happened and its short-term effects, and outlining the steps being taken to minimise harm and prevent recurrence. Candour applies proactively, not only in response to patient enquiry.

Question 14: Which viscoelastic test parameter represents clot formation rate?

R time (TEG) / CT (ROTEM)
Alpha angle (TEG/ROTEM) (Correct answer)
K time (TEG) / CFT (ROTEM)
MA (TEG) / MCF (ROTEM)

Correct answer: Alpha angle (TEG/ROTEM)

The alpha angle reflects the rate of clot formation and fibrin cross-linking in both TEG and ROTEM.

Question 15: Which of the following most accurately describes the pharmacokinetic basis for using a lower MAC of volatile anaesthetic agents in preterm neonates compared with term neonates aged 1–6 months?

Lower MAC in preterms reflects reduced neuronal density and synaptic connectivity, combined with higher CNS progesterone and neurosteroid concentrations that potentiate GABA-A activity (Correct answer)
Preterm neonates have decreased cardiac output relative to body weight, resulting in faster achievement of alveolar equilibrium and thus apparent lower MAC requirements
Preterm neonates have higher plasma protein binding, reducing free drug concentration at receptor sites
Preterm neonates have a higher proportion of γ-aminobutyric acid type A (GABA-A) receptors in the excitatory neonatal configuration, but lower cerebral cholesterol content reduces membrane lipid solubility

Correct answer: Lower MAC in preterms reflects reduced neuronal density and synaptic connectivity, combined with higher CNS progesterone and neurosteroid concentrations that potentiate GABA-A activity

MAC in preterm neonates is lower than in term neonates or older infants (where MAC peaks around 1–6 months). The mechanisms are multifactorial but primarily neurological: preterm brains have reduced synaptic density and less mature neural circuitry requiring lower anaesthetic concentrations for equivalent effect. Crucially, elevated endogenous neurosteroids (allopregnanolone and related progesterone metabolites, which are high in late foetal/preterm life due to placental transfer) act as potent positive allosteric modulators of GABA-A receptors, reducing the exogenous anaesthetic requirement. Cardiac output is actually relatively higher per kg in neonates (not lower), which would slow equilibration. Plasma protein binding is lower in preterms (not higher), increasing free drug.

Question 16: A term neonate requires emergency laparotomy. What is the most appropriate ETT size?

2.5 mm uncuffed
4.0 mm uncuffed
3.0–3.5 mm uncuffed (Correct answer)
3.5 mm cuffed

Correct answer: 3.0–3.5 mm uncuffed

A term neonate typically requires a 3.0–3.5 mm uncuffed (or microcuffed) endotracheal tube.

Question 17: On a variable-bypass vaporizer, increasing the temperature of the operating room will have what effect on vapor output concentration if the dial remains unchanged?

Concentration remains stable due to temperature compensation (Correct answer)
Concentration fluctuates unpredictably
Concentration decreases
Concentration increases

Correct answer: Concentration remains stable due to temperature compensation

Variable-bypass vaporizers incorporate bimetallic strip temperature-compensating mechanisms that maintain a constant output concentration despite ambient temperature changes.

Question 18: The principle of 'pharmacological antagonism' used to reverse neuromuscular blockade with sugammadex differs from neostigmine because sugammadex:

Stimulates acetylcholine release from motor nerve terminals
Competes with rocuronium for nicotinic receptor binding sites
Directly encapsulates rocuronium/vecuronium molecules, reducing free drug concentration (Correct answer)
Inhibits acetylcholinesterase to increase ACh at the neuromuscular junction

Correct answer: Directly encapsulates rocuronium/vecuronium molecules, reducing free drug concentration

Sugammadex is a modified cyclodextrin that encapsulates (chelates) aminosteroid NMBAs (rocuronium, vecuronium) with high affinity, creating a gradient that draws drug away from the NMJ.

Question 19: James Reason's 'Swiss cheese model' of accident causation is widely applied in patient safety. What does it describe?

Multiple defensive system layers each containing latent failures; harm occurs when failures in all layers align simultaneously (Correct answer)
A root cause analysis method in which errors are attributed to individual negligence
A grading system for anaesthetic adverse events based on severity
The tendency for Swiss healthcare institutions to have superior safety cultures

Correct answer: Multiple defensive system layers each containing latent failures; harm occurs when failures in all layers align simultaneously

In Reason's model, healthcare systems have multiple defensive barriers (like slices of cheese), each with latent holes (system weaknesses, not just individual errors). A critical incident occurs when holes in successive layers momentarily align, allowing a hazard to pass through all defences and cause harm. This model shifted safety thinking from 'blame the individual' to 'fix the system'.

Question 20: A competent adult Jehovah's Witness patient has signed an advance refusal of blood products and verbally reaffirms this refusal in the anaesthetic room before emergency laparotomy for a ruptured ectopic pregnancy. The surgeon believes transfusion will be necessary to prevent death. What is the ethically and legally correct action?

Delay surgery until a psychiatrist certifies the patient lacks capacity
Respect the patient's refusal and proceed without blood products, using all available blood conservation strategies (Correct answer)
Transfuse immediately — preservation of life overrides refusal in an emergency
Obtain an emergency court order permitting transfusion

Correct answer: Respect the patient's refusal and proceed without blood products, using all available blood conservation strategies

A competent adult's advance refusal of treatment — when made with full understanding of the consequences — is legally binding and must be respected even if it results in the patient's death. Overriding the refusal would constitute unlawful battery. The duty of the anaesthetist is to respect autonomy while employing maximum blood conservation techniques (cell salvage, haemostatic agents, permissive hypotension). The ethical framework here is respect for patient autonomy, which outweighs paternalistic beneficence.

Question 21: Which of the following most accurately explains why milrinone produces a greater increase in heart rate than dobutamine at equi-inotropic doses in patients with decompensated heart failure?

Milrinone directly activates sinoatrial node phosphodiesterase-3 isoforms, producing more profound chronotropy than the partial β1-agonism of dobutamine
Milrinone lacks β1-receptor agonism and therefore does not activate baroreceptor-mediated reflex bradycardia to counteract its tachycardic effect from peripheral vasodilation (Correct answer)
Dobutamine's simultaneous β2-mediated vasodilation triggers greater reflex sympathetic activation that opposes its chronotropic effect at the SA node
Milrinone's longer half-life causes sustained cAMP accumulation in nodal tissue, producing more persistent rate increases than the rapidly desensitizing β-receptor activation from dobutamine

Correct answer: Milrinone lacks β1-receptor agonism and therefore does not activate baroreceptor-mediated reflex bradycardia to counteract its tachycardic effect from peripheral vasodilation

Both milrinone and dobutamine increase heart rate through elevated intracellular cAMP. However, dobutamine directly stimulates β1-receptors in the SA node for its chronotropic effect but simultaneously activates β1-receptors in the myocardium improving contractility and cardiac output, which partially restores arterial pressure—thus triggering baroreceptor-mediated reflex parasympathetic activity (vagal tone increase) that opposes tachycardia. Milrinone, acting downstream of receptors via PDE-3 inhibition, bypasses receptor-level regulation and causes peripheral vasodilation that reduces afterload and mean arterial pressure, eliciting reflex sympathetic activation (increased HR) without the receptor-level counterbalancing. The net effect is greater tachycardia with milrinone relative to equivalent inotropic doses of dobutamine, particularly in patients with impaired baroreflex sensitivity.

Question 22: What is the primary function of the adjustable pressure-limiting (APL) valve in an anesthesia breathing circuit?

Prevent rebreathing of CO2
Vent excess gas to the scavenging system (Correct answer)
Regulate fresh gas flow rate
Humidify inspired gases

Correct answer: Vent excess gas to the scavenging system

The APL valve opens to release excess gas from the circuit into the waste gas scavenging system, controlling circuit pressure.

Question 23: A 58-year-old man with severe COPD (FEV₁ 28% predicted) undergoes left upper lobectomy via VATS. Postoperatively he develops progressive dyspnoea and hypoxaemia. CT shows a large right-sided air space with contralateral mediastinal shift. His peak airway pressure is 42 cmH₂O. What is the MOST likely diagnosis and its mechanism?

Post-pneumonectomy pulmonary oedema of the right lung
Dynamic hyperinflation (auto-PEEP) causing bilateral gas trapping and haemodynamic compromise (Correct answer)
Tension pneumothorax on the right caused by a contralateral bronchial stump leak
Right-sided mucus plug causing lobar collapse with compensatory hyperinflation

Correct answer: Dynamic hyperinflation (auto-PEEP) causing bilateral gas trapping and haemodynamic compromise

Severe COPD with markedly reduced FEV₁ produces severe expiratory flow limitation. Post-operatively, increased respiratory drive combined with airflow obstruction leads to breath stacking and auto-PEEP. Bilateral gas trapping raises intrathoracic pressure, compresses mediastinal structures (giving a 'shift' appearance on CT) and impairs venous return. High peak airway pressures (>40 cmH₂O) and the clinical context confirm dynamic hyperinflation. A contralateral bronchial stump leak would be exceptionally rare immediately post-VATS lobectomy. Mucus plugging causes atelectasis, not hyperinflation with raised airway pressures. Post-pneumonectomy pulmonary oedema affects the contralateral lung and is not associated with auto-PEEP.

Question 24: In a patient anaesthetised with 68% nitrous oxide, an infrared sidestream capnograph displays ETCO₂ of 6.8 kPa while arterial blood gas confirms PaCO₂ of 5.4 kPa. Beyond the normal a-ETCO₂ gradient, which physical mechanism most specifically accounts for the capnograph's overestimation of CO₂?

Collision (pressure) broadening of the CO₂ infrared absorption band caused by N₂O molecules (Correct answer)
Thermal emission from N₂O molecules generating background infrared noise at 4.26 µm
Raman backscattering from N₂O creating spurious signal at the CO₂ detection wavelength
Doppler broadening of the CO₂ absorption spectrum due to high gas velocities in the sampling line

Correct answer: Collision (pressure) broadening of the CO₂ infrared absorption band caused by N₂O molecules

Collision broadening (pressure broadening) occurs when N₂O molecules collide with CO₂ molecules, widening their infrared absorption band and increasing apparent absorbance at the 4.26 µm CO₂ detection wavelength. High N₂O concentrations therefore cause the capnograph to overread ETCO₂. Modern capnographs incorporate correction algorithms when N₂O is detected simultaneously; uncorrected or legacy devices may exhibit clinically significant error. Doppler broadening (caused by thermal molecular motion) is a separate phenomenon not specific to N₂O–CO₂ mixtures. Raman-scatter-based devices handle gas analysis differently and are not susceptible to this particular error.

Question 25: Thyroid storm (thyrotoxic crisis) can be precipitated by surgery and presents with which combination of features?

Hyperthermia, tachycardia, and high-output cardiac failure (Correct answer)
Hypotension, bradycardia, and hyponatremia
Normothermia, hypertension, and seizures
Hypothermia, bradycardia, and altered consciousness

Correct answer: Hyperthermia, tachycardia, and high-output cardiac failure

Thyroid storm is characterized by extreme hyperthermia, tachyarrhythmia, high-output heart failure, and altered mental status due to massive thyroid hormone release.

Question 26: Which of the following best describes the hepatic clearance of drugs in neonates compared to older children?

