EPIC OR350 STUDY GUIDE 2026 ACTUAL EXAM
QUESTIONS AND ANSWERS ALREADY A SCORE.
1. A 45-year-old patient with a history of coronary artery disease and recent stent placement (6
months ago) is scheduled for elective laparoscopic cholecystectomy. The patient is on dual
antiplatelet therapy (aspirin and clopidogrel). The surgeon requests that antiplatelet therapy be
continued perioperatively due to high thrombotic risk. The anesthesiologist is concerned about
bleeding risk. Which of the following management strategies is most consistent with current
evidence and guidelines?
A. Stop clopidogrel 7 days before surgery and continue aspirin; bridge with heparin if needed.
B. Continue both aspirin and clopidogrel throughout the perioperative period.
C. Stop both aspirin and clopidogrel 5 days before surgery and bridge with enoxaparin.
D. Stop aspirin 3 days before surgery and continue clopidogrel; monitor platelet function.
Answer: A
Rationale: For patients with recent drug-eluting stents (<12 months) requiring surgery, current
ACC/AHA guidelines recommend continuing aspirin and stopping clopidogrel 5-7 days preoperatively if
thrombotic risk is high. Bridging with a short-acting antiplatelet agent (e.g., heparin) is not standard but
may be considered. Option A aligns with this approach. Option B increases bleeding risk unacceptably.
Option C eliminates both agents, increasing stent thrombosis risk. Option D is not recommended as
clopidogrel alone is insufficient.
2. In the context of a root cause analysis (RCA) following a retained surgical instrument event,
which of the following is the most appropriate primary action to prevent recurrence?
A. Retrain the surgical team on manual counting protocols and enforce double-counting.
B. Implement a standardized radiofrequency (RF) detection system for all surgical procedures.
C. Conduct a time-out before closure to confirm count accuracy and document in the EMR.
D. Establish a non-punitive reporting system and redesign the counting process using human factors principles.
Answer: D
Rationale: RCA focuses on system-level failures rather than individual blame. Option D addresses both
the reporting culture and the system design, which is most effective for prevention. Option A is a
band-aid; retraining alone does not address latent errors. Option B may be effective but is costly and not
universally available; it is not the primary action. Option C is a good practice but does not address the
root causes such as distractions or workflow issues.
3. A 70-year-old patient with diabetes and chronic kidney disease (GFR 35 mL/min) is undergoing
a total knee arthroplasty. Postoperatively, the patient develops oliguria and serum creatinine rises
to 2.5 mg/dL from a baseline of 1.2 mg/dL. Which of the following perioperative factors is most
likely contributing to this acute kidney injury (AKI)?
A. Intraoperative use of cefazolin for surgical prophylaxis.
Page 1
,B. Administration of 2 units of packed red blood cells for hemoglobin of 8.0 g/dL.
C. Use of a tourniquet inflated to 300 mmHg for 90 minutes.
D. Intraoperative hypotension with mean arterial pressure (MAP) below 65 mmHg for 20 minutes.
Answer: D
Rationale: Intraoperative hypotension (MAP <65 mmHg) is a well-established risk factor for
postoperative AKI, especially in patients with preexisting CKD and diabetes. Option A: cefazolin is
generally safe in renal impairment with dose adjustment. Option B: transfusion is not directly
nephrotoxic but may cause volume overload; not the primary cause. Option C: tourniquet use can cause
reperfusion injury but is less likely to be the main contributor compared to sustained hypotension.
4. During a robotic-assisted radical prostatectomy, the surgical team notices a sudden decrease in
end-tidal CO2 from 38 to 22 mmHg, accompanied by a drop in oxygen saturation to 90% and
hypotension. The surgeon is currently in the console with the robot docked. What is the most
immediate next step?
A. Increase the pneumoperitoneum pressure to 20 mmHg to improve visualization and assess for bleeding.
B. Ask the surgeon to undock the robot immediately and prepare for possible open conversion.
C. Administer a fluid bolus and increase the fraction of inspired oxygen (FiO2) to 100%.
D. Perform a rapid ultrasound of the chest to rule out pneumothorax or hemothorax.
Answer: B
Rationale: The presentation suggests possible venous gas embolism (VGE) or tension pneumothorax. The
immediate priority is to undock the robot to allow patient repositioning and access for resuscitation.
Option A is contraindicated as increasing pressure may worsen VGE. Option C is supportive but delays
definitive action. Option D is diagnostic but should not precede undocking and life-saving measures.
