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

Question 1: Combined spinal-epidural (CSE) analgesia offers which advantage over epidural-only technique for labor analgesia?

Provides better sacral coverage for second stage
Faster onset of analgesia with the spinal component (Correct answer)
Lower incidence of fetal bradycardia
Eliminates need for subsequent epidural dosing

Correct answer: Faster onset of analgesia with the spinal component

The intrathecal component of CSE provides rapid-onset analgesia within minutes, compared to the 15-20 minute onset of epidural alone.

Question 2: A 6-year-old (22 kg) with a known G6PD deficiency is scheduled for tonsillectomy and adenoidectomy. Which of the following anesthetic agents carries the greatest risk of precipitating a hemolytic crisis in this patient?

Nitrous oxide 50% in oxygen
Acetaminophen 15 mg/kg IV for multimodal analgesia
Ranitidine 1 mg/kg IV for aspiration prophylaxis
Propofol infusion at 200 mcg/kg/min for TIVA (Correct answer)

Correct answer: Propofol infusion at 200 mcg/kg/min for TIVA

G6PD deficiency impairs the hexose monophosphate shunt, reducing NADPH availability and the cell's capacity to regenerate glutathione — leaving erythrocytes vulnerable to oxidative stress. Propofol (2,6-diisopropylphenol) is a known oxidative stressor to red blood cells; at infusion rates used for TIVA (particularly prolonged or high-dose), it can generate sufficient oxidative load to precipitate hemolysis in G6PD-deficient patients. Case reports of hemolytic anemia following propofol TIVA in G6PD-deficient patients exist in the literature. Nitrous oxide does not cause direct oxidative hemolysis (its risk in G6PD is not established). Ranitidine at clinical doses has not been shown to cause hemolysis. Acetaminophen in standard dosing is generally considered safe in G6PD deficiency, though historically questioned — current evidence supports its use at therapeutic doses. Of the listed options, high-dose propofol infusion presents the most clinically relevant oxidative threat.

Question 3: Which of the following best describes the effect of vasopressin (at therapeutic doses for vasoplegic shock) on systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR)?

Decreases both SVR and PVR
Increases SVR and increases PVR
Increases SVR with minimal or no effect on PVR (Correct answer)
Decreases SVR and increases PVR

Correct answer: Increases SVR with minimal or no effect on PVR

Vasopressin acts on V1 receptors in vascular smooth muscle to cause potent vasoconstriction, thereby significantly increasing systemic vascular resistance (SVR). However, its effect on the pulmonary vasculature is different. Several studies have shown that vasopressin has minimal to no vasoconstrictive effect on the pulmonary arteries, and it may even cause a relative decrease in the PVR to SVR ratio. This makes it a useful pressor in patients with right ventricular dysfunction or pulmonary hypertension where an increase in PVR would be detrimental.

Question 4: At very prolonged infusion durations (>10 hours), how does the context-sensitive half-time of remifentanil compare to that of fentanyl?

It remains dramatically shorter than fentanyl's context-sensitive half-time (Correct answer)
It equals alfentanil's context-sensitive half-time at that duration
It converges with fentanyl's context-sensitive half-time
It exceeds fentanyl's context-sensitive half-time due to accumulation of active metabolites

Correct answer: It remains dramatically shorter than fentanyl's context-sensitive half-time

Remifentanil is metabolized by non-specific plasma and tissue esterases independent of hepatic or renal function, giving it a context-sensitive half-time of approximately 3–4 minutes regardless of infusion duration. Fentanyl, by contrast, accumulates extensively in peripheral compartments, causing its context-sensitive half-time to increase dramatically (to >300 minutes) with prolonged infusions. This is a defining pharmacokinetic distinction between the two opioids.

Question 5: Which inhalational agent has the LEAST inhibitory effect on hypoxic pulmonary vasoconstriction at clinically used concentrations?

Isoflurane
Sevoflurane
Desflurane
Nitrous oxide (Correct answer)

Correct answer: Nitrous oxide

Nitrous oxide has minimal direct effect on HPV compared to the volatile halogenated agents, though it is rarely used alone in thoracic surgery.

Question 6: During tracheoesophageal fistula (TEF) repair in a neonate, which intraoperative event should prompt the anesthesiologist to check for a right-sided intubation?

Sudden deterioration of SpO2 with decreased chest rise on the left (Correct answer)
Increase in peak airway pressure with improved SpO2
Development of ST changes on ECG
Sudden decrease in ETCO2

Correct answer: Sudden deterioration of SpO2 with decreased chest rise on the left

Surgical manipulation can advance the ETT into the right mainstem bronchus; left-sided decreased breath sounds with falling SpO2 indicates endobronchial intubation.

Question 7: James Reason's 'Swiss cheese model' of accident causation is widely applied in patient safety. What does it describe?

A grading system for anaesthetic adverse events based on severity
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
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 8: During a video laryngoscopy with a hyperangulated blade, the most common reason for inability to pass the tube despite a good view is:

Excessive neck extension
Oversized endotracheal tube
Laryngospasm
Failure to align the blade angle with the tube trajectory (Correct answer)

Correct answer: Failure to align the blade angle with the tube trajectory

Hyperangulated blades provide excellent views but the acute angle often requires a stylet matched to blade curvature to navigate the tube into the trachea.

Question 9: The Pin Index Safety System (PISS) on gas cylinders is designed to:

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

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 10: Carbon dioxide retention during one-lung ventilation is best managed by:

Switching to volume-controlled ventilation exclusively
Administering sodium bicarbonate
Applying CPAP to the operative lung
Increasing respiratory rate rather than tidal volume (Correct answer)

Correct answer: Increasing respiratory rate rather than tidal volume

Increasing respiratory rate raises minute ventilation while keeping tidal volumes low, minimizing barotrauma and volutrauma during OLV.

Question 11: The WHO analgesic ladder for cancer pain recommends which sequence of analgesic approach?

Adjuvant analgesics first, escalating to opioids only if ineffective
Interventional techniques before systemic opioids
Opioids first, then adjuvants, then NSAIDs
Non-opioids → weak opioids → strong opioids, with adjuvants at each step (Correct answer)

Correct answer: Non-opioids → weak opioids → strong opioids, with adjuvants at each step

The WHO three-step ladder starts with non-opioids (Step 1), adds weak opioids for mild-to-moderate pain (Step 2), and escalates to strong opioids for moderate-to-severe pain (Step 3), with adjuvants at all steps.

Question 12: A 78-year-old male on long-term apixaban for atrial fibrillation presents to the emergency department with a life-threatening gastrointestinal bleed. He requires urgent endoscopy. Which of the following is the most appropriate agent for the immediate reversal of apixaban's anticoagulant effect?

Vitamin K
Andexanet alfa (Correct answer)
Fresh Frozen Plasma (FFP)
Prothrombin Complex Concentrate (PCC)

Correct answer: Andexanet alfa

Andexanet alfa is a recombinant modified factor Xa protein that acts as a decoy, binding to and sequestering factor Xa inhibitors like apixaban and rivaroxaban. [2, 3] This action rapidly neutralizes their anticoagulant effect. [1, 12] PCC contains factors II, VII, IX, and X, and can be used off-label, but it is not a specific antidote. Vitamin K is used to reverse warfarin and has no effect on DOACs. FFP contains all clotting factors but is not concentrated, requires large volumes, and is not a first-line reversal agent for factor Xa inhibitors. [9, 22]

Question 13: A 34-year-old woman is brought in after an intentional overdose of sustained-release verapamil (approximately 4g). She is bradycardic (HR 38 bpm), hypotensive (BP 70/40 mmHg), and has a serum glucose of 9.2 mmol/L. Atropine and calcium gluconate have been given with minimal effect. Which intervention has the strongest evidence for refractory calcium channel blocker toxicity?

Immediate transvenous pacing
IV lipid emulsion therapy 20% at 1.5 mL/kg bolus
IV glucagon 10 mg bolus followed by infusion
High-dose insulin euglycaemic therapy (HIET) at 1 unit/kg/hr with dextrose infusion (Correct answer)

Correct answer: High-dose insulin euglycaemic therapy (HIET) at 1 unit/kg/hr with dextrose infusion

High-dose insulin euglycaemic therapy (HIET) is the cornerstone of refractory calcium channel blocker toxicity management. Cardiac myocytes in CCB toxicity shift to glucose as their primary fuel; insulin facilitates this uptake and improves inotropy. The modest hyperglycaemia seen here (9.2 mmol/L) reflects toxin-mediated insulin resistance, not adequate metabolic compensation. Glucagon has theoretical benefit but poor clinical evidence and causes vomiting. Transcutaneous/transvenous pacing addresses rate but not myocardial contractility. Lipid emulsion is used for lipophilic agents like bupivacaine but has very limited evidence for verapamil specifically.

Question 14: What is the primary concern with using nitrous oxide in neonates with suspected bowel obstruction?

Cardiotoxicity in the neonatal myocardium
Impaired hypoxic pulmonary vasoconstriction
Increased risk of laryngospasm
Diffusion into air-filled spaces causing bowel distension (Correct answer)

Correct answer: Diffusion into air-filled spaces causing bowel distension

Nitrous oxide diffuses into closed air-containing spaces 30 times faster than nitrogen exits, causing distension of obstructed bowel loops and worsening the surgical field.

Question 15: 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)
Right-sided mucus plug causing lobar collapse with compensatory hyperinflation
Tension pneumothorax on the right caused by a contralateral bronchial stump leak

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 16: Which component of the anesthesia machine is responsible for reducing cylinder pressure from approximately 2000 psi to a safe working pressure of around 45 psi?

Flow control valve
Check valve
Pressure relief valve
Pressure regulator (reducing valve) (Correct answer)

Correct answer: Pressure regulator (reducing valve)

The pressure regulator (reducing valve) steps down high cylinder pressure to a safe, consistent working pressure of approximately 45 psi for use in the machine.

Question 17: A trauma patient with a Glasgow Coma Scale (GCS) of 8 requires airway management. What is the most appropriate approach?

Bag-valve-mask ventilation until CT scan
Rapid sequence intubation (RSI) (Correct answer)
Laryngeal mask airway (LMA)
Nasopharyngeal airway and observation

Correct answer: Rapid sequence intubation (RSI)

GCS ≤8 indicates inability to protect the airway and mandates definitive airway management via rapid sequence intubation in trauma patients.