Neonates have reduced clearance due to immature cytochrome P450 enzyme activity (Correct answer)
Hepatic clearance is irrelevant in neonates as renal excretion predominates
Neonates and older children have equivalent hepatic drug clearance per kg
Neonates have higher hepatic clearance due to proportionally larger liver

Correct answer: Neonates have reduced clearance due to immature cytochrome P450 enzyme activity

Cytochrome P450 enzyme systems (especially CYP3A4) are markedly immature at birth, significantly reducing hepatic drug clearance in neonates.

Question 27: A second-generation supraglottic airway device (e.g., LMA Supreme, i-gel) differs from a first-generation device primarily by:

Allowing unobstructed passage of a standard endotracheal tube
Incorporating a gastric drainage channel and improved oropharyngeal seal (Correct answer)
Providing a higher oropharyngeal seal pressure exceeding 40 cmH₂O
Being designed exclusively for pediatric use

Correct answer: Incorporating a gastric drainage channel and improved oropharyngeal seal

Second-generation supraglottic airways feature a dedicated gastric access/drainage channel and an improved oropharyngeal seal, substantially reducing aspiration risk compared to first-generation devices.

Question 28: For postoperative pain management following a posterolateral thoracotomy, which regional anesthesia technique is considered to provide analgesia of similar efficacy to a thoracic epidural but with a more favorable side-effect profile?

Serratus anterior plane block
Intercostal nerve block
Erector spinae plane block
Paravertebral block (Correct answer)

Correct answer: Paravertebral block

The thoracic paravertebral block (TPVB) is considered a first-line regional technique for thoracotomy pain. It provides dense unilateral somatic and sympathetic blockade, effectively covering both incisional and visceral pain. Multiple studies and meta-analyses have shown TPVB to have analgesic efficacy comparable to thoracic epidural analgesia (TEA) but with fewer side effects, such as hypotension, urinary retention, and bilateral motor blockade.

Question 29: Which vasopressor is recommended as first-line therapy for septic shock in current surviving sepsis guidelines?

Vasopressin
Norepinephrine (Correct answer)
Phenylephrine
Epinephrine

Correct answer: Norepinephrine

Norepinephrine is the first-line vasopressor for septic shock due to its strong α-adrenergic effect and favorable cardiac output profile.

Question 30: A 58-year-old patient with severe COPD (FEV₁ 32% predicted, RV/TLC 68%) is undergoing right lower lobectomy under general anaesthesia with OLV. After 45 minutes of OLV the airway pressure alarm triggers. Plateau pressure rises from 28 to 41 cmH₂O while peak pressure rises from 34 to 52 cmH₂O. SpO₂ remains 96%, HR 110, BP 140/85. The DLT position is confirmed. What is the most likely explanation?

Tension pneumothorax in the ventilated (dependent) left lung
Malposition of the DLT with herniation of the tracheal cuff
Dynamic hyperinflation with auto-PEEP in the ventilated lung (Correct answer)
Mucous plug obstructing the left mainstem bronchus

Correct answer: Dynamic hyperinflation with auto-PEEP in the ventilated lung

The hallmark of dynamic hyperinflation (air trapping / auto-PEEP) is a proportional rise in both peak and plateau pressures with maintained SpO₂ and haemodynamic stability — the lung is simply over-distended, not obstructed at a single point. Severe COPD with high RV/TLC ratio indicates severely impaired expiratory flow; during OLV the single ventilated lung must handle the entire minute ventilation with even less time for exhalation relative to inspiration, accelerating gas trapping. Management includes prolonging expiratory time (I:E 1:4 or longer), reducing respiratory rate, and allowing permissive hypercapnia. Tension pneumothorax would produce haemodynamic collapse and tracheal deviation. A mucous plug would raise peak pressure more than plateau. DLT cuff herniation would be identified by bronchoscopy and present with sudden complete airway obstruction rather than a gradual pressure rise.

Question 31: A cuffed endotracheal tube cuff pressure should be maintained below which value to prevent tracheal mucosal ischemia?

10 cmH2O
40 cmH2O
30 cmH2O (Correct answer)
20 cmH2O

Correct answer: 30 cmH2O

Cuff pressures above 30 cmH2O exceed tracheal mucosal capillary perfusion pressure and risk ischemic injury.

Question 32: In a cardiac catheterisation laboratory, a type CF (cardiac-floating) defibrillator-proof device is directly connected to a cardiac catheter inside the heart. Under a single-fault condition (e.g., loss of earth continuity), what is the maximum permissible patient leakage current according to IEC 60601-1, and why is this limit so much lower than for type B equipment?

10 µA; because the cardiac muscle is depolarised at threshold currents of 10 µA when current is delivered directly to the myocardium via an intracardiac catheter.
500 µA; the higher limit is acceptable because CF devices are double-insulated, providing additional protection against microshock.
50 µA; because a direct intracardiac pathway means ventricular fibrillation can be triggered by currents as low as 50–100 µA bypassing skin resistance, compared to the macroshock threshold of ~100 mA for intact skin. (Correct answer)
100 µA; because the impedance of the intracardiac catheter reduces the effective current delivered to the myocardium by a factor of ten.

Correct answer: 50 µA; because a direct intracardiac pathway means ventricular fibrillation can be triggered by currents as low as 50–100 µA bypassing skin resistance, compared to the macroshock threshold of ~100 mA for intact skin.

IEC 60601-1 sets leakage current limits based on the probability of ventricular fibrillation. Intact skin has resistance of ~10,000–100,000 Ω, meaning macroshock requires ~100 mA (at mains voltage) to produce dangerous myocardial current. An intracardiac catheter bypasses this resistance completely — VF can be induced by as little as 50–100 µA applied directly to the myocardium (microshock). Therefore, type CF equipment (directly connected to the heart) must limit patient leakage to ≤10 µA normally and ≤50 µA under single-fault conditions, compared to ≤500 µA for type B (body-surface contact). Type BF (floating, body surface) allows ≤100 µA under fault conditions.

Question 33: A drug with a narrow therapeutic index and primarily renal elimination is most dangerous in which clinical scenario?

Mild hepatic impairment
Thyroid storm with increased metabolic rate
Acute kidney injury with oliguria (Correct answer)
Obesity requiring dose adjustment by total body weight

Correct answer: Acute kidney injury with oliguria

Acute kidney injury reduces renal drug clearance, causing drug accumulation and toxicity for renally eliminated narrow therapeutic index drugs.

Question 34: A patient is extubated after right upper lobectomy but develops progressive dyspnea 6 hours later with tracheal deviation to the right. Chest X-ray shows a large right pleural opacity. The diagnosis is:

Right-sided pneumothorax
Bronchial stump dehiscence with air leak
Hemothorax from a bleeding intercostal vessel (Correct answer)
Postpneumonectomy pulmonary edema

Correct answer: Hemothorax from a bleeding intercostal vessel

Tracheal deviation toward the operative side with a pleural opacity after lobectomy indicates hemothorax compressing the remaining right lung, consistent with uncontrolled bleeding.

Question 35: A 29-year-old is retrieved from a frozen lake in cardiac arrest with a core temperature of 23°C. CPR has been ongoing for 50 minutes in the field and ED. Three defibrillation attempts and cumulative amiodarone 450 mg IV have been given; ventricular fibrillation persists. Which is the most appropriate next step according to current ERC/ESICM guidelines?

Administer a further 150 mg amiodarone and escalate to dual sequential external defibrillation
Transfer urgently to an ECMO-capable centre for extracorporeal CPR and active internal rewarming (Correct answer)
Continue standard ACLS and defibrillate every 2 minutes; hypothermic hearts respond once potassium normalises
Declare resuscitation futile after >45 minutes of refractory VF in the absence of a witnessed arrest

Correct answer: Transfer urgently to an ECMO-capable centre for extracorporeal CPR and active internal rewarming

In severe accidental hypothermia (<28°C), the myocardium is refractory to defibrillation and antiarrhythmics until rewarmed. The principle 'not dead until warm and dead' applies: standard defibrillation attempts beyond three should be deferred until the core temperature exceeds 30°C. Extracorporeal CPR (ECPR) with venoarterial ECMO simultaneously maintains perfusion and achieves rapid internal rewarming — the only modality proven to reliably reverse hypothermic cardiac arrest. ERC 2021 guidelines specifically recommend transport to an ECMO-capable centre if there are no clear signs of futility (e.g., non-asphyxia aetiology, serum potassium <12 mmol/L). Continued field defibrillation without rewarming has no additional benefit.

Question 36: A patient with traumatic brain injury has an ICP of 28 mmHg and MAP of 88 mmHg. Cerebral perfusion pressure (CPP)–guided therapy is being used. The intensivist calculates the pressure reactivity index (PRx) from a continuous 5-minute correlation between ICP and MAP waveforms and obtains a value of +0.42. What does this PRx value indicate, and what is the CORRECT interpretation for optimising CPP target?

Impaired autoregulation; CPP at 60 mmHg is the recommended minimum target and no further optimisation is possible
Impaired autoregulation; the CPP should be adjusted toward the patient's optimal CPP (CPPopt) identified from the U-shaped PRx vs CPP curve (Correct answer)
Impaired autoregulation; CPP should be reduced to decrease MAP-driven ICP swings
Intact autoregulation; the current CPP is within the autoregulatory plateau and no adjustment is needed

Correct answer: Impaired autoregulation; the CPP should be adjusted toward the patient's optimal CPP (CPPopt) identified from the U-shaped PRx vs CPP curve

PRx is the moving Pearson correlation coefficient between slow-wave MAP and ICP. A positive PRx (+0.42) indicates impaired cerebrovascular pressure reactivity — ICP is passively tracking MAP rather than being buffered, signifying loss of autoregulation. The correct clinical action is not simply to raise or lower CPP arbitrarily, but to identify the individual patient's CPPopt — the CPP value at the nadir of a U-shaped PRx vs CPP curve (where PRx is most negative, indicating best autoregulation). Targeting CPPopt has been associated with improved outcomes in TBI research (Rao et al., Steiner et al.). Answer A is wrong because +0.42 (positive) signals impaired, not intact, autoregulation. Answer B oversimplifies — reducing CPP when autoregulation is impaired can worsen ischaemia. Answer C quotes a guideline floor but does not capture the nuanced CPPopt concept.

Question 37: Which statement about the Windkessel effect of the aorta is correct?

It is enhanced in patients with arteriosclerosis
It increases pulse pressure in young patients
It refers to aortic valve competence during diastole
Aortic compliance buffers systolic pressure and maintains diastolic flow (Correct answer)

Correct answer: Aortic compliance buffers systolic pressure and maintains diastolic flow

The Windkessel effect describes how aortic compliance stores energy during systole and releases it in diastole, maintaining forward flow and reducing pulse pressure.

Question 38: Which neuromuscular blocking agent is preferred for rapid sequence intubation when succinylcholine is contraindicated in pediatric patients?

Vecuronium 0.1 mg/kg
Rocuronium 1.2 mg/kg (Correct answer)
Cisatracurium 0.2 mg/kg
Mivacurium 0.25 mg/kg

Correct answer: Rocuronium 1.2 mg/kg

High-dose rocuronium (1.2 mg/kg) provides intubating conditions comparable to succinylcholine and can be reversed with sugammadex if needed.

Question 39: A patient with severe hepatic cirrhosis (Child-Pugh C) has a prolonged PT/INR of 2.8 and platelet count of 55 × 10⁹/L. Point-of-care viscoelastic testing (ROTEM/TEG) shows normal clot formation time and normal maximum clot firmness. What is the MOST appropriate pre-operative coagulation management?

