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 (20 Questions)
Q1: A 68-year-old man with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 35%
predicted, resting SpO2 91% on room air) is scheduled for open cholecystectomy. His resting
PaCO2 is 48 mmHg. Which anesthetic strategy best minimizes the risk of perioperative
exacerbation?
A. General anesthesia with high tidal volumes (10-12 mL/kg) to prevent atelectasis and maintain
FRC
B. Combined epidural-general anesthesia with lung-protective ventilation (6 mL/kg tidal volume,
PEEP 8-10 cm H2O, FiO2 minimized to maintain SpO2 88-92%) [CORRECT]
C. Spinal anesthesia to T4 level to avoid airway instrumentation and mechanical ventilation
D. General anesthesia with nitrous oxide to reduce FiO2 requirements and prevent oxygen
toxicity
Correct Answer: B
Rationale: Interstitial lung disease (ILD) patients require meticulous lung-protective strategies.
Option B is correct because: (1) Epidural analgesia reduces systemic opioid requirements,
preserving respiratory drive and cough reflex—critical in ILD where respiratory muscle fatigue is
poorly tolerated; (2) Lung-protective ventilation (low tidal volume, moderate PEEP) prevents
volutrauma while maintaining recruitment; (3) Permissive hypoxemia (SpO2 88-92%) avoids
hyperoxic lung injury, which can trigger acute exacerbations in fibrotic lungs. The 2023
ATS/ERS/JRS/ALAT Clinical Practice Guideline for Idiopathic Pulmonary Fibrosis emphasizes
avoiding high FiO2 and mechanical stress. Option A is incorrect because high tidal volumes
cause barotrauma and volutrauma in stiff, fibrotic lungs. Option C is appealing but dangerous—
high spinal anesthesia causes respiratory muscle weakness and sympathectomy-induced
hypotension in a patient with marginal pulmonary reserve; the resulting hypercapnia and
acidosis could trigger pulmonary hypertension crisis. Option D is incorrect because nitrous oxide
expands closed air spaces and increases pulmonary vascular resistance, potentially worsening
right heart strain in advanced ILD.
,Q2: A 59-year-old woman with severe mitral stenosis (valve area 0.9 cm², mean gradient 12
mmHg, severe pulmonary hypertension) presents for elective parathyroidectomy. She is in sinus
rhythm. Immediately after induction with propofol and fentanyl, her blood pressure drops from
118/72 to 78/52 mmHg with unchanged heart rate. The most appropriate immediate
intervention is:
A. Administer phenylephrine 100 mcg to increase afterload and coronary perfusion
B. Administer ephedrine 10 mg to increase heart rate and contractility
C. Administer fluid bolus 500 mL crystalloid to increase preload
D. Administer norepinephrine infusion starting at 0.05 mcg/kg/min to support SVR without
significantly increasing heart rate [CORRECT]
Correct Answer: D
Rationale: In severe mitral stenosis, cardiac output is fixed and depends on adequate preload
(to maintain flow across the stenotic valve) and controlled heart rate (to allow adequate
diastolic filling time). The hemodynamic collapse here represents vasodilation from propofol in
a patient with precarious forward flow. Option D is optimal: norepinephrine restores systemic
vascular pressure, maintains coronary perfusion, and its mild β1 effects support contractility
without the chronotropic surge seen with ephedrine. The 2022 AHA/ACC Guideline for
Management of Patients With Valvular Heart Disease emphasizes maintaining sinus rhythm and
avoiding tachycardia in mitral stenosis. Option A (phenylephrine) is reasonable but pure α-
agonism increases afterload without inotropic support, potentially worsening right heart failure
in the setting of pulmonary hypertension. Option B (ephedrine) is dangerous—tachycardia
dramatically shortens diastolic filling time in mitral stenosis, potentially causing acute
pulmonary edema or cardiovascular collapse. Option C (fluid bolus) addresses preload but is
insufficient alone; excessive fluid can precipitate right heart failure given the fixed obstruction
and pulmonary hypertension.
Q3: A 72-year-old man with Cushing's syndrome (ACTH-secreting pituitary macroadenoma,
serum cortisol 28 mcg/dL) presents for transsphenoidal hypophysectomy. He has uncontrolled
hypertension (BP 168/102 mmHg) and glucose of 312 mg/dL. Which perioperative management
strategy is most appropriate?
