Welcome to your Test 25 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? Proceed with spinal anaesthesia immediately Perform spinal anaesthesia using a smaller needle Delay neuraxial block until an appropriate anticoagulant-free interval has elapsed Reverse apixaban with protamine and proceed None 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? Myocardial infarction TURP syndrome Pulmonary embolism Bladder perforation None 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? Bronchospasm Venous air embolism Myocardial infarction Malignant hyperthermia None A patient undergoing thyroidectomy develops: • Hoarseness • Weak voice immediately after extubation. What is the most likely nerve injury? Hypoglossal nerve Recurrent laryngeal nerve Facial nerve Glossopharyngeal nerve None 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? High spinal block Bone Cement Implantation Syndrome Myocardial infarction Tension pneumothorax None During pituitary surgery, the anaesthetist notices: • Urine output 800 mL/hour • Rising serum sodium What is the most likely diagnosis? SIADH Diabetes insipidus TURP syndrome Acute kidney injury None A patient undergoing retinal detachment repair receives succinylcholine. The surgeon suddenly complains: "The eye is becoming very tense." What is the explanation? Reduced intraocular pressure Increased intraocular pressure Choroidal haemorrhage Acute glaucoma None A child undergoing adenotonsillectomy develops: • Severe inspiratory effort • No air movement • SpO₂ 75% What is the most likely diagnosis? Bronchospasm Laryngospasm Aspiration Pulmonary oedema None A patient undergoing TURBT develops obturator nerve stimulation. What is the most likely intraoperative consequence? Bradycardia Adductor muscle contraction Bronchospasm Hypothermia None A patient undergoing clipping of a cerebral aneurysm suddenly develops: • BP 220/120 mmHg • HR 110/min during laryngoscopy. Why is this particularly dangerous? Increased risk of bronchospasm Increased risk of aneurysm rupture Increased urine output Reduced cerebral blood flow None 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? Serum sodium measurement Troponin level D-dimer Serum magnesium None 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? Bronchospasm Recurrent laryngeal nerve injury Expanding neck haematoma Pulmonary oedema None 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? High spinal block Fat embolism Bronchospasm TURP syndrome None During transsphenoidal pituitary surgery, the surgeon asks for a relaxed, bloodless field. Which physiological parameter is most important to avoid? Mild hypocapnia Severe hypertension FiO₂ 100% Mild hypothermia None A patient with an open globe injury requires emergency surgery. Which induction drug is most controversial? Propofol Ketamine Succinylcholine Fentanyl None A child undergoing microlaryngoscopy develops complete airway obstruction during laser surgery. What is the immediate priority? Increase oxygen concentration Remove the laser and secure the airway Continue surgery rapidly Administer diuretics None A patient undergoing awake craniotomy suddenly becomes confused and develops right arm weakness during tumour resection. What is the most likely explanation? Local anaesthetic toxicity Seizure activity or cortical stimulation Hyperkalaemia TURP syndrome None 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? Septic shock Malignant hyperthermia Anaphylaxis Pulmonary embolism None During scoliosis surgery, MEPs suddenly disappear. MAP is 42 mmHg. What is the most appropriate first step? Wake the patient immediately Increase volatile anaesthetic concentration Restore blood pressure Terminate surgery None A patient develops severe postoperative nausea and vomiting after strabismus surgery. Which factor most likely contributed? Male gender Ophthalmic surgery Smoking Advanced age None 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? Better sciatic nerve coverage Reduced risk of local anaesthetic toxicity Preservation of quadriceps strength Longer duration of analgesia None 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? Pneumothorax Phrenic nerve blockade Pulmonary embolism Local anaesthetic toxicity None 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? Bronchospasm Kinked endotracheal tube Reduced lung compliance due to positioning Circuit leak None During a supraclavicular brachial plexus block, the patient develops: • Sudden pleuritic chest pain • Mild dyspnoea What complication should be suspected? Recurrent laryngeal nerve palsy Pneumothorax Horner syndrome LAST None 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? Local anaesthetic toxicity Cerebral ischaemia Hyperglycaemia Anaphylaxis None A patient undergoing TURBT suddenly develops violent adductor muscle contraction. Which nerve is responsible? Femoral