Administer tranexamic acid prophylactically and transfuse FFP
Administer platelet transfusion to achieve a count >100 × 10⁹/L
Proceed without haemostatic correction — viscoelastic testing indicates balanced haemostasis (Correct answer)
Transfuse 4 units of FFP to correct the INR to <1.5 before proceeding

Correct answer: Proceed without haemostatic correction — viscoelastic testing indicates balanced haemostasis

Conventional coagulation tests (PT/INR) are poor predictors of bleeding risk in cirrhosis because they measure only the procoagulant limb and do not account for the parallel reduction in anticoagulant proteins (protein C, S, antithrombin). Patients with cirrhosis often achieve 'rebalanced haemostasis.' Viscoelastic testing (ROTEM/TEG) provides a global assessment of clot formation and stability in whole blood, incorporating both pro- and anticoagulant factors. A normal ROTEM/TEG despite an elevated INR indicates functionally adequate haemostasis, and prophylactic FFP transfusion is not indicated — it carries risks of fluid overload, transfusion reactions, and portal hypertension exacerbation without haemostatic benefit. Proceeding without correction is supported by current EASL and ESICM guidelines.

Question 40: During one-lung ventilation (OLV) for a right pneumonectomy, the patient develops severe hypoxaemia (SpO₂ 78%) despite 100% FiO₂ and PEEP 5 cmH₂O to the dependent lung. Which intervention is MOST likely to improve oxygenation without compromising the surgical field?

Switch to high-frequency jet ventilation of the dependent lung
Apply continuous positive airway pressure (CPAP) of 2–5 cmH₂O to the non-dependent (operative) lung (Correct answer)
Clamp the pulmonary artery on the operative side before re-expanding the lung
Increase tidal volume to 10 mL/kg IBW on the dependent lung

Correct answer: Apply continuous positive airway pressure (CPAP) of 2–5 cmH₂O to the non-dependent (operative) lung

Low-level CPAP (2–5 cmH₂O) applied to the non-dependent operative lung recruits alveoli and allows passive oxygenation across a partially distended lung without full re-expansion, substantially reducing shunt fraction while keeping the surgical field acceptable. Increasing tidal volume risks ventilator-induced lung injury in the dependent lung. HFJV to the dependent lung is not a standard first-line rescue. PA clamping is a surgical manoeuvre appropriate only at the moment of pneumonectomy, not as an anaesthetic intervention for hypoxaemia.

Question 41: The Pin Index Safety System (PISS) on gas cylinders is designed to:

Regulate pressure from the cylinder
Prevent accidental connection of wrong gas cylinders to yokes (Correct answer)
Prevent backflow of gases into the cylinder
Indicate the remaining volume of gas

Correct answer: Prevent accidental connection of wrong gas cylinders to yokes

PISS uses unique pin configurations for each gas to prevent incorrect cylinders from being mounted on the wrong yoke connection.

Question 42: A patient with severe hepatic cirrhosis receives midazolam. Which pharmacokinetic change is most expected?

Increased first-pass metabolism
Decreased clearance prolonging elimination half-life (Correct answer)
Decreased volume of distribution
Reduced protein binding increasing free fraction

Correct answer: Decreased clearance prolonging elimination half-life

Severe hepatic cirrhosis reduces hepatic metabolic capacity, decreasing midazolam clearance and markedly prolonging its elimination half-life.

Question 43: A patient with heparin-induced thrombocytopenia (HIT) confirmed by positive PF4-heparin ELISA and positive serotonin release assay requires urgent coronary artery bypass grafting. Which anticoagulation strategy is the preferred choice for cardiopulmonary bypass?

Argatroban infusion with standard ACT targets of >400 seconds
Fondaparinux at high doses with anti-Xa monitoring
Unfractionated heparin with platelet transfusion pre-bypass to prevent HIT antibody binding
Bivalirudin with monitoring by ACT targets adjusted to >480 seconds (Correct answer)

Correct answer: Bivalirudin with monitoring by ACT targets adjusted to >480 seconds

Bivalirudin is the preferred anticoagulant for cardiac surgery with CPB in confirmed HIT. Unlike argatroban, bivalirudin is cleared primarily by enzymatic degradation (not hepatically), has predictable pharmacokinetics during CPB, and can be monitored with ACT (target >480s during CPB, higher than standard heparin targets). Argatroban is hepatically cleared and accumulates unpredictably during the hypothermic, non-pulsatile flow of CPB, making it a less reliable choice. Fondaparinux has no reversal agent and its behaviour on CPB is inadequately characterised. Unfractionated heparin is absolutely contraindicated in acute HIT as all heparin formulations (including LMWH) cross-react with HIT antibodies.

Question 44: Which neuromuscular blocking agent has the shortest duration of action due to rapid hydrolysis by plasma cholinesterase?

Succinylcholine (Correct answer)
Rocuronium
Mivacurium
Cisatracurium

Correct answer: Succinylcholine

Succinylcholine is hydrolyzed within 5–10 minutes by plasma pseudocholinesterase, giving it the shortest duration among neuromuscular blockers.

Question 45: A 45-year-old woman scheduled for left VATS lobectomy has a predicted postoperative FEV1 of 52% and DLCO of 55%. According to ESTS guidelines, her surgical risk category is:

Moderate risk — consider cardiopulmonary exercise testing
Low risk — no further testing required (Correct answer)
High risk — surgery contraindicated
Very high risk — palliative treatment only

Correct answer: Low risk — no further testing required

Both predicted postoperative FEV1 and DLCO >40% place the patient in the low-risk category, and surgery may proceed without mandatory CPET.

Question 46: During massive transfusion for a ruptured abdominal aortic aneurysm, rotational thromboelastometry (ROTEM) shows: EXTEM CT normal, EXTEM CFR severely prolonged (>140 sec), EXTEM MCF 25 mm, FIBTEM MCF 4 mm. Which targeted intervention is most appropriate?

Administer tranexamic acid, as the pattern is consistent with primary fibrinolysis causing clot lysis
Give platelet concentrate, since a low EXTEM MCF with near-normal FIBTEM MCF points to thrombocytopenia
Administer cryoprecipitate or fibrinogen concentrate, as the pattern indicates isolated hypofibrinogenaemia (Correct answer)
Transfuse 4 units of FFP to correct clotting factor deficiency indicated by the prolonged CFR

Correct answer: Administer cryoprecipitate or fibrinogen concentrate, as the pattern indicates isolated hypofibrinogenaemia

In ROTEM interpretation, EXTEM MCF reflects contributions from fibrinogen and platelets, while FIBTEM MCF isolates fibrinogen's contribution (platelet contribution is blocked by cytochalasin D). A low EXTEM MCF (25 mm) combined with a low FIBTEM MCF (4 mm, normal >10 mm) indicates the primary deficit is fibrinogen — not platelets, because if platelets were the problem, FIBTEM MCF would be preserved. The prolonged CFR (clot formation rate, equivalent to α-angle) reinforces poor fibrin polymerisation. FFP provides inadequate fibrinogen concentrations (~2 g/L) to correct severe hypofibrinogenaemia rapidly. The correct action is fibrinogen concentrate or cryoprecipitate. Platelet concentrate would be indicated if EXTEM MCF were low with normal FIBTEM MCF.

Question 47: During a continuous erector spinae plane (ESP) block for thoracic surgery analgesia, you notice the patient develops a T4–T8 dermatomal sensory block but reports pain in the ipsilateral shoulder and anterior chest wall. Which mechanism best explains this analgesic gap?

Failure of local anaesthetic to reach the dorsal rami at the target levels
Sparing of the lateral cutaneous branches of intercostal nerves T2–T4 (Correct answer)
Inadequate spread to rami communicantes supplying visceral afferents
Incomplete block of the ipsilateral phrenic nerve (C3–C5)

Correct answer: Sparing of the lateral cutaneous branches of intercostal nerves T2–T4

The ESP block acts primarily on dorsal and ventral rami via paravertebral spread. However, the lateral cutaneous branches of the upper intercostal nerves (T2–T4) pierce the serratus anterior and supply the anterior and lateral chest wall including pectoral and axillary regions. These branches can be spared if spread is insufficient anteriorly. Phrenic nerve involvement does not explain anterior chest wall pain, and rami communicantes carry visceral afferents, not somatic shoulder/chest pain. The dorsal rami supply the posterior thorax only.

Question 48: During video-assisted thoracoscopic surgery (VATS), inadequate lung collapse despite a correctly positioned DLT is most efficiently addressed by:

Increasing PEEP on the ventilated lung
Switching to a single-lumen tube with bronchial blocker
Insufflating CO2 into the pleural space at low pressure (Correct answer)
Applying 5 cmH2O CPAP to the collapsed lung

Correct answer: Insufflating CO2 into the pleural space at low pressure

Low-pressure CO2 insufflation (up to 8 mmHg) into the pleural cavity rapidly collapses the operative lung and improves surgical visualization when passive collapse is incomplete.

Question 49: In chronic pain management, what mechanism underlies the analgesic effect of tricyclic antidepressants (TCAs)?

Inhibition of norepinephrine and serotonin reuptake in descending inhibitory pathways (Correct answer)
Blockade of voltage-gated sodium channels only
GABA-A receptor potentiation
Opioid receptor agonism

Correct answer: Inhibition of norepinephrine and serotonin reuptake in descending inhibitory pathways

TCAs enhance descending pain inhibition by blocking reuptake of norepinephrine and serotonin in the spinal cord, and also have sodium channel blocking properties that contribute to analgesia.

Question 50: The WHO Surgical Safety Checklist is structured around three pause points during the surgical episode. Which of the following correctly identifies all three?

Pre-admission, pre-induction, post-operative
Pre-operative ward round, anaesthetic room check, recovery room handover
Consent, anaesthetic machine check, post-operative review
Sign In (before induction), Time Out (before skin incision), Sign Out (before patient leaves theatre) (Correct answer)

Correct answer: Sign In (before induction), Time Out (before skin incision), Sign Out (before patient leaves theatre)

The WHO Surgical Safety Checklist (introduced 2008) comprises: (1) Sign In — before induction of anaesthesia, confirming patient identity, consent, allergies, airway assessment, and anaesthetic machine check; (2) Time Out — before skin incision, confirming team introductions, procedure, site, imaging, and antibiotic prophylaxis; (3) Sign Out — before the patient leaves theatre, confirming instrument/swab counts, specimen labelling, and recovery plan. Systematic use has been shown to reduce surgical mortality and complication rates.

Question 51: The plateau of the oxygen-hemoglobin dissociation curve has clinical significance because it means:

Small drops in PaO2 from 100 to 70 mmHg cause large drops in SaO2
Hemoglobin releases oxygen more readily at high pH
Oxygen delivery is maximized at PaO2 of 40 mmHg
SaO2 remains high over a wide range of PaO2 values above 60 mmHg (Correct answer)

Correct answer: SaO2 remains high over a wide range of PaO2 values above 60 mmHg

The flat upper portion of the oxyhemoglobin dissociation curve means SaO2 remains above 90% across a wide PaO2 range (60-100 mmHg), providing a safety margin.

Question 52: In a patient with traumatic brain injury, which PaCO2 target is recommended during initial resuscitation to avoid secondary injury?

45-50 mmHg
25-30 mmHg
35-40 mmHg (Correct answer)
30-35 mmHg

Correct answer: 35-40 mmHg

Normocapnia (PaCO2 35-40 mmHg) is recommended; prophylactic hyperventilation reduces cerebral blood flow and can cause ischemia.

