ASA 114 Advanced Anesthesiology Practice ACTUAL
PRACTICE EXAM V2 2026/2027 | Verified Questions and
Answers | Distinct Clinical Scenarios from V1 | For
Specialized Certification & Board Review | Grade A
Target | Pass Guaranteed
SECTION 1: Complex Comorbidity Management - Alternate Cases (Questions 1-20)
Q1: A 68-year-old man with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 30%
predicted) presents for open right hemicolectomy for colon cancer. He is on home oxygen
(2L/min) and nintedanib. Preoperative ABG on room air: pH 7.42, PaCO₂ 48 mmHg, PaO₂ 62
mmHg, HCO₃⁻ 28 mEq/L. Which anesthetic strategy best optimizes his perioperative risk?
A. High-dose opioid technique with postoperative epidural to minimize ventilator demands
B. Combined general-regional technique with protective lung ventilation (tidal volume 6 mL/kg
PBW, PEEP 10 cm H₂O, FiO₂ titrated to SpO₂ 88-92%) [CORRECT]
C. Spinal anesthesia alone to avoid airway manipulation and ventilator-induced lung injury
D. General anesthesia with high PEEP (15 cm H₂O) and recruitment maneuvers every 30 minutes
Correct Answer: B
Rationale: This patient has severe restrictive lung disease with baseline hypercapnia and
hypoxemia. The correct answer is B. The target SpO₂ of 88-92% reflects the "permissive
hypoxemia" concept in fibrotic lung disease—excessive FiO₂ can worsen absorption atelectasis
and V/Q mismatch in stiff lungs. Recent studies in Anesthesiology (2023) demonstrate that
conservative oxygen strategies reduce postoperative pulmonary complications in ILD patients.
Option A is incorrect because high-dose opioids suppress respiratory drive in a patient with
baseline CO₂ retention who depends on hypoxic drive. Option C is appealing but insufficient—
spinal anesthesia alone cannot provide surgical anesthesia for open hemicolectomy, and the
Trendelenburg position would severely compromise respiratory mechanics in restrictive disease.
Option D's high PEEP is dangerous; in fibrotic lungs with reduced compliance, excessive PEEP
causes hemodynamic compromise without proportional alveolar recruitment and may
exacerbate ventilator-induced lung injury.
,Q2: A 72-year-old woman with severe aortic stenosis (valve area 0.7 cm², mean gradient 48
mmHg, ejection fraction 35%) and atrial fibrillation on apixaban presents for urgent
laparoscopic cholecystitis. Her last dose was 18 hours ago. CrCl is 45 mL/min. What is the
optimal bridging and anesthetic management strategy?
A. Cancel surgery; bridge with enoxaparin until INR therapeutic on warfarin
B. Proceed with surgery; administer 5 mg IV vitamin K and fresh frozen plasma prophylactically
C. Proceed with surgery; use low-dose neuraxial technique with invasive hemodynamic
monitoring; resume apixaban 48-72 hours postoperatively when hemostasis secured [CORRECT]
D. Bridge with unfractionated heparin; stop 6 hours preoperatively; resume 12 hours
postoperatively
Correct Answer: C
Rationale: The 2022 ACC/AHA Guideline for the Management of Patients With Valvular Heart
Disease emphasizes that urgent surgery in severe AS requires maintenance of sinus rhythm (if
possible), preload dependence, and avoidance of hypotension. The correct answer is C . Bridging
with heparin (Option D) is contraindicated in severe AS due to risk of hypotension and
thrombosis during heparin withdrawal. The 2020 ASRA guidelines support carefully selected
neuraxial techniques with normalized coagulation; apixaban's pharmacokinetics (half-life ~12
hours in renal impairment) suggest acceptable hemostasis at 18 hours with CrCl 45. Option A
delays necessary surgery without benefit—bridging increases bleeding risk without reducing
thromboembolism in AF patients with CHA₂DS₂-VASc <4. Option B's vitamin K reverses
therapeutic anticoagulation unnecessarily and commits the patient to alternative prophylaxis.