nerve Obturator nerve Sciatic nerve Genitofemoral nerve None 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? Neck haematoma Bilateral recurrent laryngeal nerve injury Bronchospasm Tracheomalacia None 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? Increase FiO₂ Local anaesthetic scalp block Furosemide Dexamethasone None A patient receives an axillary brachial plexus block. Which nerve is most likely to be missed if specifically not sought? Median nerve Ulnar nerve Radial nerve Musculocutaneous nerve None 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? Anaphylaxis Venous air embolism Bronchospasm TURP syndrome None 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? Blood glucose Presence of airway oedema Haemoglobin concentration Neuromuscular monitoring only None 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? Blood loss is minor and unlikely to explain the haemodynamic instability Blood loss represents approximately 10% of blood volume Blood loss represents approximately 25% of blood volume Blood loss represents approximately 40% of blood volume and is likely contributing significantly to shock None 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? Hyperkalaemia Cortical stimulation-induced seizure Local anaesthetic toxicity Venous air embolism None 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? Raised ICP Cerebral hypoperfusion Hypercapnia Cerebral vasodilation None A patient undergoing percutaneous nephrolithotomy (PCNL) develops: • Increased airway pressure • Hypoxaemia • Reduced breath sounds on one side What complication should be suspected? TURP syndrome Pneumothorax Hyperkalaemia Bronchospasm None A patient undergoing middle ear surgery suddenly develops: • Bradycardia • Hypotension during manipulation near the tympanic membrane. What reflex is most likely responsible? Cushing reflex Oculocardiac reflex Trigeminocardiac reflex Bezold-Jarisch reflex None An ultrasound-guided popliteal sciatic nerve block is performed for foot surgery. Which area is LEAST likely to be anaesthetised by the block alone? Sole of foot Dorsum of foot Heel Medial aspect of lower leg None 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? SIADH Diabetes insipidus Acute tubular necrosis Cerebral salt wasting None A patient with glaucoma presents for emergency laparotomy. Which drug may significantly increase intraocular pressure? Propofol Rocuronium Succinylcholine Fentanyl None During total hip arthroplasty, shortly after cementation, the patient develops: • Severe hypotension • Hypoxaemia • ETCO₂ reduction What is the most likely diagnosis? Fat embolism syndrome Bone Cement Implantation Syndrome Myocardial infarction Anaphylaxis None A patient undergoing microlaryngoscopy requires laser excision of a vocal cord lesion. Which factor MOST increases the risk of airway fire? Low FiO₂ Air/Oxygen mixture High oxygen concentration around the airway Use of saline-soaked pledgets None 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? Excessive neck flexion and venous obstruction Hyperkalaemia Bronchospasm Malignant hyperthermia None 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? Middle meningeal artery Internal carotid artery Facial artery Vertebral artery None A patient undergoing radical cystectomy develops: • Temperature 35°C • INR rising • Increased bleeding from surgical field What factor is most likely contributing? Hypothermia-induced coagulopathy Hyperglycaemia Hypercapnia Increased MAC None During endoscopic sinus surgery, the surgeon requests controlled hypotension. Which MAP target is generally considered acceptable in a healthy adult? 30–40 mmHg 50–65 mmHg 90–100 mmHg >110 mmHg None A patient undergoing shoulder arthroscopy receives an interscalene block. Postoperatively he develops: • Ptosis • Miosis • Facial anhidrosis What is the most likely diagnosis? Stroke Horner syndrome Pneumothorax LAST None A 70-year-old patient undergoing TURP develops: • Hypertension • Bradycardia • Confusion Serum sodium returns as: 118 mmol/L What is the definitive treatment? Hypertonic saline in severe symptomatic cases Furosemide only Mannitol Calcium gluconate None During clipping of a cerebral aneurysm, temporary clipping is applied. What monitoring modality is most useful for detecting cerebral ischaemia? BIS Train-of-four SSEP monitoring CVP monitoring None A patient undergoing ophthalmic surgery receives a peribulbar block. Immediately afterwards he becomes: • Confused • Unresponsive • Apnoeic What complication should be suspected? Retrobulbar haemorrhage Brainstem anaesthesia Acute glaucoma Oculocardiac reflex None A patient undergoing total knee replacement receives: • Adductor canal block • IPACK block What is the main purpose of the IPACK block? Anaesthetise anterior knee capsule Provide posterior knee analgesia Block femoral nerve None