Question 53: During caudal epidural block in a 12 kg, 2-year-old child using 1 mL/kg of 0.2% ropivacaine, the anaesthesiologist inadvertently performs an intravascular injection. Which ECG change is the EARLIEST reliable indicator of ropivacaine systemic toxicity in a paediatric patient under general anaesthesia with sevoflurane?

Widening of the QRS complex >25% from baseline (Correct answer)
Sudden onset of peaked T-waves followed by PR prolongation
Ventricular ectopic beats followed by ventricular tachycardia
New ST-segment depression >1 mm in limb leads

Correct answer: Widening of the QRS complex >25% from baseline

Ropivacaine (like all amide local anaesthetics) causes cardiac toxicity primarily through fast sodium channel blockade in conduction tissue. The earliest reliable ECG sign of systemic LA toxicity under general anaesthesia — where the patient cannot report prodromal CNS symptoms — is QRS widening >25% from baseline, reflecting slowed ventricular conduction before frank arrhythmia develops. This precedes ST changes, T-wave abnormalities, or overt dysrhythmias. ST depression suggests ischaemia rather than LA toxicity. Peaked T-waves are associated with hyperkalaemia. Ventricular tachycardia is a late, often pre-terminal sign. Recognising QRS prolongation early allows timely administration of 20% intralipid emulsion before progression to cardiovascular collapse.

Question 54: A 58-year-old man with Child-Pugh Class C cirrhosis undergoes emergency laparotomy. Intraoperatively, coagulation is severely deranged with a prothrombin time of 28 seconds and platelet count of 42,000/µL. He develops diffuse microvascular bleeding. Thromboelastography (TEG) reveals a prolonged R-time, reduced α-angle, and reduced MA. Which transfusion strategy is most appropriate?

Administer recombinant Factor VIIa as first-line therapy
Transfuse fresh frozen plasma alone to correct the PT
Transfuse cryoprecipitate followed by platelet concentrate and fresh frozen plasma guided by TEG parameters (Correct answer)
Transfuse packed red blood cells to a haemoglobin target of 10 g/dL before addressing coagulopathy

Correct answer: Transfuse cryoprecipitate followed by platelet concentrate and fresh frozen plasma guided by TEG parameters

TEG showing prolonged R-time (factor deficiency), reduced α-angle (fibrinogen deficit), and reduced MA (platelet dysfunction) indicates a combined coagulopathy. In cirrhotic patients with active bleeding, a goal-directed approach using viscoelastic testing is superior to empirical FFP alone. Cryoprecipitate addresses fibrinogen deficiency (the most critical substrate for clot formation), followed by platelets and FFP to correct factor deficiency and platelet function. Recombinant FVIIa is not first-line and carries thrombotic risk. Targeting Hb 10 g/dL is excessive and not the priority when microvascular bleeding is driven by coagulopathy.

Question 55: A 67-year-old male presents with acute altered consciousness, BP 210/130 mmHg, papilloedema, and serum creatinine 320 µmol/L (baseline unknown). MRI shows posterior reversible encephalopathy syndrome (PRES). Which of the following statements regarding blood pressure management is CORRECT?

Sodium nitroprusside is the preferred agent as it directly reduces cerebral oedema via vasodilation
BP should be aggressively normalised to <140/90 mmHg within 1 hour using IV labetalol
MAP should be reduced by no more than 25% within the first hour to avoid cerebral ischaemia (Correct answer)
Thrombolysis should be considered if ischaemic stroke cannot be excluded on imaging

Correct answer: MAP should be reduced by no more than 25% within the first hour to avoid cerebral ischaemia

In hypertensive emergency complicated by PRES, rapid overcorrection of BP is dangerous and can precipitate cerebral ischaemia due to impaired autoregulation. Guidelines recommend reducing MAP by no more than 25% in the first hour, then targeting 160/100 mmHg over the next 2–6 hours. PRES is a radiological diagnosis that does not constitute a contraindication to gradual BP reduction but does mandate avoiding overshoot. Aggressive normalisation risks watershed infarction. Thrombolysis is contraindicated in PRES (it is not ischaemic stroke). Nitroprusside can cause cyanide toxicity with prolonged use and does not directly reduce cerebral oedema.

Question 56: According to Poiseuille's law for laminar flow, which of the following modifications to a standard intravenous cannula setup would result in the greatest increase in flow rate for a given infusion pressure?

Halving the viscosity of the infused fluid (e.g., using crystalloid instead of blood).
Increasing the internal radius of the cannula by 50%. (Correct answer)
Doubling the height of the IV bag above the patient.
Doubling the length of the infusion tubing.

Correct answer: Increasing the internal radius of the cannula by 50%.

Poiseuille's law states that flow is directly proportional to the fourth power of the radius (r^4) and inversely proportional to the length of the tube and the fluid's viscosity. Increasing the radius by 50% (a factor of 1.5) increases the flow by a factor of 1.5^4, which is 5.0625. Halving the viscosity or doubling the pressure gradient (by doubling the height) would only double the flow rate. Doubling the length would halve the flow rate. Therefore, increasing the cannula's radius has the most profound effect on flow.

Question 57: A 70 kg patient receiving an intravenous regional anaesthesia (Bier's block) with 40 mL of 0.5% prilocaine develops methaemoglobinaemia postoperatively. At what total prilocaine dose threshold is this complication most likely to occur, and which metabolite is responsible?

Above 300 mg total; ortho-chlorotoluidine is the responsible metabolite
Above 200 mg total; o-toluidine is the responsible metabolite (Correct answer)
Above 600 mg total; hydroxyprilocaine is the responsible metabolite
Above 400 mg total; MEGX (monoethylglycinexylidide) is the responsible metabolite

Correct answer: Above 200 mg total; o-toluidine is the responsible metabolite

Prilocaine is metabolised in the liver to o-toluidine (ortho-toluidine), which oxidises haemoglobin to methaemoglobin. Clinically significant methaemoglobinaemia (>10%) becomes likely above approximately 600 mg total dose in adults, but symptoms can appear at lower cumulative exposures in susceptible patients. A 40 mL dose of 0.5% prilocaine = 200 mg — this is near the safe upper limit for Bier's block, and cuff deflation before full hepatic redistribution can unmask toxicity. MEGX is a lignocaine metabolite, not prilocaine's. Hydroxyprilocaine and ortho-chlorotoluidine are distractors; o-toluidine is the correct culpable species.

Question 58: Type II pneumocytes differ from Type I pneumocytes in that they:

Are primarily responsible for gas exchange
Cover 95% of the alveolar surface area
Lack the ability to proliferate
Produce surfactant and can regenerate Type I cells (Correct answer)

Correct answer: Produce surfactant and can regenerate Type I cells

Type II pneumocytes secrete pulmonary surfactant to reduce alveolar surface tension and serve as progenitor cells capable of regenerating Type I cells after injury.

Question 59: A 4-year-old child (18 kg) requires atropine for refractory bradycardia during anesthesia. What is the correct IV dose?

0.36 mg (0.02 mg/kg) (Correct answer)
0.18 mg (0.01 mg/kg)
0.72 mg (0.04 mg/kg)
0.09 mg (0.005 mg/kg)

Correct answer: 0.36 mg (0.02 mg/kg)

The recommended IV dose of atropine for pediatric bradycardia is 0.02 mg/kg (minimum 0.1 mg), giving 0.36 mg for an 18 kg child.

Question 60: A patient undergoes video-assisted thoracoscopic surgery (VATS) lobectomy in the lateral decubitus position. The anaesthetist uses a size 39F left-sided double-lumen tube. After repositioning from supine to lateral decubitus, the surgeon reports incomplete lung collapse. Fibreoptic bronchoscopy through the tracheal lumen reveals the tracheal cuff is positioned 1 cm above the carina with no endobronchial herniation. What is the most appropriate next step?

Apply suction to the bronchial lumen of the DLT (Correct answer)
Withdraw the DLT by 1–2 cm and re-check bronchoscopically
Replace with a right-sided DLT to allow better left-lung isolation
Advance the DLT by 1–2 cm until the bronchial cuff is further into the left mainstem bronchus

Correct answer: Apply suction to the bronchial lumen of the DLT

When a bronchoscopically confirmed well-positioned DLT fails to achieve adequate lung collapse, applying suction (negative pressure) to the bronchial lumen of the operative (non-ventilated) lung actively evacuates residual gas and dramatically accelerates lung deflation. This is the recommended manoeuvre before repositioning the tube. The DLT position described (tracheal cuff 1 cm above carina, no cuff herniation) is actually ideal — withdrawing would risk losing bronchial seal; advancing risks right upper lobe obstruction on the ventilated side. Switching to a right-sided DLT is technically more difficult, associated with a higher failure rate, and is not indicated when left-sided isolation is the goal and tube position is confirmed correct.

Question 61: Jugular venous oxygen saturation (SjvO2) below what threshold indicates global cerebral ischemia?

65%
45%
55% (Correct answer)
75%

Correct answer: 55%

SjvO2 below 55% indicates increased oxygen extraction and global cerebral ischemia, requiring immediate intervention to increase oxygen delivery.

Question 62: In acute upper GI hemorrhage, what is the primary hemodynamic target for initial resuscitation before endoscopy?

Restrictive transfusion targeting Hb 7 g/dL (Correct answer)
MAP > 75 mmHg
Heart rate < 60 bpm
Hemoglobin > 10 g/dL

Correct answer: Restrictive transfusion targeting Hb 7 g/dL

Restrictive transfusion strategy targeting Hb of 7 g/dL has been shown to improve outcomes in acute upper GI bleeding compared to liberal transfusion.

Question 63: Which of the following chronic medications should routinely be CONTINUED on the morning of elective non-cardiac surgery?

ACE inhibitors / angiotensin receptor blockers
Metformin (before major abdominal surgery)
Warfarin
Chronically prescribed beta-blockers (Correct answer)

Correct answer: Chronically prescribed beta-blockers

Chronically prescribed beta-blockers must be continued perioperatively; abrupt withdrawal risks rebound hypertension, tachycardia, and myocardial ischaemia. Metformin is typically withheld ≥ 24–48 hours before major surgery due to lactic acidosis risk in the setting of haemodynamic instability. ACE inhibitors/ARBs are generally withheld on the morning of surgery to reduce the risk of refractory intraoperative hypotension. Warfarin requires bridging or cessation based on thrombotic and haemorrhagic risk assessment.

Question 64: Infrared absorption spectroscopy in anaesthetic gas analysers is based on the principle that:

All gases absorb infrared radiation equally and are distinguished by refractive index
Monatomic gases like xenon have the highest infrared absorption
Paramagnetic molecules absorb infrared at wavelengths proportional to their magnetic susceptibility
Polyatomic molecules absorb infrared radiation at characteristic wavelengths corresponding to vibrational modes (Correct answer)

Correct answer: Polyatomic molecules absorb infrared radiation at characteristic wavelengths corresponding to vibrational modes

Heteronuclear polyatomic molecules (CO₂, N₂O, volatile agents) have dipole moment changes during vibration, allowing them to absorb IR at specific wavelengths used for identification and quantification.

Question 65: During orthotopic liver transplantation, ROTEM analysis at the start of reperfusion reveals: EXTEM CT 840s (ref <80s), INTEM CT 620s (ref <240s), but HEPTEM CT 74s (ref <240s). EXTEM MCF and FIBTEM MCF are both within normal limits. What is the most appropriate immediate intervention?

