Free DHA Anesthesiology mock test

Anesthesiology sample questions with answers

10 more original exam-style Anesthesiology questions, worked in full. They are not real or recalled exam questions, and none of them is in the diagnostic above, so sit that first if you have not.

1. Question 1 · Trauma, Burns, Orthopedic and Organ-Based/Specialty Anesthesia

   During damage control surgery for a bleeding pelvic fracture, ROTEM shows an EXTEM clotting time near the upper limit of normal, an EXTEM A5 of 30 mm and a FIBTEM A5 of 4 mm, with no evidence of lysis. The surgical field is diffusely oozing. What is the most appropriate targeted therapy?

   1. AFibrinogen concentrate or cryoprecipitate
   2. BPooled platelet transfusion
   3. CProtamine sulphate
   4. DFresh frozen plasma 15 mL/kg alone
   Show answer and explanation

   Correct answer: A. Fibrinogen concentrate or cryoprecipitate

   FIBTEM assesses clot firmness after platelet inhibition, so a low FIBTEM A5 with a relatively preserved EXTEM A5 indicates functional hypofibrinogenaemia, which is corrected with fibrinogen concentrate or cryoprecipitate. Platelets would be indicated if EXTEM amplitude were low with a normal FIBTEM. Protamine is for heparin effect, which is not suggested here, and plasma alone is a poor and slow way to raise fibrinogen.

   Reference: European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (Rossaint et al., Critical Care 2023)

2. Question 2 · Preoperative Assessment, Risk Stratification and Anesthesia for Co-Existing Disease

   A 44-year-old man with a biochemically confirmed noradrenaline-secreting phaeochromocytoma is scheduled for laparoscopic adrenalectomy. He has episodic hypertension to 210/120 mmHg and palpitations. Which preoperative preparation is most appropriate?

   1. AAlpha-adrenergic blockade for 10 to 14 days with liberalised salt and fluid intake, adding a beta-blocker only once alpha blockade is established and reflex tachycardia appears
   2. BStart atenolol immediately to control the tachycardia, then add an alpha-blocker on the day before surgery
   3. CNo specific preparation is needed provided a sodium nitroprusside infusion and phentolamine are available intraoperatively
   4. DPreload with three litres of crystalloid on the morning of surgery instead of any adrenoceptor blockade
   Show answer and explanation

   Correct answer: A. Alpha-adrenergic blockade for 10 to 14 days with liberalised salt and fluid intake, adding a beta-blocker only once alpha blockade is established and reflex tachycardia appears

   Standard preparation is 10 to 14 days of alpha blockade (for example phenoxybenzamine or doxazosin) with a high-salt diet and generous fluid intake to re-expand the chronically contracted intravascular volume, using endpoints such as resolution of paroxysms, mild postural hypotension and nasal stuffiness. Beta blockade is added only after alpha blockade because unopposed alpha stimulation from a beta-blocker given first can precipitate a hypertensive crisis and acute pulmonary oedema. Intraoperative vasodilators are essential but do not replace preoperative optimisation, and fluid alone does not control catecholamine-driven vasoconstriction.

   Reference: Endocrine Society Clinical Practice Guideline, Pheochromocytoma and Paraganglioma, J Clin Endocrinol Metab 2014; Stoelting's Anesthesia and Co-Existing Disease, 8th edition, 2022

3. Question 3 · Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks

   A 24-year-old man had internal fixation of a tibial plateau fracture and has a continuous popliteal sciatic catheter running ropivacaine 0.2%. Eight hours postoperatively he develops severe deep calf pain that breaks through the block and requires escalating intravenous morphine, with a tense, swollen calf. What is the most appropriate action?

   1. AGive a 10 mL bolus of ropivacaine 0.2% through the catheter and reassess in 30 minutes
   2. BIncrease the basal infusion rate and add a patient-controlled bolus
   3. CStop the infusion and urgently assess for acute compartment syndrome, including compartment pressure measurement and surgical review
   4. DReplace the catheter, assuming secondary failure from dislodgement
   Show answer and explanation

   Correct answer: C. Stop the infusion and urgently assess for acute compartment syndrome, including compartment pressure measurement and surgical review

   Escalating, disproportionate deep pain breaking through a previously working block in a high-risk tibial fracture is a red flag for acute compartment syndrome, and the correct response is to stop masking it, examine the limb and obtain immediate surgical assessment with compartment pressures. Bolusing, increasing the infusion or resiting the catheter would all obscure the diagnosis and delay fasciotomy, which is the time-critical determinant of limb outcome.

   Reference: Association of Anaesthetists / Regional Anaesthesia UK guidance on regional anaesthesia and compartment syndrome (Anaesthesia, 2021)

4. Question 4 · Critical Care Medicine and Resuscitation

   A patient with a tunnelled central venous catheter develops fever. Paired blood cultures are drawn simultaneously from the catheter and a peripheral vein. Which finding most strongly supports a catheter-related bloodstream infection while the catheter is still in situ?

