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
Q1: A 68-year-old male (BMI 42 kg/m²) with severe aortic stenosis (valve area 0.8 cm², mean
gradient 42 mmHg), HFrEF (EF 30%), moderate pulmonary hypertension (PASP 55 mmHg), and
OSA presents for emergent laparoscopic cholecystectomy for acute cholecystitis. Preoperative
TTE shows concentric LVH and RV dilation. Current medications include carvedilol 25 mg BID,
furosemide 40 mg daily, and apixaban 5 mg BID (last dose 12 hours ago). Hemoglobin is 10.2
g/dL, creatinine 1.8 mg/dL. Which anesthetic strategy best balances hemodynamic stability with
surgical requirements?
A. General anesthesia with rapid sequence intubation using etomidate 0.3 mg/kg and
succinylcholine 1.5 mg/kg, maintain with sevoflurane 0.5-1 MAC, avoid neuraxial techniques,
and utilize low-pressure pneumoperitoneum (8-10 mmHg) with steep reverse Trendelenburg
positioning.
B. General anesthesia with propofol 2 mg/kg and rocuronium 0.6 mg/kg for induction, high-
dose opioid technique (fentanyl 10 mcg/kg) to blunt sympathetic response, and standard
pneumoperitoneum (12-15 mmHg) with head-up tilt to reduce venous return.
C. Spinal anesthesia with hyperbaric bupivacaine 15 mg to achieve T4 sensory level,
supplemented with midazolam 2 mg IV for anxiolysis, and maintain spontaneous ventilation
with supplemental O2 via nasal cannula.
D. Combined general-epidural technique with low-dose propofol infusion (25-50 mcg/kg/min),
thoracic epidural bolus of 5 mL 0.25% bupivacaine, and aggressive fluid loading (30 mL/kg
crystalloid) prior to epidural placement to prevent hypotension.
Correct Answer: A
Rationale: This patient presents a collision of four high-risk conditions: fixed cardiac output
from critical AS, preload-dependent RV from pulmonary hypertension, obesity-related
ventilatory challenges, and anticoagulation complicating neuraxial options.
Correct Answer Analysis: Option A represents the optimal balance. Etomidate maintains
sympathetic tone and hemodynamic stability in the setting of severe AS where stroke volume is
,fixed and dependent on preload/afterload maintenance. The reduced MAC of sevoflurane
minimizes myocardial depression while providing adequate depth. Avoiding neuraxial
techniques is essential given therapeutic apixaban within the prior 24 hours (per ASRA
guidelines, 48-hour hold recommended for twice-daily dosing). Low-pressure
pneumoperitoneum (8-10 mmHg) reduces the hemodynamic insult compared to standard
insufflation pressures; studies by Odeberg et al. demonstrate significant reductions in SVR and
cardiac index with pressures >12 mmHg in cardiac patients. Reverse Trendelenburg positioning
further unloads the RV while improving surgical exposure in obesity.
Distractor Analysis:
• Option B: Propofol causes significant vasodilation and myocardial depression, potentially
precipitating cardiovascular collapse in critical AS. High-dose opioids, while useful for
blunting stimulation, combined with head-up tilt may cause excessive venous pooling
and catastrophic hypotension in this preload-dependent patient. Standard
pneumoperitoneum pressures (>12 mmHg) dramatically increase afterload and reduce
venous return—contraindicated here.
• Option C: Spinal anesthesia produces sympathectomy and hypotension that cannot be
tolerated in fixed-output AS. A T4 level would cause significant cardiac sympathetic
denervation. Spontaneous ventilation in a morbidly obese patient with OSA and
pulmonary hypertension risks rapid desaturation, hypercapnia-induced pulmonary
vasoconstriction, and RV failure.
• Option D: Epidural placement is absolutely contraindicated with therapeutic apixaban
(12 hours since last dose). Additionally, "aggressive" fluid loading in a patient with HFrEF,
severe AS, and RV dysfunction risks acute decompensated heart failure and pulmonary
edema. The combined hypotensive effects of propofol and epidural sympathectomy
would be poorly tolerated.
Q2: A 54-year-old female with end-stage renal disease (ESRD) on hemodysis (last session 48
hours ago), type 2 diabetes with autonomic neuropathy, and difficult airway anatomy
(Mallampati IV, limited mouth opening, short thyromental distance) presents for emergent
lower extremity amputation for necrotizing fasciitis. Potassium is 6.2 mEq/L, bicarbonate 18
mEq/L, BUN 98 mg/dL, creatinine 8.4 mg/dL, glucose 340 mg/dL. Which anesthetic plan
addresses the highest priority concerns in appropriate sequence?
A. Proceed with rapid sequence intubation using rocuronium 1.2 mg/kg and video laryngoscopy,
treat hyperkalemia with calcium gluconate 1g, insulin 10 units with glucose, and sodium
bicarbonate 50 mEq, then induce with ketamine 1.5 mg/kg and maintain with sevoflurane.