Fresh frozen plasma 15 mL/kg to correct clotting factor deficiency
Tranexamic acid 1 g to treat hyperfibrinolysis from reperfusion
Fibrinogen concentrate 2 g to improve clot firmness
Protamine sulfate 25–50 mg IV to reverse heparin effect from the donor liver flush (Correct answer)

Correct answer: Protamine sulfate 25–50 mg IV to reverse heparin effect from the donor liver flush

HEPTEM contains heparinase, which neutralises heparin in the sample. When HEPTEM CT normalises while EXTEM and INTEM CTs are markedly prolonged — with preserved MCF values — the pattern is pathognomonic for heparin effect rather than factor deficiency or fibrinolysis. This occurs because donor livers are flushed with heparin-containing preservation solution (e.g., University of Wisconsin solution) that releases into the circulation upon reperfusion. Small doses of protamine (25–50 mg) reverse this rapidly. FFP would not address a heparin effect, fibrinogen concentrate is irrelevant when MCF is normal, and TXA treats fibrinolysis (which would show an abnormal APTEM pattern).

Question 66: A 58-year-old patient undergoes ultrasound-guided erector spinae plane (ESP) block at the T5 level for thoracic surgery analgesia. Post-procedure, the patient develops unexpected ipsilateral lower limb weakness. Which anatomical mechanism best explains this complication?

Epidural spread through the intervertebral foramina at the thoracolumbar junction
Direct spread of local anaesthetic to the ipsilateral lumbar paravertebral space via the erector spinae fascial plane (Correct answer)
Contralateral sympathetic block causing vasodilation and relative hypoperfusion of the motor cortex
Intravascular injection into a radicular artery supplying the thoracic spinal cord

Correct answer: Direct spread of local anaesthetic to the ipsilateral lumbar paravertebral space via the erector spinae fascial plane

The ESP block deposits local anaesthetic deep to the erector spinae muscle and superficial to the transverse processes. The fascial plane is continuous craniocaudally, and large-volume injections can track inferiorly to the lumbar paravertebral space, potentially blocking lumbar nerve roots and causing lower limb motor weakness. This caudal spread has been documented in cadaveric and clinical studies and is the most plausible anatomical explanation for ipsilateral limb weakness remote from the injection site.

Question 67: The 'difficult airway' encountered during planned fiberoptic intubation for thoracic surgery is best managed by which backup strategy according to the DAS guidelines?

Supraglottic airway (LMA) insertion followed by fiber-optic intubation through it (Correct answer)
Blind nasal intubation
Immediate surgical tracheostomy
Cricothyroidotomy as first rescue option

Correct answer: Supraglottic airway (LMA) insertion followed by fiber-optic intubation through it

DAS guidelines recommend a second-generation supraglottic airway as a rescue device; fiberoptic intubation through the LMA can then establish a definitive airway.

Question 68: The Fick principle applied to hepatic drug clearance states that hepatic clearance equals:

Intrinsic clearance divided by protein binding fraction
Dose divided by area under the concentration-time curve
Volume of distribution divided by elimination half-life
Hepatic blood flow multiplied by the extraction ratio (Correct answer)

Correct answer: Hepatic blood flow multiplied by the extraction ratio

Hepatic clearance = hepatic blood flow (Q) × extraction ratio (E); this is derived from the Fick principle applied to organ drug elimination.

Question 69: The hepatic artery supplies approximately what percentage of total hepatic blood flow?

50%
75%
25% (Correct answer)
10%

Correct answer: 25%

The hepatic artery provides approximately 25% of total hepatic blood flow but delivers about 50% of hepatic oxygen supply due to its high oxygen content.

Question 70: A ventilated ICU patient has a plateau pressure of 34 cmH2O and a PEEP of 8 cmH2O. The driving pressure is:

26 cmH2O (Correct answer)
42 cmH2O
8 cmH2O
34 cmH2O

Correct answer: 26 cmH2O

Driving pressure = Plateau pressure − PEEP = 34 − 8 = 26 cmH2O.

Question 71: Critical incident reporting systems in anaesthesia departments encourage reporting of 'near miss' events. What is the primary rationale for analysing near misses rather than focusing only on adverse outcomes?

Near misses expose system vulnerabilities before harm reaches the patient, enabling preventive system changes (Correct answer)
Near misses are legally equivalent to adverse events in all European jurisdictions
Near misses occur less frequently than actual adverse events and are therefore more informative
Near misses require mandatory financial compensation to the patient

Correct answer: Near misses expose system vulnerabilities before harm reaches the patient, enabling preventive system changes

Near misses ('close calls') are incidents where a harmful outcome was averted by chance or last-minute intervention. They are far more frequent than serious adverse events and share the same upstream causal factors. Analysing them identifies latent system failures before harm occurs — providing a low-cost, high-yield opportunity for system improvement. This is central to High Reliability Organisation (HRO) principles in healthcare.

Question 72: The cricothyroid membrane, the target for emergency surgical airway access, connects which two cartilaginous structures?

Thyroid and arytenoid cartilage
Cricoid and arytenoid cartilage
Epiglottis and thyroid cartilage
Thyroid and cricoid cartilage (Correct answer)

Correct answer: Thyroid and cricoid cartilage

The cricothyroid membrane spans between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage. It lies in the midline, is relatively avascular, and is the preferred site for needle or surgical cricothyroidotomy in a 'can't intubate, can't oxygenate' scenario.

Question 73: The minimum alveolar concentration (MAC) of a volatile anesthetic is best described as the concentration that:

Blocks memory formation in 99% of patients
Prevents movement in 50% of patients in response to a surgical skin incision (Correct answer)
Prevents cardiovascular response to laryngoscopy in 50% of patients
Causes unconsciousness in 95% of unpremedicated patients

Correct answer: Prevents movement in 50% of patients in response to a surgical skin incision

MAC is defined as the alveolar concentration of volatile anesthetic at 1 atm that prevents purposeful movement in response to a surgical skin incision in 50% of patients.

Question 74: In a patient with hypertrophic obstructive cardiomyopathy (HOCM) under general anaesthesia, acute systemic hypotension occurs. A registrar administers phenylephrine (200 mcg IV bolus). Five minutes later, the patient develops syncope with LVOT gradient increasing from 40 to 110 mmHg. What is the most likely explanation?

Pure alpha-1 agonism raised aortic pressure, increasing ventricular wall stress, triggering a Bezold-Jarisch reflex that worsened obstruction
Phenylephrine caused coronary vasospasm, inducing ischaemia of the septum and worsening hypertrophy-driven obstruction acutely
Reflex bradycardia from phenylephrine's baroreceptor activation prolonged diastole, increased LV filling and end-diastolic volume, paradoxically worsening SAM and LVOT obstruction by increasing contractility-driven obstruction
Phenylephrine's alpha-1-mediated increase in SVR reduced forward flow, but the simultaneous negative chronotropic effect increased time for systolic anterior motion (SAM) to develop (Correct answer)

Correct answer: Phenylephrine's alpha-1-mediated increase in SVR reduced forward flow, but the simultaneous negative chronotropic effect increased time for systolic anterior motion (SAM) to develop

Phenylephrine, a pure alpha-1 agonist, raises SVR and arterial pressure — which is generally desirable in HOCM to increase afterload and reduce obstruction. However, via baroreceptor reflex, it causes significant reflex bradycardia. The prolonged diastolic filling time increases LV end-diastolic volume, and the slower heart rate increases time available per systole for SAM to develop. Paradoxically, in a setting of already elevated contractility, the combination of reflex bradycardia + increased preload may worsen the dynamic obstruction. While the increase in SVR helps, the net effect in this case was worsening. This subtle interaction is clinically important: phenylephrine is still preferred over vasodilators, but the reflex bradycardia component can worsen dynamic obstruction.

Question 75: For informed consent to anaesthesia to be legally and ethically valid, which of the following is the most complete description of what the patient must be told?

The statistical probability of each complication from published meta-analyses
Only the most serious (potentially fatal) complications
Only complications occurring in more than 1% of cases
The nature, purpose, material risks, benefits, and reasonable alternatives of the proposed anaesthetic (Correct answer)

Correct answer: The nature, purpose, material risks, benefits, and reasonable alternatives of the proposed anaesthetic

Valid informed consent requires disclosure of the nature of the procedure, its purpose, the material risks (those a reasonable patient would want to know, even if rare), the benefits, and available alternatives including no treatment. The 'material risk' standard (established in Montgomery v Lanarkshire and equivalent European case law) replaced the old 'reasonable doctor' standard — the patient's perspective now determines what must be disclosed, not just what clinicians deem important.

Question 76: Which of the following describes the effect of increased afterload on the LV pressure-volume loop?

Increased loop width with decreased loop height
Decreased LVEDP with unchanged stroke volume
Increased stroke volume with unchanged LVEDV
Decreased stroke volume with increased end-systolic volume (Correct answer)

Correct answer: Decreased stroke volume with increased end-systolic volume

Increased afterload raises the pressure against which the ventricle must eject, resulting in decreased stroke volume and an elevated end-systolic volume.

Question 77: A 68-year-old male with a history of COPD is scheduled for a right upper lobectomy for a lung mass. His preoperative FEV1 is 1.6 L (55% predicted). A quantitative V/Q scan shows the right upper lobe contributes 20% to total lung function. What is the best estimate of his predicted postoperative FEV1 (ppoFEV1)?

1.06 L
1.44 L
1.28 L (Correct answer)
0.88 L

Correct answer: 1.28 L

The predicted postoperative FEV1 (ppoFEV1) is calculated by the formula: ppoFEV1 = Preoperative FEV1 × (1 − fraction of functional lung tissue to be removed). In this case, the V/Q scan indicates the lobe to be resected contributes 20% (0.20) of function. Therefore, ppoFEV1 = 1.6 L × (1 - 0.20) = 1.6 L × 0.8 = 1.28 L. This calculation is crucial for assessing postoperative risk.

Question 78: In a patient with distributive shock, which hemodynamic profile is expected?

High CO, high SVR, low PCWP
Low CO, high SVR, high PCWP
Low CO, low SVR, high CVP
High CO, low SVR, low to normal PCWP (Correct answer)

Correct answer: High CO, low SVR, low to normal PCWP

Distributive shock (e.g., septic shock) is characterized by high cardiac output, low systemic vascular resistance, and inappropriately low tissue perfusion despite high flow.

Question 79: In a trauma patient receiving massive transfusion, rotational thromboelastometry (ROTEM) demonstrates an isolated, markedly prolonged EXTEM lysis index at 30 minutes (LI30 <85%) with a normal FIBTEM and INTEM. What does this pattern indicate and what is the most appropriate intervention?

Severe hypothermia-induced coagulopathy — treat with warming and calcium chloride
Disseminated intravascular coagulation with consumption coagulopathy — treat with FFP and platelets
Factor XIII deficiency causing weak cross-linking — treat with Factor XIII concentrate
Hyperfibrinolysis as the dominant abnormality — treat with tranexamic acid (Correct answer)

Correct answer: Hyperfibrinolysis as the dominant abnormality — treat with tranexamic acid

An LI30 <85% on EXTEM (or LI60 <85%) indicates fibrinolysis occurring within 30 minutes of clot formation, a hallmark of hyperfibrinolysis. This pattern is distinct from DIC (which shows prolonged CTs and low MCF) and Factor XIII deficiency (which prolongs clot retraction but not early lysis). Hyperfibrinolysis in trauma is driven by massive tissue plasminogen activator release from endothelium. The CRASH-2 and MATTERS trials demonstrated mortality benefit of tranexamic acid (TXA) in trauma haemorrhage, and ROTEM-guided TXA use is standard practice. TXA is most effective when given within 3 hours of injury. Isolated hyperfibrinolysis does not require FFP or platelets.

