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)
Question 1 A 68-year-old male with severe aortic stenosis (valve area 0.7 cm², mean gradient 48
mmHg), LVEF 30%, and pulmonary hypertension (PASP 65 mmHg) presents for urgent
laparoscopic cholecystectomy for acute cholecystitis. His blood pressure is 98/62 mmHg with a
heart rate of 88 bpm. Which hemodynamic goal is MOST critical to maintain during anesthetic
induction?
A. Maintain high-normal heart rate (90-100 bpm) to preserve cardiac output B. Avoid decreases
in systemic vascular resistance to prevent coronary hypoperfusion C. Aggressively hydrate with
crystalloid to optimize preload D. Use ketamine as the sole induction agent to maintain
sympathetic tone
Correct Answer: B Rationale: In severe aortic stenosis with reduced LVEF, the hypertrophied,
non-compliant left ventricle depends on adequate preload and afterload to maintain coronary
perfusion. The fixed obstruction creates a pressure-loaded ventricle where coronary perfusion
occurs primarily during diastole and requires a sufficient aortic diastolic pressure gradient above
LV end-diastolic pressure. Option A is incorrect because tachycardia reduces diastolic filling time
and increases myocardial oxygen demand, potentially causing ischemia in the hypertrophied
ventricle; the goal is actually to avoid significant tachycardia while preventing bradycardia.
Option C is dangerous because these patients have diastolic dysfunction and are preload-
dependent but not preload-responsive in the traditional sense—aggressive crystalloid can cause
pulmonary edema without improving stroke volume, especially with coexisting pulmonary
hypertension. Option D is problematic because while ketamine preserves sympathetic tone, it
directly depresses myocardial contractility and may increase pulmonary artery pressure,
exacerbating right heart strain in the setting of pulmonary hypertension. The correct approach
,in B emphasizes maintaining afterload (SVR) because vasodilation from anesthetic agents can
precipitously drop coronary perfusion pressure, causing cardiovascular collapse in AS patients
who cannot increase stroke volume to compensate.
Question 2 A 54-year-old female with end-stage renal disease (eGFR 8 mL/min) on hemodysis
presents for emergent exploratory laparotomy for suspected mesenteric ischemia. Her last
dialysis was 4 days ago. Labs: K+ 6.2 mEq/L, HCO3 14 mEq/L, BUN 142 mg/dL, Cr 8.4 mg/dL,
ionized Ca 0.92 mmol/L. Which anesthetic management strategy is MOST appropriate?
A. Proceed with rapid sequence induction using succinylcholine after hyperventilation B.
Administer calcium chloride, insulin with glucose, and sodium bicarbonate, then induce with
rocuronium C. Perform emergent hemodialysis for 2 hours before surgery D. Use etomidate and
succinylcholine with defasciculating dose of rocuronium
Correct Answer: B Rationale: This patient has life-threatening hyperkalemia (K+ 6.2) with
metabolic acidosis requiring emergent surgery. The ASA and ABA guidelines emphasize that
unstable patients with surgical sources of sepsis or ischemia require source control before
optimization can occur. Option A is dangerous because succinylcholine can raise potassium by
0.5-1.0 mEq/L in renal failure patients due to upregulation of extrajunctional acetylcholine
receptors, potentially causing cardiac arrest at this potassium level. Option C is contraindicated
because mesenteric ischemia requires emergent surgical intervention; delaying for dialysis risks
bowel necrosis and death from sepsis. Option D repeats the succinylcholine error and adds
etomidate, which suppresses adrenal function—problematic in septic patients who need
endogenous cortisol. The correct answer B follows ACLS hyperkalemia management: calcium
chloride (cardiac membrane stabilization, onset 1-3 minutes), insulin with glucose (intracellular
potassium shift), and bicarbonate (corrects acidosis which drives potassium extracellularly).
Rocuronium is the appropriate neuromuscular blocker as it is metabolized hepatically and can
be reversed with sugammadex if needed.
Question 3 A 72-year-old male with Child-Pugh Class C cirrhosis presents for emergent repair of
a strangulated umbilical hernia. He has refractory ascites, encephalopathy grade 2, and INR 3.2.
His blood pressure is 82/48 mmHg despite albumin administration. Which vasopressor strategy
is MOST appropriate for initial hemodynamic support?
