Quiz Archives

A 31-year-old primigravida with severe preeclampsia is undergoing emergency Caesarean section under spinal anaesthesia. Baseline: • BP 175/110 mmHg • HR 95/min Five minutes after spinal injection: • BP 80/40 mmHg • HR 120/min • Fetal heart rate falls from 140 bpm to 85 bpm What is the MOST likely explanation for the fetal bradycardia?

A 68-year-old man undergoes cemented hemiarthroplasty for fractured neck of femur. Five minutes after cement insertion: • BP 130/80 → 65/35 mmHg • SpO₂ 99% → 82% • ETCO₂ 34 → 14 mmHg The surgeon asks: "Could this be a pulmonary embolism?" What feature MOST strongly supports Bone Cement Implantation Syndrome rather than thrombotic pulmonary embolism?

A 4-year-old child undergoes adenotonsillectomy. In recovery: • HR 165/min • BP 75/40 mmHg • SpO₂ 98% • Repeated swallowing noted • Child increasingly restless A junior doctor attributes the agitation to emergence delirium. What is the MOST likely diagnosis?

A patient undergoes posterior fossa craniotomy in the sitting position. Suddenly: • ETCO₂ falls from 35 to 18 mmHg • SpO₂ falls to 90% • BP falls to 80/40 mmHg The surgeon reports: "I just entered a venous sinus." What is the MOST appropriate immediate action?

A 70-year-old patient undergoes robotic radical prostatectomy. After 6 hours in steep Trendelenburg: • Face swollen • Tongue swollen • Conjunctival oedema present The surgeon says: "The operation is finished." What is the MOST important question before extubation?

A 58-year-old woman undergoes laparoscopic hemicolectomy. Two hours after pneumoperitoneum: • ETCO₂ gradually rises from 36 to 55 mmHg • Peak airway pressure rises slightly • SpO₂ remains 99% • HR 82/min • Temperature 36.7°C The trainee becomes concerned about malignant hyperthermia. What is the MOST likely explanation?

A 34-year-old woman in labour develops the following CTG: • Baseline 170 bpm • Variability 3 bpm • Recurrent late decelerations BP is 75/40 mmHg following epidural top-up. What is the MOST likely primary cause of the CTG abnormality?

A 5-year-old child undergoes emergency bronchoscopy for suspected peanut aspiration. During bronchoscopy: • HR falls from 120 to 55/min • SpO₂ falls from 98% to 78% What is the MOST appropriate immediate action?

A patient undergoing scoliosis correction develops: • Sudden loss of MEP signals • SSEPs remain normal • MAP 48 mmHg What is the MOST likely explanation?

A 72-year-old man undergoes TURP under spinal anaesthesia. After 90 minutes: • Restless • Confused • HR 52/min • BP 180/95 mmHg Serum sodium returns: 118 mmol/L What is the MOST dangerous immediate complication?

A patient undergoing VATS lobectomy is on one-lung ventilation. Suddenly: • SpO₂ falls to 84% • FiO₂ already 100% • DLT position confirmed bronchoscopically What is the BEST next step?

A 67-year-old diabetic patient is undergoing carotid endarterectomy under regional anaesthesia. During carotid clamping he suddenly says: "I cannot move my right arm." What is the MOST important interpretation?

A patient undergoing thyroidectomy is extubated. Ten minutes later: • Increasing stridor • Neck swelling • Anxiety • Oxygen saturation falling What is the MOST dangerous mistake?

A patient receives an interscalene block before shoulder arthroscopy. After surgery: • Ptosis • Miosis • Hoarse voice but normal oxygenation. What is the MOST likely explanation?

A septic ICU patient has: • Lactate 8 mmol/L • ScvO₂ 44% • Hb 11 g/dL • Cardiac Index 1.6 L/min/m² Which intervention is MOST likely to improve oxygen delivery?

A 67-year-old woman is undergoing total knee replacement under spinal anaesthesia with sedation. Thirty minutes after tourniquet inflation: • BP 125/75 mmHg • HR 72/min Immediately after tourniquet release: • BP 85/45 mmHg • ETCO₂ rises from 34 to 42 mmHg • HR 105/min What is the MOST likely explanation?

A 5-year-old child undergoes adenotonsillectomy. In recovery: • Stridor • Suprasternal recession • SpO₂ 92% • Good air movement What is the MOST likely diagnosis?

A 72-year-old man undergoing robotic prostatectomy develops: • Peak pressure 40 cmH₂O • Plateau pressure 38 cmH₂O Which interpretation is MOST accurate?

A woman with severe postpartum haemorrhage has: • Blood loss 2500 mL • BP 75/40 mmHg • HR 140/min Despite fluids, hypotension persists. Laboratory values: • Fibrinogen 0.9 g/L What is the MOST concerning finding?

A patient undergoes clipping of an anterior communicating artery aneurysm. During temporary clipping: • MEP amplitude decreases by 70% • SSEPs unchanged What is the MOST likely interpretation?

A 62-year-old diabetic patient undergoes carotid endarterectomy. Immediately after unclamping: • BP 220/120 mmHg • HR 105/min What complication is the surgeon most concerned about?

A patient undergoing thyroidectomy suddenly develops: • HR 38/min • BP 70/40 mmHg during surgical manipulation. The surgeon is dissecting near the carotid sheath. What is the MOST likely mechanism?

A patient undergoing VATS develops: • ETCO₂ 18 mmHg • BP 70/35 mmHg • SpO₂ 85% Immediately after central venous catheter insertion. What is the MOST likely diagnosis? • Vagal activation • Bradycardia • Hypotension Usually resolves when the stimulus is removed. Prometric Pearl Neck surgery can trigger profound vagal reflexes.

A 3-year-old child with Tetralogy of Fallot develops: • SpO₂ 50% • Severe cyanosis • Tachypnoea during induction. Which intervention is MOST likely to improve oxygenation?

A patient undergoes endoscopic sinus surgery. The surgeon reports progressively worsening visibility despite minimal bleeding earlier. ABG: • pH 7.31 • PaCO₂ 58 mmHg What is the MOST likely explanation?

A 64-year-old man is undergoing laparoscopic right hemicolectomy. During trocar insertion, the capnograph suddenly changes: • ETCO₂ falls from 36 mmHg to 12 mmHg • BP falls from 130/80 to 70/40 mmHg • SpO₂ falls to 86% The surgeon says: "I just insufflated the abdomen." What is the MOST likely diagnosis?

A 30-year-old woman in labour has the following CTG: • Baseline 145 bpm • Variability 10 bpm • Recurrent variable decelerations The obstetrician asks whether this suggests placental insufficiency. What is the MOST likely explanation?