Question 80: A patient with a large right-sided pleural effusion requires thoracentesis under general anesthesia. During drainage, she suddenly becomes hypotensive and dyspneic. The most likely diagnosis is:

Hemorrhagic shock from intercostal vessel laceration
Vasovagal syncope
Re-expansion pulmonary edema (Correct answer)
Tension pneumothorax on the right

Correct answer: Re-expansion pulmonary edema

Rapid drainage of large pleural effusions can cause re-expansion pulmonary edema as chronically collapsed lung tissue rapidly fills with fluid, releasing inflammatory mediators.

Question 81: Which drug should be immediately available when performing test dose confirmation of epidural catheter placement?

Naloxone for opioid reversal
Phenylephrine for hypotension
Atropine for bradycardia treatment
Epinephrine to detect intravascular placement (Correct answer)

Correct answer: Epinephrine to detect intravascular placement

Epidural test dose contains epinephrine 15 mcg; intravascular injection causes a transient heart rate increase >20 bpm, confirming misplacement.

Question 82: A patient in the ICU develops acute respiratory distress syndrome (ARDS). What tidal volume is recommended for lung-protective ventilation?

10-12 mL/kg predicted body weight
8 mL/kg predicted body weight
6 mL/kg predicted body weight (Correct answer)
4 mL/kg predicted body weight

Correct answer: 6 mL/kg predicted body weight

The ARDSNet trial established that 6 mL/kg predicted body weight reduces mortality compared to conventional 12 mL/kg ventilation in ARDS.

Question 83: Which finding on bedside echocardiography most reliably indicates fluid responsiveness?

E/e' ratio >14
Inferior vena cava diameter >2.5 cm
Left ventricular ejection fraction <40%
Respiratory variation in IVC diameter >18% in ventilated patients (Correct answer)

Correct answer: Respiratory variation in IVC diameter >18% in ventilated patients

IVC collapsibility (spontaneous breathing) or distensibility (positive pressure ventilation) >18% predicts fluid responsiveness with reasonable sensitivity and specificity.

Question 84: A 58-year-old patient with a biochemically confirmed phaeochromocytoma is scheduled for laparoscopic adrenalectomy. Despite 3 weeks of alpha-blockade with phenoxybenzamine, intraoperative hypertensive crisis (BP 240/130 mmHg) occurs during tumour manipulation. After IV phentolamine fails to control BP adequately, which agent is most appropriate as second-line therapy?

IV nicardipine as a titratable calcium channel blocker (Correct answer)
IV sodium nitroprusside (SNP) as a direct vasodilator
IV magnesium sulphate to inhibit catecholamine release
IV esmolol to address reflex tachycardia and reduce BP

Correct answer: IV nicardipine as a titratable calcium channel blocker

Nicardipine, a dihydropyridine calcium channel blocker, is highly effective as a second-line agent for phaeochromocytoma-related hypertensive crisis. It provides rapid, titratable, predictable vasodilation without the risk of cyanide toxicity associated with sodium nitroprusside (problematic in prolonged use or hepatic dysfunction). SNP remains an option but carries toxicity risk. Esmolol (a beta-blocker) must NEVER be used without adequate alpha-blockade in phaeochromocytoma, as unopposed alpha-stimulation can paradoxically worsen hypertension — and even with prior phenoxybenzamine, adding a beta-blocker during active catecholamine surge is dangerous. Magnesium can reduce catecholamine release and is used as an adjunct but is not potent enough as a sole second-line agent for severe crisis.

Question 85: A 58-year-old male is undergoing surgical clipping of a ruptured anterior communicating artery aneurysm. Intraoperatively, the surgeons announce sudden, brisk bleeding from the aneurysm dome. Which of the following is the most appropriate immediate anesthetic management step?

Administer a bolus of mannitol 1 g/kg.
Start a rapid infusion of 3% hypertonic saline.
Administer a bolus of norepinephrine to maintain cerebral perfusion pressure.
Induce profound hypotension (MAP 40-50 mmHg) transiently. (Correct answer)

Correct answer: Induce profound hypotension (MAP 40-50 mmHg) transiently.

In the event of an intraoperative aneurysm rupture, the immediate goals are to facilitate surgical control of the bleeding and maintain adequate cerebral perfusion. Transiently inducing profound hypotension (Mean Arterial Pressure 40-50 mmHg) reduces the pressure head against which the surgeon is working, decreases blood loss, and can allow for proximal control and clipping of the aneurysm. Norepinephrine would worsen bleeding. While mannitol or hypertonic saline are used to reduce brain bulk, they are not the primary immediate intervention for controlling active, brisk hemorrhage.

Question 86: Disseminated intravascular coagulation (DIC) is best described as:

Primary fibrinolysis without thrombosis
Simultaneous activation of coagulation and fibrinolysis leading to both clotting and bleeding (Correct answer)
Isolated thrombocytopenia with normal coagulation
Isolated factor XII deficiency

Correct answer: Simultaneous activation of coagulation and fibrinolysis leading to both clotting and bleeding

DIC involves paradoxical simultaneous activation of both coagulation and fibrinolysis, consuming clotting factors and causing multi-organ dysfunction.

Question 87: A 70 kg patient receives rocuronium 1.2 mg/kg for rapid-sequence intubation. Sugammadex 16 mg/kg is given 3 minutes later for immediate reversal. Six hours post-reversal, the patient develops recurarisation. Which pharmacokinetic explanation is MOST plausible?

The sugammadex–rocuronium complex dissociates as renal clearance of sugammadex is impaired, releasing free rocuronium
Sugammadex induces CYP3A4 upregulation, accelerating its own clearance and leaving unbound rocuronium
Sugammadex undergoes hepatic metabolism, producing a metabolite that displaces rocuronium from the complex
Rocuronium redistributes from deep peripheral compartments back into plasma after the initial sugammadex effect, exceeding the encapsulation capacity (Correct answer)

Correct answer: Rocuronium redistributes from deep peripheral compartments back into plasma after the initial sugammadex effect, exceeding the encapsulation capacity

After a large rocuronium dose, significant drug resides in peripheral (muscle and fat) compartments. Sugammadex rapidly encapsulates plasma rocuronium and drives redistribution, but rocuronium continues to re-equilibrate from deep compartments back into plasma over hours. If the total rocuronium load in peripheral tissues exceeds the amount of sugammadex available to bind newly released drug, free rocuronium re-accumulates at the neuromuscular junction causing recurarisation. This is a recognised phenomenon particularly after high-dose rocuronium in patients with large volumes of distribution (obesity, oedema).

Question 88: Which region of the nephron is the PRIMARY site of sodium reabsorption under aldosterone's influence?

Glomerulus
Distal tubule and collecting duct (Correct answer)
Loop of Henle descending limb
Proximal convoluted tubule

Correct answer: Distal tubule and collecting duct

Aldosterone acts on principal cells of the distal tubule and collecting duct to upregulate Na+/K+-ATPase and ENaC channels, increasing sodium reabsorption.

Question 89: Which condition is an absolute contraindication to succinylcholine in pediatric patients?

Hyperkalemia from renal failure
Severe burns more than 24 hours old
Open globe injury
Undiagnosed skeletal muscle myopathy (Correct answer)

Correct answer: Undiagnosed skeletal muscle myopathy

Undiagnosed skeletal muscle myopathy (e.g., Duchenne's) can cause life-threatening hyperkalemia and rhabdomyolysis with succinylcholine.

Question 90: Which volatile anesthetic agent is considered MOST hepatotoxic and carries the highest risk of immune-mediated fulminant hepatic necrosis?

Sevoflurane
Isoflurane
Desflurane
Halothane (Correct answer)

Correct answer: Halothane

Halothane undergoes extensive reductive and oxidative hepatic metabolism, producing reactive intermediates that trigger immune-mediated hepatocellular necrosis (halothane hepatitis) at an incidence of ~1:10,000.

Question 91: In a patient with end-stage liver disease, the volume of distribution of highly protein-bound drugs is most likely to:

Increase due to hypoalbuminemia increasing free drug fraction (Correct answer)
Decrease due to ascites reducing extracellular fluid
Decrease due to reduced hepatic blood flow
Remain unchanged

Correct answer: Increase due to hypoalbuminemia increasing free drug fraction

Hypoalbuminemia in liver failure increases the unbound (free) fraction of protein-bound drugs, effectively increasing their volume of distribution and pharmacodynamic effect.

Question 92: In a patient with a large right-sided bronchopleural fistula (BPF) requiring general anesthesia, which sequence of induction and airway management is MOST appropriate to prevent tension pneumothorax and ensure lung isolation BEFORE positive pressure ventilation?

Rapid sequence induction with succinylcholine, then left-sided double-lumen tube (DLT) placement after intubation
Insertion of a right-sided chest drain under local anesthesia followed by standard RSI with orotracheal tube and bronchial blocker
Inhalational induction with sevoflurane maintaining spontaneous ventilation, followed by left-sided DLT with bronchoscopic confirmation (Correct answer)
Awake fiberoptic intubation with a left-sided DLT under spontaneous ventilation, confirming position before induction of general anesthesia

Correct answer: Inhalational induction with sevoflurane maintaining spontaneous ventilation, followed by left-sided DLT with bronchoscopic confirmation

With a large BPF, positive pressure ventilation before lung isolation risks converting a communicating fistula into a tension pneumothorax. Inhalational induction maintaining spontaneous respiration preserves the patient's own airway pressures (which are lower) until the DLT is placed and the fistula side is isolated. Awake FOI with a DLT is also acceptable but technically demanding with a large DLT in an awake patient. RSI before isolation risks immediate barotrauma. A chest drain alone does not prevent ventilatory loss through the fistula. The left-sided DLT is chosen because right-sided DLTs have poor endobronchial fit variability and a BPF is already on the right.

Question 93: A 68-year-old patient in the ICU with septic shock is anuric and requires vasopressors to maintain a MAP of 65 mmHg. Laboratory results show severe metabolic acidosis and life-threatening hyperkalemia. Renal replacement therapy is indicated. What is the primary advantage of initiating Continuous Renal Replacement Therapy (CRRT) over intermittent hemodialysis (IHD) for this patient?

Lower anticoagulation requirement
Improved hemodynamic stability (Correct answer)
More rapid correction of hyperkalemia
Significantly lower cost and complexity

Correct answer: Improved hemodynamic stability

In hemodynamically unstable patients, such as those with septic shock on vasopressors, CRRT is generally preferred because it removes fluid and solutes slowly and continuously. [17, 25, 31] This gradual process leads to greater hemodynamic stability and avoids the large, rapid fluid shifts that can cause hypotension during intermittent hemodialysis. While IHD can correct hyperkalemia more rapidly, the risk of worsening hypotension often outweighs this benefit in unstable patients.

Question 94: Which monitoring test is most appropriate for assessing direct thrombin inhibitor (e.g., dabigatran) effect?

Prothrombin time
Bleeding time
Anti-Xa level
Ecarin clotting time or diluted thrombin time (Correct answer)

Correct answer: Ecarin clotting time or diluted thrombin time

Ecarin clotting time and diluted thrombin time most reliably reflect dabigatran anticoagulant activity.