Question 18: Which of the following is the strongest independent predictor of difficult bag-mask ventilation?

High Mallampati score (Class III or IV)
Limited cervical spine extension
History of obstructive sleep apnea
Presence of a beard obscuring mask seal (Correct answer)

Correct answer: Presence of a beard obscuring mask seal

A beard is one of the most significant predictors of difficult bag-mask ventilation because it prevents an adequate seal between the mask and the patient's face, regardless of other airway anatomy.

Question 19: What is the correct needle decompression site for tension pneumothorax using the second intercostal space approach?

Second ICS, anterior axillary line, above the third rib
Second ICS, midclavicular line, above the third rib (Correct answer)
Second ICS, midaxillary line, below the second rib
Second ICS, midclavicular line, below the second rib

Correct answer: Second ICS, midclavicular line, above the third rib

Needle decompression is performed at the 2nd ICS, midclavicular line, above the upper border of the third rib to avoid the neurovascular bundle.

Question 20: Levobupivacaine (S(−)-bupivacaine) exhibits reduced cardiotoxicity compared to the R(+) enantiomer. Which mechanism BEST accounts for this difference at the cardiac sodium channel level?

The S(−) enantiomer dissociates more rapidly from cardiac sodium channels during diastole (fast-in, fast-out kinetics), preventing cumulative channel blockade (Correct answer)
The S(−) enantiomer has lower lipid solubility, limiting passive diffusion into myocardial phospholipid membranes and reducing total myocardial drug burden
The S(−) enantiomer preferentially binds the inactivated state of cardiac sodium channels rather than the open state, sparing conduction during depolarisation
The S(−) enantiomer competitively antagonises calcium entry through L-type channels, counteracting the pro-arrhythmic effect of sodium channel blockade

Correct answer: The S(−) enantiomer dissociates more rapidly from cardiac sodium channels during diastole (fast-in, fast-out kinetics), preventing cumulative channel blockade

Bupivacaine blocks cardiac sodium channels in a use-dependent manner. The critical difference between enantiomers lies in dissociation kinetics: the R(+) enantiomer displays 'fast-in, slow-out' kinetics — it blocks readily but dissociates so slowly during diastole that channels accumulate in the blocked state with each successive beat, producing progressive conduction failure and ventricular dysrhythmia. The S(−) enantiomer (levobupivacaine) also blocks rapidly but dissociates substantially faster during diastole, preventing this cumulative blockade. Lipid solubility is similar between enantiomers, ruling out option A. The channel-state selectivity described in option C applies more to class Ib antiarrhythmics like lidocaine.

Question 21: Which feature of the Cormack–Lehane grade IV laryngoscopic view differentiates it from grade III?

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

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 22: A competitive antagonist shifts the agonist concentration-response curve:

Downward and to the right, reducing both Emax and EC50
To the right in a parallel fashion, without reducing Emax (Correct answer)
To the left, increasing agonist potency
Downward, reducing the maximum effect (Emax)

Correct answer: To the right in a parallel fashion, without reducing Emax

A competitive antagonist causes a parallel rightward shift of the agonist dose-response curve (increased EC50) without reducing Emax because its effect is surmountable by excess agonist.

Question 23: 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?

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

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 24: 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 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
Milrinone directly activates sinoatrial node phosphodiesterase-3 isoforms, producing more profound chronotropy than the partial β1-agonism of 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 25: 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?

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

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 26: In heparin-induced thrombocytopenia (HIT), which anticoagulant is preferred for ongoing anticoagulation?

Protamine sulfate
Low molecular weight heparin
Warfarin alone
Argatroban (Correct answer)

Correct answer: Argatroban

Argatroban is a direct thrombin inhibitor not derived from heparin and is safe to use in HIT.

Question 27: A 58-year-old patient undergoing clipping of a giant posterior communicating artery aneurysm has baseline somatosensory evoked potentials (SSEPs) recorded. Fifteen minutes after temporary clip application, the ipsilateral cortical N20 amplitude decreases by 55% with a 3 ms latency increase. The surgeon wishes to extend the temporary clip time. According to established neurophysiological warning criteria, which statement is CORRECT?

Latency change is more clinically significant than amplitude change for SSEP ischaemia alerts
Only a >50% amplitude decrease combined with >10% latency prolongation constitutes a significant alert
The changes described are within normal intraoperative variability and do not require notification
A 55% amplitude decrease alone meets the standard alert threshold requiring action (Correct answer)

Correct answer: A 55% amplitude decrease alone meets the standard alert threshold requiring action

The universally accepted SSEP warning criterion is ≥50% reduction in cortical N20 amplitude AND/OR ≥10% increase in latency compared to stable baseline. A 55% amplitude decrease alone satisfies this threshold and obligates immediate notification of the surgical team. The criterion is fulfilled by EITHER parameter, not necessarily both simultaneously. Amplitude is considered more sensitive to acute ischaemia than latency. A 55% drop is clearly outside normal variability (typically ≤10–15%).

Question 28: A parturient at 36 weeks gestation receives a combined spinal-epidural (CSE) for labor analgesia. Thirty minutes later, she develops progressive bilateral lower limb weakness, urinary retention, and a sensory block to T4. Vitals are stable and the epidural catheter was not dosed. What is the MOST likely mechanism for this presentation?

Epidural venous engorgement compressing the spinal cord causing neurological deficits
Intravascular migration of the epidural catheter causing systemic local anesthetic toxicity
Enhanced spread of intrathecal drug via the needle-through-needle technique creating a conduit for epidural drug leak into the subarachnoid space (Correct answer)
Aortocaval compression reducing spinal cord perfusion pressure

Correct answer: Enhanced spread of intrathecal drug via the needle-through-needle technique creating a conduit for epidural drug leak into the subarachnoid space

The 'epidural through spinal' or dural puncture epidural (DPE) effect is a recognized phenomenon in CSE. The dural hole created by the spinal needle acts as a conduit allowing epidural drugs to pass into the subarachnoid space, augmenting spread. Even without epidural dosing, residual intrathecal hyperbaric bupivacaine combined with fentanyl can spread further than expected, particularly in the lateral decubitus position. This high block with motor involvement and urinary retention in an undosed epidural is classic for this mechanism. LAST typically requires higher doses than seen here, and spinal cord compression would be unlikely without a space-occupying lesion.

Question 29: A parturient with severe preeclampsia requires cesarean delivery. Which antihypertensive is CONTRAINDICATED in this setting?

Nicardipine
Labetalol
Hydralazine
ACE inhibitors (Correct answer)

Correct answer: ACE inhibitors

ACE inhibitors are contraindicated in pregnancy due to fetal renal toxicity and oligohydramnios.

Question 30: Which of the following statements most accurately describes the effect of propofol on cerebral physiology?

It increases CMRO2 but decreases CBF, leading to a risk of ischemia.
It decreases both CBF and CMRO2 while preserving the coupling between them. (Correct answer)
It significantly impairs cerebral autoregulation at clinical doses.
It causes cerebral vasodilation, increasing cerebral blood flow (CBF) while decreasing the cerebral metabolic rate of oxygen (CMRO2).

Correct answer: It decreases both CBF and CMRO2 while preserving the coupling between them.

Propofol is a potent cerebral vasoconstrictor that causes a dose-dependent reduction in both cerebral blood flow (CBF) and the cerebral metabolic rate of oxygen (CMRO2). Crucially, the coupling between cerebral metabolism and blood flow is maintained, meaning that the reduction in blood flow is matched to the reduced metabolic demand, which is a desirable property in neuroanesthesia. Cerebral autoregulation is generally preserved at clinical doses.

Question 31: 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?

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

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 32: Which of the following best describes Poiseuille's law as applied to vascular resistance?

Resistance increases linearly with blood velocity
Resistance is proportional to vessel length and inversely to viscosity
Resistance is inversely proportional to the fourth power of radius (Correct answer)
Resistance is proportional to vessel radius

Correct answer: Resistance is inversely proportional to the fourth power of radius

Poiseuille's law states resistance = 8ηL/πr⁴, meaning resistance is inversely proportional to the fourth power of radius—a small change in radius causes a large change in resistance.

Question 33: During transcranial Doppler (TCD) monitoring of a patient 7 days after a subarachnoid hemorrhage, the mean flow velocity in the middle cerebral artery (MCA) is measured at 180 cm/s. The mean flow velocity in the ipsilateral extracranial internal carotid artery (ICA) is 50 cm/s. What is the most likely interpretation of these findings?

Normal cerebral blood flow
Intracranial hypertension
Severe cerebral vasospasm (Correct answer)
Cerebral hyperemia

Correct answer: Severe cerebral vasospasm

These findings are indicative of cerebral vasospasm. The high MCA velocity (>120 cm/s is suggestive, >160cm/s is moderate, and >200cm/s is severe) points to arterial narrowing. To differentiate vasospasm from hyperemia (which also increases velocity), the Lindegaard ratio (MCA velocity / ICA velocity) is calculated. In this case, 180/50 = 3.6. A Lindegaard ratio greater than 3 is consistent with vasospasm, and a ratio between 3 and 6 suggests mild-to-moderate vasospasm. Hyperemia would have a ratio less than 3.

Question 34: During posterior fossa surgery in the sitting position, which complication is most immediately life-threatening?

Peripheral nerve stretch injury
Venous air embolism (Correct answer)
Postoperative pneumocephalus
Macroglossia

Correct answer: Venous air embolism

Venous air embolism can cause cardiovascular collapse and paradoxical arterial air embolism, making it the most immediately life-threatening sitting position complication.

Question 35: A neonate born at 28 weeks gestation undergoes emergent laparotomy for necrotizing enterocolitis at 3 weeks of postnatal age. Post-operatively, what is the minimum postconceptional age at which this infant can safely be managed without mandatory apnoea monitoring?