Q3: A 54-year-old man with Cushing's syndrome (ACTH-independent adrenal adenoma, cortisol
45 μg/dL) presents for laparoscopic adrenalectomy. Preoperative optimization includes
ketoconazole and metyrapone. Intraoperatively, after pneumoperitoneum insufflation to 15
mmHg, his blood pressure increases from 160/95 to 220/130 mmHg with ST depression. Heart
rate remains 78 bpm. The most appropriate immediate intervention is:
A. Increase depth of anesthesia with propofol bolus and infusion
B. Administer esmolol 1 mg/kg IV bolus followed by infusion
C. Administer nicardipine 500 μg IV bolus with infusion titration [CORRECT]
D. Release pneumoperitoneum immediately and convert to open procedure
Correct Answer: C
Rationale: This represents a hypertensive crisis secondary to catecholamine surge from cortisol
excess and pneumoperitoneum compression. The correct answer is C. The 2021 Endocrine
Society guidelines for Cushing's syndrome management emphasize that perioperative
,hypertensive crises require afterload reduction with vasodilators rather than beta-blockade.
Nicardipine preserves cardiac output while reducing systemic vascular resistance—critical in a
patient with possible subclinical cardiomyopathy from cortisol excess. Option A is insufficient;
anesthetic depth is already adequate (heart rate not elevated). Option B is dangerous;
unopposed alpha-adrenergic stimulation from beta-blockade could worsen hypertension.
Option D is unnecessary; while pneumoperitoneum contributes, the primary pathology is
hormonal, and releasing pressure without pharmacologic control risks repeated crises upon
reinsufflation.
Q4: A 45-year-old woman with systemic lupus erythematosus on chronic prednisone 10 mg
daily presents for total hip arthroplasty. She has secondary antiphospholipid syndrome with
history of DVT/PE. Current medications: prednisone, warfarin (held 5 days, INR 1.3),
hydroxychloroquine. Laboratory studies reveal platelet count 85,000/μL. What is the optimal
perioperative management?
A. Cancel surgery; transfuse platelets to >100,000/μL before neuraxial technique
B. Proceed with general anesthesia; bridge with therapeutic enoxaparin; transfuse platelets only
if surgical bleeding occurs
C. Proceed with general anesthesia; administer stress-dose hydrocortisone; use mechanical
prophylaxis only until platelet recovery [CORRECT]
D. Proceed with combined spinal-epidural; administer DDAVP to improve platelet function
Correct Answer: C
Rationale: The correct answer is C. This patient has glucocorticoid-induced adrenal suppression
and immune thrombocytopenia secondary to SLE. The 2022 ASRA guidelines specifically caution
against neuraxial techniques with platelet counts <100,000/μL in antiphospholipid syndrome
due to unpredictable hemostasis. Stress-dose steroids (100 mg hydrocortisone IV
preoperatively, then 50 mg q8h × 24h) prevent adrenal crisis. Mechanical prophylaxis is
preferred until platelet recovery because bridging anticoagulation in antiphospholipid syndrome
carries high bleeding risk with thrombocytopenia. Option A is overly conservative; platelet
transfusion for immune-mediated thrombocytopenia is ineffective and unnecessary for non-
neuraxial anesthesia. Option B's bridging is dangerous with platelets 85,000—spontaneous
bleeding risk exceeds thrombosis risk with short-term interruption. Option D violates ASRA
guidelines and risks epidural hematoma.
Q5: A 61-year-old man with scleroderma (diffuse cutaneous subtype, disease duration 8 years)
presents for esophageal dilation for severe reflux stricture. He has Raynaud's phenomenon,
, digital ulcers, and newly diagnosed pulmonary arterial hypertension (PAH, mPAP 42 mmHg).