5. A 55-year-old patient with a history of obstructive sleep apnea (OSA) is undergoing bariatric
surgery. The anesthesia plan includes total intravenous anesthesia (TIVA) with propofol and
remifentanil, and a multimodal analgesic regimen. Which of the following postoperative
monitoring strategies is most strongly supported by evidence to reduce the risk of respiratory
complications?
A. Continuous pulse oximetry monitoring for 24 hours in the PACU.
B. Capnography monitoring on the surgical ward for 48 hours.
C. Use of a continuous positive airway pressure (CPAP) device immediately postextubation.
D. Admission to a step-down unit with continuous telemetry and respiratory rate monitoring.
Answer: B
Rationale: For patients with OSA undergoing surgery, capnography monitoring on the ward (or
step-down) for 24-48 hours is recommended by guidelines to detect hypoventilation early. Option A:
pulse oximetry alone may miss hypoventilation if supplemental oxygen is used. Option C: CPAP is
beneficial but not a monitoring strategy. Option D: telemetry does not directly measure ventilation;
capnography is superior.
Page 2
,6. A 30-year-old patient with no significant medical history is undergoing an emergency
appendectomy. After induction, the patient develops severe bronchospasm, hypoxia, and
hypotension. The end-tidal CO2 waveform shows a sudden decrease. Which of the following is the
most likely diagnosis?
A. Anaphylaxis to the neuromuscular blocking agent.
B. Endobronchial intubation.
C. Pulmonary embolism.
D. Malignant hyperthermia.
Answer: A
Rationale: The acute onset of bronchospasm, hypoxia, and hypotension immediately after induction
suggests anaphylaxis, often due to neuromuscular blocking agents. Endobronchial intubation would
cause unilateral breath sounds and hypoxia but not hypotension. Pulmonary embolism is unlikely
intraoperatively without risk factors. Malignant hyperthermia presents with hypercarbia, tachycardia,
and rigidity, not primarily bronchospasm.
7. Which of the following best describes the concept of 'safety-II' in the context of high-reliability
organizations (HROs) applied to the operating room?
A. Focusing on learning from adverse events and near misses to prevent recurrence.
B. Standardizing procedures to minimize variability and reduce errors.
C. Understanding why things go right and adapting to variability to ensure successful outcomes.
D. Implementing checklists and time-outs to catch errors before they cause harm.
Answer: C
Rationale: Safety-II is a resilience engineering concept that emphasizes understanding how and why
things go right in complex systems, and using that knowledge to enhance adaptability. Option A
describes Safety-I (learning from failures). Option B and D are traditional risk management
approaches, not specifically Safety-II.
8. A 65-year-old patient with a history of hypertension and diabetes is undergoing a Whipple
procedure. The surgery is prolonged (6 hours). The patient receives 4 L of crystalloid and 2 units of
packed red blood cells. At the end of surgery, the patient is edematous, and the urine output is 30
mL/hr. The central venous pressure (CVP) is 18 mmHg. Which of the following is the most
appropriate interpretation of these findings?
A. The patient is volume overloaded and needs diuresis.
B. The patient is in acute kidney injury and requires further fluid resuscitation.
C. The patient is in cardiogenic shock and requires inotropic support.
D. The CVP is unreliable due to increased intra-abdominal pressure from the surgical site.
Answer: D
Rationale: In a prolonged abdominal surgery with significant fluid administration, intra-abdominal
hypertension can falsely elevate CVP, making it unreliable for volume status assessment. Option A may
be premature without considering dynamic measures (e.g., pulse pressure variation). Option B is
incorrect given high CVP and edema. Option C is not supported by the data; cardiogenic shock would
likely present with hypotension.
Page 3
, 9. A 50-year-old patient with a BMI of 42 kg/m² is undergoing a laparoscopic sleeve gastrectomy.
The surgeon uses a Veress needle to establish pneumoperitoneum. After insufflation, the patient's
heart rate drops from 80 to 40 bpm, and blood pressure decreases from 130/80 to 70/40 mmHg.
Capnography shows a sudden decrease in end-tidal CO2. What is the most likely cause?