, B. Perform awake fiberoptic intubation with topical anesthesia and sedation, initiate dialysis
intraoperatively via vascular access, administer rocuronium 0.6 mg/kg only after confirming safe
airway, and avoid succinylcholine entirely.
C. Administer calcium gluconate 1g IV immediately, perform rapid sequence intubation with
rocuronium 1.2 mg/kg and video laryngoscopy with backup surgical airway ready, induce with
etomidate 0.2 mg/kg, and avoid hyperventilation to prevent respiratory alkalosis-driven
hypokalemia.
D. Delay surgery for emergent dialysis to correct potassium, perform awake tracheostomy under
local anesthesia due to predicted difficult mask ventilation, and use regional anesthesia (spinal)
alone to avoid airway manipulation.
Correct Answer: C
Rationale: This scenario requires prioritization of three simultaneous life threats: hyperkalemia
with ECG changes (implied by K+ 6.2), difficult airway with high aspiration risk from diabetic
gastroparesis, and uremic coagulopathy affecting surgical hemostasis. The sequence of
interventions matters critically.
Correct Answer Analysis: Option C correctly sequences interventions: first, cardioprotection
with calcium gluconate (stabilizes myocardial membrane against hyperkalemic depolarization),
then controlled airway management. Etomidate preserves hemodynamics in the setting of
autonomic neuropathy where blood pressure lability is common. Rocuronium 1.2 mg/kg
provides rapid onset (60-90 seconds) comparable to succinylcholine without the 0.5-1.0 mEq/L
potassium release—critical in ESRD with K+ 6.2. Video laryngoscopy optimizes first-pass success
in Mallampati IV anatomy. Avoiding hyperventilation prevents alkalemia that would shift
potassium intracellularly, potentially masking true potassium status and causing rebound
hyperkalemia postoperatively.
Distractor Analysis:
• Option A: While hyperkalemia treatment is appropriate, this option fatally sequences
airway management BEFORE cardioprotection. Intubation stress without calcium
pretreatment risks lethal arrhythmias. Additionally, ketamine increases sympathetic
outflow, potentially causing hypertension and tachycardia that stress the cardiac
membrane further.
• Option B: Awake fiberoptic intubation is theoretically appealing but impractical in
emergent necrotizing fasciitis (sepsis, time-critical). Intraoperative dialysis is rarely
available and technically challenging; the patient needs source control surgery, not
delayed optimization. This option prioritizes perfect physiology over surgical emergency.
PRACTICE EXAM V1 2026/2027 | Verified Questions and
Answers | For Specialized Certification & Board Review
| Grade A Target | Pass Guaranteed
Q1: A 68-year-old male (BMI 42 kg/m²) with severe aortic stenosis (valve area 0.8 cm², mean
gradient 42 mmHg), HFrEF (EF 30%), moderate pulmonary hypertension (PASP 55 mmHg), and
OSA presents for emergent laparoscopic cholecystectomy for acute cholecystitis. Preoperative
TTE shows concentric LVH and RV dilation. Current medications include carvedilol 25 mg BID,
furosemide 40 mg daily, and apixaban 5 mg BID (last dose 12 hours ago). Hemoglobin is 10.2
g/dL, creatinine 1.8 mg/dL. Which anesthetic strategy best balances hemodynamic stability with
surgical requirements?
A. General anesthesia with rapid sequence intubation using etomidate 0.3 mg/kg and
succinylcholine 1.5 mg/kg, maintain with sevoflurane 0.5-1 MAC, avoid neuraxial techniques,
and utilize low-pressure pneumoperitoneum (8-10 mmHg) with steep reverse Trendelenburg
positioning.
B. General anesthesia with propofol 2 mg/kg and rocuronium 0.6 mg/kg for induction, high-
dose opioid technique (fentanyl 10 mcg/kg) to blunt sympathetic response, and standard
pneumoperitoneum (12-15 mmHg) with head-up tilt to reduce venous return.
C. Spinal anesthesia with hyperbaric bupivacaine 15 mg to achieve T4 sensory level,
supplemented with midazolam 2 mg IV for anxiolysis, and maintain spontaneous ventilation
with supplemental O2 via nasal cannula.
D. Combined general-epidural technique with low-dose propofol infusion (25-50 mcg/kg/min),
thoracic epidural bolus of 5 mL 0.25% bupivacaine, and aggressive fluid loading (30 mL/kg
crystalloid) prior to epidural placement to prevent hypotension.
Correct Answer: A
Rationale: This patient presents a collision of four high-risk conditions: fixed cardiac output
from critical AS, preload-dependent RV from pulmonary hypertension, obesity-related
ventilatory challenges, and anticoagulation complicating neuraxial options.
