ASA 114 Advanced Anesthesiology Practice ACTUAL
PRACTICE EXAM V1 2026/2027 | Verified Questions and
Answers | For Specialized Certification & Board Review
| Grade A Target | Pass Guaranteed
Section 1: Complex Comorbidity Management (Questions 1-20)
Q1: A 68-year-old male with NYHA Class III heart failure (EF 25%), severe pulmonary
hypertension (PASP 65 mmHg), and chronic kidney disease (eGFR 32 mL/min/1.73m²) presents
for open abdominal aortic aneurysm repair. Preoperative medications include
sacubitril/valsartan, spironolactone, and sildenafil. Which preoperative intervention is most
critical to optimize his hemodynamic status before induction?
A. Continue all medications through the morning of surgery without modification B. Discontinue
sacubitril/valsartan 36 hours preoperatively, continue sildenafil, and initiate invasive monitoring
placement prior to induction [CORRECT] C. Discontinue sildenafil 24 hours preoperatively due to
risk of hypotension with general anesthesia D. Initiate high-dose β-blockade to achieve heart
rate <60 bpm before surgery
Correct Answer: B
Rationale: This patient presents with severe combined pre- and post-capillary pulmonary
hypertension superimposed on advanced systolic heart failure, creating a precarious
hemodynamic profile where acute afterload reduction or increases in pulmonary vascular
resistance (PVR) can precipitate right ventricular failure and cardiogenic shock. The
sacubitril/valsartan (ARNI) must be held 36 hours preoperatively due to the risk of refractory
angioedema and profound hypotension on induction, particularly when combined with
anesthetic agents. Sildenafil (phosphodiesterase-5 inhibitor) should be continued as abrupt
withdrawal can precipitate rebound pulmonary hypertension. Option A risks catastrophic
hypotension on induction. Option C is incorrect because discontinuing sildenafil would worsen
pulmonary hypertension and right heart failure. Option D is contraindicated—negative
chronotropy without addressing afterload mismatch would further compromise cardiac output
in this low-EF patient with fixed stroke volume. Pre-induction arterial line and likely pulmonary
artery catheter placement allow real-time management of this high-risk hemodynamic milieu.
,Q2: A 54-year-old female with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and
Pickwickian syndrome presents for laparoscopic gastric bypass. Preoperative room air SpO2 is
88%. Which anesthetic strategy optimizes perioperative safety?
A. Rapid sequence induction with succinylcholine and avoidance of positive pressure ventilation
until intubation B. Awake fiber-optic intubation with topical anesthesia, followed by cautious
induction after airway security [CORRECT] C. Standard inhalational induction with sevoflurane in
100% oxygen D. High-dose propofol induction (3 mg/kg actual body weight) with immediate
surgical incision
Correct Answer: B
Rationale: This patient exhibits the lethal triad of morbid obesity, severe obstructive sleep
apnea, and obesity-hypoventilation syndrome (Pickwickian syndrome), characterized by chronic
hypercapnia, hypoxemia, and pulmonary hypertension. Her baseline hypoxemia (SpO2 88% on
room air) indicates severe ventilation-perfusion mismatch and limited cardiopulmonary reserve.
The ASA Difficult Airway Algorithm and society guidelines for bariatric surgery anesthesia
emphasize that the safest approach in patients with predicted difficult mask ventilation (obesity,
beard, OSA, limited mandibular protrusion) AND difficult intubation (large neck circumference,
high Mallampati) is awake fiber-optic intubation. This preserves spontaneous ventilation and
airway reflexes until definitive airway control is achieved. Option A risks cannot-intubate-
cannot-ventilate scenario with rapid desaturation due to reduced functional reserve capacity
and high oxygen consumption. Option C would cause rapid apnea and desaturation. Option D
demonstrates profound misunderstanding of propofol pharmacokinetics in obesity—actual
body weight dosing causes overdose, and immediate incision without airway control is lethal.
Q3: A 72-year-old male with end-stage liver disease (MELD 24, Child-Pugh C) presents for
emergent laparotomy for peritonitis. Laboratory values: INR 2.8, platelets 45,000/μL, fibrinogen
89 mg/dL, creatinine 2.4 mg/dL. Which component of his coagulopathy represents the highest
immediate risk for intraoperative bleeding?
A. Thrombocytopenia requiring platelet transfusion to >100,000/μL B. Hypofibrinogenemia
requiring cryoprecipitate or fibrinogen concentrate to achieve >150 mg/dL [CORRECT] C.
Elevated INR requiring FFP to normalize PT/INR D. Uremic platelet dysfunction requiring DDAVP
Correct Answer: B
Rationale: In advanced liver disease with consumptive coagulopathy and sepsis, fibrinogen
levels below 100 mg/dL represent a critical threshold for surgical hemostasis. Fibrinogen is
essential for clot formation as the substrate for platelet aggregation and fibrin polymerization.