A. Bradyarrhythmia from increased vagal tone due to peritoneal stretch.
B. Gas embolism due to Veress needle placement in a blood vessel.
C. Cardiac tamponade due to needle injury to the pericardium.
D. Myocardial ischemia due to hypotension from pneumoperitoneum.
Answer: B
Rationale: The sudden onset of bradycardia, hypotension, and decreased end-tidal CO2 immediately after
insufflation is classic for venous gas embolism, which can occur if the Veress needle is intravascular.
Option A: vagal response is possible but typically does not cause such a dramatic drop in ETCO2.
Option C is unlikely without precordial needle placement. Option D is less acute and would not cause an
immediate ETCO2 drop.
10. Which of the following strategies is most effective in reducing surgical site infection (SSI) rates
for colorectal surgery, according to the latest evidence-based guidelines?
A. Administering prophylactic antibiotics within 30 minutes of incision.
B. Using a wound protector and performing a mechanical bowel preparation with oral antibiotics.
C. Maintaining normothermia (core temperature >36°C) throughout the procedure.
D. Using a closed-incision negative pressure wound therapy (ciNPT) device for high-risk patients.
Answer: B
Rationale: For elective colorectal surgery, a combination of mechanical bowel preparation and oral
antibiotics has been shown to significantly reduce SSI rates compared to either alone or no preparation.
Option A is standard but not the most effective single strategy. Option C is important but less impactful
than option B. Option D is emerging evidence but not yet the primary recommendation.
11. In the context of a multi-agent reinforcement learning system designed for dynamic resource
allocation in a cloud computing environment, which of the following best characterizes the primary
challenge when integrating a centralized critic with decentralized actors under non-stationary
transition dynamics?
A. The centralized critic's value estimates become biased due to the actors' independent policy updates, leading
to a non-stationary target distribution.
B. The decentralized actors cannot access the global state information, rendering the critic's gradients ineffective
for policy improvement.
C. The communication overhead between the centralized critic and decentralized actors grows quadratically
with the number of agents, causing convergence instability.
D. The centralized critic fails to capture inter-agent credit assignment because it averages rewards across all
agents, masking individual contributions.
Answer: A
Rationale: In multi-agent reinforcement learning with centralized training and decentralized execution,
the centralized critic estimates a joint value function. However, as each actor updates its policy
independently, the transition dynamics for any given agent become non-stationary from the perspective
of others, causing the critic's target values to shift, introducing bias. Option B is incorrect because
Page 4
QUESTIONS AND ANSWERS ALREADY A SCORE.
1. A 45-year-old patient with a history of coronary artery disease and recent stent placement (6
months ago) is scheduled for elective laparoscopic cholecystectomy. The patient is on dual
antiplatelet therapy (aspirin and clopidogrel). The surgeon requests that antiplatelet therapy be
continued perioperatively due to high thrombotic risk. The anesthesiologist is concerned about
bleeding risk. Which of the following management strategies is most consistent with current
evidence and guidelines?
A. Stop clopidogrel 7 days before surgery and continue aspirin; bridge with heparin if needed.
B. Continue both aspirin and clopidogrel throughout the perioperative period.
C. Stop both aspirin and clopidogrel 5 days before surgery and bridge with enoxaparin.
D. Stop aspirin 3 days before surgery and continue clopidogrel; monitor platelet function.
Answer: A
Rationale: For patients with recent drug-eluting stents (<12 months) requiring surgery, current
ACC/AHA guidelines recommend continuing aspirin and stopping clopidogrel 5-7 days preoperatively if
thrombotic risk is high. Bridging with a short-acting antiplatelet agent (e.g., heparin) is not standard but
may be considered. Option A aligns with this approach. Option B increases bleeding risk unacceptably.
Option C eliminates both agents, increasing stent thrombosis risk. Option D is not recommended as
clopidogrel alone is insufficient.
2. In the context of a root cause analysis (RCA) following a retained surgical instrument event,
which of the following is the most appropriate primary action to prevent recurrence?
A. Retrain the surgical team on manual counting protocols and enforce double-counting.
B. Implement a standardized radiofrequency (RF) detection system for all surgical procedures.
C. Conduct a time-out before closure to confirm count accuracy and document in the EMR.
D. Establish a non-punitive reporting system and redesign the counting process using human factors principles.
Answer: D
Rationale: RCA focuses on system-level failures rather than individual blame. Option D addresses both
the reporting culture and the system design, which is most effective for prevention. Option A is a
band-aid; retraining alone does not address latent errors. Option B may be effective but is costly and not
universally available; it is not the primary action. Option C is a good practice but does not address the
root causes such as distractions or workflow issues.