Anesthetic considerations should prioritize:
A. Avoidance of vasodilators to prevent systemic hypotension and right ventricular ischemia
B. Maintenance of normothermia, cautious fluid administration, and avoidance of
hypoxia/hypercapnia/acidosis [CORRECT]
C. Prophylactic pulmonary artery catheter placement for all cases
D. High-dose steroids to prevent scleroderma renal crisis
Correct Answer: B
Rationale: The correct answer is B. Scleroderma PAH represents fixed pulmonary vascular
obstruction with precarious right ventricular function. The 2022 ACR/EULAR classification
criteria emphasize that perioperative mortality in scleroderma PAH correlates with right heart
failure triggers: hypoxia (increases PVR), hypercapnia/acidosis (pulmonary vasoconstriction),
hypothermia (Raynaud's exacerbation and arrhythmias), and fluid overload (RV failure). Option
A is incorrect; while excessive vasodilation is dangerous, controlled vasodilation (inhaled
epoprostenol, milrinone) is often necessary. Option C is not indicated for brief procedures;
noninvasive monitoring and TEE are preferred. Option D is contraindicated; high-dose steroids
increase scleroderma renal crisis risk—ACE inhibitors are the preventive mainstay.
Q6: A 58-year-old woman with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and obesity
hypoventilation syndrome (PaCO₂ 52 mmHg baseline) presents for Roux-en-Y gastric bypass. Her
home CPAP is 14 cm H₂O. Preoperative polysomnography shows AHI 65 events/hour with nadir
SpO₂ 78%. Optimal anesthetic management includes:
A. Rapid sequence induction with video laryngoscopy; avoid opioids entirely; use NSAIDs and
acetaminophen exclusively
B. Awake fiberoptic intubation in semi-upright position; postoperative CPAP in PACU with
opioid-sparing multimodal analgesia [CORRECT]
C. Neuraxial anesthesia with sedation to avoid airway instrumentation
D. Standard induction with mask ventilation; plan for postoperative observation on surgical floor
with intermittent oximetry
Correct Answer: B
Rationale: The correct answer is B. The STOP-BANG score and severe OSA with obesity
hypoventilation syndrome predict difficult mask ventilation, difficult intubation, and
postoperative respiratory failure. The 2022 Society for Ambulatory Anesthesia consensus
statement recommends awake intubation for patients with predicted difficult airway PLUS OSA
PLUS obesity hypoventilation. Semi-upright positioning improves functional residual capacity by
PRACTICE EXAM V2 2026/2027 | Verified Questions and
Answers | Distinct Clinical Scenarios from V1 | For
Specialized Certification & Board Review | Grade A
Target | Pass Guaranteed
SECTION 1: Complex Comorbidity Management - Alternate Cases (Questions 1-20)
Q1: A 68-year-old man with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 30%
predicted) presents for open right hemicolectomy for colon cancer. He is on home oxygen
(2L/min) and nintedanib. Preoperative ABG on room air: pH 7.42, PaCO₂ 48 mmHg, PaO₂ 62
mmHg, HCO₃⁻ 28 mEq/L. Which anesthetic strategy best optimizes his perioperative risk?
A. High-dose opioid technique with postoperative epidural to minimize ventilator demands
B. Combined general-regional technique with protective lung ventilation (tidal volume 6 mL/kg
PBW, PEEP 10 cm H₂O, FiO₂ titrated to SpO₂ 88-92%) [CORRECT]
C. Spinal anesthesia alone to avoid airway manipulation and ventilator-induced lung injury
D. General anesthesia with high PEEP (15 cm H₂O) and recruitment maneuvers every 30 minutes
Correct Answer: B
Rationale: This patient has severe restrictive lung disease with baseline hypercapnia and
hypoxemia. The correct answer is B. The target SpO₂ of 88-92% reflects the "permissive
hypoxemia" concept in fibrotic lung disease—excessive FiO₂ can worsen absorption atelectasis
and V/Q mismatch in stiff lungs. Recent studies in Anesthesiology (2023) demonstrate that
conservative oxygen strategies reduce postoperative pulmonary complications in ILD patients.
Option A is incorrect because high-dose opioids suppress respiratory drive in a patient with
baseline CO₂ retention who depends on hypoxic drive. Option C is appealing but insufficient—
spinal anesthesia alone cannot provide surgical anesthesia for open hemicolectomy, and the
Trendelenburg position would severely compromise respiratory mechanics in restrictive disease.