44 weeks postconceptional age
52 weeks postconceptional age (Correct answer)
60 weeks postconceptional age
No specific threshold exists; monitoring should continue until 6 months corrected age

Correct answer: 52 weeks postconceptional age

Former premature infants are at risk for postoperative apnoea due to immature respiratory control. The widely accepted threshold is 60 weeks postconceptional age, but because this infant was born at 28 weeks and is now 31 weeks postconceptional age, the relevant clinical guidance (supported by Cote et al. meta-analysis) recommends mandatory inpatient apnoea monitoring until at least 60 weeks postconceptional age. However, the threshold most supported in EDAIC-level literature for when apnoea risk becomes acceptably low is 60 weeks. 52 weeks is actually the threshold often cited for former term or near-term infants without comorbidities. Given extreme prematurity (28 weeks) and major abdominal surgery with anaemia risk, 60 weeks is the safest and most evidence-based answer cited in European anaesthesia guidelines.

Question 36: You are anaesthetising a patient in the prone position. Your capnograph suddenly shows a decrease in ETCO₂ from 5.2 kPa to 2.1 kPa with a normal waveform shape, while SpO₂ remains 98% and airway pressures are unchanged. The MOST likely diagnosis is:

Sampling line disconnection from the airway (Correct answer)
Accidental extubation with mask ventilation maintained
Endobronchial intubation
Pulmonary embolism

Correct answer: Sampling line disconnection from the airway

A sampling line disconnection produces a sudden drop to near-zero or very low ETCO₂ with a preserved (normal morphology) waveform because the analyser is now sampling room air, which contains ~0.04% CO₂, producing a flat or minimally elevated trace. Crucially, all other parameters remain normal because ventilation and oxygenation are unaffected. Pulmonary embolism causes reduced ETCO₂ but also produces haemodynamic instability, tachycardia and the trace is typically unchanged in shape. Endobronchial intubation would increase airway pressures and reduce SpO₂. Accidental extubation would cause a loss of the capnograph trace entirely and loss of airway pressure, and would be rapidly apparent in the prone position.

Question 37: A patient with a known mediastinal mass causing 60% tracheal compression at the carina is scheduled for tissue biopsy under general anesthesia. After induction and tracheal intubation, complete airway obstruction occurs despite the ETT tip being above the carina. The MOST effective immediate maneuver is:

Change patient position to lateral decubitus and apply continuous positive airway pressure
Change patient position to prone and attempt manual chest compressions
Withdraw the ETT to a more proximal tracheal position and apply positive end-expiratory pressure
Advance the ETT past the carina into the right main bronchus (Correct answer)

Correct answer: Advance the ETT past the carina into the right main bronchus

Mediastinal masses can cause dynamic airway compression at or below the carina. When extrinsic compression occludes the distal trachea or mainstem bronchi after induction (due to loss of muscle tone and negative intrathoracic pressure), advancing the ETT past the obstruction into the right or left main bronchus can re-establish a patent airway lumen distal to the mass. Changing to lateral decubitus may help in some cases by shifting the mass, but is a slower maneuver. Prone positioning has no established benefit for acute tracheal obstruction. Withdrawing the ETT would worsen obstruction if the carina is the level of compression.

Question 38: When using a videolaryngoscope with a hyperangulated blade (e.g., C-MAC D-Blade or GlideScope) you obtain an excellent Cormack–Lehane grade 1 view, but are unable to advance the tracheal tube despite multiple attempts. Which of the following strategies is MOST evidence-based for resolving this?

Switch to a direct laryngoscope to allow standard line-of-sight tube placement
Use a less curved stylet with a reduced angle (≤60°) to better match the blade geometry
Apply BURP manoeuvre to improve the alignment between mouth, pharynx and larynx
Use a pre-shaped stylet with a ≥90° anterior bend at its distal end to match blade curvature (Correct answer)

Correct answer: Use a pre-shaped stylet with a ≥90° anterior bend at its distal end to match blade curvature

Hyperangulated videolaryngoscope blades create a 'around-the-corner' view that is paradoxically harder to intubate because the line of sight does not correspond to the axis of tube travel. The tube must be sharply pre-curved (≥90° anteriorly at the distal 4–6 cm) to follow the blade geometry. A 60° or shallower bend — appropriate for standard blades — will cause the tube to impact the anterior tracheal wall or arytenoids. BURP and direct laryngoscopy do not address the geometric mismatch inherent to hyperangulated blades. This is a common advanced airway pitfall in the EDAIC curriculum.

Question 39: 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 require mandatory financial compensation to the patient
Near misses occur less frequently than actual adverse events and are therefore more informative
Near misses are legally equivalent to adverse events in all European jurisdictions
Near misses expose system vulnerabilities before harm reaches the patient, enabling preventive system changes (Correct answer)

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 40: A 70-year-old patient with anuria due to end-stage renal disease requires neuromuscular blockade for an emergency laparotomy. Which of the following neuromuscular blocking agents would have the most significantly prolonged duration of action?

Succinylcholine
Pancuronium (Correct answer)
Cisatracurium
Atracurium

Correct answer: Pancuronium

Pancuronium is a long-acting neuromuscular blocker that is primarily cleared by the kidneys (approximately 80% renal excretion). In a patient with anuria, its clearance is drastically reduced, leading to a markedly prolonged duration of action and a risk of postoperative residual paralysis. In contrast, atracurium and cisatracurium undergo organ-independent Hofmann elimination, and succinylcholine is metabolized by plasma pseudocholinesterase, making their durations of action largely unaffected by renal failure.

Question 41: What is the initial treatment of choice for von Willebrand disease type 1 in a bleeding patient?

Factor VIII concentrate
Cryoprecipitate
Platelet transfusion
Desmopressin (DDAVP) (Correct answer)

Correct answer: Desmopressin (DDAVP)

DDAVP stimulates endothelial release of stored von Willebrand factor and is first-line for mild type 1 vWD.

Question 42: During liver transplantation, the anhepatic phase is associated with which hemodynamic change?

Hypertension from systemic vascular resistance increase
Hypotension due to inferior vena cava (IVC) occlusion and reduced venous return (Correct answer)
Tachycardia from sympathetic stimulation only
Increased cardiac output from portal hypertension relief

Correct answer: Hypotension due to inferior vena cava (IVC) occlusion and reduced venous return

Clamping the IVC during the anhepatic phase dramatically reduces venous return to the right heart, causing significant hypotension that may require venovenous bypass or careful fluid management.

Question 43: The 'context-sensitive half-time' is a critical pharmacokinetic concept for predicting recovery after an intravenous drug infusion. It is defined as the time required for:

the plasma drug concentration to decrease by 50% after stopping an infusion of a specific duration. (Correct answer)
50% of the total drug dose to be eliminated from the body.
the drug to be completely metabolized by the liver, independent of infusion time.
the drug concentration at the effect site to reach 50% of its peak.

Correct answer: the plasma drug concentration to decrease by 50% after stopping an infusion of a specific duration.

The context-sensitive half-time is the time taken for the plasma concentration of a drug to decrease by 50% after stopping an infusion of a certain duration (the 'context'). It is a more clinically useful measure than elimination half-life for infused drugs because it accounts for the redistribution of the drug from peripheral tissues back into the central compartment, which can significantly prolong the drug's effect. For many lipophilic drugs like fentanyl, the context-sensitive half-time increases with the duration of the infusion.

Question 44: A patient with TIPSS (transjugular intrahepatic portosystemic shunt) placement requires general anesthesia. What is a major hemodynamic concern unique to this patient?

Reduced splanchnic blood flow causing mesenteric ischemia under anesthesia
Severe portal hypertension requiring beta-blockade continuation intraoperatively
Increased cardiac output and right heart volume overload due to shunt flow (Correct answer)
Left-to-right cardiac shunt causing pulmonary hypertension

Correct answer: Increased cardiac output and right heart volume overload due to shunt flow

TIPSS creates a large portosystemic communication that increases venous return to the right heart, worsening the hyperdynamic circulatory state of cirrhosis and potentially precipitating right heart failure.

Question 45: Compared to a healthy adult, which of the following physiological characteristics is typical of a neonate?

Higher volume of distribution for water-soluble drugs. (Correct answer)
Functional residual capacity (FRC) is significantly larger than closing capacity (CC).
Heart rate is primarily dependent on stroke volume for cardiac output.
Lower oxygen consumption per kilogram of body weight.

Correct answer: Higher volume of distribution for water-soluble drugs.

Neonates have a significantly higher percentage of their body weight as total body water (approximately 75-80%) compared to adults (approximately 60%). This results in a larger volume of distribution (Vd) for hydrophilic (water-soluble) drugs, such as succinylcholine or non-depolarizing muscle relaxants, which may necessitate a higher initial dose on a mg/kg basis to achieve the desired effect.

Question 46: Morphine-6-glucuronide (M6G) is clinically significant because it:

Undergoes enterohepatic recirculation causing delayed sedation after oral dosing
Inhibits morphine metabolism by competitive glucuronidation
Is a more potent mu-opioid agonist than morphine and accumulates in renal failure (Correct answer)
Is pharmacologically inactive and excreted unchanged in bile

Correct answer: Is a more potent mu-opioid agonist than morphine and accumulates in renal failure

M6G is an active metabolite with greater mu-opioid receptor affinity than morphine, and it accumulates to toxic levels in renal failure due to impaired renal excretion.

Question 47: Which factor deficiency is associated with a prolonged aPTT but no clinical bleeding tendency?

Factor XII deficiency (Correct answer)
Factor IX deficiency
Factor VIII deficiency
Factor XI deficiency

Correct answer: Factor XII deficiency

Factor XII (Hageman factor) deficiency prolongs aPTT but does not cause bleeding because it is not essential for in vivo hemostasis.

Question 48: Which opioid is most appropriate for a patient with severe renal impairment requiring analgesia?

Hydromorphone
Fentanyl (Correct answer)
Morphine
Codeine

Correct answer: Fentanyl

Fentanyl has no active renally-cleared metabolites, making it the preferred opioid in renal failure; morphine-6-glucuronide accumulates in renal failure and can cause profound sedation.

Question 49: A 68-year-old patient on long-term amiodarone therapy requires urgent surgery. Intraoperatively, refractory hypotension occurs despite high-dose noradrenaline. Which pharmacokinetic and pharmacodynamic property of amiodarone MOST directly explains the catecholamine resistance?