Correct Answer Analysis: Option A represents the optimal balance. Etomidate maintains
sympathetic tone and hemodynamic stability in the setting of severe AS where stroke volume is
,fixed and dependent on preload/afterload maintenance. The reduced MAC of sevoflurane
minimizes myocardial depression while providing adequate depth. Avoiding neuraxial
techniques is essential given therapeutic apixaban within the prior 24 hours (per ASRA
guidelines, 48-hour hold recommended for twice-daily dosing). Low-pressure
pneumoperitoneum (8-10 mmHg) reduces the hemodynamic insult compared to standard
insufflation pressures; studies by Odeberg et al. demonstrate significant reductions in SVR and
cardiac index with pressures >12 mmHg in cardiac patients. Reverse Trendelenburg positioning
further unloads the RV while improving surgical exposure in obesity.
Distractor Analysis:
• Option B: Propofol causes significant vasodilation and myocardial depression, potentially
precipitating cardiovascular collapse in critical AS. High-dose opioids, while useful for
blunting stimulation, combined with head-up tilt may cause excessive venous pooling
and catastrophic hypotension in this preload-dependent patient. Standard
pneumoperitoneum pressures (>12 mmHg) dramatically increase afterload and reduce
venous return—contraindicated here.
• Option C: Spinal anesthesia produces sympathectomy and hypotension that cannot be
tolerated in fixed-output AS. A T4 level would cause significant cardiac sympathetic
denervation. Spontaneous ventilation in a morbidly obese patient with OSA and
pulmonary hypertension risks rapid desaturation, hypercapnia-induced pulmonary
vasoconstriction, and RV failure.
• Option D: Epidural placement is absolutely contraindicated with therapeutic apixaban
(12 hours since last dose). Additionally, "aggressive" fluid loading in a patient with HFrEF,
severe AS, and RV dysfunction risks acute decompensated heart failure and pulmonary
edema. The combined hypotensive effects of propofol and epidural sympathectomy
would be poorly tolerated.
Q2: A 54-year-old female with end-stage renal disease (ESRD) on hemodysis (last session 48
hours ago), type 2 diabetes with autonomic neuropathy, and difficult airway anatomy
(Mallampati IV, limited mouth opening, short thyromental distance) presents for emergent
lower extremity amputation for necrotizing fasciitis. Potassium is 6.2 mEq/L, bicarbonate 18
mEq/L, BUN 98 mg/dL, creatinine 8.4 mg/dL, glucose 340 mg/dL. Which anesthetic plan
addresses the highest priority concerns in appropriate sequence?
A. Proceed with rapid sequence intubation using rocuronium 1.2 mg/kg and video laryngoscopy,
treat hyperkalemia with calcium gluconate 1g, insulin 10 units with glucose, and sodium
bicarbonate 50 mEq, then induce with ketamine 1.5 mg/kg and maintain with sevoflurane.
, B. Perform awake fiberoptic intubation with topical anesthesia and sedation, initiate dialysis
intraoperatively via vascular access, administer rocuronium 0.6 mg/kg only after confirming safe
airway, and avoid succinylcholine entirely.
C. Administer calcium gluconate 1g IV immediately, perform rapid sequence intubation with
rocuronium 1.2 mg/kg and video laryngoscopy with backup surgical airway ready, induce with
etomidate 0.2 mg/kg, and avoid hyperventilation to prevent respiratory alkalosis-driven
hypokalemia.
D. Delay surgery for emergent dialysis to correct potassium, perform awake tracheostomy under
local anesthesia due to predicted difficult mask ventilation, and use regional anesthesia (spinal)
alone to avoid airway manipulation.
Correct Answer: C
Rationale: This scenario requires prioritization of three simultaneous life threats: hyperkalemia
with ECG changes (implied by K+ 6.2), difficult airway with high aspiration risk from diabetic
gastroparesis, and uremic coagulopathy affecting surgical hemostasis. The sequence of
interventions matters critically.
Correct Answer Analysis: Option C correctly sequences interventions: first, cardioprotection
with calcium gluconate (stabilizes myocardial membrane against hyperkalemic depolarization),
then controlled airway management. Etomidate preserves hemodynamics in the setting of
autonomic neuropathy where blood pressure lability is common. Rocuronium 1.2 mg/kg
provides rapid onset (60-90 seconds) comparable to succinylcholine without the 0.5-1.0 mEq/L
potassium release—critical in ESRD with K+ 6.2. Video laryngoscopy optimizes first-pass success
in Mallampati IV anatomy. Avoiding hyperventilation prevents alkalemia that would shift
potassium intracellularly, potentially masking true potassium status and causing rebound
hyperkalemia postoperatively.
Distractor Analysis:
• Option A: While hyperkalemia treatment is appropriate, this option fatally sequences
airway management BEFORE cardioprotection. Intubation stress without calcium
pretreatment risks lethal arrhythmias. Additionally, ketamine increases sympathetic
outflow, potentially causing hypertension and tachycardia that stress the cardiac
membrane further.
• Option B: Awake fiberoptic intubation is theoretically appealing but impractical in
emergent necrotizing fasciitis (sepsis, time-critical). Intraoperative dialysis is rarely
available and technically challenging; the patient needs source control surgery, not
delayed optimization. This option prioritizes perfect physiology over surgical emergency.