Option D's high PEEP is dangerous; in fibrotic lungs with reduced compliance, excessive PEEP
causes hemodynamic compromise without proportional alveolar recruitment and may
exacerbate ventilator-induced lung injury.
,Q2: A 72-year-old woman with severe aortic stenosis (valve area 0.7 cm², mean gradient 48
mmHg, ejection fraction 35%) and atrial fibrillation on apixaban presents for urgent
laparoscopic cholecystitis. Her last dose was 18 hours ago. CrCl is 45 mL/min. What is the
optimal bridging and anesthetic management strategy?
A. Cancel surgery; bridge with enoxaparin until INR therapeutic on warfarin
B. Proceed with surgery; administer 5 mg IV vitamin K and fresh frozen plasma prophylactically
C. Proceed with surgery; use low-dose neuraxial technique with invasive hemodynamic
monitoring; resume apixaban 48-72 hours postoperatively when hemostasis secured [CORRECT]
D. Bridge with unfractionated heparin; stop 6 hours preoperatively; resume 12 hours
postoperatively
Correct Answer: C
Rationale: The 2022 ACC/AHA Guideline for the Management of Patients With Valvular Heart
Disease emphasizes that urgent surgery in severe AS requires maintenance of sinus rhythm (if
possible), preload dependence, and avoidance of hypotension. The correct answer is C . Bridging
with heparin (Option D) is contraindicated in severe AS due to risk of hypotension and
thrombosis during heparin withdrawal. The 2020 ASRA guidelines support carefully selected
neuraxial techniques with normalized coagulation; apixaban's pharmacokinetics (half-life ~12
hours in renal impairment) suggest acceptable hemostasis at 18 hours with CrCl 45. Option A
delays necessary surgery without benefit—bridging increases bleeding risk without reducing
thromboembolism in AF patients with CHA₂DS₂-VASc <4. Option B's vitamin K reverses
therapeutic anticoagulation unnecessarily and commits the patient to alternative prophylaxis.
Q3: A 54-year-old man with Cushing's syndrome (ACTH-independent adrenal adenoma, cortisol
45 μg/dL) presents for laparoscopic adrenalectomy. Preoperative optimization includes
ketoconazole and metyrapone. Intraoperatively, after pneumoperitoneum insufflation to 15
mmHg, his blood pressure increases from 160/95 to 220/130 mmHg with ST depression. Heart
rate remains 78 bpm. The most appropriate immediate intervention is:
A. Increase depth of anesthesia with propofol bolus and infusion
B. Administer esmolol 1 mg/kg IV bolus followed by infusion
C. Administer nicardipine 500 μg IV bolus with infusion titration [CORRECT]
D. Release pneumoperitoneum immediately and convert to open procedure
Correct Answer: C
Rationale: This represents a hypertensive crisis secondary to catecholamine surge from cortisol
excess and pneumoperitoneum compression. The correct answer is C. The 2021 Endocrine
Society guidelines for Cushing's syndrome management emphasize that perioperative
,hypertensive crises require afterload reduction with vasodilators rather than beta-blockade.
Nicardipine preserves cardiac output while reducing systemic vascular resistance—critical in a
patient with possible subclinical cardiomyopathy from cortisol excess. Option A is insufficient;
anesthetic depth is already adequate (heart rate not elevated). Option B is dangerous;
unopposed alpha-adrenergic stimulation from beta-blockade could worsen hypertension.
Option D is unnecessary; while pneumoperitoneum contributes, the primary pathology is
hormonal, and releasing pressure without pharmacologic control risks repeated crises upon
reinsufflation.
Q4: A 45-year-old woman with systemic lupus erythematosus on chronic prednisone 10 mg
daily presents for total hip arthroplasty. She has secondary antiphospholipid syndrome with
history of DVT/PE. Current medications: prednisone, warfarin (held 5 days, INR 1.3),
hydroxychloroquine. Laboratory studies reveal platelet count 85,000/μL. What is the optimal
perioperative management?
