A 72-year-old man is scheduled for emergency fixation of a fractured neck of femur. Past history: • Hypertension • Ischaemic heart disease • Atrial fibrillation on apixaban Spinal anaesthesia is planned. His last dose of apixaban was taken 8 hours ago. What is the most appropriate management?

A 65-year-old patient is undergoing transurethral resection of the prostate (TURP). After 60 minutes of resection, he develops: • Confusion • Bradycardia • Hypertension • Nausea What is the most likely diagnosis?

A patient is undergoing posterior fossa craniotomy in the sitting position. Suddenly: • ETCO₂ falls from 34 to 18 mmHg • BP falls from 130/80 to 75/40 mmHg • Mill-wheel murmur is heard What is the most likely diagnosis?

A patient undergoing thyroidectomy develops: • Hoarseness • Weak voice immediately after extubation. What is the most likely nerve injury?

A 68-year-old patient is undergoing total hip replacement under spinal anaesthesia. Thirty minutes after cement insertion: • BP falls from 140/80 to 70/40 mmHg • SpO₂ falls from 99% to 85% • ETCO₂ falls from 35 to 18 mmHg What is the most likely diagnosis?

During pituitary surgery, the anaesthetist notices: • Urine output 800 mL/hour • Rising serum sodium What is the most likely diagnosis?

A patient undergoing retinal detachment repair receives succinylcholine. The surgeon suddenly complains: "The eye is becoming very tense." What is the explanation?

A child undergoing adenotonsillectomy develops: • Severe inspiratory effort • No air movement • SpO₂ 75% What is the most likely diagnosis?

A patient undergoing TURBT develops obturator nerve stimulation. What is the most likely intraoperative consequence?

A patient undergoing clipping of a cerebral aneurysm suddenly develops: • BP 220/120 mmHg • HR 110/min during laryngoscopy. Why is this particularly dangerous?

A 74-year-old man is undergoing transurethral resection of the prostate (TURP) under spinal anaesthesia. Forty-five minutes into the procedure he complains of: • Headache • Restlessness • Blurred vision • Nausea Observations: • BP 180/95 mmHg • HR 52/min • SpO₂ 99% What is the most appropriate next investigation?

A 62-year-old woman is undergoing anterior cervical discectomy and fusion (ACDF). At the end of surgery she develops: • Progressive neck swelling • Stridor • Difficulty breathing What is the most likely diagnosis?

A patient undergoing total knee replacement under spinal anaesthesia suddenly develops: • Chest pain • Hypoxaemia • ETCO₂ drop from 34 to 20 mmHg during femoral canal instrumentation. What is the most likely diagnosis?

During transsphenoidal pituitary surgery, the surgeon asks for a relaxed, bloodless field. Which physiological parameter is most important to avoid?

A patient with an open globe injury requires emergency surgery. Which induction drug is most controversial?

A child undergoing microlaryngoscopy develops complete airway obstruction during laser surgery. What is the immediate priority?

A patient undergoing awake craniotomy suddenly becomes confused and develops right arm weakness during tumour resection. What is the most likely explanation?

A patient undergoing ureteroscopy develops: • HR 120/min • Temperature 39°C • BP 85/45 mmHg after manipulation of an infected obstructed kidney. What is the most likely diagnosis?

During scoliosis surgery, MEPs suddenly disappear. MAP is 42 mmHg. What is the most appropriate first step?

A patient develops severe postoperative nausea and vomiting after strabismus surgery. Which factor most likely contributed?

A 68-year-old man undergoes total knee replacement under spinal anaesthesia combined with an adductor canal block. Postoperatively he has: • Excellent analgesia • Preserved ability to straight-leg raise • Able to participate in physiotherapy What is the main advantage of an adductor canal block compared with a femoral nerve block?

A 45-year-old patient undergoes shoulder arthroopy. An ultrasound-guided interscalene block is performed. Thirty minutes later he complains of: • Mild shortness of breath Examination reveals: • Reduced air entry at the right base • SpO₂ 97% on room air What is the most likely explanation?