3. A 70-year-old patient with diabetes and chronic kidney disease (GFR 35 mL/min) is undergoing
a total knee arthroplasty. Postoperatively, the patient develops oliguria and serum creatinine rises
to 2.5 mg/dL from a baseline of 1.2 mg/dL. Which of the following perioperative factors is most
likely contributing to this acute kidney injury (AKI)?
A. Intraoperative use of cefazolin for surgical prophylaxis.
Page 1
,B. Administration of 2 units of packed red blood cells for hemoglobin of 8.0 g/dL.
C. Use of a tourniquet inflated to 300 mmHg for 90 minutes.
D. Intraoperative hypotension with mean arterial pressure (MAP) below 65 mmHg for 20 minutes.
Answer: D
Rationale: Intraoperative hypotension (MAP <65 mmHg) is a well-established risk factor for
postoperative AKI, especially in patients with preexisting CKD and diabetes. Option A: cefazolin is
generally safe in renal impairment with dose adjustment. Option B: transfusion is not directly
nephrotoxic but may cause volume overload; not the primary cause. Option C: tourniquet use can cause
reperfusion injury but is less likely to be the main contributor compared to sustained hypotension.
4. During a robotic-assisted radical prostatectomy, the surgical team notices a sudden decrease in
end-tidal CO2 from 38 to 22 mmHg, accompanied by a drop in oxygen saturation to 90% and
hypotension. The surgeon is currently in the console with the robot docked. What is the most
immediate next step?
A. Increase the pneumoperitoneum pressure to 20 mmHg to improve visualization and assess for bleeding.
B. Ask the surgeon to undock the robot immediately and prepare for possible open conversion.
C. Administer a fluid bolus and increase the fraction of inspired oxygen (FiO2) to 100%.
D. Perform a rapid ultrasound of the chest to rule out pneumothorax or hemothorax.
Answer: B
Rationale: The presentation suggests possible venous gas embolism (VGE) or tension pneumothorax. The
immediate priority is to undock the robot to allow patient repositioning and access for resuscitation.
Option A is contraindicated as increasing pressure may worsen VGE. Option C is supportive but delays
definitive action. Option D is diagnostic but should not precede undocking and life-saving measures.
5. A 55-year-old patient with a history of obstructive sleep apnea (OSA) is undergoing bariatric
surgery. The anesthesia plan includes total intravenous anesthesia (TIVA) with propofol and
remifentanil, and a multimodal analgesic regimen. Which of the following postoperative
monitoring strategies is most strongly supported by evidence to reduce the risk of respiratory
complications?
A. Continuous pulse oximetry monitoring for 24 hours in the PACU.
B. Capnography monitoring on the surgical ward for 48 hours.
C. Use of a continuous positive airway pressure (CPAP) device immediately postextubation.
D. Admission to a step-down unit with continuous telemetry and respiratory rate monitoring.
Answer: B
Rationale: For patients with OSA undergoing surgery, capnography monitoring on the ward (or
step-down) for 24-48 hours is recommended by guidelines to detect hypoventilation early. Option A:
pulse oximetry alone may miss hypoventilation if supplemental oxygen is used. Option C: CPAP is
beneficial but not a monitoring strategy. Option D: telemetry does not directly measure ventilation;
capnography is superior.
Page 2
,6. A 30-year-old patient with no significant medical history is undergoing an emergency
appendectomy. After induction, the patient develops severe bronchospasm, hypoxia, and
hypotension. The end-tidal CO2 waveform shows a sudden decrease. Which of the following is the
most likely diagnosis?
A. Anaphylaxis to the neuromuscular blocking agent.
B. Endobronchial intubation.
C. Pulmonary embolism.
D. Malignant hyperthermia.
Answer: A
Rationale: The acute onset of bronchospasm, hypoxia, and hypotension immediately after induction
suggests anaphylaxis, often due to neuromuscular blocking agents. Endobronchial intubation would
cause unilateral breath sounds and hypoxia but not hypotension. Pulmonary embolism is unlikely
intraoperatively without risk factors. Malignant hyperthermia presents with hypercarbia, tachycardia,
and rigidity, not primarily bronchospasm.
7. Which of the following best describes the concept of 'safety-II' in the context of high-reliability
organizations (HROs) applied to the operating room?