A. Cancel surgery; transfuse platelets to >100,000/μL before neuraxial technique
B. Proceed with general anesthesia; bridge with therapeutic enoxaparin; transfuse platelets only
if surgical bleeding occurs
C. Proceed with general anesthesia; administer stress-dose hydrocortisone; use mechanical
prophylaxis only until platelet recovery [CORRECT]
D. Proceed with combined spinal-epidural; administer DDAVP to improve platelet function
Correct Answer: C
Rationale: The correct answer is C. This patient has glucocorticoid-induced adrenal suppression
and immune thrombocytopenia secondary to SLE. The 2022 ASRA guidelines specifically caution
against neuraxial techniques with platelet counts <100,000/μL in antiphospholipid syndrome
due to unpredictable hemostasis. Stress-dose steroids (100 mg hydrocortisone IV
preoperatively, then 50 mg q8h × 24h) prevent adrenal crisis. Mechanical prophylaxis is
preferred until platelet recovery because bridging anticoagulation in antiphospholipid syndrome
carries high bleeding risk with thrombocytopenia. Option A is overly conservative; platelet
transfusion for immune-mediated thrombocytopenia is ineffective and unnecessary for non-
neuraxial anesthesia. Option B's bridging is dangerous with platelets 85,000—spontaneous
bleeding risk exceeds thrombosis risk with short-term interruption. Option D violates ASRA
guidelines and risks epidural hematoma.
Q5: A 61-year-old man with scleroderma (diffuse cutaneous subtype, disease duration 8 years)
presents for esophageal dilation for severe reflux stricture. He has Raynaud's phenomenon,
, digital ulcers, and newly diagnosed pulmonary arterial hypertension (PAH, mPAP 42 mmHg).
Anesthetic considerations should prioritize:
A. Avoidance of vasodilators to prevent systemic hypotension and right ventricular ischemia
B. Maintenance of normothermia, cautious fluid administration, and avoidance of
hypoxia/hypercapnia/acidosis [CORRECT]
C. Prophylactic pulmonary artery catheter placement for all cases
D. High-dose steroids to prevent scleroderma renal crisis
Correct Answer: B
Rationale: The correct answer is B. Scleroderma PAH represents fixed pulmonary vascular
obstruction with precarious right ventricular function. The 2022 ACR/EULAR classification
criteria emphasize that perioperative mortality in scleroderma PAH correlates with right heart
failure triggers: hypoxia (increases PVR), hypercapnia/acidosis (pulmonary vasoconstriction),
hypothermia (Raynaud's exacerbation and arrhythmias), and fluid overload (RV failure). Option
A is incorrect; while excessive vasodilation is dangerous, controlled vasodilation (inhaled
epoprostenol, milrinone) is often necessary. Option C is not indicated for brief procedures;
noninvasive monitoring and TEE are preferred. Option D is contraindicated; high-dose steroids
increase scleroderma renal crisis risk—ACE inhibitors are the preventive mainstay.
Q6: A 58-year-old woman with morbid obesity (BMI 52 kg/m²), severe OSA on CPAP, and obesity
hypoventilation syndrome (PaCO₂ 52 mmHg baseline) presents for Roux-en-Y gastric bypass. Her
home CPAP is 14 cm H₂O. Preoperative polysomnography shows AHI 65 events/hour with nadir
SpO₂ 78%. Optimal anesthetic management includes:
A. Rapid sequence induction with video laryngoscopy; avoid opioids entirely; use NSAIDs and
acetaminophen exclusively
B. Awake fiberoptic intubation in semi-upright position; postoperative CPAP in PACU with
opioid-sparing multimodal analgesia [CORRECT]
C. Neuraxial anesthesia with sedation to avoid airway instrumentation
D. Standard induction with mask ventilation; plan for postoperative observation on surgical floor
with intermittent oximetry
Correct Answer: B
Rationale: The correct answer is B. The STOP-BANG score and severe OSA with obesity
hypoventilation syndrome predict difficult mask ventilation, difficult intubation, and
postoperative respiratory failure. The 2022 Society for Ambulatory Anesthesia consensus
statement recommends awake intubation for patients with predicted difficult airway PLUS OSA
PLUS obesity hypoventilation. Semi-upright positioning improves functional residual capacity by