A 75-year-old man undergoes hip fracture fixation under spinal anaesthesia. Thirty minutes later: • BP 70/35 mmHg • HR 42/min The block level is T3. Which physiological mechanism BEST explains the bradycardia?

A patient undergoing VATS lobectomy develops: • SpO₂ 85% • FiO₂ 100% • DLT position confirmed • CPAP to operative lung ineffective What is the MOST appropriate next step?

A 66-year-old diabetic patient undergoes carotid endarterectomy under regional anaesthesia. During clamping: • Speech becomes slurred • Contralateral arm weakness develops BP is 105/60 mmHg. What is the BEST immediate action?

A 4-year-old child undergoes adenotonsillectomy. Ten minutes after extubation: • Severe inspiratory effort • No air movement • SpO₂ 68% Jaw thrust and CPAP fail. What is the BEST next step?

A patient undergoing pituitary surgery develops: • Urine output 1500 mL over 2 hours • Serum sodium rises from 139 to 151 mmol/L What is the MOST likely diagnosis?

A patient undergoes thyroidectomy. Twenty minutes after extubation: • Stridor • Neck swelling • Oxygen saturation 88% What is the MOST dangerous error?

A septic ICU patient has: • Lactate 9 mmol/L • ScvO₂ 43% • Cardiac Index 1.5 L/min/m² • Hb 11 g/dL What is the MOST likely physiological problem?

A patient undergoes shoulder arthroscopy under general anaesthesia with an interscalene block. Postoperatively: • Ptosis • Miosis • Hoarseness SpO₂ 98% What is the MOST likely interpretation?

A 29-year-old woman with severe postpartum haemorrhage has received: • 4 units PRBC • 4 units FFP • Uterotonics • Tranexamic acid Current observations: • BP 85/45 mmHg • HR 138/min Laboratory results: • Hb 8.2 g/dL • Platelets 42 × 10⁹/L • Fibrinogen 0.8 g/L What is the MOST important blood product to administer next?

A 7-year-old child undergoes emergency appendicectomy. During induction: • Difficult mask ventilation • Increasing ETCO₂ • Progressive desaturation Laryngoscopy reveals: • Large tonsils • Copious secretions • Poor view What is the MOST important mistake to avoid?

A patient undergoing clipping of a ruptured aneurysm develops: • MAP 55 mmHg • MEP amplitude reduced by 80% • SSEPs unchanged What is the MOST appropriate immediate intervention?

A patient undergoing robotic cystectomy has been in steep Trendelenburg for 7 hours. At the end of surgery: • Facial oedema • Tongue swelling • Conjunctival oedema What is the BEST assessment before extubation?

A patient undergoing TURBT develops: • Sudden violent adductor contraction • Bladder wall perforation The surgeon asks how this might have been prevented. What is the BEST answer?

A patient undergoing one-lung ventilation has: • FiO₂ 100% • SpO₂ 86% • DLT correctly positioned ABG: • PaO₂ 55 mmHg • PaCO₂ 38 mmHg What physiological process is MOST responsible for maintaining oxygenation during OLV?

A woman in labour develops: • Sudden hypoxaemia • Hypotension • Cardiac arrest immediately after delivery. ROSC is achieved. Laboratory tests later reveal: • DIC • Low fibrinogen What is the MOST likely diagnosis?

A 4-year-old child weighing 20 kg has: • Estimated blood volume 1400 mL During surgery, blood loss reaches 350 mL. The child remains normotensive. What is the MOST important lesson?

A patient receives an interscalene block. Thirty minutes later: • Mild dyspnoea • Reduced diaphragmatic movement on ultrasound • SpO₂ 98% What is the MOST likely explanation?

A patient undergoing posterior fossa surgery develops: • ETCO₂ 14 mmHg • BP 65/35 mmHg • SpO₂ 88% The surgeon reports opening a large venous channel. What diagnosis BEST integrates all the findings?

A 68-year-old man is undergoing endovascular abdominal aortic aneurysm repair (EVAR). Thirty minutes after deployment of the stent graft: • Urine output falls sharply • BP remains 130/75 mmHg • HR 78/min The surgeon reports difficulty cannulating the renal arteries during the procedure. What is the MOST likely explanation?

A 32-year-old woman undergoes emergency Caesarean section under spinal anaesthesia. Five minutes later: • BP 65/35 mmHg • HR 45/min • Difficulty breathing • Unable to move upper limbs What is the MOST likely diagnosis?

A patient undergoing VATS lobectomy develops: • SpO₂ 82% • FiO₂ 100% • DLT correctly positioned The surgeon says: "I can pause if needed." What is the MOST effective immediate manoeuvre?

A 70-year-old woman undergoes thyroidectomy. Twenty minutes after extubation: • Stridor • SpO₂ 90% • Neck swelling • Anxiety The surgeon is still in the recovery area. What is the MOST appropriate immediate action?

A 6-year-old child undergoes tonsillectomy. In recovery: • HR 160/min • BP 75/40 mmHg • Repeated swallowing • Pallor The surgical site appears dry. What is the MOST likely diagnosis?

A patient undergoing clipping of an intracranial aneurysm develops: • BP 90/50 mmHg • MEPs disappear • SSEPs unchanged What is the MOST important first intervention?

A patient undergoing TURP develops: • Restlessness • Confusion • Sodium 116 mmol/L What is the MOST dangerous neurological complication?

A patient with severe COPD undergoes laparoscopic colectomy. During pneumoperitoneum: • ETCO₂ rises from 38 to 58 mmHg • HR stable • Temperature normal What is the MOST appropriate management?

A patient receives an adductor canal block before TKR. Postoperatively: • Excellent analgesia • Able to perform straight-leg raise What is the BEST explanation?

A patient undergoing posterior fossa surgery develops: • ETCO₂ falls from 35 to 15 mmHg • BP 70/40 mmHg • SpO₂ 88% TEE demonstrates air in the right atrium. What is the MOST important immediate anaesthetic change?

A 65-year-old man is undergoing total hip replacement under spinal anaesthesia. Thirty minutes after cement insertion: • BP 65/35 mmHg • SpO₂ 82% • ETCO₂ 15 mmHg The surgeon asks whether he should continue with wound closure. What is the MOST important physiological process causing the ETCO₂ fall?

A woman undergoing emergency Caesarean section develops: • Sudden hypotension • Bronchospasm • Severe hypoxaemia immediately after delivery. Twenty minutes later: • Oozing from IV sites • Fibrinogen 0.7 g/L What diagnosis BEST explains the entire picture?

A patient undergoes awake craniotomy. During cortical stimulation: • Speech suddenly stops • Patient remains conscious • No motor weakness What is the MOST likely interpretation?