A. Focusing on learning from adverse events and near misses to prevent recurrence.
B. Standardizing procedures to minimize variability and reduce errors.
C. Understanding why things go right and adapting to variability to ensure successful outcomes.
D. Implementing checklists and time-outs to catch errors before they cause harm.
Answer: C
Rationale: Safety-II is a resilience engineering concept that emphasizes understanding how and why
things go right in complex systems, and using that knowledge to enhance adaptability. Option A
describes Safety-I (learning from failures). Option B and D are traditional risk management
approaches, not specifically Safety-II.
8. A 65-year-old patient with a history of hypertension and diabetes is undergoing a Whipple
procedure. The surgery is prolonged (6 hours). The patient receives 4 L of crystalloid and 2 units of
packed red blood cells. At the end of surgery, the patient is edematous, and the urine output is 30
mL/hr. The central venous pressure (CVP) is 18 mmHg. Which of the following is the most
appropriate interpretation of these findings?
A. The patient is volume overloaded and needs diuresis.
B. The patient is in acute kidney injury and requires further fluid resuscitation.
C. The patient is in cardiogenic shock and requires inotropic support.
D. The CVP is unreliable due to increased intra-abdominal pressure from the surgical site.
Answer: D
Rationale: In a prolonged abdominal surgery with significant fluid administration, intra-abdominal
hypertension can falsely elevate CVP, making it unreliable for volume status assessment. Option A may
be premature without considering dynamic measures (e.g., pulse pressure variation). Option B is
incorrect given high CVP and edema. Option C is not supported by the data; cardiogenic shock would
likely present with hypotension.
Page 3
, 9. A 50-year-old patient with a BMI of 42 kg/m² is undergoing a laparoscopic sleeve gastrectomy.
The surgeon uses a Veress needle to establish pneumoperitoneum. After insufflation, the patient's
heart rate drops from 80 to 40 bpm, and blood pressure decreases from 130/80 to 70/40 mmHg.
Capnography shows a sudden decrease in end-tidal CO2. What is the most likely cause?
A. Bradyarrhythmia from increased vagal tone due to peritoneal stretch.
B. Gas embolism due to Veress needle placement in a blood vessel.
C. Cardiac tamponade due to needle injury to the pericardium.
D. Myocardial ischemia due to hypotension from pneumoperitoneum.
Answer: B
Rationale: The sudden onset of bradycardia, hypotension, and decreased end-tidal CO2 immediately after
insufflation is classic for venous gas embolism, which can occur if the Veress needle is intravascular.
Option A: vagal response is possible but typically does not cause such a dramatic drop in ETCO2.
Option C is unlikely without precordial needle placement. Option D is less acute and would not cause an
immediate ETCO2 drop.
10. Which of the following strategies is most effective in reducing surgical site infection (SSI) rates
for colorectal surgery, according to the latest evidence-based guidelines?
A. Administering prophylactic antibiotics within 30 minutes of incision.
B. Using a wound protector and performing a mechanical bowel preparation with oral antibiotics.
C. Maintaining normothermia (core temperature >36°C) throughout the procedure.
D. Using a closed-incision negative pressure wound therapy (ciNPT) device for high-risk patients.
Answer: B
Rationale: For elective colorectal surgery, a combination of mechanical bowel preparation and oral
antibiotics has been shown to significantly reduce SSI rates compared to either alone or no preparation.
Option A is standard but not the most effective single strategy. Option C is important but less impactful
than option B. Option D is emerging evidence but not yet the primary recommendation.
11. In the context of a multi-agent reinforcement learning system designed for dynamic resource
allocation in a cloud computing environment, which of the following best characterizes the primary
challenge when integrating a centralized critic with decentralized actors under non-stationary
transition dynamics?
A. The centralized critic's value estimates become biased due to the actors' independent policy updates, leading
to a non-stationary target distribution.
B. The decentralized actors cannot access the global state information, rendering the critic's gradients ineffective
for policy improvement.
C. The communication overhead between the centralized critic and decentralized actors grows quadratically
with the number of agents, causing convergence instability.
D. The centralized critic fails to capture inter-agent credit assignment because it averages rewards across all
agents, masking individual contributions.
Answer: A
Rationale: In multi-agent reinforcement learning with centralized training and decentralized execution,
the centralized critic estimates a joint value function. However, as each actor updates its policy
independently, the transition dynamics for any given agent become non-stationary from the perspective
of others, causing the critic's target values to shift, introducing bias. Option B is incorrect because
Page 4