Amiodarone saturates hepatic CYP2D6, preventing conversion of noradrenaline to its active metabolites
Amiodarone's active metabolite desethylamiodarone causes non-competitive antagonism at beta-adrenoceptors and partial alpha-adrenoceptor blockade, persisting due to the drug's extremely long half-life of 40–55 days (Correct answer)
Amiodarone blocks L-type calcium channels in vascular smooth muscle, directly antagonising vasopressor-induced vasoconstriction
Iodine load from amiodarone causes reversible hypothyroidism, reducing adrenoceptor density by 40%

Correct answer: Amiodarone's active metabolite desethylamiodarone causes non-competitive antagonism at beta-adrenoceptors and partial alpha-adrenoceptor blockade, persisting due to the drug's extremely long half-life of 40–55 days

Amiodarone and its primary active metabolite desethylamiodarone exhibit non-competitive (insurmountable) beta-blockade and partial alpha-blockade. Because amiodarone has an exceptionally long half-life (40–55 days) and large volume of distribution (60 L/kg), these adrenoceptor-blocking effects persist for weeks to months after discontinuation. This renders standard doses of catecholamines ineffective, requiring vasopressin (V1 receptor, bypassing adrenoceptors) or methylene blue (inhibits NO synthase/guanylate cyclase) as rescue vasopressors. CYP2D6 involvement, calcium channel blockade, and thyroid effects are real but not the dominant cause of acute catecholamine resistance.

Question 50: What is the recommended glucose-containing fluid strategy for neonates undergoing major surgery?

Use 5% dextrose in normal saline as the sole fluid
Use isotonic balanced crystalloid for volume replacement and a separate low-rate glucose infusion (Correct answer)
Give 10% dextrose as the primary intraoperative fluid
Avoid all glucose-containing fluids intraoperatively

Correct answer: Use isotonic balanced crystalloid for volume replacement and a separate low-rate glucose infusion

Neonates require a background glucose infusion (4–8 mg/kg/min) to prevent hypoglycemia, while isotonic fluid is used separately for deficit and blood loss replacement.

Question 51: A patient receives a drug that selectively blocks I_f (funny current) channels. What is the primary effect?

Decreased automaticity of the SA node (Correct answer)
Increased AV nodal conduction
Prolonged QT interval
Reduced ventricular contractility

Correct answer: Decreased automaticity of the SA node

I_f channels carry mixed Na+/K+ inward current responsible for pacemaker depolarization; blocking them (e.g., ivabradine) reduces SA node automaticity and heart rate.

Question 52: Macro-shock in a clinical setting refers to electrical current passing through which pathway?

Directly across the myocardium via an intracardiac catheter
Only through the brain
Through the body surface from hand to hand or hand to foot (Correct answer)
Through a single limb only

Correct answer: Through the body surface from hand to hand or hand to foot

Macro-shock is externally applied current flowing across the body surface (e.g., hand to hand), requiring relatively larger currents (>100 mA) to cause ventricular fibrillation.

Question 53: A nitrous oxide cylinder at 22°C reads 52 bar on the pressure gauge. After verified clinical use equivalent to approximately half the cylinder's content by weight, what pressure would the gauge most likely display?

Approximately 26 bar, proportional to the remaining gas volume
Approximately 38 bar, reflecting partial depletion of the liquid phase
Below 10 bar, as the critical temperature has been exceeded during use
Approximately 52 bar, essentially unchanged from the initial reading (Correct answer)

Correct answer: Approximately 52 bar, essentially unchanged from the initial reading

At 22°C, nitrous oxide is below its critical temperature of 36.5°C, so the cylinder contains a liquid–vapour equilibrium. The gauge pressure reflects the saturated vapour pressure of N₂O (~52 bar at room temperature), which remains constant as long as any liquid phase persists. Pressure only begins to fall when the liquid is nearly exhausted (roughly the last 25% of content). Consequently, the pressure gauge cannot be used to estimate remaining N₂O content — the cylinder must be weighed. This contrasts with oxygen cylinders, where all contents are gaseous at room temperature and pressure is directly proportional to remaining volume.

Question 54: The recommended tidal volume during one-lung ventilation to minimize ventilator-induced lung injury is:

10-12 mL/kg IBW
3-4 mL/kg IBW
5-6 mL/kg IBW (Correct answer)
8-10 mL/kg IBW

Correct answer: 5-6 mL/kg IBW

Current lung-protective OLV strategy uses tidal volumes of 5-6 mL/kg ideal body weight to prevent overdistension of the ventilated lung.

Question 55: A parturient with antiphospholipid syndrome on therapeutic low-molecular-weight heparin presents for delivery. When is neuraxial anesthesia safe to perform?

12 hours after prophylactic or 24 hours after therapeutic LMWH dose (Correct answer)
4 hours after the last dose
Never safe with LMWH use
Immediately after stopping LMWH

Correct answer: 12 hours after prophylactic or 24 hours after therapeutic LMWH dose

ASRA guidelines recommend waiting 12 hours after prophylactic LMWH and 24 hours after therapeutic LMWH before neuraxial procedures to minimize epidural hematoma risk.

Question 56: The Fick principle applied to hepatic drug clearance states that hepatic clearance equals:

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

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 57: Which of the following correctly describes the hypoxic pulmonary vasoconstriction (HPV) response during one-lung ventilation and its interaction with anaesthetic agents?

Propofol TIVA abolishes HPV to the same degree as equipotent concentrations of volatile agents
Volatile agents at ≤1 MAC have a clinically negligible effect on HPV compared to their benefit via bronchodilation
Almitrine bismesilate potentiates HPV in the non-ventilated lung but is no longer available in most countries due to peripheral neuropathy (Correct answer)
Hypercapnia in the non-ventilated lung selectively reverses HPV and worsens shunt fraction

Correct answer: Almitrine bismesilate potentiates HPV in the non-ventilated lung but is no longer available in most countries due to peripheral neuropathy

Almitrine bismesilate is a specific pharmacological potentiator of HPV that diverts blood flow away from the collapsed non-ventilated lung, improving V/Q matching and PaO₂ during OLV. It was used clinically in France and some European centres but was withdrawn from most markets because of dose-dependent peripheral sensory neuropathy with long-term use. This combination of mechanism and toxicity is a classic EDAIC exam point. Option A is incorrect: propofol TIVA does NOT abolish HPV (intravenous agents preserve HPV), whereas volatile agents cause dose-dependent HPV inhibition — this is the key pharmacological difference. Option B is partially correct in that ≤1 MAC volatile agents have modest HPV inhibition, but this is still clinically significant and is not 'negligible.' Option D is incorrect: hypercapnia and hypoxia both POTENTIATE HPV (not reverse it) via shared intracellular pathways.

Question 58: 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?

Direct spread of local anaesthetic to the ipsilateral lumbar paravertebral space via the erector spinae fascial plane (Correct answer)
Epidural spread through the intervertebral foramina at the thoracolumbar junction
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 59: Surgical tracheostomy is typically performed at which level of the trachea?

Immediately below the cricoid cartilage at ring 1
Between the 1st and 2nd tracheal rings
Between the 4th and 6th tracheal rings
Between the 2nd and 4th tracheal rings (Correct answer)

Correct answer: Between the 2nd and 4th tracheal rings

Surgical tracheostomy is performed between the 2nd and 4th tracheal rings to avoid damage to the cricoid cartilage (subglottic stenosis risk) while remaining within safe upper tracheal territory.

Question 60: During thoracic epidural anaesthesia for post-thoracotomy analgesia, a patient develops profound hypotension (BP 72/40 mmHg), bradycardia (HR 42 bpm), and paradoxical mydriasis (dilated pupils) 20 minutes after a bolus of 0.5% bupivacaine 8 ml through a T4–T5 epidural catheter. SpO₂ is 95% on 4 L/min O₂. What is the most likely mechanism and correct immediate treatment?

Epidural haematoma compressing the spinal cord at T4; treat with emergent MRI and neurosurgical decompression
High spinal spread to C3–C5 causing phrenic nerve block; treat with immediate endotracheal intubation and vasopressors
Intravascular injection of bupivacaine causing direct myocardial sodium-channel blockade; treat with 20% lipid emulsion IV bolus (Correct answer)
Sympathectomy from thoracic epidural block at T1–T4 abolishing cardiac accelerator fibres; treat with atropine and IV fluids

Correct answer: Intravascular injection of bupivacaine causing direct myocardial sodium-channel blockade; treat with 20% lipid emulsion IV bolus

The clinical picture — rapid onset of cardiovascular collapse with bradycardia, hypotension, and mydriasis after a bolus dose through a presumably correct epidural catheter — represents local anaesthetic systemic toxicity (LAST) from unrecognised intravascular injection of bupivacaine. Bupivacaine is particularly cardiotoxic because it blocks cardiac sodium channels in a use-dependent manner and dissociates very slowly ('fast-in, slow-out'), causing refractory arrhythmias and myocardial depression. Mydriasis (not miosis) due to sympathetic dominance is a key differentiating sign — high spinal and epidural spread cause miosis through interruption of the cervical sympathetic chain. The AAGBI/ESRA guideline treatment is immediate 20% intralipid emulsion (1.5 ml/kg bolus then infusion), vasopressors, and preparation for CPR. Option C (sympathectomy at T1–T4) could explain bradycardia and hypotension but not mydriasis, and would not produce this acute severity with a 8 ml dose at T4–T5. Option D (epidural haematoma) presents subacutely with back pain and neurological deficit, not acute cardiovascular collapse.

Question 61: A patient with severe tricuspid regurgitation undergoes thermodilution cardiac output (CO) measurement via a pulmonary artery catheter. Compared to the true cardiac output, the thermodilution result is most likely to be:

Underestimated, because recirculation of cold injectate causes the thermistor to detect a prolonged temperature drop, enlarging the area under the curve
Overestimated, because a portion of the cold injectate recirculates into the right atrium and is rewarmed before reaching the pulmonary artery thermistor (Correct answer)
Accurate, because the thermistor in the pulmonary artery integrates all forward flow regardless of regurgitation
Unmeasurable, as the temperature baseline in the pulmonary artery is unstable in severe tricuspid regurgitation

Correct answer: Overestimated, because a portion of the cold injectate recirculates into the right atrium and is rewarmed before reaching the pulmonary artery thermistor

By the Stewart-Hamilton equation, CO is inversely proportional to the area under the thermodilution temperature-time curve. In severe TR, a fraction of the cold indicator is regurgitated back into the right atrium during RV systole, where it is partially rewarmed by incoming blood before re-entering the right ventricle. The thermistor consequently detects a smaller temperature change than was actually injected, yielding a smaller area under the curve. Since CO ∝ 1/area, this produces overestimation of the true cardiac output — a clinically important error in the haemodynamic monitoring of TR patients.