Question 95: A neonate born at 30 weeks gestation is now 8 weeks old and requires inguinal hernia repair. What is the postconceptional age and what does this imply?

38 weeks — still at high risk for postoperative apnea requiring monitoring (Correct answer)
44 weeks — requires ICU admission postoperatively
44 weeks — safe for day surgery without monitoring
38 weeks — can be treated as full-term for anesthesia purposes

Correct answer: 38 weeks — still at high risk for postoperative apnea requiring monitoring

At 38 weeks postconceptional age, this infant remains at significant risk for postoperative apnea and requires at least 12–24 hours of monitored observation.

Question 96: Which regional anesthesia consideration is most important when planning a brachial plexus block for AV fistula creation in a CKD patient?

Limit local anesthetic dose because of altered protein binding increasing free drug (Correct answer)
Avoid all regional techniques due to bleeding risk
Use axillary approach to avoid phrenic nerve block
Use chloroprocaine only

Correct answer: Limit local anesthetic dose because of altered protein binding increasing free drug

Hypoalbuminemia in CKD increases the free fraction of amide local anesthetics, raising the risk of systemic toxicity at standard doses.

Question 97: The administration of a pure positive inotropic agent, such as dobutamine, would cause which of the following changes on a left ventricular pressure-volume (PV) loop, assuming constant preload and afterload?

A rightward shift of the entire loop with a decreased end-systolic pressure.
An upward and leftward shift of the end-systolic pressure-volume relationship (ESPVR) line. (Correct answer)
A downward shift of the end-diastolic pressure-volume relationship (EDPVR) line.
An increase in end-systolic volume and a decrease in stroke volume.

Correct answer: An upward and leftward shift of the end-systolic pressure-volume relationship (ESPVR) line.

Positive inotropic agents increase myocardial contractility. On a PV loop, this is represented by an increase in the slope of the end-systolic pressure-volume relationship (ESPVR) and a shift of this line to the left. This means that for any given end-systolic volume, the ventricle can generate more pressure. The loop itself becomes wider (increased stroke volume) and shifts to the left (decreased end-systolic volume) as the heart ejects blood more effectively.

Question 98: A paramagnetic O₂ analyser in the inspiratory limb of a circle system reads 32% during maintenance of anaesthesia with sevoflurane in an O₂/air mixture (set FiO₂ 0.40). The agent analyser simultaneously reads sevoflurane 2.1%. The MOST likely explanation for the discrepancy in the O₂ reading is:

A leak at the paramagnetic cell causing dilution with room air inside the analyser
Preferential uptake of O₂ by the patient exceeding the O₂ delivery rate, creating a true hypoxic mixture
Paramagnetic interference from the diamagnetic properties of sevoflurane vapour at elevated concentrations (Correct answer)
Cross-sensitivity of the paramagnetic analyser to nitrous oxide contaminating the circuit

Correct answer: Paramagnetic interference from the diamagnetic properties of sevoflurane vapour at elevated concentrations

Paramagnetic O₂ analysers measure oxygen by exploiting its unique paramagnetic susceptibility (O₂ is attracted into a magnetic field). However, most volatile anaesthetic agents — including sevoflurane, isoflurane, and desflurane — are diamagnetic (weakly repelled from a magnetic field) and at clinically significant concentrations can interfere with the paramagnetic cell, causing artificially low O₂ readings. At 2.1% sevoflurane, this interference is measurable and clinically relevant. This is a known limitation of paramagnetic analysers not fully compensated by older instruments. A 10-percentage-point drop for a set FiO₂ of 0.40 would be extreme for a simple cell leak (option A). Nitrous oxide (option B) is not in the circuit. Option D would require metabolic O₂ consumption to exceed delivery, which would show on other monitors first.

Question 99: Diabetes insipidus after transsphenoidal pituitary surgery is characterized by which laboratory finding?

High serum potassium with oliguria
Low serum sodium with concentrated urine
Low serum sodium with large volumes of dilute urine
High serum sodium with large volumes of dilute urine (Correct answer)

Correct answer: High serum sodium with large volumes of dilute urine

Central diabetes insipidus causes ADH deficiency, resulting in massive production of dilute urine, volume depletion, and hypernatremia due to free water loss.

Question 100: A 44-year-old patient with a large anterior mediastinal mass (5 × 7 cm) is scheduled for mediastinoscopy under general anaesthesia. Preoperative CT shows >50% tracheal cross-sectional area compression at the level of the carina. The patient is symptomatic when supine. Which of the following is the safest induction strategy?

Inhalational induction with sevoflurane maintaining spontaneous ventilation, with the patient semi-recumbent or in lateral position, and rigid bronchoscopy on standby (Correct answer)
Standard RSI with propofol and suxamethonium in the supine position, followed by orotracheal intubation
Awake flexible bronchoscopy to assess the airway, followed by intravenous induction with ketamine and rocuronium
Femoral-femoral cardiopulmonary bypass initiated before induction of general anaesthesia in all cases with >50% tracheal compression

Correct answer: Inhalational induction with sevoflurane maintaining spontaneous ventilation, with the patient semi-recumbent or in lateral position, and rigid bronchoscopy on standby

Anterior mediastinal masses with significant (>50%) tracheal compression and positional symptoms represent one of the highest-risk scenarios in thoracic anaesthesia. Loss of spontaneous ventilation and muscle tone at induction can cause complete airway collapse (the mass compresses the trachea when thoracic muscle tone is lost), leading to 'can't intubate, can't oxygenate' cardiac arrest. The gold-standard approach is inhalational induction with sevoflurane in a semi-upright or lateral decubitus position, preserving spontaneous ventilation throughout, with rigid bronchoscopy and an experienced bronchoscopist immediately available to stent the airway open if collapse occurs. RSI abolishes spontaneous breathing and muscle tone, which is contraindicated. Awake fibreoptic intubation addresses vocal cord/upper airway issues but does not protect against tracheal or carinal collapse distal to the tube tip. Pre-bypass is reserved for cases where collapse is judged inevitable or where less invasive strategies have failed — not used routinely for all >50% compression cases.

Question 101: Which type of vaporizer is classified as 'out-of-circuit' and agent-specific, using a variable bypass design?

Tec-series (e.g., Tec 7) vaporizer (Correct answer)
Copper Kettle vaporizer
Oxford Miniature Vaporizer (OMV)
Goldman vaporizer

Correct answer: Tec-series (e.g., Tec 7) vaporizer

Tec-series vaporizers are out-of-circuit, agent-specific, variable-bypass vaporizers that split fresh gas flow between a bypass channel and a vaporizing chamber.

Question 102: A 6-week-old infant (weight 4.2 kg) with Pierre Robin sequence requires awake fibreoptic nasotracheal intubation. After topicalising the airway with lidocaine, what is the maximum safe total dose of lidocaine that should be administered, and why is this dose lower than for older children?

42 mg total; the dose per kilogram is the same as adults but absolute dose is limited by weight
21 mg total; neonates have higher volume of distribution but impaired protein binding reduces free drug clearance (Correct answer)
8.4 mg total; neonates have reduced hepatic metabolism and higher risk of systemic toxicity at lower doses
12.6 mg total; neonates have immature blood-brain barrier making CNS toxicity more likely at standard doses per kg

Correct answer: 21 mg total; neonates have higher volume of distribution but impaired protein binding reduces free drug clearance

The maximum topical lidocaine dose in neonates is approximately 3–4 mg/kg; at 4.2 kg this is ~12.6–16.8 mg. However, the pharmacokinetic rationale is critical for EDAIC purposes: neonates have reduced alpha-1-acid glycoprotein (AAG) levels, the primary plasma protein binding lidocaine. Lower protein binding means a higher fraction of free (active/toxic) drug is present at any given total plasma concentration. Additionally, hepatic microsomal enzyme systems are immature, reducing clearance. The combination means that even at doses per kg lower than adults, systemic toxicity risk is elevated. 5 mg/kg (21 mg) is closer to the adult topical limit, not appropriate here. The immature blood-brain barrier also contributes but is not the primary pharmacokinetic explanation.

Question 103: A child with Down syndrome (trisomy 21) is scheduled for elective surgery. Which preoperative assessment is MOST important from an anesthetic standpoint?

Atlantoaxial instability assessment (Correct answer)
Renal function panel
Thyroid function tests
Echocardiogram for congenital heart disease

Correct answer: Atlantoaxial instability assessment

Atlantoaxial instability occurs in 10–20% of children with Down syndrome and poses a risk of spinal cord injury with neck manipulation during intubation.

Question 104: Which ultrasound finding confirms correct needle placement for an adductor canal block?

Posterior spread around the popliteal vessels
Local anesthetic spread surrounding the femoral artery in the femoral triangle
Local anesthetic spread surrounding the saphenous nerve between the sartorius and adductor longus muscles (Correct answer)
Medial spread of local anesthetic around the sciatic nerve

Correct answer: Local anesthetic spread surrounding the saphenous nerve between the sartorius and adductor longus muscles

The adductor canal contains the saphenous nerve alongside the superficial femoral artery deep to the sartorius muscle; correct placement shows LA spreading around these structures.

Question 105: A 58-year-old with diabetic nephropathy (eGFR 18 mL/min) requires lower limb revascularization. Postoperative potassium rises to 6.8 mEq/L with ECG changes. What is the MOST immediate treatment?

IV calcium gluconate 10 mL of 10% solution (Correct answer)
IV sodium bicarbonate 50 mEq
Salbutamol 10-20 mg nebulized
Insulin 10 units IV with 50 mL 50% dextrose

Correct answer: IV calcium gluconate 10 mL of 10% solution

IV calcium gluconate is the most immediate treatment for hyperkalemia with ECG changes as it stabilizes the myocardial membrane within 1-3 minutes, though it does not lower serum potassium.

Question 106: Near-infrared spectroscopy (NIRS) monitors cerebral oxygenation in which vascular territory?

Predominantly arterial (70% arterial, 30% venous)
Equal arterial and venous contributions
Pure arterial capillary bed only
Predominantly venous (25% arterial, 75% venous) (Correct answer)

Correct answer: Predominantly venous (25% arterial, 75% venous)

NIRS measures regional cerebral oxygen saturation (rSO2) in a predominantly venous (75%) compartment, reflecting overall cerebral oxygen supply-demand balance.

Question 107: A diabetic patient on metformin presents for elective surgery. Metformin should be withheld perioperatively primarily to prevent:

Hypoglycemia during fasting
Postoperative nausea and vomiting
Interaction with volatile anesthetics
Lactic acidosis if contrast or renal dysfunction occurs perioperatively (Correct answer)

Correct answer: Lactic acidosis if contrast or renal dysfunction occurs perioperatively

Metformin is associated with lactic acidosis risk when renal clearance is impaired (e.g., from contrast nephropathy, fluid shifts, or hypoperfusion) and is typically withheld 24–48 hours perioperatively.

Question 108: Which pharmacokinetic parameter changes most significantly when a drug transitions from IV to oral administration?

Volume of distribution
Clearance
Bioavailability (Correct answer)
Elimination half-life

Correct answer: Bioavailability

Bioavailability is the fraction of administered drug reaching systemic circulation and is 100% for IV but variable (often <100%) for oral due to incomplete absorption and first-pass metabolism.

Question 109: During awake craniotomy for eloquent cortex resection, a patient develops breakthrough seizure activity following cortical stimulation mapping. After irrigating with cold saline fails to terminate the seizure, which of the following is the MOST appropriate next pharmacological step that minimises interference with continued intraoperative neurophysiological monitoring?