A patient undergoing lumbar laminectomy in the prone position develops: • Peak airway pressure 38 cmH₂O • Plateau pressure 34 cmH₂O Which is the most likely explanation?

During a supraclavicular brachial plexus block, the patient develops: • Sudden pleuritic chest pain • Mild dyspnoea What complication should be suspected?

A 70-year-old patient is undergoing carotid endarterectomy under regional anaesthesia. Suddenly he develops: • Inability to speak • Right arm weakness What is the most likely diagnosis?

A patient undergoing TURBT suddenly develops violent adductor muscle contraction. Which nerve is responsible?

A 35-year-old woman undergoes thyroidectomy. Soon after extubation she develops: • Inspiratory stridor • Increased work of breathing • Normal neck appearance Flexible laryngoscopy shows bilateral vocal cord immobility. What is the most likely diagnosis?

A patient undergoing clipping of a ruptured cerebral aneurysm develops: • BP 210/115 mmHg • HR 120/min during pinning of the skull. What is the most appropriate preventative strategy before pin insertion?

A patient receives an axillary brachial plexus block. Which nerve is most likely to be missed if specifically not sought?

A patient undergoing endoscopic sinus surgery develops: • HR 110/min • BP 75/40 mmHg • ETCO₂ drops from 35 to 20 mmHg immediately after venous sinus injury. What is the most likely diagnosis?

A 68-year-old man is undergoing robotic radical prostatectomy in steep Trendelenburg position. After 4 hours of surgery, airway pressures have increased and facial oedema is noted. Before extubation, which factor is MOST important to assess?

A 58-year-old patient is undergoing awake craniotomy. During cortical mapping, the patient suddenly develops rhythmic movements of the right arm. What is the most likely cause?

A patient undergoing shoulder arthroscopy in the beach-chair position develops: • BP 80/40 mmHg • ETCO₂ decreases from 34 to 26 mmHg What is the major neurological concern?

A patient undergoing percutaneous nephrolithotomy (PCNL) develops: • Increased airway pressure • Hypoxaemia • Reduced breath sounds on one side What complication should be suspected?

A patient undergoing middle ear surgery suddenly develops: • Bradycardia • Hypotension during manipulation near the tympanic membrane. What reflex is most likely responsible?

An ultrasound-guided popliteal sciatic nerve block is performed for foot surgery. Which area is LEAST likely to be anaesthetised by the block alone?

During pituitary surgery, urine output rises to 1200 mL over one hour. Serum sodium increases from 140 to 150 mmol/L. What is the most likely diagnosis?

A patient with glaucoma presents for emergency laparotomy. Which drug may significantly increase intraocular pressure?

During total hip arthroplasty, shortly after cementation, the patient develops: • Severe hypotension • Hypoxaemia • ETCO₂ reduction What is the most likely diagnosis?

A patient undergoing microlaryngoscopy requires laser excision of a vocal cord lesion. Which factor MOST increases the risk of airway fire?

A 55-year-old man is undergoing lumbar spine decompression in the prone position. Three hours into surgery, the anaesthetist notices: • Progressive facial swelling • Conjunctival oedema • Increased airway pressures What is the most likely contributing factor?

A patient undergoes endoscopic transsphenoidal pituitary surgery. At the end of surgery there is sudden brisk bleeding into the surgical field. Which vessel injury is most feared?

A patient undergoing radical cystectomy develops: • Temperature 35°C • INR rising • Increased bleeding from surgical field What factor is most likely contributing?

During endoscopic sinus surgery, the surgeon requests controlled hypotension. Which MAP target is generally considered acceptable in a healthy adult?

A patient undergoing shoulder arthroscopy receives an interscalene block. Postoperatively he develops: • Ptosis • Miosis • Facial anhidrosis What is the most likely diagnosis?