A. Continue only the patient's home metyrapone until the morning of surgery to maintain
cortisol control
B. Administer stress-dose hydrocortisone 100 mg IV pre-induction, followed by 50 mg q8h,
while continuing home steroidogenesis inhibitors through the morning of surgery [CORRECT]
, C. Withhold all home medications and administer dexamethasone 4 mg IV pre-induction to
provide glucocorticoid coverage without interfering with postoperative cortisol testing
D. Administer propofol infusion for total intravenous anesthesia to minimize cardiovascular
stimulation, withholding steroids until tumor resection is confirmed
Correct Answer: B
Rationale: This question tests understanding of perioperative steroid management in Cushing's
disease. Option B is correct because: (1) Patients with ACTH-dependent Cushing's have adrenal
hyperplasia and suppressed hypothalamic-pituitary-adrenal axis; surgical removal of the
pituitary tumor causes immediate adrenal insufficiency requiring stress-dose coverage; (2)
Continuing steroidogenesis inhibitors (metyrapone, ketoconazole) through the morning of
surgery prevents intraoperative hypercortisolism complications (hypertension, hyperglycemia,
immunosuppression); (3) The Endocrine Society Clinical Practice Guideline (2021) recommends
perioperative stress-dose steroids for pituitary surgery in Cushing's disease. Option A is
incorrect because it omits stress-dose steroids, risking adrenal crisis post-resection. Option C is
incorrect because dexamethasone interferes with postoperative cortisol assays used to confirm
remission; additionally, withholding home medications risks intraoperative hypercortisolism
crisis. Option D is incorrect because withholding steroids entirely risks adrenal insufficiency;
while TIVA is reasonable for hemodynamic control, it does not address the critical endocrine
management.
Q4: A 34-year-old woman with systemic lupus erythematosus (SLE) on chronic prednisone 15
mg daily, mycophenolate mofetil, and hydroxychloroquine presents for total hip arthroplasty.
She has a history of pericarditis and secondary antiphospholipid syndrome. Her platelet count is
98,000/μL. The most significant concern regarding neuraxial anesthesia is:
A. The risk of spinal hematoma due to antiphospholipid antibody-associated coagulopathy and
thrombocytopenia [CORRECT]
B. The risk of catastrophic infection due to immunosuppression
C. The risk of adhesive arachnoiditis from hydroxychloroquine
D. The risk of autonomic instability from chronic steroid use
Correct Answer: A
Rationale: Antiphospholipid syndrome (APS) creates a paradoxical prothrombotic state with
laboratory evidence of coagulopathy (elevated aPTT, thrombocytopenia). Option A is correct
because: (1) APS patients often have mild thrombocytopenia (100,000-150,000/μL) due to
immune-mediated platelet destruction; (2) Despite thrombocytopenia, these patients are
hypercoagulable, but the combination of low platelets plus perioperative anticoagulation (often
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 (20 Questions)
Q1: A 68-year-old man with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 35%
predicted, resting SpO2 91% on room air) is scheduled for open cholecystectomy. His resting
PaCO2 is 48 mmHg. Which anesthetic strategy best minimizes the risk of perioperative
exacerbation?
A. General anesthesia with high tidal volumes (10-12 mL/kg) to prevent atelectasis and maintain
FRC
B. Combined epidural-general anesthesia with lung-protective ventilation (6 mL/kg tidal volume,
PEEP 8-10 cm H2O, FiO2 minimized to maintain SpO2 88-92%) [CORRECT]
C. Spinal anesthesia to T4 level to avoid airway instrumentation and mechanical ventilation
D. General anesthesia with nitrous oxide to reduce FiO2 requirements and prevent oxygen
toxicity
Correct Answer: B
Rationale: Interstitial lung disease (ILD) patients require meticulous lung-protective strategies.
Option B is correct because: (1) Epidural analgesia reduces systemic opioid requirements,
preserving respiratory drive and cough reflex—critical in ILD where respiratory muscle fatigue is
poorly tolerated; (2) Lung-protective ventilation (low tidal volume, moderate PEEP) prevents
volutrauma while maintaining recruitment; (3) Permissive hypoxemia (SpO2 88-92%) avoids
hyperoxic lung injury, which can trigger acute exacerbations in fibrotic lungs. The 2023
ATS/ERS/JRS/ALAT Clinical Practice Guideline for Idiopathic Pulmonary Fibrosis emphasizes
avoiding high FiO2 and mechanical stress. Option A is incorrect because high tidal volumes
cause barotrauma and volutrauma in stiff, fibrotic lungs. Option C is appealing but dangerous—
high spinal anesthesia causes respiratory muscle weakness and sympathectomy-induced
hypotension in a patient with marginal pulmonary reserve; the resulting hypercapnia and
acidosis could trigger pulmonary hypertension crisis. Option D is incorrect because nitrous oxide
expands closed air spaces and increases pulmonary vascular resistance, potentially worsening
right heart strain in advanced ILD.