A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ decrease • Hypotension • Oxygen desaturation TEE demonstrates intracardiac air. What is the immediate anaesthetic management? Nitrous oxide administration Increase volatile agent concentration 100% oxygen and inform surgeon immediately Extubate the patient None 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? Myocardial infarction Bone cement implantation syndrome High spinal block Pulmonary embolism None A patient receives an ultrasound-guided TAP block after laparotomy. Which nerves are primarily targeted? C5–T1 T6–L1 L2–L4 S1–S4 None A patient undergoing VATS lobectomy develops: • SpO₂ 84% The DLT position is confirmed with bronchoscopy. What is the next best step? Reduce FiO₂ Apply CPAP to the non-dependent lung Remove DLT Give mannitol None A woman undergoing Caesarean section develops: • Sudden hypoxia • Severe hypotension • Coagulopathy immediately after delivery. What is the most likely diagnosis? Pulmonary embolism Amniotic fluid embolism High spinal block Magnesium toxicity None A patient undergoing breast surgery receives a PECS II block. Which nerves are primarily targeted? Brachial plexus roots Intercostal nerves supplying the chest wall Femoral nerve Sciatic nerve None A patient with traumatic brain injury develops: • BP 180/100 mmHg • HR 42/min What does this combination suggest? Hypovolaemia Cushing response Anaphylaxis Hyperkalaemia None 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? Malignant hyperthermia Septic shock Anaphylaxis Thyroid storm None A patient receives a PENG block before total hip replacement. What is the primary aim? Block sciatic nerve Block posterior knee capsule Provide motor-sparing analgesia for hip surgery Anaesthetise the entire lower limb None A patient undergoing cervical spine surgery is being extubated. Which factor most strongly predicts a difficult reintubation if extubation fails? Mild hypertension Neck swelling and restricted access Normal oxygen saturation Age over 60 years None 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? Anxiety attack Local anaesthetic systemic toxicity (LAST) Hypoglycaemia Emergence delirium None 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? Brachial plexus injury Spinal cord ischaemia Stroke Hyperkalaemia None A 6-year-old child undergoes orchidopexy. A caudal block is planned. What is the most common complication of a caudal block? Total spinal anaesthesia Infection Intravascular injection Block failure None A patient undergoes clipping of a cerebral aneurysm. During temporary clipping, the surgeon requests mild hypocapnia. What is the primary physiological effect? Cerebral vasodilation Increased cerebral blood flow Cerebral vasoconstriction Increased ICP None During endoscopic sinus surgery, the surgeon reports excessive bleeding despite normal coagulation. Which anaesthetic intervention may improve surgical visibility? Controlled hypotension Hypercapnia Tachycardia Hypertension None A patient undergoing shoulder replacement receives an interscalene block. Which nerve is most commonly affected unintentionally? Femoral nerve Obturator nerve Obturator nerve Sciatic nerve None A patient undergoing TURP develops: • Confusion • Hyponatraemia • Pulmonary oedema Which mechanism is primarily responsible? Absorption of irrigation fluid Myocardial infarction Anaphylaxis Hyperkalaemia None A patient undergoing awake craniotomy suddenly becomes unable to speak during cortical stimulation. What does this most likely indicate? Seizure Language cortex localisation Hypercapnia Venous air embolism None A patient undergoing robotic prostatectomy has been in steep Trendelenburg for 5 hours. Which postoperative complication is most likely? Airway oedema Hyperthermia Hypoglycaemia Hypercalcaemia None 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? Femoral nerve Lateral femoral cutaneous nerve Tibial nerve Common peroneal nerve None 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? High spinal block Bone Cement Implantation Syndrome Pulmonary oedema Anaphylaxis None 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? Reduce blood pressure Increase blood pressure and inform surgeon Administer adenosine Continue surgery None A patient receives an ultrasound-guided erector spinae plane (ESP) block before VATS surgery. What is the primary indication? Solely visceral analgesia Chest wall analgesia Complete brachial plexus blockade Sciatic nerve blockade None A patient undergoing posterior fossa surgery develops: • Sudden ETCO₂ decrease • Hypotension • Desaturation What is the most sensitive monitor for detecting this complication? Pulse oximetry ECG Transoesophageal echocardiography (TEE) Temperature probe None A patient undergoing microlaryngoscopy requires laser excision of a laryngeal lesion. Which gas should be avoided because it