A 70-year-old patient undergoing TURP develops: • Hypertension • Bradycardia • Confusion Serum sodium returns as: 118 mmol/L What is the definitive treatment?

During clipping of a cerebral aneurysm, temporary clipping is applied. What monitoring modality is most useful for detecting cerebral ischaemia?

A patient undergoing ophthalmic surgery receives a peribulbar block. Immediately afterwards he becomes: • Confused • Unresponsive • Apnoeic What complication should be suspected?

A patient undergoing total knee replacement receives: • Adductor canal block • IPACK block What is the main purpose of the IPACK block?

A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ decrease • Hypotension • Oxygen desaturation TEE demonstrates intracardiac air. What is the immediate anaesthetic management?

A 78-year-old woman undergoes hemiarthroplasty for fractured neck of femur under spinal anaesthesia. Twenty minutes after positioning, she develops: • BP 65/35 mmHg • HR 38/min The sensory level is found to be T2. What is the most likely diagnosis?

A patient receives an ultrasound-guided TAP block after laparotomy. Which nerves are primarily targeted?

A patient undergoing VATS lobectomy develops: • SpO₂ 84% The DLT position is confirmed with bronchoscopy. What is the next best step?

A woman undergoing Caesarean section develops: • Sudden hypoxia • Severe hypotension • Coagulopathy immediately after delivery. What is the most likely diagnosis?

A patient undergoing breast surgery receives a PECS II block. Which nerves are primarily targeted?

A patient with traumatic brain injury develops: • BP 180/100 mmHg • HR 42/min What does this combination suggest?

A patient undergoes ureteroscopy for an infected obstructed ureteric stone. Thirty minutes into the procedure: • Temp 39.2°C • HR 130/min • BP 78/42 mmHg What is the most likely diagnosis?

A patient receives a PENG block before total hip replacement. What is the primary aim?

A patient undergoing cervical spine surgery is being extubated. Which factor most strongly predicts a difficult reintubation if extubation fails?

A 45-year-old woman undergoes laparoscopic cholecystectomy under general anaesthesia. At the end of surgery, the surgeon infiltrates 20 mL of 0.25% bupivacaine into the port sites. Fifteen minutes later, the patient develops: • Perioral tingling • Tinnitus • Agitation What is the most likely diagnosis?

A patient undergoing thoracic endovascular aortic repair (TEVAR) suddenly develops: • Loss of lower limb motor responses • Preserved upper limb responses What complication should be suspected?

A 6-year-old child undergoes orchidopexy. A caudal block is planned. What is the most common complication of a caudal block?

A patient undergoes clipping of a cerebral aneurysm. During temporary clipping, the surgeon requests mild hypocapnia. What is the primary physiological effect?

During endoscopic sinus surgery, the surgeon reports excessive bleeding despite normal coagulation. Which anaesthetic intervention may improve surgical visibility?

A patient undergoing shoulder replacement receives an interscalene block. Which nerve is most commonly affected unintentionally?

A patient undergoing TURP develops: • Confusion • Hyponatraemia • Pulmonary oedema Which mechanism is primarily responsible?

A patient undergoing awake craniotomy suddenly becomes unable to speak during cortical stimulation. What does this most likely indicate?

A patient undergoing robotic prostatectomy has been in steep Trendelenburg for 5 hours. Which postoperative complication is most likely?

A patient undergoing total knee replacement receives: • Adductor canal block • IPACK block Despite excellent analgesia, he complains of severe lateral thigh pain. Which nerve territory is most likely not covered?

A 72-year-old woman undergoes cemented total hip replacement. Immediately after femoral cement insertion: • BP falls from 135/80 to 60/35 mmHg • SpO₂ falls from 99% to 82% • ETCO₂ falls from 34 to 16 mmHg What is the most likely diagnosis?

A 65-year-old man undergoes carotid endarterectomy. During carotid cross-clamping: • Left-sided weakness develops • Speech becomes slurred What is the most appropriate next step?