A 4-year-old child weighing 18 kg develops: • HR 170/min • Capillary refill 4 seconds • BP 90/60 mmHg after prolonged abdominal surgery. Estimated blood loss is 350 mL. What is the MOST important interpretation?

A patient undergoing one-lung ventilation has: • FiO₂ 100% • SpO₂ 84% • DLT position correct The surgeon asks: "Why is this happening if the lung is isolated properly?" What is the BEST explanation?

A patient undergoes thyroidectomy. During dissection: • HR falls from 75 to 35/min • BP falls to 70/40 mmHg The surgeon reports working close to the carotid bifurcation. What is the MOST likely mechanism?

A patient with septic shock has: • MAP 72 mmHg • Lactate 8 mmol/L • ScvO₂ 74% • Oliguria The junior doctor says: "The ScvO₂ is normal, so perfusion must be adequate." What is the BEST response?

A patient receives an interscalene block. Thirty minutes later: • Mild dyspnoea • Reduced ipsilateral diaphragmatic excursion • SpO₂ 99% What is the MOST likely explanation?

A patient undergoing robotic prostatectomy develops: • Facial oedema • Tongue swelling • Peak airway pressure rise after 6 hours in steep Trendelenburg. What is the MOST important concern?

The scenario is really an airway question. Airway oedema may make: • Extubation hazardous • Reintubation difficult A structured extubation plan is essential. Prometric Pearl Safe extubation requires the same planning as safe intubation.

A 62-year-old woman is undergoing laparoscopic hysterectomy. Ninety minutes into surgery: • ETCO₂ rises gradually from 35 to 52 mmHg • Temperature remains 36.8°C • HR remains 78/min • BP remains stable The trainee is concerned about malignant hyperthermia. What finding most strongly argues AGAINST malignant hyperthermia?

A 75-year-old man undergoes carotid endarterectomy under regional anaesthesia. During carotid cross-clamping: • He becomes confused • Speech becomes slurred • Contralateral arm weakness develops Blood pressure is 110/65 mmHg. What is the BEST immediate management?

A 28-year-old woman undergoes emergency Caesarean section. Ten minutes after delivery she develops: • Persistent uterine bleeding • BP 80/40 mmHg • HR 135/min The uterus is: • Soft • Enlarged • Poorly contracted What is the MOST likely cause of the haemorrhage?

A patient undergoing thoracotomy develops: • Severe postoperative pain • Poor cough • Reduced inspiratory effort Despite IV opioids. Which regional technique would most likely improve all three problems?

A 5-year-old child presents for emergency bronchoscopy. History: • Sudden choking episode • Persistent unilateral wheeze • Reduced air entry on the right What is the MOST likely diagnosis?

A patient undergoing scoliosis correction develops: • MEP amplitudes fall by 80% • SSEPs unchanged • MAP 45 mmHg What is the MOST likely explanation?

A patient receives an interscalene block. Thirty minutes later: • Ptosis • Miosis • Facial anhidrosis but no neurological deficit. What is the MOST likely diagnosis?

A patient undergoing pituitary surgery develops: • Urine output 1200 mL in 90 minutes • Serum sodium 152 mmol/L What is the MOST appropriate treatment?

A patient undergoing robotic prostatectomy has: • Peak pressure 42 cmH₂O • Plateau pressure 39 cmH₂O What is the BEST interpretation?

A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ drop • Hypotension • Desaturation The surgeon reports entering a venous sinus. What is the MOST likely diagnosis?

A 72-year-old woman undergoes cemented hemiarthroplasty for fractured neck of femur. Immediately after cement insertion: • ETCO₂ falls from 34 to 12 mmHg • BP falls from 140/80 to 60/30 mmHg • SpO₂ falls to 78% The surgeon asks: "Why did the ETCO₂ drop so dramatically?" What is the BEST physiological explanation?

A 30-year-old primigravida develops: • Persistent fetal bradycardia • Maternal BP 65/35 mmHg 5 minutes after spinal anaesthesia for Caesarean section. What is the MOST appropriate first intervention?

A patient undergoing carotid endarterectomy under regional anaesthesia suddenly develops: • Contralateral arm weakness • Slurred speech BP is 95/55 mmHg. What is the MOST likely diagnosis?

A 4-year-old child undergoes tonsillectomy. In recovery: • HR 165/min • Pale • Repeated swallowing • BP 85/50 mmHg The nurse reports: "The throat looks clean." What is the MOST likely diagnosis?

A patient undergoing one-lung ventilation develops: • SpO₂ 84% • FiO₂ 100% • DLT position correct What physiological mechanism is MOST responsible for preventing even worse hypoxaemia?

A patient undergoing thyroidectomy develops: • HR 35/min • BP 70/40 mmHg during dissection around the carotid bifurcation. What is the MOST likely mechanism?

A patient with septic shock has: • Lactate 9 mmol/L • ScvO₂ 78% • Oliguria • Mottled skin The junior trainee says: "ScvO₂ is normal, so tissue perfusion must be adequate." What is the BEST response?

A patient receives an interscalene block. After surgery: • Mild dyspnoea • Reduced diaphragmatic movement • SpO₂ 99% What is the MOST likely explanation?

A patient undergoes robotic radical prostatectomy. After 7 hours in steep Trendelenburg: • Facial oedema • Tongue swelling • Conjunctival oedema What is the MOST important concern before extubation?

A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ fall • Hypotension • SpO₂ 88% TEE demonstrates air in the right atrium. What is the MOST important immediate intervention?

A 68-year-old man undergoing laparotomy under TIVA has: • BIS 32 • BP 85/45 mmHg • HR 52/min The trainee decides to increase the propofol target because: "The patient is moving slightly." What is the MOST important concern with this decision?

A patient undergoing thoracic surgery on OLV develops: • SpO₂ 85% • FiO₂ 100% • DLT correctly positioned The surgeon asks: "Why isn't the oxygen level normal if the ventilated lung is receiving 100% oxygen?" What is the BEST explanation?

A labouring woman develops the following CTG: • Baseline 145 bpm • Variability 12 bpm • Recurrent variable decelerations What is the MOST likely cause?

A patient undergoing laparoscopic colectomy develops: • ETCO₂ rises from 38 to 65 mmHg • Temperature 40°C • HR 145/min • Generalised rigidity What is the MOST likely diagnosis?

A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ drop • Hypotension • Desaturation The surgeon reports: "I entered a large venous sinus." Which monitor would have detected this complication earliest?

A 5-year-old child undergoes adenotonsillectomy. Following extubation: • Severe inspiratory effort • No airflow • SpO₂ 60% Jaw thrust and CPAP fail. What is the BEST next step?