,Q2: A 59-year-old woman with severe mitral stenosis (valve area 0.9 cm², mean gradient 12
mmHg, severe pulmonary hypertension) presents for elective parathyroidectomy. She is in sinus
rhythm. Immediately after induction with propofol and fentanyl, her blood pressure drops from
118/72 to 78/52 mmHg with unchanged heart rate. The most appropriate immediate
intervention is:
A. Administer phenylephrine 100 mcg to increase afterload and coronary perfusion
B. Administer ephedrine 10 mg to increase heart rate and contractility
C. Administer fluid bolus 500 mL crystalloid to increase preload
D. Administer norepinephrine infusion starting at 0.05 mcg/kg/min to support SVR without
significantly increasing heart rate [CORRECT]
Correct Answer: D
Rationale: In severe mitral stenosis, cardiac output is fixed and depends on adequate preload
(to maintain flow across the stenotic valve) and controlled heart rate (to allow adequate
diastolic filling time). The hemodynamic collapse here represents vasodilation from propofol in
a patient with precarious forward flow. Option D is optimal: norepinephrine restores systemic
vascular pressure, maintains coronary perfusion, and its mild β1 effects support contractility
without the chronotropic surge seen with ephedrine. The 2022 AHA/ACC Guideline for
Management of Patients With Valvular Heart Disease emphasizes maintaining sinus rhythm and
avoiding tachycardia in mitral stenosis. Option A (phenylephrine) is reasonable but pure α-
agonism increases afterload without inotropic support, potentially worsening right heart failure
in the setting of pulmonary hypertension. Option B (ephedrine) is dangerous—tachycardia
dramatically shortens diastolic filling time in mitral stenosis, potentially causing acute
pulmonary edema or cardiovascular collapse. Option C (fluid bolus) addresses preload but is
insufficient alone; excessive fluid can precipitate right heart failure given the fixed obstruction
and pulmonary hypertension.
Q3: A 72-year-old man with Cushing's syndrome (ACTH-secreting pituitary macroadenoma,
serum cortisol 28 mcg/dL) presents for transsphenoidal hypophysectomy. He has uncontrolled
hypertension (BP 168/102 mmHg) and glucose of 312 mg/dL. Which perioperative management
strategy is most appropriate?
A. Continue only the patient's home metyrapone until the morning of surgery to maintain
cortisol control
B. Administer stress-dose hydrocortisone 100 mg IV pre-induction, followed by 50 mg q8h,
while continuing home steroidogenesis inhibitors through the morning of surgery [CORRECT]
, C. Withhold all home medications and administer dexamethasone 4 mg IV pre-induction to
provide glucocorticoid coverage without interfering with postoperative cortisol testing
D. Administer propofol infusion for total intravenous anesthesia to minimize cardiovascular
stimulation, withholding steroids until tumor resection is confirmed
Correct Answer: B
Rationale: This question tests understanding of perioperative steroid management in Cushing's
disease. Option B is correct because: (1) Patients with ACTH-dependent Cushing's have adrenal
hyperplasia and suppressed hypothalamic-pituitary-adrenal axis; surgical removal of the
pituitary tumor causes immediate adrenal insufficiency requiring stress-dose coverage; (2)
Continuing steroidogenesis inhibitors (metyrapone, ketoconazole) through the morning of
surgery prevents intraoperative hypercortisolism complications (hypertension, hyperglycemia,
immunosuppression); (3) The Endocrine Society Clinical Practice Guideline (2021) recommends
perioperative stress-dose steroids for pituitary surgery in Cushing's disease. Option A is
incorrect because it omits stress-dose steroids, risking adrenal crisis post-resection. Option C is
incorrect because dexamethasone interferes with postoperative cortisol assays used to confirm
remission; additionally, withholding home medications risks intraoperative hypercortisolism
crisis. Option D is incorrect because withholding steroids entirely risks adrenal insufficiency;
while TIVA is reasonable for hemodynamic control, it does not address the critical endocrine
management.
Q4: A 34-year-old woman with systemic lupus erythematosus (SLE) on chronic prednisone 15
mg daily, mycophenolate mofetil, and hydroxychloroquine presents for total hip arthroplasty.
She has a history of pericarditis and secondary antiphospholipid syndrome. Her platelet count is
98,000/μL. The most significant concern regarding neuraxial anesthesia is:
A. The risk of spinal hematoma due to antiphospholipid antibody-associated coagulopathy and
thrombocytopenia [CORRECT]
B. The risk of catastrophic infection due to immunosuppression
C. The risk of adhesive arachnoiditis from hydroxychloroquine
D. The risk of autonomic instability from chronic steroid use
Correct Answer: A
Rationale: Antiphospholipid syndrome (APS) creates a paradoxical prothrombotic state with
laboratory evidence of coagulopathy (elevated aPTT, thrombocytopenia). Option A is correct
because: (1) APS patients often have mild thrombocytopenia (100,000-150,000/μL) due to
immune-mediated platelet destruction; (2) Despite thrombocytopenia, these patients are
hypercoagulable, but the combination of low platelets plus perioperative anticoagulation (often