, In this patient with fibrinogen 89 mg/dL, primary hemostasis and clot stability are severely
compromised regardless of INR correction. Current massive transfusion and trauma guidelines
(European Task Force for Advanced Bleeding Care in Trauma, ACS TQIP) prioritize fibrinogen
replacement (target >150-200 mg/dL in severe bleeding) before or concurrent with other
factors. Option A is incorrect—platelet counts >50,000/μL are generally adequate for surgical
hemostasis unless platelet dysfunction coexists. Option C addresses PT/INR but FFP volume (15-
20 mL/kg) risks volume overload and TACO in this cirrhotic patient without addressing the
fundamental clot substrate deficiency. Option D addresses uremic dysfunction, but the
creatinine of 2.4 in this acute-on-chronic picture is less immediately relevant than the profound
hypofibrinogenemia. Goal-directed therapy with viscoelastic testing (TEG/ROTEM) would guide
specific component therapy.
Q4: A 45-year-old female with idiopathic pulmonary arterial hypertension (PAH) on continuous
IV epoprostenol presents for cholecystectomy. Intraoperatively, after induction, her systemic
blood pressure is 85/50 mmHg with CVP 18 mmHg, PA pressure 68/40 mmHg, and cardiac index
1.8 L/min/m². Which intervention is most appropriate?
A. Fluid bolus 2L crystalloid to increase preload and cardiac output B. Initiate norepinephrine to
increase systemic vascular resistance and coronary perfusion [CORRECT] C. Increase
epoprostenol infusion to reduce PA pressures D. Administer phenylephrine 100 μg bolus
Correct Answer: B
Rationale: This patient demonstrates acute right ventricular failure with systemic hypotension
and inadequate cardiac index—the hallmark of PAH crisis. The pathophysiology involves RV
pressure overload causing septal shift, reduced LV filling, and ultimately cardiogenic shock. In
this scenario, maintaining systemic vascular pressure (afterload) is critical to preserve RV
coronary perfusion, as the RV is perfused during both systole and diastole and is highly
susceptible to ischemia at low systemic pressures. Norepinephrine, with its combined α1 and
weak β1 effects, increases SVR and provides inotropic support without increasing PVR
significantly. Option A is dangerous—volume loading distends the failing RV, worsens septal
shift, and further compromises LV filling. Option C is contraindicated in acute decompensation—
increasing epoprostenol causes systemic hypotension and may worsen RV perfusion. Option D
(pure α-agonist) increases SVR but provides no inotropic support and may increase PVR. The
ERAs/Prostanoids and Phosphodiesterase Inhibitors in PAH guidelines support norepinephrine
as first-line for PAH crisis with hypotension.
PRACTICE EXAM V1 2026/2027 | Verified Questions and
Answers | For Specialized Certification & Board Review
| Grade A Target | Pass Guaranteed
Section 1: Complex Comorbidity Management (Questions 1-20)
Q1: A 68-year-old male with NYHA Class III heart failure (EF 25%), severe pulmonary
hypertension (PASP 65 mmHg), and chronic kidney disease (eGFR 32 mL/min/1.73m²) presents
for open abdominal aortic aneurysm repair. Preoperative medications include
sacubitril/valsartan, spironolactone, and sildenafil. Which preoperative intervention is most
critical to optimize his hemodynamic status before induction?
A. Continue all medications through the morning of surgery without modification B. Discontinue
sacubitril/valsartan 36 hours preoperatively, continue sildenafil, and initiate invasive monitoring
placement prior to induction [CORRECT] C. Discontinue sildenafil 24 hours preoperatively due to
risk of hypotension with general anesthesia D. Initiate high-dose β-blockade to achieve heart
rate <60 bpm before surgery
Correct Answer: B
Rationale: This patient presents with severe combined pre- and post-capillary pulmonary
hypertension superimposed on advanced systolic heart failure, creating a precarious
hemodynamic profile where acute afterload reduction or increases in pulmonary vascular
resistance (PVR) can precipitate right ventricular failure and cardiogenic shock. The
sacubitril/valsartan (ARNI) must be held 36 hours preoperatively due to the risk of refractory
angioedema and profound hypotension on induction, particularly when combined with
anesthetic agents. Sildenafil (phosphodiesterase-5 inhibitor) should be continued as abrupt
withdrawal can precipitate rebound pulmonary hypertension. Option A risks catastrophic
hypotension on induction. Option C is incorrect because discontinuing sildenafil would worsen
pulmonary hypertension and right heart failure. Option D is contraindicated—negative
chronotropy without addressing afterload mismatch would further compromise cardiac output
in this low-EF patient with fixed stroke volume. Pre-induction arterial line and likely pulmonary
artery catheter placement allow real-time management of this high-risk hemodynamic milieu.
,Q2: A 54-year-old female with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and
Pickwickian syndrome presents for laparoscopic gastric bypass. Preoperative room air SpO2 is
88%. Which anesthetic strategy optimizes perioperative safety?