A patient with severe sepsis has: • Lactate 8 mmol/L • ScvO₂ 42% • Cardiac index 1.7 L/min/m² What is the MOST likely haemodynamic problem?

During endoscopic sinus surgery, visibility progressively worsens. ABG: • PaCO₂ 60 mmHg What is the MOST likely explanation?

A patient receives an interscalene block. Postoperatively: • Ptosis • Miosis • Facial anhidrosis No weakness elsewhere. What is the MOST likely diagnosis?

A patient undergoing robotic prostatectomy has: • Peak pressure 42 cmH₂O • Plateau pressure 40 cmH₂O What is the MOST likely explanation?

A patient undergoing laser excision of a vocal cord lesion develops flames from the airway. What is the FIRST action?

A trauma patient has: • Eyes open to speech • Confused conversation • Localises pain What is the GCS?

A patient undergoing scoliosis correction develops: • MEP loss • MAP 45 mmHg What is the MOST important first intervention?

A patient undergoing Caesarean section develops: • Sudden hypoxaemia • Severe hypotension • DIC What diagnosis best explains all findings?

A 72-year-old man undergoes hip fracture fixation under spinal anaesthesia. Thirty minutes later: • BP 65/35 mmHg • HR 38/min • Sensory block T2 What is the MOST likely diagnosis?

A 67-year-old man with diabetes mellitus, ischemic heart disease, chronic kidney disease (creatinine 2.4 mg/dL), and previous stroke is scheduled for elective colectomy. According to the Revised Cardiac Risk Index (RCRI), which factor contributes to his score?

A 32-year-old woman in labour has the following CTG: • Baseline: 165 bpm • Variability: 3 bpm • Recurrent late decelerations How should this trace be classified?

A patient undergoing major abdominal surgery has a BIS value of 88. Heart rate and blood pressure are increasing during skin incision. What is the most likely interpretation?

A patient undergoing upper abdominal surgery develops progressive hypothermia. Which mechanism accounts for the greatest intraoperative heat loss?

A laser is being used during microlaryngoscopy. Which factor contributes most to operating theatre fire risk?

A patient presents after head injury. Examination reveals: • Eyes open to pain • Incomprehensible sounds • Withdraws from pain What is the GCS?

A flow-volume loop demonstrates: • Flattened inspiratory limb • Normal expiratory limb What is the most likely diagnosis?

During OLV, oxygen saturation falls to 86%. Bronchoscopy confirms correct DLT position. CPAP to the operative lung fails to improve oxygenation. What is the next best step?

A patient with sickle cell disease presents for emergency laparotomy. Which perioperative factor most strongly promotes sickling?

During spinal surgery, MEPs disappear but SSEPs remain normal. What structure is most likely affected?

A 58-year-old diabetic man is scheduled for elective hemicolectomy. During preoperative assessment, he reports climbing two flights of stairs daily without stopping and has no cardiac symptoms. Which finding best indicates adequate functional capacity?

A labouring woman develops sudden fetal bradycardia after epidural top-up. Maternal observations: • BP 65/35 mmHg • HR 58/min What is the most likely cause of fetal bradycardia?

A patient undergoing TIVA for scoliosis surgery has: • BIS = 28 • MAP = 60 mmHg • HR = 45/min What is the most likely interpretation?

During a prolonged laparotomy, core temperature falls from 36.8°C to 34.9°C. Which complication is most likely?

A laser airway procedure is being performed. Which intervention most effectively reduces airway fire risk?

A trauma patient has: • Eyes open spontaneously • Confused conversation • Localizes pain What is the GCS?

A flow-volume loop demonstrates flattening of both inspiratory and expiratory limbs. What is the most likely diagnosis?

During OLV, oxygen saturation falls to 88%. DLT position is correct. CPAP and recruitment manoeuvres have failed. What physiological mechanism is causing hypoxaemia?

A patient with sickle cell disease develops: • Fever • Chest pain • New pulmonary infiltrate • Hypoxaemia 48 hours after surgery. What is the most likely diagnosis?

During scoliosis correction, SSEPs decrease by 70%, while MEPs remain unchanged. What structure is most likely affected?

A 32-year-old primigravida with severe preeclampsia is undergoing emergency Caesarean section under spinal anaesthesia. Five minutes after the block: • BP falls from 160/100 mmHg to 75/40 mmHg • HR 58/min • Fetal heart rate falls from 145 bpm to 80 bpm The obstetrician asks whether immediate delivery should begin. What is the most appropriate next step?

A 4-year-old child is brought to the operating theatre for control of post-tonsillectomy haemorrhage. In the emergency department: • HR: 165/min • BP: 72/38 mmHg • RR: 32/min • SpO₂: 97% • The child is pale and lethargic • Parents report repeated swallowing over the previous hour • Approximately 250 mL of blood has been vomited On arrival in theatre, the surgeon asks whether a rapid sequence induction (RSI) is necessary because the child has been "fasted" since the original operation. What is the most appropriate anaesthetic approach?

A 68-year-old man is admitted to the ICU with septic shock secondary to perforated sigmoid diverticulitis. He has already received: • 30 mL/kg crystalloid • Broad-spectrum antibiotics • Norepinephrine infusion at 0.18 µg/kg/min Current observations: Parameter Value MAP 67 mmHg HR 118/min Lactate 7.1 mmol/L ScvO₂ 44% Hb 10.8 g/dL Cardiac Index 1.6 L/min/m² Urine Output 0.2 mL/kg/hr The ICU consultant asks: "Should we simply increase the norepinephrine further?" What is the most appropriate next intervention?

A 31-year-old primigravida at 40 weeks gestation is in active labour. She has been receiving an oxytocin infusion for augmentation of labour. The midwife becomes concerned about the CTG. CTG Findings • Baseline fetal heart rate: 170 bpm • Variability: 3 bpm • Recurrent late decelerations • Contractions: 6 contractions every 10 minutes Maternal observations: • BP: 122/74 mmHg • HR: 96/min • SpO₂: 99% • Temperature: 36.8°C The obstetric registrar asks: "Should we continue observing for another 30 minutes?" What is the most appropriate immediate management?

A 62-year-old man with COPD is scheduled for elective right upper lobectomy for bronchogenic carcinoma. A left-sided double-lumen tube has been inserted uneventfully. After positioning the patient in the left lateral decubitus position and commencing one-lung ventilation (OLV), the following occurs: Parameter Before OLV 15 min After OLV SpO₂ 99% 86% FiO₂ 0.5 1.0 ETCO₂ 35 mmHg 37 mmHg BP 128/74 124/70 HR 78 82 You perform fibreoptic bronchoscopy. The DLT is perfectly positioned. A recruitment manoeuvre to the dependent lung has already been performed. The surgeon asks: "Can we continue? The saturation is still 86%." What is the MOST appropriate next step?