supports combustion? Air Helium Nitrous oxide Carbon dioxide None A 58-year-old patient undergoes TURBT under spinal anaesthesia. Suddenly there is severe adductor muscle contraction. Which block could have reduced this risk? Femoral nerve block Sciatic nerve block Obturator nerve block TAP block None 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. Fluid restriction Desmopressin Mannitol Furosemide None A patient undergoes retinal detachment surgery. Traction on the extraocular muscles produces: • HR decrease from 80 to 35/min What reflex is responsible? Cushing reflex Oculocardiac reflex Bezold-Jarisch reflex Trigeminocardiac reflex None 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? Reduced venous return Increased MAC Hyperglycaemia Hypocalcaemia None A patient receives a supraclavicular block. Thirty minutes later he develops: • Ptosis • Miosis but is otherwise well. What is the most likely diagnosis? Stroke Horner syndrome Brainstem anaesthesia LAST None 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? Forceful airway examination in ED Inhalational induction maintaining spontaneous ventilation Immediate muscle relaxant and intubation Sedation with midazolam in the ward None A patient undergoing lobectomy develops: • Persistent hypoxaemia during OLV • DLT position confirmed What physiological mechanism is primarily responsible for maintaining oxygenation during OLV? Increased cardiac output Hypoxic pulmonary vasoconstriction (HPV) Increased ICP Bronchoconstriction None A patient receives a quadratus lumborum (QL) block after abdominal surgery. What is the primary benefit compared with a TAP block? Better upper abdominal and visceral analgesic spread Complete lower limb anaesthesia Sciatic nerve blockade Brachial plexus blockade None A patient undergoing clipping of an intracranial aneurysm suddenly develops: • Brain swelling • Difficult surgical exposure Which ABG finding would most likely contribute? PaCO₂ 25 mmHg PaCO₂ 30 mmHg PaCO₂ 55 mmHg PaCO₂ 35 mmHg None A patient undergoing robotic prostatectomy has: • Peak airway pressure 40 cmH₂O • Plateau pressure 36 cmH₂O What is the most likely cause? Bronchospasm Reduced respiratory compliance from pneumoperitoneum and Trendelenburg Circuit leak Tube disconnection None 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? 10% 20% 30% 40% None 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? Pulmonary embolism Oxytocin-induced vasodilation High spinal block Amniotic fluid embolism None A trauma patient has: • Eyes open to pain • Incomprehensible sounds • Withdraws from pain What is the GCS? 7 8 9 10 None 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? Anaemia Excess oxygen delivery Inadequate oxygen delivery due to low flow Hyperventilation None A patient receives an ultrasound-guided femoral nerve block. Which motor deficit is expected? Foot drop Weak knee extension Wrist drop Weak plantar flexion None A premature infant presents for inguinal hernia repair. Which postoperative complication requires prolonged monitoring? Hypertension Hyperglycaemia Apnoea Hyperthermia None A patient undergoing labour epidural analgesia suddenly develops: • Tinnitus • Metallic taste • Agitation What should be suspected? High spinal block LAST Pulmonary embolism Eclampsia None A patient undergoing thoracotomy develops severe postoperative pain despite PCA morphine. Which regional technique provides the most effective analgesia? Femoral block TAP block Thoracic epidural Wrist block None A patient with Tetralogy of Fallot develops: • Sudden cyanosis • Tachypnoea • Irritability during induction. What is the most likely diagnosis? Bronchospasm Tet spell Pulmonary oedema Pneumothorax None A patient undergoing ophthalmic surgery develops severe bradycardia during traction on the medial rectus muscle. What is the first step? Defibrillation Stop surgical traction Administer amiodarone Give furosemide None A patient undergoing emergency laparotomy develops: • Temperature 40°C • ETCO₂ 75 mmHg • Generalized rigidity What is the definitive treatment? Mannitol Dantrolene Calcium gluconate Magnesium sulfate None A patient undergoing total knee replacement receives an adductor canal block. Which nerve is primarily targeted? Sciatic nerve Saphenous nerve Obturator nerve Tibial nerve None A patient undergoing labour develops a CTG showing: • Baseline 170 bpm • Reduced variability • Recurrent late decelerations How should this trace be classified? Normal Suspicious Pathological Pathological None A patient undergoing posterior fossa surgery develops: • ETCO₂ decrease • Hypotension • Desaturation What is the most likely diagnosis? Bronchospasm Venous air embolism Myocardial infarction Hyperkalaemia None 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? Salbutamol Dexamethasone Succinylcholine Furosemide None Name Email Time's up