   1. AErythema at the exit site without any positive culture
   2. BGrowth of coagulase-negative staphylococci from the catheter sample only, with a sterile peripheral sample
   3. CA rise in C-reactive protein and procalcitonin within 24 hours of the fever
   4. DGrowth of the same organism from both samples, with the catheter sample turning positive at least 2 hours earlier than the peripheral sample
   Show answer and explanation

   Correct answer: D. Growth of the same organism from both samples, with the catheter sample turning positive at least 2 hours earlier than the peripheral sample

   Differential time to positivity of at least 2 hours in favour of the catheter-drawn sample, with the same organism isolated from both sites, is the accepted microbiological criterion for catheter-related bloodstream infection when the line is retained, because it reflects a higher organism burden within the catheter lumen. A positive catheter culture alone with a sterile peripheral culture more often indicates hub colonisation or contamination. Inflammatory markers are non-specific, and exit-site erythema without positive cultures indicates a local exit-site infection rather than a bloodstream infection.

   Reference: IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection (Mermel LA et al.), Clinical Infectious Diseases

5. Question 5 · Pediatric and Neonatal Anesthesia

   Regarding the mechanistic basis of anesthetic neurotoxicity described in immature animal models, which statement is most accurate?

   1. ANMDA receptor antagonism and GABA-A receptor agonism during synaptogenesis have been associated with accelerated neuroapoptosis and altered dendritic architecture in rodents and non-human primates
   2. BOpioids are the principal agents implicated, acting through mu receptor mediated apoptosis
   3. CThe effect is mediated solely by intraoperative hypotension and hypocapnia rather than by any direct drug action
   4. DDexmedetomidine has been shown to be the most neurotoxic agent in rodent models
   Show answer and explanation

   Correct answer: A. NMDA receptor antagonism and GABA-A receptor agonism during synaptogenesis have been associated with accelerated neuroapoptosis and altered dendritic architecture in rodents and non-human primates

   In neonatal rodent and non-human primate models, agents that block NMDA receptors (ketamine, nitrous oxide) or potentiate GABA-A receptors (volatiles, propofol, benzodiazepines) during the peak of synaptogenesis produce increased neuroapoptosis and altered dendritic spine density, with dose and duration dependence. Opioids are not the main implicated class in these models. Physiological derangements such as hypotension, hypoglycaemia and hypocapnia can contribute and confound but are not the sole explanation of the observed direct effects. Dexmedetomidine, an alpha-2 agonist, appears relatively sparing and has shown neuroprotective effects in several models.

   Reference: Jevtovic-Todorovic et al., Journal of Neuroscience 2003; SmartTots/FDA consensus statements on anesthetic neurotoxicity in the developing brain

6. Question 6 · Acute and Chronic Pain Medicine

   You plan a diagnostic medial branch block of the right L4-L5 zygapophysial (facet) joint before considering radiofrequency denervation. Which nerves must be anaesthetised?

   1. AThe L3 and L4 medial branches
   2. BThe L4 medial branch alone
   3. CThe L4 and L5 medial branches
   4. DThe L5 dorsal ramus and the S1 lateral branch
   Show answer and explanation

   Correct answer: A. The L3 and L4 medial branches

   Each lumbar facet joint has a dual innervation from the medial branches of the dorsal rami of the level above and of the same level, so the L4-L5 joint is supplied by the L3 and L4 medial branches, which are targeted at the junction of the superior articular and transverse processes of L4 and L5 respectively. Blocking a single medial branch leaves half the joint innervated and produces a false-negative result. The L4/L5 pairing and the L5 dorsal ramus with S1 lateral branch correspond to different target joints and to sacroiliac rather than facet innervation.

   Reference: Spine Intervention Society Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd ed (2013); Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 5th ed

7. Question 7 · Airway Management

   During a rapid sequence induction with cricoid pressure applied, laryngoscopy reveals only the epiglottis (grade 3). The most appropriate immediate action is to:

   1. AIncrease the cricoid force to 40 newtons to bring the larynx into view
   2. BAsk the assistant to reduce or release the cricoid pressure while the laryngoscopic view is maintained
   3. CAbandon intubation and wake the patient
   4. DAttempt blind nasal intubation
   Show answer and explanation

   Correct answer: B. Ask the assistant to reduce or release the cricoid pressure while the laryngoscopic view is maintained

   Correctly applied cricoid pressure of about 30 newtons still worsens the laryngoscopic view, impedes bag-mask ventilation and hinders supraglottic airway placement in a significant proportion of patients, so reducing or releasing it is an explicit step in the difficult intubation algorithm when the view is poor. Increasing the force makes the view worse. Waking the patient is premature after a single suboptimal look, and blind nasal intubation has no role in this emergency setting.