A 24-year-old man is brought to the Emergency Department following a high-speed road traffic collision. On arrival: Parameter Finding Eyes Open to pain Verbal Response Inappropriate words Motor Response Withdraws from pain BP 168/92 mmHg HR 52/min RR Irregular SpO₂ 94% on 15 L oxygen A CT scan is being arranged. The emergency physician asks: "Should we intubate now, or wait for the CT scan first?" What is the MOST appropriate next step?

A 35-year-old woman presents for emergency laparotomy with severe abdominal pain. Past history reveals: • Recurrent episodes of severe abdominal pain • Multiple previous admissions with "unexplained abdominal crises" • Hypertension • Dark reddish urine during previous attacks In the emergency department she becomes increasingly agitated and develops: • HR: 135/min • BP: 190/110 mmHg • Mild proximal muscle weakness The surgical trainee suspects bowel ischemia and requests urgent anaesthesia review. Which of the following is the MOST likely diagnosis?

A 29-year-old primigravida at 39 weeks gestation is taken for an emergency Caesarean section because of a pathological CTG. A spinal anaesthetic is performed successfully. Ten minutes after delivery, the obstetrician says: "The uterus is very atonic." Oxytocin 5 IU is administered slowly intravenously. Within 60 seconds the following occurs: Parameter Before Oxytocin After Oxytocin BP 128/76 mmHg 68/34 mmHg HR 88/min 142/min SpO₂ 99% 98% ETCO₂ 34 mmHg 24 mmHg The patient complains of: • Dizziness • Nausea • Feeling faint The obstetric SHO asks: "Has she developed a pulmonary embolism?" What is the MOST likely explanation for the sudden deterioration?

A 7-year-old child weighing 25 kg is undergoing posterior spinal fusion for scoliosis. The anaesthetic technique consists of: • Propofol infusion • Remifentanil infusion • No additional neuromuscular blocker after intubation The surgery has been uneventful for 3 hours. Suddenly, the neurophysiology technician reports: "The motor evoked potentials (MEPs) from both lower limbs have disappeared." The monitoring screen shows: Parameter Value MAP 48 mmHg HR 105/min SpO₂ 100% ETCO₂ 37 mmHg Temperature 36.5°C BIS 42 The surgeon immediately asks: "Have I injured the spinal cord?" What is the MOST appropriate first action?

A 56-year-old man with obesity (BMI 38 kg/m²), hypertension, and type 2 diabetes is scheduled for elective laparoscopic colectomy. Anaesthesia is induced uneventfully with: Propofol Fentanyl Rocuronium The trachea is intubated successfully. Approximately 15 minutes after pneumoperitoneum is established, the ventilator alarms. Current findings: Parameter Before Pneumoperitoneum Current Peak Airway Pressure 22 cmH₂O 42 cmH₂O Plateau Pressure 18 cmH₂O 36 cmH₂O ETCO₂ 36 mmHg 39 mmHg SpO₂ 99% 96% BP 132/76 138/82 Auscultation reveals: Bilateral breath sounds No wheeze The surgical registrar asks: "Has the patient developed bronchospasm?" What is the MOST likely explanation?

A 56-year-old man with obesity (BMI 38 kg/m²), hypertension, and type 2 diabetes is scheduled for elective laparoscopic colectomy. Anaesthesia is induced uneventfully with: • Propofol • Fentanyl • Rocuronium The trachea is intubated successfully. Approximately 15 minutes after pneumoperitoneum is established, the ventilator alarms. Current findings: Parameter Before Pneumoperitoneum Current Peak Airway Pressure 22 cmH₂O 42 cmH₂O Plateau Pressure 18 cmH₂O 36 cmH₂O ETCO₂ 36 mmHg 39 mmHg SpO₂ 99% 96% BP 132/76 138/82 Auscultation reveals: • Bilateral breath sounds • No wheeze The surgical registrar asks: "Has the patient developed bronchospasm?"

A 3-year-old child (weight 15 kg) is undergoing emergency laparotomy for intussusception. The procedure has been complicated by bowel ischemia and difficult surgical dissection. After 2 hours of surgery, the anaesthetist notices: Parameter Value HR 165/min BP 68/35 mmHg ETCO₂ 22 mmHg SpO₂ 99% Temperature 36.7°C The surgeon estimates blood loss at: "About 250 mL" The surgical trainee comments: "The blood loss doesn't sound too significant." What is the MOST appropriate interpretation?

A 72-year-old man is scheduled for an emergency laparotomy for perforated sigmoid diverticulitis. His past medical history includes: • Previous myocardial infarction (3 years ago) • Insulin-dependent diabetes mellitus • Chronic kidney disease (Creatinine 2.4 mg/dL) • Hypertension On examination: • BP 135/80 mmHg • HR 82/min • SpO₂ 97% on room air The surgical registrar says: "His ECG is okay today, so his cardiac risk should be low." During the anaesthetic assessment, you calculate his Revised Cardiac Risk Index (RCRI). What is his RCRI score?

A 3-year-old child (weight 15 kg) is undergoing emergency laparotomy for intussusception. The procedure has been complicated by bowel ischemia and difficult surgical dissection. After 2 hours of surgery, the anaesthetist notices: Parameter Value HR 165/min BP 68/35 mmHg ETCO₂ 22 mmHg SpO₂ 99% Temperature 36.7°C The surgeon estimates blood loss at: "About 250 mL" The surgical trainee comments: "The blood loss doesn't sound too significant." What is the MOST appropriate interpretation?

A 28-year-old woman is undergoing an emergency Caesarean section for fetal distress. A spinal anaesthetic is performed uneventfully. The baby is delivered within 8 minutes. Immediately after delivery, the obstetrician says: "The uterus feels firm, but there is much more bleeding than expected." Current observations: Parameter Value BP 105/62 mmHg HR 118/min SpO₂ 99% Estimated Blood Loss 1200 mL The uterus remains: Well contracted The obstetrician asks: "Could this still be uterine atony?" What is the MOST likely cause of postpartum haemorrhage?

A 5-year-old child (20 kg) is undergoing adenotonsillectomy. Anaesthesia and surgery are uneventful. The child is extubated awake and transferred to recovery. Five minutes later, the recovery nurse calls urgently. The child has: • Marked inspiratory effort • No air movement heard • Oxygen saturation falling from 99% to 82% • Suprasternal and intercostal recession • Paradoxical chest movement The recovery nurse says: "I think this is bronchospasm." What is the MOST likely diagnosis?