Question 62: In a patient with a bronchopleural fistula requiring general anesthesia, the safest initial airway management strategy is:

Mask induction with sevoflurane to spontaneous ventilation
Rapid sequence induction with succinylcholine and immediate intubation
High-frequency jet ventilation via a rigid bronchoscope
Awake fiberoptic intubation with a double-lumen tube before induction (Correct answer)

Correct answer: Awake fiberoptic intubation with a double-lumen tube before induction

Awake intubation with a DLT isolates the fistula side before positive pressure is applied, preventing massive air leak and tension pneumothorax under anesthesia.

Question 63: Near-infrared spectroscopy (NIRS) monitors cerebral oxygenation in which vascular territory?

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

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 64: A 58-year-old male with FEV1 40% predicted requires right lower lobectomy. His predicted postoperative FEV1 is calculated to be 28% predicted. This finding suggests:

Intraoperative HFJV should be planned
The patient has a high risk and requires cardiopulmonary exercise testing (Correct answer)
No additional workup is needed if DLCO is normal
Surgery is absolutely contraindicated

Correct answer: The patient has a high risk and requires cardiopulmonary exercise testing

Predicted postoperative FEV1 <40% predicted places the patient in a high-risk category requiring further evaluation such as cardiopulmonary exercise testing to assess VO2max.

Question 65: Ketamine's unique cardiovascular stimulating properties are primarily mediated by:

Direct myocardial beta-1 agonism
Peripheral alpha-2 adrenoceptor activation
Central sympathetic nervous system stimulation (Correct answer)
Inhibition of vagal tone

Correct answer: Central sympathetic nervous system stimulation

Ketamine indirectly increases heart rate and blood pressure by stimulating central sympathetic outflow and inhibiting catecholamine reuptake, masking its direct myocardial depressant effects.

Question 66: A 45-year-old patient with cirrhosis (Child-Pugh C) has an INR of 2.9 prior to an invasive hepatic procedure. The anesthesiologist debates whether to correct the INR. Which statement most accurately reflects the haemostatic balance in decompensated cirrhosis?

The elevated INR reliably reflects a true bleeding tendency because PT/INR captures the full haemostatic axis including protein C, thrombomodulin and von Willebrand factor
The thrombocytopenia in cirrhosis is the sole determinant of haemostatic failure, making platelet transfusion the only relevant pre-procedural intervention
Cirrhotic patients have a rebalanced haemostasis with proportional reduction in both pro- and anticoagulant factors; the elevated INR overestimates bleeding risk because it does not capture concurrent reductions in Protein C and S (Correct answer)
Cirrhosis causes isolated extrinsic pathway deficiency which is accurately reflected by the PT/INR, justifying routine FFP correction before procedures

Correct answer: Cirrhotic patients have a rebalanced haemostasis with proportional reduction in both pro- and anticoagulant factors; the elevated INR overestimates bleeding risk because it does not capture concurrent reductions in Protein C and S

The concept of 'rebalanced haemostasis' in cirrhosis (Tripodi et al., NEJM 2011) is fundamental. Cirrhosis reduces both procoagulant factors (II, V, VII, IX, X) AND anticoagulant proteins (Protein C, Protein S, antithrombin). The PT/INR only measures procoagulant factor activity (calibrated against vitamin K deficiency, not liver disease) and therefore dramatically overestimates bleeding risk. Thrombin generation assays in cirrhotic plasma show near-normal or even hypercoagulable states when Protein C is added. Similarly, VWF levels rise in cirrhosis (from impaired clearance), partially compensating for thrombocytopenia. Routine FFP correction of INR in cirrhosis before procedures is not evidence-based and risks volume overload and citrate toxicity.

Question 67: Which phase of hepatic drug metabolism involves oxidation, reduction, and hydrolysis reactions via cytochrome P450 enzymes?

Phase IV
Phase I (Correct answer)
Phase III
Phase II

Correct answer: Phase I

Phase I metabolism introduces or exposes functional groups via CYP450-mediated oxidation/reduction/hydrolysis, often producing metabolites more reactive than the parent drug.

Question 68: During low-flow anaesthesia at 0.5 L/min total fresh gas flow, compound A accumulates in the breathing circuit. Which property of compound A makes it of greatest clinical concern at low flows compared to high flows?

Its conversion to trifluoromethyl vinyl ether (TFMVE), which irreversibly inhibits cytochrome P450 2E1
Its dose-dependent nephrotoxicity mediated by inorganic fluoride release from renal metabolism
Its production increases as desiccated absorbent temperature rises, and its accumulation is proportional to the ratio of circuit volume to fresh gas flow (Correct answer)
Its potent inhibition of hypoxic pulmonary vasoconstriction

Correct answer: Its production increases as desiccated absorbent temperature rises, and its accumulation is proportional to the ratio of circuit volume to fresh gas flow

Compound A (fluoromethyl-2,2-difluoro-1-(trifluoromethyl)vinyl ether) is produced from sevoflurane reacting with CO₂ absorbents, particularly when desiccated and at elevated temperature. At low flows, the ratio of rebreathed gas volume to fresh gas washout is high, causing Compound A to accumulate in the circuit rather than being diluted. Inorganic fluoride nephrotoxicity (option B) is the mechanism proposed for older agents like methoxyflurane and is not the primary concern with Compound A. Option D describes an incorrect metabolic pathway. Compound A's clinical nephrotoxicity in humans remains debated, but the mechanism of accumulation is the circuit dilution ratio.

Question 69: When a breathing system leak test is performed and the circuit cannot maintain pressure at 30 cmH2O, the FIRST corrective action should be:

Replace the entire breathing circuit immediately
Proceed with the case and monitor SpO2 closely
Increase fresh gas flow to compensate for the leak
Systematically inspect all connections, the reservoir bag, and the CO2 absorber canister seal (Correct answer)

Correct answer: Systematically inspect all connections, the reservoir bag, and the CO2 absorber canister seal

A systematic check of all connections, the bag, and the canister seal identifies the most common sites of leak before replacing components or proceeding.

Question 70: A 2-year-old, 12 kg child is undergoing an orchidopexy. A single-shot caudal block is planned for postoperative analgesia using bupivacaine 0.25%. What is the maximum recommended volume to administer without exceeding the safe dose limit?

12 mL (Correct answer)
15 mL
6 mL
18 mL

Correct answer: 12 mL

The maximum recommended safe dose for a single-shot bupivacaine block in pediatrics is generally accepted as 2.5 mg/kg. For a 12 kg child, the maximum dose is 12 kg * 2.5 mg/kg = 30 mg. The concentration of the solution is 0.25%, which is equivalent to 2.5 mg/mL. To find the maximum volume, divide the total dose by the concentration: 30 mg / 2.5 mg/mL = 12 mL.

Question 71: 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
Remain unchanged
Decrease due to reduced hepatic blood flow

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 72: A 62-year-old man with hepatic hydrothorax secondary to portal hypertension is intubated and ventilated post-hepatic resection. He develops acute hypoxaemia (PaO2/FiO2 ratio 180 mmHg) and increasing right pleural effusion. His hepatic venous pressure gradient (HVPG) is 18 mmHg. Which statement about ventilatory management is MOST accurate?

Permissive hypercapnia should be avoided because CO2 causes hepatic arterial vasoconstriction, reducing hepatic blood flow
High PEEP (12–15 cmH2O) should be applied immediately to recruit alveoli and improve oxygenation
PEEP >8 cmH2O may increase hepatic venous outflow resistance, worsen portal hypertension and accelerate hepatic hydrothorax re-accumulation (Correct answer)
Non-invasive positive pressure ventilation is preferable to invasive ventilation to avoid the hepatic haemodynamic effects of positive pressure

Correct answer: PEEP >8 cmH2O may increase hepatic venous outflow resistance, worsen portal hypertension and accelerate hepatic hydrothorax re-accumulation

In portal hypertension with hepatic hydrothorax, high PEEP elevates intrathoracic pressure, which transmits to the hepatic veins, increasing hepatic venous outflow resistance. This raises the sinusoidal pressure, worsens portal hypertension, increases transudation across the diaphragmatic defect, and accelerates re-accumulation of the hepatic hydrothorax. PEEP should be titrated to the minimum required for adequate oxygenation. Permissive hypercapnia, while generally well tolerated, can cause splanchnic vasodilation (not vasoconstriction) and actually increases portal flow, but this is a secondary concern. NIPPV is contraindicated in this post-operative scenario with active hypoxaemia and is not superior to invasive ventilation for the hepatic haemodynamic reasons cited.

Question 73: During a prolonged ICU infusion of midazolam, context-sensitive half-time increases dramatically compared to a brief bolus dose. Which mechanism BEST explains why context-sensitive half-time for midazolam diverges so markedly from its elimination half-life in this scenario?

Midazolam undergoes enterohepatic recirculation that slows its apparent elimination
Extensive redistribution into peripheral fat compartments creates a large tissue reservoir that sustains plasma concentrations after the infusion ends (Correct answer)
Midazolam saturates hepatic CYP3A4 enzymes at high infusion rates, switching to zero-order kinetics
Active metabolite 1-hydroxymidazolam accumulates in renal failure and competes for the same receptor

Correct answer: Extensive redistribution into peripheral fat compartments creates a large tissue reservoir that sustains plasma concentrations after the infusion ends

Context-sensitive half-time is the time for plasma concentration to fall 50% after stopping an infusion of defined duration. Midazolam is highly lipophilic with a large volume of distribution (~3.4 L/kg). During prolonged infusion, peripheral adipose tissue becomes saturated; when the infusion stops, drug redistributes back from fat into plasma, maintaining concentrations and extending the effective half-time far beyond what the elimination half-life alone would predict. CYP3A4 saturation is not a clinically significant mechanism at therapeutic doses.

Question 74: Which of the following is considered the most serious, albeit infrequent, major complication associated with mediastinoscopy?

Major hemorrhage (Correct answer)
Tracheal compression
Pneumothorax
Recurrent laryngeal nerve injury

Correct answer: Major hemorrhage

While all the options are known complications of mediastinoscopy, major hemorrhage is the most serious and potentially fatal. It can occur from injury to the great vessels, such as the innominate artery, superior vena cava, or pulmonary artery, and may require immediate sternotomy for control. Although its incidence is low (around 0.4%), its severity makes it the most feared major complication.