IV levetiracetam 1500 mg
IV phenytoin 15 mg/kg
IV propofol 30–50 mg bolus (Correct answer)
IV lorazepam 2 mg

Correct answer: IV propofol 30–50 mg bolus

A small propofol bolus (30–50 mg) rapidly terminates cortical spreading seizures within seconds and has an ultra-short context-sensitive half-time, allowing the patient to return to a cooperative state within 1–2 minutes with minimal residual EEG suppression. Benzodiazepines (lorazepam) have a prolonged sedative tail that impairs further awake mapping. Phenytoin and levetiracetam act too slowly for acute intraoperative seizure termination and the loading infusion time would abort the procedure.

Question 110: Regarding the use of local anesthetics for labor epidural analgesia, which statement best describes a primary advantage of ropivacaine over bupivacaine?

It produces less motor block at equipotent analgesic concentrations. (Correct answer)
It has a significantly longer duration of action.
It is associated with a lower incidence of pruritus.
It has a much faster onset of sensory blockade.

Correct answer: It produces less motor block at equipotent analgesic concentrations.

Ropivacaine is an S-enantiomer that exhibits a greater degree of sensory-motor differentiation compared to the racemic mixture bupivacaine. This means that at concentrations providing similar levels of sensory analgesia, ropivacaine causes less profound motor blockade. This is advantageous for laboring patients, allowing for greater mobility. It also has a lower potential for cardiotoxicity. Onset and duration are generally comparable in clinical practice, and pruritus is primarily related to the use of opioids, not the local anesthetic itself.

Question 111: An anesthesiologist is performing an ultrasound-guided nerve block. They notice that the nerve, which initially appeared bright and distinct, becomes dark and difficult to see when the ultrasound probe is tilted slightly. What is the name of this ultrasound artifact?

Reverberation
Acoustic shadowing
Mirror image
Anisotropy (Correct answer)

Correct answer: Anisotropy

Anisotropy is the property of a tissue to exhibit different ultrasonic characteristics depending on the angle of insonation. [16, 19, 26, 28] Nerves and tendons are highly anisotropic, appearing brightest (hyperechoic) when the ultrasound beam is perpendicular to them and becoming dark (hypoechoic) as the angle deviates. Recognizing and correcting for anisotropy by tilting the probe is a fundamental skill in ultrasound-guided regional anesthesia.

Question 112: A patient on mechanical ventilation develops acute hypercapnia (PaCO2 increases from 40 mmHg to 65 mmHg) with associated acidosis. What are the expected direct effects on the systemic and pulmonary vasculatures?

Systemic vasoconstriction and pulmonary vasoconstriction
Systemic vasodilation and pulmonary vasoconstriction (Correct answer)
Systemic vasoconstriction and pulmonary vasodilation
Systemic vasodilation and pulmonary vasodilation

Correct answer: Systemic vasodilation and pulmonary vasoconstriction

Hypercapnic acidosis has opposing effects on the systemic and pulmonary circulations. Systemically, it causes vasodilation, which decreases afterload. In contrast, in the pulmonary vasculature, hypercapnia is a vasoconstrictor, an effect that can augment hypoxic pulmonary vasoconstriction (HPV). This response in the lungs helps to match perfusion to ventilation. The systemic effects are often counteracted by a sympathoadrenal response leading to a net increase in cardiac output, but the direct vascular effect is dilation.

Question 113: Which type of fire triangle element is represented by nitrous oxide in the context of operating room fires?

Ignition source
Fuel
Oxidizer (Correct answer)
Catalyst

Correct answer: Oxidizer

Nitrous oxide is an oxidizing agent that supports and accelerates combustion, functioning as an oxidizer in the fire triangle alongside oxygen.

Question 114: A fast-flush test of an arterial line transducer system reveals two oscillations before returning to baseline. Knowing the natural frequency is adequate, which damping coefficient (ζ) best characterises the optimal system response for arterial waveform accuracy, and why is it preferred over critical damping (ζ = 1.0)?

ζ = 0.64, because it yields a maximally flat frequency response with less than 5% overshoot (Correct answer)
ζ = 1.5, because mild overdamping protects against systolic pressure overestimation
ζ = 0.2, because maximum resonance amplification improves detection of rapid systolic upstrokes
ζ = 1.0, because critical damping eliminates all oscillation and prevents artefact

Correct answer: ζ = 0.64, because it yields a maximally flat frequency response with less than 5% overshoot

A damping coefficient of 0.64 (the Butterworth or maximally flat condition) is optimal for arterial pressure transducer systems. It provides a flat frequency response up to the system's natural frequency, limiting overshoot to <5% while preserving the high-frequency components of the arterial waveform needed for accurate systolic pressure. Critical damping (ζ = 1.0) attenuates these components and underestimates systolic pressure. Overdamping (ζ > 1.0) smooths the waveform and narrows pulse pressure. Severe underdamping (ζ < 0.4) causes resonance, exaggerating systolic peaks and producing artefactually wide pulse pressure.

Question 115: When using a double-lumen tube (DLT) for OLV, fibreoptic bronchoscopy confirms correct initial placement. After repositioning the patient from supine to lateral decubitus, SpO₂ drops and breath sounds are heard bilaterally but with wheeze. What is the MOST probable cause?

The patient has developed bronchospasm in the dependent lung
The DLT has migrated distally, with the bronchial cuff now obstructing the right upper lobe bronchus
The tracheal lumen cuff has herniated over the carina
The DLT has migrated proximally, making the bronchial cuff sit above the carina and both lumens now ventilate both lungs (Correct answer)

Correct answer: The DLT has migrated proximally, making the bronchial cuff sit above the carina and both lumens now ventilate both lungs

Repositioning from supine to lateral commonly causes proximal migration of a DLT (the tube effectively 'rides up' with gravity and neck/thorax movement). If the bronchial cuff retreats above the carina, both lumens open to both lungs — bilateral breath sounds return, but the loss of lung isolation leads to inadequate surgical conditions and the 'wheeze' may reflect carina stimulation or partial obstruction. Distal migration would cause right upper lobe obstruction (right DLT) or complete right lung exclusion (left DLT), not bilateral sounds. Cuff herniation over the carina causes complete airway obstruction, not bilateral ventilation. Bronchospasm is possible but does not explain bilateral sounds returning after previous successful isolation.

Question 116: Which test best reflects the extrinsic coagulation pathway?

Bleeding time
Prothrombin time (PT) (Correct answer)
Thrombin time (TT)
Activated partial thromboplastin time (aPTT)

Correct answer: Prothrombin time (PT)

Prothrombin time (PT) measures the extrinsic pathway (tissue factor/Factor VII) and common pathway.

Question 117: Bronchospasm during thoracic surgery is LEAST likely to respond to which intervention?

Inhaled salbutamol via the breathing circuit
Deepening volatile anesthetic depth
IV rocuronium (Correct answer)
IV ketamine

Correct answer: IV rocuronium

Neuromuscular blocking agents have no bronchodilatory effect; bronchospasm requires agents that relax airway smooth muscle via adrenergic or anti-cholinergic mechanisms.

Question 118: What is the recommended left lateral tilt angle for a term pregnant patient undergoing general anesthesia to prevent aortocaval compression?

45-60 degrees
Full lateral decubitus
15-30 degrees (Correct answer)
5-10 degrees

Correct answer: 15-30 degrees

Left lateral tilt of 15-30 degrees (typically using a wedge under the right hip) effectively displaces the gravid uterus off the aorta and inferior vena cava.

Question 119: A patient undergoing cardiac surgery has an aortic diastolic pressure of 70 mmHg and a left ventricular end-diastolic pressure (LVEDP) of 20 mmHg. What is the calculated coronary perfusion pressure (CPP) for the left ventricle?

90 mmHg
20 mmHg
70 mmHg
50 mmHg (Correct answer)

Correct answer: 50 mmHg

The left ventricle is perfused almost exclusively during diastole because the high intra-myocardial pressure during systole compresses the coronary vessels. Therefore, the coronary perfusion pressure (CPP) for the left ventricle is calculated as the difference between the aortic diastolic pressure (the driving pressure) and the left ventricular end-diastolic pressure (the back pressure or impedance to flow). CPP = Aortic Diastolic Pressure - LVEDP. In this case, CPP = 70 mmHg - 20 mmHg = 50 mmHg.

Question 120: A 29-year-old male presents with progressive ascending weakness, areflexia, and autonomic instability 3 weeks after a gastrointestinal illness. He develops acute respiratory failure requiring intubation. His CSF shows albumino-cytological dissociation. Which of the following statements about ICU management of Guillain-Barré syndrome is MOST accurate?

IVIg is preferred over plasma exchange because of superior long-term neurological outcomes at 6 months
Plasma exchange and IVIg are equally effective and should not be combined as combination therapy is no more beneficial than either alone (Correct answer)
Corticosteroids are a useful adjunct to IVIg and should be routinely added
Early tracheostomy within 48 hours of intubation is mandatory to prevent ventilator-associated pneumonia

Correct answer: Plasma exchange and IVIg are equally effective and should not be combined as combination therapy is no more beneficial than either alone

The Dutch GBS Study Group and subsequent Cochrane reviews confirm that plasma exchange (PE) and IVIg are equally effective in GBS. Crucially, combining both treatments offers no additional benefit over either alone — a common misconception. IVIg is preferred for practical reasons (easier to administer, lower risk profile) but not due to superior neurological outcomes at 6 months, which are equivalent. Corticosteroids (including IV methylprednisolone) have been shown in RCTs to be ineffective and are not recommended. Early tracheostomy timing depends on clinical trajectory (NIV trials, bulbar function, expected duration >2 weeks), not a blanket 48-hour rule.

Question 121: During massive transfusion for trauma, viscoelastic testing (ROTEM) shows: EXTEM CT 95s (normal <80s), EXTEM MCF 35mm (normal >50mm), FIBTEM MCF 6mm (normal >10mm), INTEM CT 260s (normal <240s). Which targeted intervention is MOST appropriate as the first priority?

Administer 4-factor PCC to correct the prolonged EXTEM CT
Administer fresh frozen plasma to correct both prolonged clotting times simultaneously
Administer fibrinogen concentrate or cryoprecipitate to correct FIBTEM MCF (Correct answer)
Transfuse 2 units of platelets to correct the low EXTEM MCF

Correct answer: Administer fibrinogen concentrate or cryoprecipitate to correct FIBTEM MCF

FIBTEM MCF reflects fibrinogen-dependent clot strength (platelet contribution is blocked by cytochalasin D). An FIBTEM MCF of 6mm indicates severe hypofibrinogenaemia as the primary driver. In ROTEM-guided therapy, low FIBTEM MCF is corrected first with fibrinogen concentrate (target FIBTEM MCF >10mm) before addressing platelet or factor deficits, because fibrinogen is the first coagulation factor to fall critically low during massive haemorrhage. The low EXTEM MCF in this case is predominantly fibrinogen-driven, not platelet-driven. The moderately prolonged CTs are secondary priorities.

EDAIC Part I — European Diploma in Anaesthesiology and Intensive Care

The EDAIC Part I exam assesses knowledge of basic sciences and clinical anaesthesiology through two papers of 60 multiple true/false questions each, covering pharmacology, physiology, anatomy, physics, and clinical anaesthesia.

120

Questions

180 min

Time Limit

60%

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