A. Norepinephrine to target MAP >65 mmHg with consideration of terlipressin if refractory B.
Phenylephrine as first-line agent to avoid splanchnic vasoconstriction C. High-dose dopamine to
improve renal perfusion and cardiac output D. Epinephrine infusion to provide both α and β
stimulation
, Correct Answer: A Rationale: Hepatorenal syndrome (HRS) and cirrhotic cardiomyopathy create
a unique hemodynamic profile: decreased systemic vascular resistance, relative hypovolemia
(splanchnic sequestration), and cardiac dysfunction. The 2021 AASLD guidelines and surviving
sepsis campaign recommend norepinephrine as first-line vasopressor in cirrhosis. Option B is
incorrect because phenylephrine's pure α-agonism increases afterload without inotropic
support and may worsen cardiac output in cirrhotic cardiomyopathy; it also fails to address the
pathophysiology of splanchnic vasodilation. Option C is outdated—high-dose dopamine causes
arrhythmias, splanchnic ischemia, and has no renal protective effects (contradicted by
evidence); dopamine is not recommended in current guidelines. Option D (epinephrine) is
reserved for cardiac arrest or severe cardiogenic shock; it causes significant lactic acidosis and
metabolic derangements that complicate hepatic metabolism. The correct answer A uses
norepinephrine, which provides both α-1 and β-1 effects, increasing MAP while maintaining
cardiac output. Terlipressin (vasopressin analog) specifically constricts splanchnic vessels and is
recommended for HRS-AKI, making it an excellent adjunct in refractory cases.
Question 4 A 45-year-old male with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and
difficult mask ventilation history presents for Roux-en-Y gastric bypass. After preoxygenation
with 100% O2 for 3 minutes in reverse Trendelenburg position, SpO2 is 98%. Which airway
management strategy is MOST appropriate?
A. Proceed with standard induction and attempt direct laryngoscopy with MAC 4 blade B.
Perform awake fiberoptic intubation with topical anesthesia and sedation C. Use video
laryngoscopy with hyperangulated blade and have LMA Supreme ready D. Administer
sugammadex immediately after rocuronium to ensure rapid reversibility
Correct Answer: C Rationale: This patient has multiple predictors of difficult mask ventilation
(obesity, OSA, history) but not necessarily difficult intubation. The ASA Difficult Airway
Algorithm 2022 emphasizes that video laryngoscopy (VL) should be considered early in
anticipated difficult airways. Option A is risky because standard direct laryngoscopy may fail,
and this patient desaturates rapidly (reduced FRC, increased oxygen consumption). Option B
(awake fiberoptic) is overly conservative for this elective case—while it guarantees airway
control, it is time-consuming, requires patient cooperation, and is not indicated when VL is
available and the patient can be safely induced. Option D is nonsensical as sugammadex given
immediately after rocuronium would prevent intubating conditions and offers no airway
protection benefit. The correct answer C employs VL with a hyperangulated blade (e.g.,
GlideScope, C-MAC D-Blade) which provides superior glottic visualization in obese patients with
redundant tissue. Having an LMA Supreme (second-generation supraglottic airway with gastric
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)
Question 1 A 68-year-old male with severe aortic stenosis (valve area 0.7 cm², mean gradient 48
mmHg), LVEF 30%, and pulmonary hypertension (PASP 65 mmHg) presents for urgent
laparoscopic cholecystectomy for acute cholecystitis. His blood pressure is 98/62 mmHg with a
heart rate of 88 bpm. Which hemodynamic goal is MOST critical to maintain during anesthetic
induction?
A. Maintain high-normal heart rate (90-100 bpm) to preserve cardiac output B. Avoid decreases
in systemic vascular resistance to prevent coronary hypoperfusion C. Aggressively hydrate with
crystalloid to optimize preload D. Use ketamine as the sole induction agent to maintain
sympathetic tone
Correct Answer: B Rationale: In severe aortic stenosis with reduced LVEF, the hypertrophied,
non-compliant left ventricle depends on adequate preload and afterload to maintain coronary
perfusion. The fixed obstruction creates a pressure-loaded ventricle where coronary perfusion
occurs primarily during diastole and requires a sufficient aortic diastolic pressure gradient above
LV end-diastolic pressure. Option A is incorrect because tachycardia reduces diastolic filling time
and increases myocardial oxygen demand, potentially causing ischemia in the hypertrophied
ventricle; the goal is actually to avoid significant tachycardia while preventing bradycardia.
Option C is dangerous because these patients have diastolic dysfunction and are preload-
dependent but not preload-responsive in the traditional sense—aggressive crystalloid can cause
pulmonary edema without improving stroke volume, especially with coexisting pulmonary
hypertension. Option D is problematic because while ketamine preserves sympathetic tone, it
directly depresses myocardial contractility and may increase pulmonary artery pressure,
exacerbating right heart strain in the setting of pulmonary hypertension. The correct approach
,in B emphasizes maintaining afterload (SVR) because vasodilation from anesthetic agents can
precipitously drop coronary perfusion pressure, causing cardiovascular collapse in AS patients
who cannot increase stroke volume to compensate.
Question 2 A 54-year-old female with end-stage renal disease (eGFR 8 mL/min) on hemodysis
presents for emergent exploratory laparotomy for suspected mesenteric ischemia. Her last
dialysis was 4 days ago. Labs: K+ 6.2 mEq/L, HCO3 14 mEq/L, BUN 142 mg/dL, Cr 8.4 mg/dL,
ionized Ca 0.92 mmol/L. Which anesthetic management strategy is MOST appropriate?