   Reference: Difficult Airway Society guidelines for management of unanticipated difficult intubation in adults 2015; Cook TM, Kelly FE. British Journal of Anaesthesia 2015

8. Question 8 · Basic Sciences: Anesthetic Pharmacology, Applied Physiology, Anatomy and Physics

   A randomized trial comparing two analgesic regimens reports a mean difference in 24-hour morphine consumption of 4 mg, with a 95 per cent confidence interval of -1 to 9 mg and p = 0.11. Which interpretation is most appropriate?

   1. AThe two regimens are proven equivalent because the p-value exceeds 0.05
   2. BThe result is not statistically significant at the 5 per cent level, and the confidence interval includes both no difference and a difference that could be clinically important, so the trial is inconclusive rather than negative
   3. CThere is a 11 per cent probability that the null hypothesis is true
   4. DThe trial demonstrates a clinically important benefit that failed to reach significance because of an inappropriate statistical test
   Show answer and explanation

   Correct answer: B. The result is not statistically significant at the 5 per cent level, and the confidence interval includes both no difference and a difference that could be clinically important, so the trial is inconclusive rather than negative

   A confidence interval that crosses zero indicates the result is not statistically significant at the 5 per cent level, but its upper limit of 9 mg is compatible with a difference that many clinicians would regard as meaningful, so the correct conclusion is that the study is underpowered and inconclusive, not that the treatments are equivalent. Demonstrating equivalence requires a prespecified equivalence or non-inferiority design with a defined margin. A p-value is the probability of observing data this extreme or more extreme if the null hypothesis were true, not the probability that the null hypothesis is true, and there is no evidence here that the wrong test was used.

   Reference: Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ, 1995; CONSORT 2010 Statement

9. Question 9 · Conduct of General Anesthesia, Equipment, Monitoring and Fluid/Transfusion Management

   A patient receiving a propofol infusion with a stable bispectral index of 45 is given a bolus of ketamine 0.5 mg/kg for analgesia. The index abruptly rises to 70 although the patient is clinically deeply anesthetized. What is the best interpretation?

   1. AThe patient has become aware and the propofol infusion must be increased immediately
   2. BKetamine produces electromyographic silence that falsely elevates the index
   3. CThe rise indicates ketamine-induced burst suppression being misinterpreted by the algorithm
   4. DKetamine increases high-frequency EEG activity, so processed EEG indices rise without a true lightening of anesthesia
   Show answer and explanation

   Correct answer: D. Ketamine increases high-frequency EEG activity, so processed EEG indices rise without a true lightening of anesthesia

   Ketamine and nitrous oxide produce high-frequency, high-amplitude EEG activity that processed indices interpret as arousal, so the displayed number rises despite deepening anesthesia; the index should therefore be interpreted alongside clinical signs and the raw EEG/spectrogram. Burst suppression would drive the index down, not up, and electromyographic artefact from ketamine-related muscle tone would also raise rather than silence the signal - but the dominant mechanism is the drug's direct EEG effect.

   Reference: Miller's Anesthesia, 9th edition (2020), Monitoring the State of the Brain; NAP5 (RCoA/AAGBI, 2014)

10. Question 10 · Cardiac, Thoracic and Vascular Anesthesia

    Two minutes into a slow protamine infusion after weaning from bypass, the pulmonary artery pressure rises abruptly from 25/12 to 60/35 mmHg, the right ventricle distends on direct vision, and systemic pressure collapses. Systemic vascular resistance is low-normal and there is no rash. What is the most appropriate immediate action?

    1. AContinue protamine at a slower rate and give calcium chloride
    2. BGive a further heparin bolus and reinstitute the pump immediately without stopping protamine
    3. CStop the protamine, support the right ventricle and be prepared to re-heparinize and return to bypass
    4. DGive methylene blue 2 mg/kg for presumed vasoplegia
    Show answer and explanation

    Correct answer: C. Stop the protamine, support the right ventricle and be prepared to re-heparinize and return to bypass

    This is a type III (catastrophic) protamine reaction - thromboxane-mediated pulmonary vasoconstriction causing acute pulmonary hypertension and right ventricular failure. The protamine must be stopped immediately, with right ventricular support (inotropes such as milrinone or dobutamine, a pulmonary vasodilator such as inhaled nitric oxide, and noradrenaline or vasopressin to maintain coronary perfusion pressure) and readiness to re-heparinize and return to bypass. Continuing protamine perpetuates the insult, and methylene blue treats vasoplegia with low systemic vascular resistance, which is not the picture here.

    Reference: Kaplan's Cardiac Anesthesia, 8th edition (2023); Nybo & Madsen, Serious anaphylactic reactions due to protamine sulfate, Basic Clin Pharmacol Toxicol (2008)