Question 75: Remifentanil is administered by weight-corrected infusion at 0.25 mcg/kg/min to an obese patient (BMI 48, total body weight 145 kg, lean body weight 75 kg). Compared to dosing on lean body weight, dosing on total body weight is MOST likely to result in:

Equivalent effect because remifentanil's large volume of distribution proportionally increases with adipose tissue
Equivalent effect because cytochrome P450 enzymes in adipose tissue metabolize the excess remifentanil
Overdose causing respiratory depression because remifentanil's clearance by non-specific plasma esterases does not scale with excess adipose tissue, while dose scales linearly with total body weight (Correct answer)
Underdose because adipose tissue acts as a pharmacokinetic reservoir rapidly sequestering remifentanil

Correct answer: Overdose causing respiratory depression because remifentanil's clearance by non-specific plasma esterases does not scale with excess adipose tissue, while dose scales linearly with total body weight

Remifentanil is metabolized by non-specific plasma and tissue esterases. Its clearance correlates with lean body mass, not total body weight, because excess adipose tissue contributes minimal additional esterase activity. Its volume of distribution is also relatively small and does not expand proportionally with obesity. Therefore, dosing on total body weight in obese patients administers proportionally more drug than can be cleared, leading to dose-dependent opioid toxicity. Guidelines recommend using lean body weight (or adjusted body weight) for remifentanil infusion calculations in obese patients.

Question 76: 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?

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

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 77: In a patient with suspected carbon monoxide poisoning, what is the most appropriate initial oxygen therapy?

Bilevel positive airway pressure (BiPAP)
Nasal cannula at 2L/min
Venturi mask at 28%
100% oxygen via non-rebreather mask (Correct answer)

Correct answer: 100% oxygen via non-rebreather mask

100% oxygen via non-rebreather mask reduces the half-life of carboxyhemoglobin from ~5 hours to ~60-90 minutes.

Question 78: 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
Transfuse 2 units of platelets to correct the low EXTEM MCF
Administer fresh frozen plasma to correct both prolonged clotting times simultaneously
Administer fibrinogen concentrate or cryoprecipitate to correct FIBTEM MCF (Correct answer)

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.

Question 79: Which statement about the oil:gas partition coefficient of volatile anesthetics is correct?

Higher oil:gas coefficient indicates greater lipid solubility and lower MAC (Correct answer)
Oil:gas coefficient determines speed of onset more than blood:gas coefficient
The oil:gas coefficient predicts hepatic metabolism rate
Higher oil:gas coefficient correlates with lower potency (higher MAC)

Correct answer: Higher oil:gas coefficient indicates greater lipid solubility and lower MAC

Higher oil:gas partition coefficient indicates greater lipid solubility and thus higher potency, corresponding with a lower MAC value (Meyer-Overton correlation).

Question 80: Infrared absorption spectroscopy in anaesthetic gas analysers is based on the principle that:

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

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 81: Which reversal agent is indicated for life-threatening bleeding in a patient on rivaroxaban?

Vitamin K
Andexanet alfa (Correct answer)
Protamine sulfate
Idarucizumab

Correct answer: Andexanet alfa

Andexanet alfa is the specific reversal agent for Factor Xa inhibitors including rivaroxaban and apixaban.

Question 82: Which inhalational anesthetic is MOST associated with fluoride-mediated nephrotoxicity, particularly after prolonged exposure or in patients with pre-existing renal disease?

Methoxyflurane (Correct answer)
Desflurane
Sevoflurane
Isoflurane

Correct answer: Methoxyflurane

Methoxyflurane undergoes extensive hepatic defluorination producing serum fluoride concentrations above the nephrotoxic threshold (>50 µmol/L), historically causing high-output renal failure; sevoflurane's defluorination is modest and renal impact minimal.

Question 83: An awake craniotomy for left temporal glioma resection is proceeding under dexmedetomidine sedation. During language mapping, the patient becomes acutely dysphasic and develops focal clonic movements of the right hand consistent with cortical spreading seizure. Propofol 50 mg IV terminates the seizure. However, 20 minutes later the patient is fully awake but refuses to cooperate with language testing, stating 'I don't want to do this anymore.' Which is the MOST appropriate next step?

Administer midazolam 1–2 mg IV to reduce anxiety and resume testing
Apply direct cortical cold Ringer's lactate irrigation to the exposed cortex to abort residual hyperexcitability before retesting
Convert to general anaesthesia with an LMA and complete resection without mapping
Pause resection, allow a minimum 10-minute recovery period, then reattempt testing with simplified tasks (Correct answer)

Correct answer: Pause resection, allow a minimum 10-minute recovery period, then reattempt testing with simplified tasks

After a cortical spreading seizure and propofol rescue, the cortex undergoes a refractory period during which mapping is unreliable (false positives are common). Best practice is to pause resection for at least 10 minutes, allow the patient to recover fully, and reattempt with simplified, validated language tasks (e.g., object naming before sentence completion). Midazolam (A) will impair cortical function and invalidate mapping. Converting to GA (B) eliminates the key safety feature of the procedure. Cold irrigation (D) has evidence for aborting intraoperative seizure activity but does not address the patient's psychological distress or the cortical refractory period, and is not the priority at this point.

Question 84: Levosimendan improves cardiac contractility primarily by:

Sensitizing troponin C to calcium (Correct answer)
Activating beta-1 adrenoceptors
Inhibiting phosphodiesterase III
Blocking potassium channels

Correct answer: Sensitizing troponin C to calcium

Levosimendan binds to troponin C and stabilizes the calcium-troponin C complex, increasing myofilament calcium sensitivity without raising intracellular calcium.

Question 85: A 34-year-old woman on direct oral anticoagulants (DOAC) — specifically dabigatran — presents with life-threatening intracranial haemorrhage. Idarucizumab is not immediately available. Which alternative haemostatic strategy has the strongest evidence in this scenario?

4-factor PCC 50 IU/kg, which reverses dabigatran by providing a substrate excess of thrombin-generating factors that overwhelm direct thrombin inhibition
Activated charcoal to reduce further gastrointestinal absorption of dabigatran, combined with haemodialysis given dabigatran's low protein binding and renal clearance (Correct answer)
Recombinant factor VIIa (rFVIIa) 90 mcg/kg, which bypasses thrombin inhibition by directly activating factor X on the platelet surface
Fresh frozen plasma (FFP) 15 mL/kg, as it replenishes all coagulation factors consumed by dabigatran's thrombin inhibition

Correct answer: Activated charcoal to reduce further gastrointestinal absorption of dabigatran, combined with haemodialysis given dabigatran's low protein binding and renal clearance

Dabigatran is unique among DOACs in having low plasma protein binding (~35%) and predominantly renal elimination (80%). This pharmacokinetic profile makes haemodialysis a genuinely effective reversal strategy — it removes approximately 60% of dabigatran within 2–3 hours. Activated charcoal is useful within 1–2 hours of ingestion to limit further absorption. FFP has no direct reversal effect on direct thrombin inhibitors and is not recommended. 4-factor PCC has weaker evidence for dabigatran compared to factor Xa inhibitors; it does not directly neutralise thrombin inhibition and carries thrombotic risk. rFVIIa similarly does not reverse dabigatran and carries high thrombotic risk. When idarucizumab is unavailable, dialysis is the most evidence-supported alternative for dabigatran specifically.

Question 86: In a spontaneously breathing patient in shock, inferior vena cava (IVC) diameter is 10 mm and collapses > 50% with inspiration on subcostal ultrasound view. What is the most appropriate interpretation?

Cardiac tamponade; pericardiocentesis is needed
Fluid overload; diuresis is indicated
Pulmonary hypertension
Low right atrial pressure, suggesting likely fluid responsiveness (Correct answer)

Correct answer: Low right atrial pressure, suggesting likely fluid responsiveness

In a spontaneously breathing patient, an IVC diameter < 21 mm with > 50% inspiratory collapse correlates with low right atrial pressure (≤ 5 mmHg) and suggests the patient is likely to respond to fluid administration. This finding should be integrated with other clinical parameters; IVC assessment is less reliable in ventilated patients (where expiratory distensibility index is used instead).

Question 87: Propofol's mechanism of action primarily involves:

Opioid receptor agonism
NMDA receptor antagonism
Alpha-2 adrenoceptor agonism
Positive allosteric modulation of GABA-A receptors (Correct answer)

Correct answer: Positive allosteric modulation of GABA-A receptors

Propofol enhances inhibitory chloride currents by binding to GABA-A receptors at a site distinct from benzodiazepines, potentiating GABAergic neurotransmission.

Question 88: The 'duty of candour' in anaesthetic practice requires a clinician to do which of the following when an intraoperative complication affects a patient?

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

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 89: During inhalational induction in a 6-week-old neonate, severe laryngospasm develops. After 30 seconds of jaw thrust and CPAP without resolution, SpO₂ falls to 72%. Which is the most appropriate immediate pharmacological intervention?

Intravenous atropine 20 mcg/kg to reduce secretions and break the spasm reflex
Intravenous rocuronium 0.6 mg/kg as the preferred muscle relaxant due to lower bradycardia risk
Intravenous propofol 1 mg/kg to deepen anaesthesia and relax the larynx
Intravenous succinylcholine 2 mg/kg or intramuscular succinylcholine 4 mg/kg if IV access is absent (Correct answer)

Correct answer: Intravenous succinylcholine 2 mg/kg or intramuscular succinylcholine 4 mg/kg if IV access is absent

In life-threatening laryngospasm with failed CPAP/jaw thrust and rapidly falling SpO₂, succinylcholine remains the agent of choice due to its rapid onset (30–60 seconds IV). The neonatal/infant IV dose is 2 mg/kg (higher than adults due to larger volume of distribution). When IV access is absent, IM succinylcholine 4 mg/kg achieves adequate relaxation within 60–90 seconds. Rocuronium 1.2 mg/kg is an alternative if sugammadex is immediately available, but 0.6 mg/kg is insufficient for emergency intubating conditions. Propofol may worsen haemodynamic instability and has slower laryngeal relaxation.