A. Proceed with rapid sequence induction using succinylcholine after hyperventilation B.
Administer calcium chloride, insulin with glucose, and sodium bicarbonate, then induce with
rocuronium C. Perform emergent hemodialysis for 2 hours before surgery D. Use etomidate and
succinylcholine with defasciculating dose of rocuronium
Correct Answer: B Rationale: This patient has life-threatening hyperkalemia (K+ 6.2) with
metabolic acidosis requiring emergent surgery. The ASA and ABA guidelines emphasize that
unstable patients with surgical sources of sepsis or ischemia require source control before
optimization can occur. Option A is dangerous because succinylcholine can raise potassium by
0.5-1.0 mEq/L in renal failure patients due to upregulation of extrajunctional acetylcholine
receptors, potentially causing cardiac arrest at this potassium level. Option C is contraindicated
because mesenteric ischemia requires emergent surgical intervention; delaying for dialysis risks
bowel necrosis and death from sepsis. Option D repeats the succinylcholine error and adds
etomidate, which suppresses adrenal function—problematic in septic patients who need
endogenous cortisol. The correct answer B follows ACLS hyperkalemia management: calcium
chloride (cardiac membrane stabilization, onset 1-3 minutes), insulin with glucose (intracellular
potassium shift), and bicarbonate (corrects acidosis which drives potassium extracellularly).
Rocuronium is the appropriate neuromuscular blocker as it is metabolized hepatically and can
be reversed with sugammadex if needed.
Question 3 A 72-year-old male with Child-Pugh Class C cirrhosis presents for emergent repair of
a strangulated umbilical hernia. He has refractory ascites, encephalopathy grade 2, and INR 3.2.
His blood pressure is 82/48 mmHg despite albumin administration. Which vasopressor strategy
is MOST appropriate for initial hemodynamic support?
A. Norepinephrine to target MAP >65 mmHg with consideration of terlipressin if refractory B.
Phenylephrine as first-line agent to avoid splanchnic vasoconstriction C. High-dose dopamine to
improve renal perfusion and cardiac output D. Epinephrine infusion to provide both α and β
stimulation
, Correct Answer: A Rationale: Hepatorenal syndrome (HRS) and cirrhotic cardiomyopathy create
a unique hemodynamic profile: decreased systemic vascular resistance, relative hypovolemia
(splanchnic sequestration), and cardiac dysfunction. The 2021 AASLD guidelines and surviving
sepsis campaign recommend norepinephrine as first-line vasopressor in cirrhosis. Option B is
incorrect because phenylephrine's pure α-agonism increases afterload without inotropic
support and may worsen cardiac output in cirrhotic cardiomyopathy; it also fails to address the
pathophysiology of splanchnic vasodilation. Option C is outdated—high-dose dopamine causes
arrhythmias, splanchnic ischemia, and has no renal protective effects (contradicted by
evidence); dopamine is not recommended in current guidelines. Option D (epinephrine) is
reserved for cardiac arrest or severe cardiogenic shock; it causes significant lactic acidosis and
metabolic derangements that complicate hepatic metabolism. The correct answer A uses
norepinephrine, which provides both α-1 and β-1 effects, increasing MAP while maintaining
cardiac output. Terlipressin (vasopressin analog) specifically constricts splanchnic vessels and is
recommended for HRS-AKI, making it an excellent adjunct in refractory cases.
Question 4 A 45-year-old male with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and
difficult mask ventilation history presents for Roux-en-Y gastric bypass. After preoxygenation
with 100% O2 for 3 minutes in reverse Trendelenburg position, SpO2 is 98%. Which airway
management strategy is MOST appropriate?
A. Proceed with standard induction and attempt direct laryngoscopy with MAC 4 blade B.
Perform awake fiberoptic intubation with topical anesthesia and sedation C. Use video
laryngoscopy with hyperangulated blade and have LMA Supreme ready D. Administer
sugammadex immediately after rocuronium to ensure rapid reversibility
Correct Answer: C Rationale: This patient has multiple predictors of difficult mask ventilation
(obesity, OSA, history) but not necessarily difficult intubation. The ASA Difficult Airway
Algorithm 2022 emphasizes that video laryngoscopy (VL) should be considered early in
anticipated difficult airways. Option A is risky because standard direct laryngoscopy may fail,
and this patient desaturates rapidly (reduced FRC, increased oxygen consumption). Option B
(awake fiberoptic) is overly conservative for this elective case—while it guarantees airway
control, it is time-consuming, requires patient cooperation, and is not indicated when VL is
available and the patient can be safely induced. Option D is nonsensical as sugammadex given
immediately after rocuronium would prevent intubating conditions and offers no airway
protection benefit. The correct answer C employs VL with a hyperangulated blade (e.g.,
GlideScope, C-MAC D-Blade) which provides superior glottic visualization in obese patients with
redundant tissue. Having an LMA Supreme (second-generation supraglottic airway with gastric