A patient receives an ultrasound-guided erector spinae plane (ESP) block before VATS surgery. What is the primary indication?

A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ decrease • Hypotension • Desaturation What is the most sensitive monitor for detecting this complication?

A patient undergoing microlaryngoscopy requires laser excision of a laryngeal lesion. Which gas should be avoided because it supports combustion?

A 58-year-old patient undergoes TURBT under spinal anaesthesia. Suddenly there is severe adductor muscle contraction. Which block could have reduced this risk?

The obturator nerve runs close to the lateral bladder wall and may be stimulated during resection. Blocking it reduces: • Adductor jerk • Bladder perforation risk Prometric Pearl TURBT + obturator block is a favourite exam combination.

A patient undergoes retinal detachment surgery. Traction on the extraocular muscles produces: • HR decrease from 80 to 35/min What reflex is responsible?

A patient undergoing prone lumbar spine surgery develops: • Sudden hypotension • Tachycardia • Increased airway pressures The abdomen is noted to be compressed against the table. What is the most likely mechanism?

A patient receives a supraclavicular block. Thirty minutes later he develops: • Ptosis • Miosis but is otherwise well. What is the most likely diagnosis?

A 4-year-old child presents with stridor and drooling. The child prefers to sit upright and appears toxic. What is the safest anaesthetic approach?

A patient undergoing lobectomy develops: • Persistent hypoxaemia during OLV • DLT position confirmed What physiological mechanism is primarily responsible for maintaining oxygenation during OLV?

A patient receives a quadratus lumborum (QL) block after abdominal surgery. What is the primary benefit compared with a TAP block?

A patient undergoing clipping of an intracranial aneurysm suddenly develops: • Brain swelling • Difficult surgical exposure Which ABG finding would most likely contribute?

A patient undergoing robotic prostatectomy has: • Peak airway pressure 40 cmH₂O • Plateau pressure 36 cmH₂O What is the most likely cause?

A 3-year-old child weighing 15 kg is undergoing emergency laparotomy for intussusception. Blood loss is estimated at 300 mL. What percentage of blood volume has been lost?

A 28-year-old woman undergoing emergency Caesarean section under spinal anaesthesia develops: • BP 60/30 mmHg • HR 120/min • Nausea immediately after delivery and oxytocin administration. What is the most likely cause?

A trauma patient has: • Eyes open to pain • Incomprehensible sounds • Withdraws from pain What is the GCS?

A patient with severe sepsis has: • Lactate 7 mmol/L • ScvO₂ 42% • Cardiac index 1.8 L/min/m² What is the primary haemodynamic problem?

A patient receives an ultrasound-guided femoral nerve block. Which motor deficit is expected?

A premature infant presents for inguinal hernia repair. Which postoperative complication requires prolonged monitoring?

A patient undergoing labour epidural analgesia suddenly develops: • Tinnitus • Metallic taste • Agitation What should be suspected?

A patient undergoing thoracotomy develops severe postoperative pain despite PCA morphine. Which regional technique provides the most effective analgesia?

A patient with Tetralogy of Fallot develops: • Sudden cyanosis • Tachypnoea • Irritability during induction. What is the most likely diagnosis?

A patient undergoing ophthalmic surgery develops severe bradycardia during traction on the medial rectus muscle. What is the first step?

A patient undergoing emergency laparotomy develops: • Temperature 40°C • ETCO₂ 75 mmHg • Generalized rigidity What is the definitive treatment?

A patient undergoing total knee replacement receives an adductor canal block. Which nerve is primarily targeted?

A patient undergoing labour develops a CTG showing: • Baseline 170 bpm • Reduced variability • Recurrent late decelerations How should this trace be classified?

A patient undergoing posterior fossa surgery develops: • ETCO₂ decrease • Hypotension • Desaturation What is the most likely diagnosis?

A 5-year-old child develops complete laryngospasm after extubation. Jaw thrust and CPAP fail. SpO₂ falls to 58%. What is the next best step?