A 65-year-old man is undergoing laparoscopic cholecystectomy. Thirty minutes after pneumoperitoneum, the capnograph shows a gradual rise in ETCO₂ from 36 mmHg to 52 mmHg. Observations: • BP: 130/78 mmHg • HR: 84/min • Temperature: 36.8°C • SpO₂: 99% What is the most likely cause?

A 34-year-old woman in labour develops the following CTG pattern: • Baseline: 140 bpm • Variability: 10 bpm • Recurrent variable decelerations What is the most likely cause?

During major spinal surgery, the neurophysiology technician reports: "SSEP amplitudes have decreased by 60%." The patient's MAP is 50 mmHg. What should be done first?

A 58-year-old patient undergoing general anaesthesia has: • BIS = 85 • Tachycardia • Hypertension during skin incision What is the most likely interpretation?

A patient with severe asthma undergoes general anaesthesia. Shortly after intubation: • Peak airway pressure rises significantly • Plateau pressure remains unchanged • Wheeze is heard What is the most likely diagnosis?

A 2-day-old neonate develops bradycardia during induction of anaesthesia. Heart rate falls from 140/min to 70/min. What is the most appropriate initial intervention?

A patient undergoing laparoscopic appendicectomy suddenly develops: • ETCO₂ drop from 38 to 15 mmHg • BP 70/40 mmHg • SpO₂ 88% What is the most likely diagnosis?

A patient undergoing thoracic surgery develops hypoxaemia during one-lung ventilation. The DLT position is confirmed bronchoscopically. What is the next best step?

A labouring woman has the following CTG: • Baseline: 125 bpm • Variability: 12 bpm • Accelerations present • No decelerations How should this CTG be classified?

A patient develops the following ECG changes: • Tall peaked T waves • QRS widening What electrolyte abnormality is most likely?

A 4-year-old child weighing 18 kg requires maintenance fluids. Using the 4-2-1 rule, what is the hourly maintenance rate?

During major abdominal surgery, core temperature falls to 34.8°C. Which complication is most likely?

A patient undergoing scoliosis correction develops sudden loss of MEP signals. MAP is 45 mmHg. What is the most appropriate first action?

A septic ICU patient has: • Lactate: 7 mmol/L • ScvO₂: 42% • Hb: 11 g/dL • Cardiac Index: 1.5 L/min/m² What is the most likely haemodynamic problem?

A 26-year-old woman receives an epidural for labour analgesia. Ten minutes after a top-up dose, she complains of: • Tinnitus • Metallic taste • Perioral numbness What is the most likely diagnosis?

A 70-year-old patient undergoes hip fracture fixation under spinal anaesthesia. Twenty minutes later: • BP: 72/40 mmHg • HR: 42/min What is the most likely cause?

A 65-year-old smoker undergoes spirometry. Flow-volume loop demonstrates: • Flattened inspiratory limb • Normal expiratory limb What is the most likely diagnosis?

A trauma patient has: • Eyes open to speech • Confused conversation • Localises pain What is the GCS?

A patient undergoing thyroidectomy develops: • Stridor • Respiratory distress • Neck swelling 30 minutes after surgery. What is the most likely diagnosis?

A 24-year-old woman with postpartum haemorrhage has lost approximately 1800 mL of blood. Which intervention has been shown to reduce mortality when given early?

A patient with sickle cell disease presents for emergency surgery. Which factor is most likely to precipitate sickling?

During laparoscopic surgery, a fire starts near the surgical drapes. Which element of the fire triad is most commonly increased by anaesthetic practice?

A patient with severe COPD undergoes general anaesthesia. ABG shows: • pH 7.31 • PaCO₂ 60 mmHg • PaO₂ 95 mmHg What is the primary acid-base disorder?

A patient in ICU with septic shock has: • MAP 68 mmHg • Lactate 5.8 mmol/L • Urine output 0.2 mL/kg/hr • ScvO₂ 72% What is the most likely interpretation?

A 32-year-old woman undergoes emergency Caesarean section under spinal anaesthesia. Five minutes after delivery, the obstetrician administers oxytocin. Shortly afterwards: • BP falls from 130/80 to 75/40 mmHg • HR increases from 85 to 135/min • ETCO₂ falls from 34 to 24 mmHg What is the most likely explanation?

A patient undergoing carotid endarterectomy develops: • Sudden right arm weakness • Inability to move the right leg during carotid cross-clamping. What is the most likely cause?

A 6-year-old child develops stridor immediately after extubation following tonsillectomy. The child is conscious and maintaining oxygen saturation at 98%. What is the most likely cause?

A patient undergoing major surgery has: • Temperature 39.5°C • ETCO₂ rising rapidly • Generalised muscle rigidity • Tachycardia What is the most likely diagnosis?

A 75-year-old patient develops new-onset atrial fibrillation during surgery. Heart rate is 160/min and blood pressure is 75/40 mmHg. What is the most appropriate management?

A 4-year-old child weighing 20 kg loses 300 mL blood during surgery. Approximately what percentage of blood volume has been lost?

During labour, a CTG shows: • Baseline 140 bpm • Variability 8 bpm • Recurrent late decelerations What is the most likely underlying problem?

A patient undergoing thyroid surgery develops: • Hoarseness • Weak cough • Breathy voice after extubation. What nerve injury is most likely?

A patient with severe sepsis has: • Lactate 8 mmol/L • MAP 72 mmHg • ScvO₂ 45% What is the most likely interpretation?

A patient undergoing scoliosis surgery has: • SSEPs unchanged • MEPs absent What structure is most likely affected?

A 68-year-old man with severe COPD is undergoing laparoscopic colectomy. Two hours into surgery, the capnogram shows a gradual increase in ETCO₂ from 38 mmHg to 58 mmHg. The ventilator settings have not changed. What is the most appropriate initial management?

A 30-year-old woman undergoes emergency Caesarean section for fetal distress. The newborn has: • HR 90/min • Poor respiratory effort • Poor tone What is the most important initial step in neonatal resuscitation?

A patient develops the following ECG changes during surgery: • ST elevation in leads II, III and aVF What is the most likely diagnosis?

A patient undergoes laser excision of a vocal cord lesion. Which measure most effectively reduces airway fire risk?

A 55-year-old man with cirrhosis is undergoing emergency laparotomy. Preoperative labs: • INR 2.4 • Platelets 48,000/mm³ The surgeon asks whether the patient is at increased bleeding risk. What is the best response?

A 4-year-old child undergoing bronchoscopy develops: • HR 60/min • SpO₂ 82% What is the most likely cause of the bradycardia?

A trauma patient has: • Eyes open spontaneously • Inappropriate words • Withdraws from pain What is the GCS?

A patient with myasthenia gravis is undergoing thymectomy. Which neuromuscular blocker characteristic is expected?