Question 90: 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:

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

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 91: What is the target fibrinogen level in massive hemorrhage according to current guidelines?

Above 1.0 g/L
Above 3.0 g/L
Above 0.5 g/L
Above 1.5–2.0 g/L (Correct answer)

Correct answer: Above 1.5–2.0 g/L

Guidelines recommend maintaining fibrinogen above 1.5–2.0 g/L during active massive hemorrhage.

Question 92: A patient with severe aortic stenosis undergoes spinal anaesthesia. Despite a 1.5 L crystalloid pre-load, blood pressure drops to 70/40 mmHg. Phenylephrine is given but cardiac output falls further. Which physiological explanation best accounts for this deterioration?

Phenylephrine caused reflex bradycardia, reducing diastolic filling time and worsening subendocardial ischaemia in the hypertrophied ventricle (Correct answer)
Phenylephrine's pure α1-agonism increased SVR, reducing the pressure gradient across the fixed stenotic valve and critically reducing stroke volume
Phenylephrine precipitated coronary vasospasm by stimulating α1-receptors on epicardial coronary vessels
Spinal-induced venodilation reduced preload below the steep portion of the Frank-Starling curve in a non-compliant ventricle

Correct answer: Phenylephrine caused reflex bradycardia, reducing diastolic filling time and worsening subendocardial ischaemia in the hypertrophied ventricle

In severe aortic stenosis, the left ventricle is concentrically hypertrophied and heavily dependent on heart rate for cardiac output (CO = HR × SV). Phenylephrine's pure α1-agonism reliably causes baroreceptor-mediated reflex bradycardia. In a fixed-output state with a stiff, non-compliant ventricle, the resulting bradycardia dramatically reduces CO. Additionally, slower heart rate prolongs systole proportionally more than diastole at lower rates, impairing subendocardial perfusion in a hypertrophied myocardium with elevated end-diastolic pressure. Ephedrine or metaraminol (which preserve or increase HR) are preferred vasopressors in this context.

Question 93: Nitroglycerin at low doses primarily reduces preload by:

Coronary artery dilation increasing supply
Venodilation reducing venous return and LVEDP (Correct answer)
Arterial vasodilation reducing SVR
Negative chronotropy reducing filling time

Correct answer: Venodilation reducing venous return and LVEDP

At low doses, nitroglycerin predominantly dilates veins, pooling blood in the venous capacitance system, reducing venous return and cardiac preload.

Question 94: The hepatic artery supplies approximately what percentage of total hepatic blood flow?

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

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 95: In a patient with aortic stenosis, which hemodynamic pattern is expected?

Low SVR, high CO
High transaortic gradient, concentric LV hypertrophy (Correct answer)
High LVEDP, low transaortic gradient
Low LVEDP, dilated LV

Correct answer: High transaortic gradient, concentric LV hypertrophy

Severe aortic stenosis creates a high pressure gradient across the valve and leads to concentric left ventricular hypertrophy from chronic pressure overload.

Question 96: Drug protein binding primarily affects pharmacokinetics by influencing:

Renal tubular secretion rate
Gut wall metabolism
The free (unbound) fraction available for distribution, metabolism, and effect (Correct answer)
Intrinsic hepatic clearance only

Correct answer: The free (unbound) fraction available for distribution, metabolism, and effect

Only the free (unbound) fraction of a drug can cross membranes, interact with receptors, undergo metabolism, and be filtered by the glomerulus.

Question 97: The Mallampati classification is used to predict difficulty with which aspect of airway management?

Laryngoscopy and intubation (Correct answer)
Cricothyrotomy
Nasotracheal intubation
Mask ventilation

Correct answer: Laryngoscopy and intubation

Mallampati scoring assesses oropharyngeal visibility to predict the likelihood of difficult direct laryngoscopy and intubation.

Question 98: Which monitoring test is most appropriate for assessing direct thrombin inhibitor (e.g., dabigatran) effect?

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

Correct answer: Ecarin clotting time or diluted thrombin time

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

Question 99: Which regional anesthesia consideration is most important when planning a brachial plexus block for AV fistula creation in a CKD patient?

Use axillary approach to avoid phrenic nerve block
Limit local anesthetic dose because of altered protein binding increasing free drug (Correct answer)
Avoid all regional techniques due to bleeding risk
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 100: Which finding on arterial blood gas analysis is most consistent with acute cyanide poisoning?

Metabolic acidosis with high venous oxygen saturation (Correct answer)
Metabolic alkalosis with normal lactate
Respiratory alkalosis with low PaCO2
Respiratory acidosis with hypoxemia

Correct answer: Metabolic acidosis with high venous oxygen saturation

Cyanide inhibits cytochrome c oxidase, blocking cellular oxygen utilization, causing lactic acidosis with paradoxically high venous PO2 as cells cannot extract oxygen.

Question 101: Which drug reduces the incidence of cerebral vasospasm after subarachnoid hemorrhage and is given for 21 days?

Diltiazem
Verapamil
Amlodipine
Nimodipine (Correct answer)

Correct answer: Nimodipine

Oral nimodipine (60 mg every 4 hours for 21 days) is the only proven pharmacological intervention to reduce neurological deficits from vasospasm after SAH.

Question 102: 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?

Doubling the height of the IV bag above the patient.
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 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 103: In a child with pulmonary hypertension undergoing cardiac catheterization, which intraoperative trigger should be MOST aggressively avoided?

Hypothermia below 35°C
Dexmedetomidine infusion
Inhalation induction with sevoflurane
Hypercapnia and acidosis (Correct answer)

Correct answer: Hypercapnia and acidosis

Hypercapnia and acidosis are potent pulmonary vasoconstrictors that can precipitate acute right ventricular failure in children with pulmonary hypertension.

Question 104: A patient with a known phaeochromocytoma is undergoing laparoscopic adrenalectomy. Despite adequate pre-operative alpha-blockade with phenoxybenzamine for 3 weeks, intraoperative insufflation of the abdomen triggers a hypertensive crisis with MAP rising to 165 mmHg and new ST-segment depression in V4-V5. Which agent is the most appropriate immediate treatment?

Intravenous labetalol 20 mg boluses titrated to effect
Intravenous phentolamine 2–5 mg boluses repeated as needed (Correct answer)
Intravenous sodium nitroprusside infusion titrated to MAP 70–80 mmHg
Intravenous esmolol infusion to control heart rate and reduce myocardial oxygen demand

Correct answer: Intravenous phentolamine 2–5 mg boluses repeated as needed

Phentolamine is a short-acting, competitive, non-selective alpha-adrenoceptor antagonist and is the agent of choice for intraoperative hypertensive crises from catecholamine excess. Its rapid onset and short duration allow precise titration during tumour manipulation. Sodium nitroprusside can be used but carries risks of cyanide toxicity with prolonged use and causes reflex tachycardia, worsening myocardial ischaemia. Labetalol is contraindicated in phaeochromocytoma when alpha-blockade is incomplete because its beta-blocking component can unmask unopposed alpha-receptor stimulation, precipitating further hypertension. Esmolol alone does not address the catecholamine-driven vasoconstriction and similarly risks worsening hypertension.

Question 105: A patient receives a large-volume peripheral nerve block for shoulder surgery. Shortly after the injection, the patient becomes agitated, reports tinnitus and a metallic taste, and then has a generalized tonic-clonic seizure. Of the following local anesthetics, which one is associated with the highest risk of severe cardiovascular collapse in this setting?

Mepivacaine
Lidocaine
Bupivacaine (Correct answer)
Ropivacaine

Correct answer: Bupivacaine

Bupivacaine is the most cardiotoxic of the commonly used long-acting amide local anesthetics. It has a high affinity for and slow dissociation from cardiac sodium channels, which can lead to severe, refractory arrhythmias and myocardial depression in the event of Local Anesthetic Systemic Toxicity (LAST). Ropivacaine, the S-enantiomer of bupivacaine, was developed to have a lower propensity for cardiotoxicity. [7, 10, 11, 21]

Question 106: A diabetic patient on metformin presents for elective surgery. Metformin should be withheld perioperatively primarily to prevent:

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

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

Sevoflurane
Halothane (Correct answer)
Isoflurane
Desflurane

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 108: The erector spinae plane (ESP) block deposits local anesthetic in which anatomical location?

Between the internal intercostal membrane and the parietal pleura
Within the paravertebral space
Within the epidural space via paramedian approach
Between the erector spinae muscle and the transverse process (Correct answer)

Correct answer: Between the erector spinae muscle and the transverse process

The ESP block injects local anesthetic into the fascial plane between the erector spinae muscles (multifidus/longissimus) and the tip of the transverse process, where it can spread to block dorsal and ventral rami.

Question 109: During posterior fossa surgery in the sitting position, a sudden increase in end-tidal CO2 from 35 to 28 mmHg, a 15% drop in ETCO2, a mill-wheel murmur on precordial Doppler, and a drop in SpO2 to 90% occur simultaneously. Transesophageal echocardiography reveals air in the right ventricle. Which sequence of interventions is MOST appropriate?

Nitrous oxide discontinuation only, as small VAE is self-limiting in sitting position
Immediately convert to supine position → 100% FiO2 → cardiac massage → adrenaline 1 mg IV
Aspirate air via central venous catheter → PEEP 10 cmH2O → notify surgeon → maintain sitting position
Flood surgical field with saline → compress jugular veins → aspirate air via central venous catheter → left lateral Trendelenburg position (Correct answer)

Correct answer: Flood surgical field with saline → compress jugular veins → aspirate air via central venous catheter → left lateral Trendelenburg position

Management of significant venous air embolism (VAE) follows a stepwise approach: (1) Flood the surgical field to stop air entrainment; (2) Compress jugular veins bilaterally (raises venous pressure, reducing air entry); (3) Aspirate via a right atrial/CVP catheter (positioned at the RA–SVC junction) to remove entrained air; (4) Place in left lateral Trendelenburg to trap air in the right ventricle apex and prevent RV outflow obstruction. Supine conversion with CPR is reserved for cardiovascular collapse. PEEP alone cannot remove air. Discontinuing N2O (if used) is correct but insufficient alone. The scenario describes haemodynamically significant VAE requiring active intervention.

Question 110: Emotional trauma is best described as a psychological response to a deeply distressing or life-threatening experience.