A. Rapid sequence induction with succinylcholine and avoidance of positive pressure ventilation
until intubation B. Awake fiber-optic intubation with topical anesthesia, followed by cautious
induction after airway security [CORRECT] C. Standard inhalational induction with sevoflurane in
100% oxygen D. High-dose propofol induction (3 mg/kg actual body weight) with immediate
surgical incision
Correct Answer: B
Rationale: This patient exhibits the lethal triad of morbid obesity, severe obstructive sleep
apnea, and obesity-hypoventilation syndrome (Pickwickian syndrome), characterized by chronic
hypercapnia, hypoxemia, and pulmonary hypertension. Her baseline hypoxemia (SpO2 88% on
room air) indicates severe ventilation-perfusion mismatch and limited cardiopulmonary reserve.
The ASA Difficult Airway Algorithm and society guidelines for bariatric surgery anesthesia
emphasize that the safest approach in patients with predicted difficult mask ventilation (obesity,
beard, OSA, limited mandibular protrusion) AND difficult intubation (large neck circumference,
high Mallampati) is awake fiber-optic intubation. This preserves spontaneous ventilation and
airway reflexes until definitive airway control is achieved. Option A risks cannot-intubate-
cannot-ventilate scenario with rapid desaturation due to reduced functional reserve capacity
and high oxygen consumption. Option C would cause rapid apnea and desaturation. Option D
demonstrates profound misunderstanding of propofol pharmacokinetics in obesity—actual
body weight dosing causes overdose, and immediate incision without airway control is lethal.
Q3: A 72-year-old male with end-stage liver disease (MELD 24, Child-Pugh C) presents for
emergent laparotomy for peritonitis. Laboratory values: INR 2.8, platelets 45,000/μL, fibrinogen
89 mg/dL, creatinine 2.4 mg/dL. Which component of his coagulopathy represents the highest
immediate risk for intraoperative bleeding?
A. Thrombocytopenia requiring platelet transfusion to >100,000/μL B. Hypofibrinogenemia
requiring cryoprecipitate or fibrinogen concentrate to achieve >150 mg/dL [CORRECT] C.
Elevated INR requiring FFP to normalize PT/INR D. Uremic platelet dysfunction requiring DDAVP
Correct Answer: B
Rationale: In advanced liver disease with consumptive coagulopathy and sepsis, fibrinogen
levels below 100 mg/dL represent a critical threshold for surgical hemostasis. Fibrinogen is
essential for clot formation as the substrate for platelet aggregation and fibrin polymerization.
, In this patient with fibrinogen 89 mg/dL, primary hemostasis and clot stability are severely
compromised regardless of INR correction. Current massive transfusion and trauma guidelines
(European Task Force for Advanced Bleeding Care in Trauma, ACS TQIP) prioritize fibrinogen
replacement (target >150-200 mg/dL in severe bleeding) before or concurrent with other
factors. Option A is incorrect—platelet counts >50,000/μL are generally adequate for surgical
hemostasis unless platelet dysfunction coexists. Option C addresses PT/INR but FFP volume (15-
20 mL/kg) risks volume overload and TACO in this cirrhotic patient without addressing the
fundamental clot substrate deficiency. Option D addresses uremic dysfunction, but the
creatinine of 2.4 in this acute-on-chronic picture is less immediately relevant than the profound
hypofibrinogenemia. Goal-directed therapy with viscoelastic testing (TEG/ROTEM) would guide
specific component therapy.
Q4: A 45-year-old female with idiopathic pulmonary arterial hypertension (PAH) on continuous
IV epoprostenol presents for cholecystectomy. Intraoperatively, after induction, her systemic
blood pressure is 85/50 mmHg with CVP 18 mmHg, PA pressure 68/40 mmHg, and cardiac index
1.8 L/min/m². Which intervention is most appropriate?
A. Fluid bolus 2L crystalloid to increase preload and cardiac output B. Initiate norepinephrine to
increase systemic vascular resistance and coronary perfusion [CORRECT] C. Increase
epoprostenol infusion to reduce PA pressures D. Administer phenylephrine 100 μg bolus
Correct Answer: B
Rationale: This patient demonstrates acute right ventricular failure with systemic hypotension
and inadequate cardiac index—the hallmark of PAH crisis. The pathophysiology involves RV
pressure overload causing septal shift, reduced LV filling, and ultimately cardiogenic shock. In
this scenario, maintaining systemic vascular pressure (afterload) is critical to preserve RV
coronary perfusion, as the RV is perfused during both systole and diastole and is highly
susceptible to ischemia at low systemic pressures. Norepinephrine, with its combined α1 and
weak β1 effects, increases SVR and provides inotropic support without increasing PVR
significantly. Option A is dangerous—volume loading distends the failing RV, worsens septal
shift, and further compromises LV filling. Option C is contraindicated in acute decompensation—
increasing epoprostenol causes systemic hypotension and may worsen RV perfusion. Option D
(pure α-agonist) increases SVR but provides no inotropic support and may increase PVR. The
ERAs/Prostanoids and Phosphodiesterase Inhibitors in PAH guidelines support norepinephrine
as first-line for PAH crisis with hypotension.