During labour, a CTG shows: • Baseline 175 bpm • Variability 2 bpm • Recurrent late decelerations How should this trace be classified?

A patient in ICU with septic shock has: • Lactate 6.5 mmol/L • ScvO₂ 48% • Hb 12 g/dL • Cardiac index 1.7 L/min/m² What is the most appropriate next haemodynamic intervention?

A 29-year-old woman with severe preeclampsia is receiving magnesium sulfate. Monitoring shows: • Respiratory rate: 10/min • Patellar reflexes present • Urine output: 15 mL/hr Which finding most increases the risk of magnesium toxicity?

A 6-year-old child weighing 20 kg requires emergency transfusion. Estimated blood volume is approximately:

During general anaesthesia, the BIS monitor suddenly reads 92. The patient simultaneously develops: • Tachycardia • Hypertension What is the most likely explanation?

A patient undergoing laparoscopic surgery suddenly develops: • ETCO₂ falls from 35 to 12 mmHg • BP falls to 70/40 mmHg • SpO₂ falls to 85% What is the most likely diagnosis?

A labouring woman develops recurrent variable decelerations on CTG. What is the most likely cause?

A patient with hyperkalaemia develops progressive ECG changes. Which ECG abnormality usually appears first?

A patient undergoing one-lung ventilation becomes hypoxaemic. The DLT position is correct. CPAP to the operative lung has failed. What is the next best step?

A patient develops: • BP 190/100 mmHg • HR 42/min during neurosurgery. What does this combination most strongly suggest?

A patient develops postpartum haemorrhage. The uterus is: • Soft • Enlarged • Poorly contracted What is the most likely diagnosis?

A septic ICU patient has: • Lactate 8 mmol/L • ScvO₂ 40% • Cardiac index 1.5 L/min/m² What is the most likely physiological problem?

A 4-week-old infant is scheduled for pyloromyotomy for hypertrophic pyloric stenosis. Preoperative blood gas: • pH 7.56 • HCO₃⁻ 36 mmol/L • Cl⁻ 88 mmol/L • K⁺ 3.0 mmol/L The surgeon says: "The baby has been vomiting for days. Let's proceed urgently." What is the MOST appropriate management?

A 2-year-old child suddenly develops severe coughing while eating peanuts. On examination: • Unilateral wheeze on the right • Reduced air entry on the right • Normal temperature What is the most likely diagnosis?

A 3-year-old child undergoes adenotonsillectomy. Thirty minutes later: • HR 155/min • BP 70/40 mmHg • Repeated swallowing observed What is the most likely diagnosis?

A neonate develops: • HR 55/min • SpO₂ 78% immediately after induction. What is the first intervention?

A 5-year-old child develops: • Generalised rigidity • ETCO₂ rising from 38 to 75 mmHg • Temperature 40°C shortly after induction. What is the most likely diagnosis?

A 10-kg infant has lost 150 mL blood during surgery. Approximately what percentage of blood volume has been lost?

A child with Tetralogy of Fallot develops sudden: • Cyanosis • Tachypnoea • Irritability • SpO₂ 55% during induction. What is the most likely event?

A premature infant presents for inguinal hernia repair. Why is postoperative apnoea a major concern?

A child with Down syndrome presents for dental surgery. Which airway feature is commonly encountered?

A 2-year-old child develops complete laryngospasm after extubation. Jaw thrust and CPAP fail. SpO₂ falls to 60%. What is the most appropriate next step?

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 3-year-old child (weight 15 kg) is undergoing emergency laparotomy for intussusception. The procedure has been complicated by bowel ischemia and difficult surgical dissection. After 2 hours of surgery, the anaesthetist notices: Parameter Value HR 165/min BP 68/35 mmHg ETCO₂ 22 mmHg SpO₂ 99% Temperature 36.7°C The surgeon estimates blood loss at: "About 250 mL" The surgical trainee comments: "The blood loss doesn't sound too significant." What is the MOST appropriate interpretation?

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?

A 29-year-old primigravida undergoes emergency Caesarean section under spinal anaesthesia for fetal distress. Five minutes after intrathecal injection, her blood pressure falls from 130/80 mmHg to 75/40 mmHg. Simultaneously, the fetal heart rate decreases from 145 bpm to 85 bpm. What is the most appropriate immediate management?

A 4-year-old child weighing 16 kg is scheduled for adenotonsillectomy. During surgery, estimated blood loss is 250 mL. Approximately what percentage of the child's total blood volume has been lost?

A 68-year-old man is admitted to ICU with septic shock secondary to pneumonia. He is mechanically ventilated and receiving norepinephrine 0.25 µg/kg/min. His current observations are: • HR: 122 bpm • BP: 82/48 mmHg • CVP: 6 mmHg • Lactate: 5.8 mmol/L • Urine output: 10 mL/hour Bedside echocardiography demonstrates a hyperdynamic left ventricle with a small end-diastolic cavity. What is the most appropriate next step?

A 62-year-old man is undergoing thoracoscopic left upper lobectomy. Thirty minutes after initiation of one-lung ventilation, oxygen saturation falls from 99% to 86% despite FiO₂ of 1.0. What is the most appropriate initial intervention?

A 30-year-old woman receives an epidural for labour analgesia. Fifteen minutes later she complains of circumoral numbness, tinnitus, and metallic taste. What is the most likely diagnosis?

A 75-year-old man is being assessed for elective colectomy. His medical history includes: • Ischaemic heart disease • Previous myocardial infarction • Insulin-dependent diabetes • Chronic kidney disease with creatinine 2.3 mg/dL According to the Revised Cardiac Risk Index (RCRI), which factor is NOT included?

A 56-year-old patient undergoes prolonged abdominal surgery lasting six hours. At the end of surgery, the core temperature is 34.5°C. Which mechanism contributes most to heat loss during surgery?

A patient is admitted following a road traffic accident. On examination: • Eyes open to pain • Incomprehensible sounds • Withdraws from painful stimulus What is the Glasgow Coma Scale score?

During scoliosis correction surgery with sensory evoked potential monitoring, a sudden loss of SSEP signals is noted. What is the most appropriate immediate action?

A patient with known sickle cell disease presents for emergency laparotomy. Which perioperative factor is most likely to precipitate sickling?

A 32-year-old primigravida in labour is undergoing continuous fetal heart rate monitoring. The CTG demonstrates: • Baseline fetal heart rate 170 bpm • Absent baseline variability • Recurrent late decelerations with more than 50% of contractions What is the most appropriate interpretation?

A patient undergoing TIVA for intracranial aneurysm clipping has a BIS value of 18. Blood pressure and heart rate are stable. What is the most likely interpretation?

During laser excision of a vocal cord lesion, flames are suddenly seen emerging from the patient's mouth. What is the immediate first step?