TRUE (Correct answer)
FALSE

Correct answer: TRUE

The term "trauma" can be used in several different ways when referring to medical cases. Physical trauma occurs as the result of an outside force against your body (car accident, fall, gunshot wound, etc.). Emotional or psychiatric trauma can result from physical trauma or as the consequence of witnessing or experiencing a severely distressing event.

Question 111: During anaesthesia for a living-donor kidney transplant recipient, the patient develops oliguria immediately after reperfusion of the graft. Mean arterial pressure is 75 mmHg, CVP is 12 mmHg, and urine output was brisk prior to clamp release. Intraoperative fluid balance is +2.8 L crystalloid. Which intervention is MOST likely to restore graft perfusion in this scenario?

Insert a pulmonary artery catheter to assess cardiac output before further intervention
Start low-dose dopamine (2 µg/kg/min) for renal-selective vasodilation
Administer an intravenous bolus of 500 mL colloid to increase preload
Administer mannitol 0.5 g/kg IV and increase MAP to ≥85 mmHg with norepinephrine (Correct answer)

Correct answer: Administer mannitol 0.5 g/kg IV and increase MAP to ≥85 mmHg with norepinephrine

Reperfusion oliguria after kidney transplantation in a euvolaemic patient (CVP 12, +2.8 L balance) suggests renal arterial vasospasm and ischaemia-reperfusion injury rather than hypovolaemia. Mannitol acts as an osmotic diuretic and free-radical scavenger, protecting the tubular cells, while targeting MAP ≥85 mmHg with vasopressors ensures adequate perfusion pressure across the renal vascular bed. Low-dose dopamine has been disproven as a renoprotective strategy in multiple RCTs. Further volume loading in an already replete patient risks pulmonary oedema. A PAC insertion delays treatment unnecessarily.

Question 112: In a patient with a Glasgow Coma Scale (GCS) of 7 following head trauma, which airway management decision is most appropriate?

Rapid sequence intubation with cricoid pressure (Correct answer)
Nasopharyngeal airway insertion and supplemental oxygen
Supraglottic airway device placement
Bag-mask ventilation until CT scan results available

Correct answer: Rapid sequence intubation with cricoid pressure

GCS ≤8 indicates inability to protect the airway; RSI with cricoid pressure (modified if basal skull fracture suspected) provides definitive airway control.

Question 113: A patient's invasive arterial blood pressure waveform displays a high systolic peak with a narrow anacrotic limb and several oscillations following the dicrotic notch. The mean arterial pressure is likely accurate. Which of the following best describes this phenomenon and its most common cause?

Overdamping, caused by an air bubble in the tubing.
Electromagnetic interference, caused by the use of surgical diathermy.
Signal aliasing, caused by a low sampling rate of the monitor.
Underdamping, caused by excessive tubing length or stiff tubing. (Correct answer)

Correct answer: Underdamping, caused by excessive tubing length or stiff tubing.

The described waveform, characterized by systolic pressure overshoot and multiple oscillations after the dicrotic notch, is a classic sign of an underdamped system. Underdamping occurs when there is insufficient resistance to dampen the natural oscillations of the measurement system. This leads to resonance, which exaggerates the pressure peaks. Common causes include the use of stiff, non-compliant tubing, excessive tubing length, or cannulas that are too narrow. Overdamping, often caused by air bubbles or clots, would result in a blunted waveform with a slurred upstroke and an underestimated systolic pressure.

Question 114: During one-lung ventilation (OLV) for a left pneumonectomy, the patient's SpO₂ drops to 88% despite FiO₂ 1.0 and PEEP 5 cmH₂O to the dependent lung. Fibreoptic bronchoscopy confirms correct DLT position. Which intervention is most likely to improve oxygenation with the least haemodynamic compromise?

Apply continuous positive airway pressure (CPAP) of 5 cmH₂O to the non-dependent (operative) lung
Switch to high-frequency jet ventilation of the non-dependent lung
Request surgical clamping of the pulmonary artery on the operative side (Correct answer)
Increase tidal volume of the ventilated lung to 10 ml/kg IBW

Correct answer: Request surgical clamping of the pulmonary artery on the operative side

During pneumonectomy, early surgical ligation or clamping of the ipsilateral pulmonary artery eliminates blood flow to the non-ventilated lung, abolishing the intrapulmonary shunt (Qs/Qt) that is causing hypoxaemia. This is the most definitive and haemodynamically well-tolerated manoeuvre at this stage of the procedure. CPAP to the operative lung (Option A) is the first-line intervention in lobectomy/non-resection thoracic cases but cannot be used once the chest is open and the lung is collapsed for pneumonectomy without obstructing the surgical field; moreover it may not be feasible with an open pleura. Increasing tidal volume risks ventilator-induced lung injury (VILI) and worsens hypercapnia without reliably improving oxygenation when shunt fraction is very high. High-frequency jet ventilation of the non-dependent lung would re-expand it, conflicting with the surgical field.

Question 115: A patient with acute fulminant hepatic failure (King's College criteria met, transplant pending) is receiving rapid massive transfusion at a rate of 1 unit of packed red blood cells every 10 minutes for variceal haemorrhage. Which parameter most reliably identifies clinically significant citrate toxicity in this context?

Ionised calcium (iCa²⁺) below 0.9 mmol/L accompanied by cardiovascular depression (hypotension, reduced cardiac contractility, or new arrhythmia) (Correct answer)
Total serum calcium below 2.0 mmol/L
Rising prothrombin time despite ongoing FFP administration
Prolongation of the QTc interval beyond 500 ms on continuous ECG monitoring

Correct answer: Ionised calcium (iCa²⁺) below 0.9 mmol/L accompanied by cardiovascular depression (hypotension, reduced cardiac contractility, or new arrhythmia)

Citrate, the anticoagulant preservative in blood products, chelates free ionised calcium. In healthy patients, the liver rapidly metabolises citrate; however, in acute liver failure, citrate clearance is severely impaired, leading to accumulation. Total serum calcium (option A) is unreliable because the majority is protein-bound and does not reflect bioavailable calcium — a patient may have a normal total calcium yet critical ionised hypocalcaemia. The iCa²⁺ is the physiologically active fraction; values below 0.9 mmol/L cause reduced myocardial contractility, vasodilation, prolonged QT, and coagulopathy. Cardiovascular signs (hypotension, low cardiac output on monitoring) signal clinically significant toxicity requiring calcium supplementation (calcium gluconate or chloride IV). QTc prolongation can occur but is a later and less sensitive sign. Rising PT reflects the underlying liver failure or dilutional coagulopathy, not citrate toxicity per se.

Question 116: When performing high-frequency jet ventilation (HFJV) for rigid bronchoscopy and subglottic tracheal stenosis resection, which physiological principle BEST explains adequate CO2 elimination despite tidal volumes smaller than anatomical dead space?

Increased functional residual capacity reducing dead space fraction
Entrainment of ambient air increasing effective tidal volume above dead space
Continuous fresh gas flow washing out CO2 via mass convection alone
Asymmetric velocity profiles and augmented molecular diffusion (Taylor dispersion) (Correct answer)

Correct answer: Asymmetric velocity profiles and augmented molecular diffusion (Taylor dispersion)

CO2 elimination during HFJV occurs through multiple mechanisms, but the most important at high frequencies with sub-dead-space tidal volumes is Taylor dispersion (augmented axial diffusion). Asymmetric turbulent velocity profiles create radial mixing, dramatically enhancing the effective diffusion coefficient for CO2 far beyond simple Fickian diffusion. Entrainment does occur with open-circuit HFJV and contributes, but it does not fully explain CO2 clearance at all frequencies. Mass convection (bulk flow) is the dominant mechanism only at lower HFJV frequencies.

Question 117: 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?

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

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

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

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 119: During cardiopulmonary bypass at 28°C, the pharmacokinetics of fentanyl will be most affected by:

Increased volume of distribution due to priming solution
Enhanced renal clearance due to hemodilution
Increased protein binding due to hypothermia
Reduced hepatic blood flow and metabolic enzyme activity (Correct answer)

Correct answer: Reduced hepatic blood flow and metabolic enzyme activity

Hypothermia during CPB reduces hepatic blood flow and CYP enzyme activity, significantly decreasing fentanyl clearance and prolonging its effect.

Question 120: During thoracic epidural analgesia (TEA) at T4–T5 for a right thoracotomy, the patient develops unexpected bradycardia and hypotension. Cardiac accelerator fibers (T1–T4) are likely blocked. Which additional reflex mechanism, specific to thoracic surgery and TEA, MOST likely contributes to the hemodynamic compromise in this setting?

Intercostal muscle paralysis causing paradoxical chest wall movement and reduced preload
Phrenic nerve palsy reducing venous return via loss of the thoracic pump
Splanchnic vasodilation from epidural spread to T5–T12 causing relative hypovolemia
Cardiac vagal (parasympathetic) predominance unopposed by blocked sympathetic accelerator fibers, exaggerated by surgical manipulation triggering carinal and pulmonary stretch receptors (Correct answer)

Correct answer: Cardiac vagal (parasympathetic) predominance unopposed by blocked sympathetic accelerator fibers, exaggerated by surgical manipulation triggering carinal and pulmonary stretch receptors

With high thoracic sympathetic blockade abolishing cardiac accelerator input (T1–T4), the cardiac vagus (CN X) is unopposed. During thoracic surgery, surgical manipulation — particularly traction near the carina, hilum, or lung parenchyma — activates stretch receptors innervated by the vagus nerve, triggering reflex bradycardia and vasodilation. This vagally-mediated reflex (Bezold-Jarisch-like) is potentiated by the absence of compensatory sympathetic tone under TEA. Phrenic nerve palsy is not a feature of mid-thoracic epidural. Intercostal paralysis does not significantly reduce preload. Splanchnic vasodilation contributes to hypotension but does not explain the bradycardia component.

Question 121: In acute liver failure, which finding indicates the poorest prognosis according to King's College Criteria?

ALT >5000 U/L
INR >6.5 in acetaminophen-induced ALF (Correct answer)
Serum albumin <20 g/L
Bilirubin >300 µmol/L alone

Correct answer: INR >6.5 in acetaminophen-induced ALF

An INR >6.5 (PT >100 s) in acetaminophen-induced ALF is an independent criterion for transplant listing under King's College Criteria.

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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