A 3-year-old child weighing 15 kg requires endotracheal intubation. What is the most appropriate uncuffed endotracheal tube size?

A mechanically ventilated ICU patient suddenly develops the following flow-volume loop: • Expiratory limb demonstrates a marked scooped-out appearance. • Peak airway pressures have increased. What is the most likely diagnosis?

A patient develops the following ECG rhythm in recovery: • Irregularly irregular rhythm • No visible P waves • Ventricular rate 140/min What is the diagnosis?

A woman with severe preeclampsia is receiving magnesium sulfate. Which clinical finding is most suggestive of magnesium toxicity?

During laparoscopic surgery, the capnograph suddenly changes from a normal square waveform to a progressively rising baseline that fails to return to zero. What is the most likely explanation?

Immediately after administration of cefazolin during induction, a patient develops: • BP 60/30 mmHg • HR 130/min • Bronchospasm • Generalised erythema What is the first-line treatment?

A term neonate weighs 3.5 kg. What is the estimated circulating blood volume?

A 28-year-old woman undergoes emergency Caesarean section under spinal anaesthesia. Ten minutes after delivery, she develops brisk vaginal bleeding. Estimated blood loss is 1500 mL. The uterus is soft and poorly contracted. What is the most likely cause?

A 2-year-old child develops complete airway obstruction immediately following extubation after adenotonsillectomy. Which of the following is the most common cause?

A mechanically ventilated ICU patient has the following ABG: • pH: 7.28 • PaCO₂: 60 mmHg • HCO₃⁻: 27 mmol/L What is the primary acid-base disorder?

During surgery, train-of-four monitoring demonstrates: • Four twitches present • Significant fade noted What is the most likely interpretation?

A patient undergoing major abdominal surgery develops the ECG shown below: • Tall peaked T waves • Progressive widening of the QRS complex What electrolyte abnormality should be suspected first?

A patient with severe COPD undergoes thoracic surgery. Which ventilatory strategy is most appropriate during one-lung ventilation?

A labouring patient receiving epidural analgesia suddenly develops: • Tinnitus • Perioral numbness • Agitation • Generalised seizure What is the most appropriate next step?

A head-injured patient has: • Eyes open spontaneously • Confused conversation • Localises pain What is the GCS score?

A patient undergoing spinal surgery is monitored with motor evoked potentials (MEPs). Which anaesthetic technique best preserves MEP signals?

A patient with septic shock remains hypotensive despite adequate fluid resuscitation. Current observations: • MAP 55 mmHg • Lactate 4.8 mmol/L Which vasopressor is recommended as first-line therapy?

A 35-year-old woman undergoes Caesarean section under spinal anaesthesia. Shortly after delivery, she becomes restless and complains of difficulty breathing. Her blood pressure is 60/30 mmHg, heart rate is 45/min, and she is unable to move her upper limbs. What is the most likely diagnosis?

A 6-year-old child weighing 20 kg requires fluid therapy after an overnight fast. According to the Holliday-Segar formula, what is the maintenance fluid requirement per hour?

A mechanically ventilated patient develops sudden hypotension and desaturation. Ventilator findings: • Increased peak airway pressure • Increased plateau pressure • Absent breath sounds on the right side What is the most likely diagnosis?

A patient undergoing general anaesthesia demonstrates the following capnography trace: • Gradually rising expiratory upstroke • Slanted alveolar plateau What is the most likely diagnosis?

A patient develops ventricular fibrillation during surgery. What is the first priority?

A patient scheduled for lung resection has an FEV₁ of 35% predicted. What is the most important concern?

A labouring patient has the following CTG: • Baseline 140 bpm • Moderate variability • Accelerations present • No decelerations How should this trace be classified?

A patient with acute porphyria presents for emergency surgery. Which induction agent should generally be considered safe?

During prolonged spinal surgery, the surgeon requests motor evoked potential monitoring. Which anaesthetic drug is most likely to interfere significantly with MEP interpretation?

A septic ICU patient has: • MAP 68 mmHg • Lactate 6 mmol/L • ScvO₂ 52% What does the low ScvO₂ most likely indicate?

A 34-year-old woman with severe preeclampsia is receiving magnesium sulfate infusion. During assessment, the nurse reports a respiratory rate of 8 breaths/min and absent patellar reflexes. What is the most appropriate immediate management?

A 5-year-old child weighing 18 kg is scheduled for inguinal hernia repair. What is the estimated blood volume?

A ventilated ICU patient suddenly develops: • ETCO₂ drop from 35 mmHg to 12 mmHg • Tachycardia • Hypotension • Increased dead space ventilation What is the most likely diagnosis?

During general anaesthesia, train-of-four monitoring demonstrates no twitches. Post-tetanic count is 2. What is the best description of the level of blockade?

A patient develops a wide-complex tachycardia at 180 bpm during surgery. The rhythm is regular and no P waves are visible. What is the most likely diagnosis?

During one-lung ventilation, oxygen saturation decreases to 88%. DLT position has been confirmed bronchoscopically. What is the next most appropriate intervention?

A CTG demonstrates recurrent variable decelerations with preserved baseline variability. What is the most likely cause?

A patient with sickle cell disease presents for emergency laparotomy. Which perioperative measure is most important to minimize sickling?

A patient undergoing craniotomy demonstrates a BIS value of 92 despite receiving propofol infusion. Blood pressure and heart rate are increasing. What is the most likely interpretation?

A patient with septic shock remains hypotensive despite norepinephrine 0.4 µg/kg/min. MAP is 58 mmHg. What is the most appropriate additional vasopressor?

A 30-year-old woman undergoes emergency Caesarean section for fetal distress. Following delivery, the neonate is noted to have poor respiratory effort, hypotonia, and a heart rate of 90/min. The mother received repeated doses of intravenous fentanyl during labour. What is the most likely cause?

A 10-month-old infant weighing 9 kg presents for pyloromyotomy. What is the estimated blood volume?

A patient with ARDS is receiving lung-protective ventilation. Which tidal volume is recommended?

A patient undergoing laparoscopic surgery develops: • ETCO₂ rising from 38 to 60 mmHg • Tachycardia • Increasing temperature • Generalised muscle rigidity What is the most likely diagnosis?

A patient develops the following ECG abnormality: • Prolonged QT interval Which electrolyte abnormality is most commonly associated?

A patient undergoing thoracic surgery develops severe hypoxaemia during OLV despite optimal positioning and CPAP. What physiological mechanism normally helps maintain oxygenation during OLV?

A labouring patient develops sudden maternal hypotension after epidural top-up. Shortly afterward, fetal bradycardia develops. What is the most likely mechanism?